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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 
Jn  acute  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 


DEPARTMENTS 

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- 
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Inhalant  Ephedrine  CPlaM,  Lilly, 

containing  ephedrine  (in  the  form  of  ephed- 
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Inhalant  Ephedrine  Compound,  Lilly, 

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Prompt  Attention  Qiven  to  Professional  Jncjuiries 

PRINCIPAL    OFFICES    AND    LABORATORIES,    INDIANAPOLIS,    INDIANA,    U.S.A. 


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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. 
Gynecology  &  Obstetrics 

EDWARD  R.  HIPP,  M.D. 

Traumatic  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   Street 


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  of  Infants  &  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  Everett  F.  Long,  M.D. 

Harry  L.  Brockmann,  M.D.,  F.A.C.S.  O'  B.  Bonner,  M.D.,  F.A.C.S. 


Phillip  W.  Flagge,  M.D.,  F.A.C.P. 


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.  PIKE,  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  BIdg. 

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.  Dentist 

A.  W.  Scheer  X-ray  Technician 

Miss  Etta  Wade  Clinical  Pathologist 


Please   Mention   THIS  JOURNAL  When   Writing  to   Advertisers 


PROFESSIONAL  CARDS 


January,  1936 


INTERNAL  MEDICINE 


STEPHEN  W.  DAVIS.  M.D. 

Diagnosis 

Internal  Medicine 

Oxygen  Therapy  Service  Passive  Vascular  Exercises 

Medical  Arts  Bldg.  Charlotte,  N.  C. 


JAMIE  W.  DICKIE,  B.S.,  M.D. 

INTERNAL  MEDICINE 
DISEASES  OF  THE  CHEST 

Pine  Crest  Manor,  Southern  Pines,  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 


Januar>-,  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 


\Vm.  Ray  Griffin,  M.D. 


Appalactiian  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. 


Bours — Nine  to  Five 


STAFF 

Andrew  J.  Crowell,  M.D.  Claude  B.  Squires,  M.D. 

Raymond  Thompson,  M.D.         Theodore  M.  Davis   M.D. 


Telephones — 3-7101 — 3-7102 


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  &  Colon 

Professional  Bldg.  Charlotte 


Please   Mention   THIS  JOURNAL  When   Writing  to   Advertis 


PROFESSIONAL  CARDS 


January-,   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  jNIEDICAL  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   Sf  SURGERY 


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 

0 

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           0                   0  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. 


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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? 


^:. 


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 


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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- 
ity and  low  in  price. 


Bacterial  vaccines  — Kirk 
are  of  high  antigenic  po- 
tency, producing  definite 
results  with  minimum  re- 
action. 


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. 

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THE  EDITING  OF  MEDICAL  PAPERS 

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ing papers  on  medicine,  surgery  and  related  subjects,  for  publication  or  presentation 
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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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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- 


MULL-SOY 

VEGETABIE     |V1  |  L  K  SUBSTITUTE 


Clinically   Proven 
concentrated  fluid  form,  easily  prepared 


Send  for  frt 


nple  and  literaluri 


THE  MULLER  LABORATORIES 


2935  FREDERICK  AVENUE 


BALTIMORE 


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  tract,  I 
prepare  them  ahead  of  time  with  the  nonresidue  diet  and 
irrigations.  I  use  a  large  number  of  irrigations  ahead  of 
time.  The  interns  say  that  the  patients  prepared  in  that 
manner  have  a  much  better  convalescence  than  do  those 
that  have  a  large  number  of  enemas.  You  can  not  expect 
much  propulsive  power  in  the  first  forty-eight  hours.  If 
you   put   a   large   enema  in   and   fill   the   patiint   up  with 


fluid,  then  you  do  get  the  patient  uncomfortable  and  dis- 
tended, and  it  takes  hours  and  hours  to  become  relieved. 

As  regards  the  soapsuds  enema,  I  notice  Dr.  Northing- 
ton's  remark  that  a  good  proctologist  told  him  a  large 
part  of  his  practice  came  from  it.  Perhaps  the  same  proc- 
tologist told  me  that.  Dr.  E.  H.  Terrell  said  last  Wednes- 
day night  that  a  large  part  of  his  practice  came  from 
laxatives  with  phenolphthalein  in  them  and  that  he  got  a 
large  part   by   reason   of   irrigating  and,  so,  irritating,  the 

anal  region. . 

The  PESs.-UiY  in  the  Treatment  of  Postpartum 

Retrodisplacements  of  the  Uterus 

(Olan  .Key,   Lubbock,    in   Texas   State   Jl.    of    Med.,    Mar.) 

My  patients  are  asked  to  report  to  the  office  for  ex- 
amination on  the  23rd  day  postpartum.  Obstetrical  pa- 
tients should  be  impressed  with  the  importance  of  regular 
postpartum  examinations.  I  have  found  it  necessary  to 
tell  them  that  the  fee  for  delivery  includes  all  the  charges 
for  postpartum  care. 

When  retroversion  is  discovered,  the  patient  is  advised 
to  have  a  pessary  inserted  unless  new  growths  or  inflamma- 
tory processes  are  present  in  the  adnexa,  uterus,  cervix,  or 
vagina.  The  uterus  is  brought  into  position.  The  size  of 
the  pessary  is  estimated  in  much  the  same  manner  as  the 
diagonal  conjugate  is  determined,  fitted  by  moulding  or 
selection  from  an  assortment  of  sizes  and  shapes.  When 
the  pessary  is  in  place,  the  patient  should  not  be  conscious 
of  its  presence.  The  examining  finger  should  pass  without 
difficulty  between  the  pessary  and  the  vaginal  walls;  the 
patient  should  be  able  to  stand,  sit,  squat  and  walk  with- 
out discomfort.  Daily  douches  are  advised  except  when 
menstruating.  She  should  report  immediately  any  pain  or 
discomfort  associated  with  the  pessary.  Too,  it  is  im- 
portant that  patients  continue  their  postpartum  physical 
culture.  Examine  in  2  weeks  for  signs  of  irritation  or 
decubitus.  If  these  are  present,  the  pessary  should  be 
removed  until  healing  has  occurred.  Thereafter,  they 
should  report  at  intervals  of  4  weeks  for  vaginal  inspec- 
tion and  cleaning  of  the  pessary. 

As  a  rule,  if  the  uterus  is  in  correct  position  and  its  size 
is  nearly  normal,  the  pessary  is  removed  at  the  end  of  the 
Qth  week  postpartum.  It  is  significant  to  note  that  I 
have  been  able  to  remove  72%  of  the  pessaries  at  the  end 
of  this  period.  Following  removal,  patients  are  instructed 
to  return  in  2  weeks  for  examination.  If  the  uterus  is  in 
proper  position,  they  are  asked  to  return  in  4  weeks  for  a 
2nd  examination.  If  the  position  is  normal  at  this  time, 
they  are  advised  to  return  in  3  to  6  months.  On  the  other 
hand,  if  retroversion  has  recurred  at  the  end  of  the  2-week 
period,  the  pessary  should  be  reinserted  for  a  period  of  2 
months,  after  which  time  the  pessary  should  be  removed. 
If  the  patients  are  symptom-free,  no  further  treatment 
should  be  advised.  If  definite  symptoms  are  associated 
with  retroversion,  the  patient  should  have  a  suspension 
upon  completion  of  involution  and  lactation. 

For  marked  subinvolution,  I  prescribe  small  tonic  doses 
of  ergot. 

I  have  used  the  Findley  modification  of  the  Albert  Smith 
pessary  to  my  extreme  satisfaction  and  certainly  with  less 
pain  to  the  patient. 

I  have  not  encountered  any  of  the  objections  so  fre- 
quently mentioned  in  regard  to  the  early  use  of  the  pes- 
sary. Backache,  heaviness  in  the  pelvis  and  nervousness 
are  promptly  relieved. 

Postpartum  retroversion  was  found  to  occur  in  33%  of 
the  cases  studied. 

Pessary  treatment  hastens  involution  and  frequently  gives 
symptomatic  relief. 

Anatomical  correction  was  obtained  in  76%  of  a  mixed 
group  of  patients  by  early  pessary  treatment. 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


The  Diagnosis  and  Treatment  of  Nephroptosis* 

J.  D.  HiGHSMiTH,  M.D.,  Fayetteville,  and  C.  J.  Albright,  M.D.,  Whiteville, 
North  Carolina 


Historical 

THE  subject  of  nephroptosis  has  for  years 
been  much  debated  as  to  its  significance 
and  as  to  the  proper  therapy.  The  first 
writing  on  the  subject  was  that  of  Mesue  of  Venice 
in  1495;  in  1581  Pedemontanus  recorded  a  case, 
and  a  hundred  years  later  Riolan  observed  a  few 
cases.  It  was  not,  however,  until  1841  that  the 
condition  was  accurately  described;  at  this  time 
Rayer  published  his  classic  observation  of  seven 
cases,  leaving  little  to  be  added  for  years  to  come 
from  an  anatomic,  symptomatic  or  diagnostic 
standpoint.  Eighteen  years  later  Dietl  described 
the  symptom-complex  to  which  his  name  is  now 
generally  attached.  In  1878  Martin  performed  two 
nephrectomies  for  ptosis  of  the  kidney,  and  three 
years  later  Hahn  did  the  first  nephropexy.  This 
was  soon  followed  by  a  wave  of  over-enthusiasm 
and  in  the  hands  of  such  surgeons  as  Schede  of 
Germany,  Morris  of  England,  Albarran  of  France, 
and  Kelly  and  Edebohls  in  this  country  the  new 
operation  of  nephrorrhaphy  or  nephropexy  was 
hailed  as  a  near  panacea.  It  was  only  natural  that 
such  extreme  radicalism  should  be  followed  by  an 
equally  extreme  reaction  of  conservative  disgust. 
Glenard  came  along  about  this  time  to  describe 
general  visceroptosis.  He  believed  that  the  fallen 
kidney  was  no  more  than  just  a  part  of  so-called 
Glenard's  disease.  This  is  no  longer  believed  to 
be  true,  but  today  in  many  quarters  the  signifi- 
cance of  the  movable  kidney  continues  to  be  under- 
rated and  the  proper  therapy  consequently  neg- 
lected. 

I  believe  that  at  the  present  time  urology  may 
justly  claim  to  have  more  diagnostic  aids  than  any 
of  the  branches  of  medical  science.  Cystoscopy 
and  ureteral  catheterization  have  contributed  im- 
measurably to  the  understanding  of  renal  pathology 
of  all  kinds.  And  in  addition,  the  development  of 
non-toxic  radio-opaque  chemicals  has  made  retro- 
grade and  intravenous  urography  a  procedure  re- 
markably free  from  reactions  of  any  kind,  rather 
than  the  more  or  less  drastic  procedure  it  was 
when  silver  compounds  and  inorganic  iodides  and 
bromides  were  employed.  Thus  we  are  able  to  ob- 
tain diagnostic  criteria  which  make  possible  a  much 
fuller  understanding  of  the  problem  of  nephroptosis 
than  was  ever  before  possible. 


Etiology 

In  quadrupeds  the  kidneys  rest  upon  a  fascial 
shelf  which  is  in  turn  supported  by  the  peritoneal 
viscera.  As  man,  in  his  evolutionary  development, 
has  come  to  walk  upright,  this  support  is  lost  as 
the  former  shelf  now  lies  in  front  of  the  kidney 
instead  of  beneath  it.  The  renal  fossae  have  be- 
come wider  instead  of  deeper. 

Nephroptosis  is  generally  reported  to  be  four 
times  as  prevalent  in  women  as  in  men.  Pregnancy 
does  not  seem  to  have  any  definite  significance  here. 
Women  generally  have  a  weaker  abdominal  mus- 
culature, allowing  protrusion  of  the  abdominal 
viscera  and  consequent  loss  of  renal  support  by 
this  means.  However,  the  most  important  factor 
is  quite  probably  the  widening  of  the  female  pelvis 
at  puberty  with  widenin-;!;  of  the  renal  fossae  at 
the  lower  end,  giving  the  shape  of  an  inverted' 
funnel;  while  in  the  male  these  fossae  are  more  apt 
to  be  narrower  at  the  lower  end,  the  shape  of  an 
inverted  pear.  This  point  is  borne  out  to  som; 
extent  by  the  fact  that  movable  kidney  producing 
symptoms  is  practically  unknown  before  the  age 
of  puberty.  Most  of  the  cases  occur  in  the  t'ird 
and  fourth  decades  of  life. 

The  right  kidney  is  far  more  often  involved  than 
the  left,  which  is  generally  explained  by  the  shal- 
lower fossa  with  wider  lower  end  on  the  right,  the 
relative  lower  attachment  of  the  hepatic  flexure, 
and  the  arrangement  and  attachment  of  the  fascial 
planes  on  the  left  side  being  more  conducive  to 
good  support. 

Becker  and  Lennhoff  and  many  others  are  of 
the  opinion  that  body  form  and  movable  kidney 
are  definitely  connected.  They  call  one  type  of 
build  positive  and  the  other  negative.  The  positive 
type  is  thin,  with  poor  posture,  long  narrow  thorax 
and  soft  ptotic  viscera;  contrasted  with  this  is  the 
negative  with  broad  thorax,  round  abdomen,  and 
relatively  short  length  with  large  sagittal  and  fron- 
tal diameters.  These  types  correspond  with  the 
asthenic  and  sthenic,  or  the  leptic  and  pyknic  types, 
about  which  so  much  has  been  written.  For  those 
who  are  mathematically  minded  there  are  various 
formulae  for  deriving  so-called  renal  indices.  A 
simple  method  is  to  measure  the  distance  from  the 
sternal  notch  to  the  symphysis  pubis  and  divide 
this  by  the  smallest  abdominal  circumference.  If 
the  resulting  quotient  is  above  77  the  renal  index 
is  called  positive  and  the  patient  is  predisposed  to 


•Presented  to  the  Tri-State  Medical  Association  of  the  Carolinas   and 
lina,  February  17th  and  ISth. 


Virginia,    meeting  at   Columbia,    South   Caro- 


April,  1936 


NEPHROPTOSIS— Higlismith  and  Albright 


nephroptosis;  if  below  77  the  renal  index  is  nega- 
tive. M.  L.  Harris  has  added  refinements  to  this 
method  and  uses  fixed  points  for  measuring  bodily 
circumference;  he  has  derived  what  he  calls  Harris' 
index  No.  1  and  No.  2.  These  methods  are  inter- 
esting but  probably  not  essential  in  determining 
whether  the  patient  is  of  the  type  in  whom  movable 
kidney  is  likely  to  occur.  This  can  usually  be 
recognized  at  a  glance. 

The  question  of  the  relation  of  trauma  to  mov- 
able kidney  often  arises,  particularly  in  connection 
with  accident  cases.  Many  a  patient  in  an  auto- 
mobile or  industrial  accident  likes  to  imadne  that 
his  kidney  has  been  knocked  out  of  place  and  that 
he  is  entitled  to  compensation.  The  consensus  of 
opinion  seems  to  be  that  a  severe  jolt  may  tear  the 
kidney  loose  and  produce  symptoms.  In  41  of 
Harris'  107  cases  of  movable  kidney  the  condition 
was  attributed  to  a  railroad  accident.  Some  ob- 
ser\'ers  think  that  hemorrhage  into  the  perirenal 
fat  may  be  a  factor  in  producing  displacement  of 
the  kidney.  The  majority  of  cases  produced  by 
acute  trauma  naturally  occur  in  those  who  are 
already  predisposed  to  nephroptosis — those  who 
have  a  positive  renal  index.  In  a  medicolegal  case 
of  this  nature,  the  question  will  always  arise  as  to 
whether  the  ptosis  existed  prior  to  the  accident. 
The  answer  to  questions  of  this  kind  must  depend 
upon  the  history  of  the  individual  case,  the  severity 
of  tl  e  trauma  and,  in  the  end,  a  good  deal  of  pure 
con.'ecture.  Chronic  or  repeated  traumata  probably 
have  more  to  do  with  causing  the  condition  than 
does  one  jar.  Among  these  are  long  standing, 
weight-bearing,  repeated  flexion  of  the  body  in  the 
lateral  and  anteroposterior  direction  such  as  is  in- 
volv  d  in  many  forms  of  manual  labor  (particular- 
ly women  washing  clothes  and  doing  work  in  the 
field;),  horseback  riding  or  automobile  riding  over 
rough  roads,  or  the  excessive  straining  that  accom- 
panies chronic  cough  and  chronic  constipation. 

There  can  be  no  doubt  that  rapid  loss  of  weight 
and  movable  kidney  are  often  associated,  but  who 
can  say  which  is  primary  and  which  is  secondary? 
Hov.  ever  this  may  be,  it  is  important  to  remember 
their  frequent  close  connection.  Mathe  has  argued 
that  if  weight  loss  had  anything  to  do  with  neph- 
roptosis, it  should  occur  as  often  in  men  as  in 
women.  This  does  not  appear  to  be  valid,  since 
the  predisposing  causes  in  women  far  exceed  in 
othe;  respects  those  in  men.  It  is  easily  conceiv- 
able that  a  rapid  depletion  of  the  perirenal  fat 
deposits  in  which  the  kidney  is  cushioned  might 
lead  to  displacement  of  that  organ.  Nor  is  this 
the  whole  story.  There  is  an  associated  loss  of 
intraperitoneal  fat  and  of  abdominal  muscular  tone, 
which  deprives  the  kidney  of  the  important  sup- 
port afforded  by  intraabdominal  tension. 


To  menstruation  has  been  ascribed  some  causal 
relation,  through  congestion;  but  this  is  hardly 
tenable,  as  the  increase  in  weight  would  not  exceed 
25  Grams  at  the  most. 

Displacements  of  the  liver,  stomach  and  colon 
have  been  considered  by  some  as  causative  of 
nephroptosis;  these  factors  are  most  probably  of 
minor  significance,  as  the  kidney  is  not  surrounded 
by  peritoneum  and  any  traction  from  that  structure 
would  necessarily  be  slight. 

To  summarize,  then,  the  causes  of  nephroptosis 
may  be  considered  as  predisposing — age,  sex,  up- 
right posture  and  bodily  type;  and  active — various 
acute  and  repeated  chronic  traumata,  and  perhaps 
rapid  loss  of  weight. 

Symptomatology  and  Diagnosis 
It  is  important  first  to  realize  that  the  symptoms 
are  very  variable.  The  principal  symptom  is  dull 
aching  or  dragging  pain  in  the  region  of  the  af- 
fected kidney,  usually  with  radiation  to  the  iliocos- 
tal space  and  to  the  hypochondrium.  The  pain  is 
worse  after  several  hours  in  the  upright  position 
and  relief  is  afforded  by  lying  down.  In  many 
cases  this  dull  pain  is  replaced  at  times  by  the 
sharp,  lightning-like,  excruciating  DietPs  crises,  the 
pain  often  radiating  along  the  ureter  to  the  blad- 
der, labium,  testis  or  thigh. 

The  pain  is  due  to  traction  upon  and  irritation 
of  the  sympathetic  nerves  of  the  renal  plexus  with 
contributions  from  the  solar  and  aortic  plexuses 
and  the  least  splanchnic  nerve.  Stimulation  of 
these  afferent  sympathetic  nerves  accounts  for  the 
radiation  of  pain  and  also  for  the  effects  upon  other 
organs.  This  phenomenon  is  what  is  known  as  the 
viscero-visceral  reflex.  The  stimulus  may  start  and 
end  in  the  same  organ,  or  in  a  different  or  lan;  as, 
for  example,  pylorospasm  may  arise  from  a  viscero- 
visceral reflex  initiated  in  a  diseased  gallbladder  or 
appendix.  This  accounts  in  all  probability  for  a 
second  group  of  symptoms  which  are  oftea  quite 
prominent  in  cases  of  nephroptosis,  namely,  the 
gastrointestinal  upsets — chiefly  nausea  and  vomit- 
ing, gaseous  eructation,  pylorospasm,  hyperacidity, 
constipation  and  diarrhea.  In  fact,  this  group  of 
symptoms  may  at  times  overshadow  the  urologic 
symptoms  and  lead  the  physician  far  astray  in  a 
vain  attempt  to  locate  the  trouble  in  the  gastro- 
intestinal tract.  The  anorexia  accompanying  these 
symptoms  may  result  in  considerable  loss  of  weight 
also,  which  makes  it  difficult  to  state  whether  the 
mobility  of  the  kidney  or  the  loss  of  weight  is 
primary. 

The  fact,  too,  that  the  psychic  centers  are  readily 
affected  by  peripheral  disease,  particularly  disease 
involving  viscera  supplied  by  the  sympathetic  nerv- 
ous system,  offers  an  explanation  of  why,  in  a 
considerable  number  of  instances,  victims  of  this 


NEPHROPTOSIS— Highsmiih  and  Albright 


April,  1936 


kind  of  disease  are  subject  to  hysteria,  neurasthe- 
nia, hypochondria,  and  even  frank  psychoses. 
Probably  few  of  us  would  be  enthusiastic  enough 
to  agree  with  them,  but  Suckling  and  Billing  have 
reported  several  cases  of  insanity  cured  by  suspen- 
sion of  an  abnormally  movable  kidney. 

The  other  symptoms  commonly  associated  with 
nephroptosis  are  mainly  urologic  and  are  related 
to  urinary  obstruction  plus  infection.  The  descent 
of  the  kidney  will  of  course  bring  the  ureter  down 
with  it,  causing  it  to  be  thrown  into  kinks  at  its 
fixed  points  or  perhaps  around  an  aberrant  blood 
vessel.  This  results  in  a  varying  degree  of  ob- 
struction to  urinary  outflow,  raises  the  intrapelvic 
pressure  and  produces  secondary  changes  ranging 
from  a  hardly  noticeable  pyelectasis  to  a  pronounc- 
ed hydronephrosis.  Undoubtedly  the  pain  in  mov- 
able kidney  is  often  due  to  the  increased  intrapelvic 
pressure,  since  drainage  by  ureteral  catheterization 
will  so  often  give  complete  temporary  relief.  Wher- 
ever there  is  stasis  of  urine,  infection  always  creeps 
in  sooner-  or  later  and  changes  the  condition  into 
pyelonephritis  or  pyonephrosis,  and  so  adds  a  septic 
element  to  the  symptom-complex,  with  chills,  fever, 
prostration,  and  vesical  symptoms  of  dysuria  and 
frequency.  Stasis  of  urine  invites  infection,  and 
stasis  plus  infection  at  times  leads  to  calculus-for- 
mation. Hematuria  by  no  means  indicates  posi- 
tively the  presence  of  a  stone;  it  may  be  due  to 
passive  congestion  caused  by  the  traction  of  the 
displaced  organ  on  its  veins,  or  to  congestion  of 
the  ureter  at  its  kinked  points.  Likewise,  the  vesi- 
cal symptoms  mentioned  as  due  to  urinary  infec- 
tion are  often  present  even  in  the  absence  of  any 
appreciable  infection  of  the  bladder,  but  they  are 
not  likely  to  be  so  pronounced. 

To  summarize,  the  symptoms  associated  with 
movable  kidney  are  very  varied  and  one  element 
in  the  symptom-complex  may  overshadow  another 
so  as  to  puzzle  the  most  astute  investigator.  The 
psychic  element  may  be  quite  prominent.  And 
finally,  secondary  changes  occur  in  the  upper  uri- 
nary tract — as  hydronephrosis,  pyelonephritis, 
pyonephrosis  with  urosepsis,  ureteritis  and  cystitis 
— these  changes  producing  their  characteristic 
symptoms. 

Glenard  divided  nephroptosis  into  three  degrees: 
first  degree,  when  the  lower  half  of  the  kidney  can 
be  felt  by  bimanual  palpation  on  deep  inspiration; 
second  degree,  when  the  whole  kidney  can  be  felt 
during  deep  inspiration ;  and  third  degree,  when  the 
palpating  finger  tips  can  be  brought  together  above 
the  upper  pole  during  the  respiratory  movements. 
This  is  historically  interesting  and  may  be  of  some 
slight  value  as  a  diagnostic  lead,  but  at  the  present 
time  we  consider  urography,  intravenous  or  retro- 
grade, as  absolutely  indispensable  evidence  in  han- 


dling these  cases.  At  times  it  is  advisable  to  make 
roentgenograms  both  in  the  horizontal  and  upright 
position  to  demonstrate  the  effect  of  gravity.  This 
is  not  always  necessary;  of  course  with  the  ma- 
jority of  patients  the  added  expense  is  a  factor 
which  must  be  considered.  As  was  mentioned 
above,  these  procedures  are  no  longer  fraught  with 
the  dangers  which  previously  attended  them.  For 
intravenous  urograms  we  are  routinely  employing 
diodrast  and  for  the  retrograde  pictures  a  solution 
of  skiodan.  The  only  untoward  reaction  that  has 
been  noted  from  the  diodrast  is  slight  transient 
nausea,  with  occasional  vomiting.  Skiodan  seems 
to  be  non-irritant  and  non-toxic,  and  even  if  there 
is  accidental  pyelovenous  backflow,  as  occasionally 
happens,  the  kidney  does  not  seem  to  be  damaged. 
Cf  course  the  retrograde  pyelogram  is  far  superior 
to  the  intravenous  picture  for  claritj^  of  detail,  but 
numerous  cases  will  arise  where  the  intravenous 
method  is  more  feasible.  The  retrograde  method 
lias  the  further  advantage  that  we  are  sometimes 
able  to  reproduce  the  pain  by  distending  the  kidney 
pelvis  and  ureter  with  the  skiodan  solution;  if  the 
patient  states  that  the  pain  is  the  same  as  that 
with  which  he  has  been  suffering,  this  is  fairly 
conclusive  evidence  to  clinch  the  diagnosis.  Un- 
fortunately this  is  not  a  constant  feature;  in  some 
cases  of  fairly  well  advanced  hydronephrosis  no 
pain  is  experienced  when  the  pelvis  is  completely 
injected. 

On  account  of  the  fact  that  many  people,  women 
especially,  have  kidneys  with  an  abnormal  range  of 
mobility  which  give  rise  to  no  symptoms  at  all,  it 
is  important,  before  labeling  a  case  as  nephroptosis 
and  proceeding  to  treat  it  on  this  premise,  that 
the  physician  weigh  all  the  factors  carefully.  He 
should  try  to  rule  out  disease  in  other  organs  as 
the  cause  of  the  symptoms.  Of  chief  importance 
in  this  connection  are  the  gallbladder,  appendix  and 
female  pelvic  organs.  If  the  investigator  can  bs 
reasonably  certain  the  disease  does  not  lie  in  other 
viscera  and  that  he  is  not  dealing  with  a  pure  neu- 
rosis with  no  somatic  background,  and  if  the  symp- 
tomatology and  the  urographic  findings  are  seen 
to  have  a  reasonable  and  logical  correlation,  then, 
and  only  then,  is  he  justified  in  proceeding  to  treat 
his  case  as  one  of  movable  kidney.  There  are  many 
borderline  cases  in  which  the  diagnosis  is  not  easy 
and  in  no  instance  is  a  diagnosis  to  be  made  with- 
out studying  the  case  from  every  possible  angle. 
Treatmut 

There  are  two  methods  of  treating  ptosed  kid- 
neys: the  palliative  or  non-operative,  and  the  cura- 
tive or  operative,  the  operation  of  nephropexy  be- 
ing performed. 

Except  in  cases  of  marked  ptosis,  or  where  there 
is  a  fixed  kink  in  the  ureter,  and  when  urography 


April,   1936 


NEPHROPTOSIS— Highsmith  and  Albright 


demonstrates  that  the  kidney  is  undergoing  de- 
struction from  intrapelvic  pressure  and  infection, 
the  palliative  treatment  should  be  given  a  trial.  In 
this  mode  of  therapy  there  are  three  points  to  be 
considered. 

First  we  try  to  hold  the  kidney  in  a  higher  posi- 
tion. One  way  is  by  having  the  patient  v/ear  a 
snugly  fitting  support  which  increases  the  intra- 
abdominal tension  and  presses  inward  and  upward 
on  the  tissues  overlying  the  kidney.  The  support 
should  always  be  applied  with  the  patient  lying 
down  to  overcome  the  effects  of  gravity,  and  it 
must  be  worn  at  all  times  when  the  patient  is  up 
walking  around.  Another  method  proposed  is  to 
put  the  patient  to  bed  with  the  foot  of  the  bed 
elevated  for  two  or  three  months  or  even  longer. 
This  is  tedious  and  not  many  patients  are  willing 
to  submit  to  it ;  the  majority  would  prefer  an  opera- 
tion. 

By  a  high-caloric  diet  we  seek  to  bring  about 
an  increase  in  the  weight  of  the  patient;  many  of 
them  are  undernourished.  Tonics  may  be  of  value 
here,  as  well  as  the  administration  of  vitamins  in 
concentrated  form.  Along  with  this  diet,  give  prop- 
erly graded  exercises  to  improve  the  tone  of  the 
abdominal  and  lumbar  muscles. 

Thirdly,  repeated  cystoscopic  treatments  are 
usually  indicated.  By  this  means,  the  ureter  on 
the  affected  side  can  be  progressively  dilated  to 
obtain  better  drainage,  making  the  patient  more 
comfortable  and  combatting  the  low-grade  chronic 
infection  so  often  present.  Then  too,  through  the 
ureteral  catheter,  we  may  inject  antiseptics  and 
other  agents  such  as  bacteriophage  solution  directly 
into  the  kidney  pelvis. 

This  conservative  plan  of  treatment  of  course 
does  not  always  give  perfect  results  but  at  times 
it  seems  to  be  of  real  benefit.  Although  patients 
under  such  a  regimen  may  become  symptom-free 
and  feel  perfectly  well,  they  should  he  examined 
pericdically  by  urinalysis,  ureteral  catheterization 
to  d  termine  pelvic  retention,  and  urography.  For 
it  would  be  foolish  to  go  to  so  much  trouble  to 
avoid  a  nephropexy,  only  to  find  later  that  a 
nepl  rectomy  is  needed  for  a  kidney  that  is  diseas- 
ed bsyond  the  possibility  of  redemption. 

When  the  palliative  treatment  has  been  given 
an  honest  trial  of  several  months  and  fails,  when 
there  is  definite  danger  to  the  kidney  from  advanc- 
ing obstruction  and  infection,  when  there  is  a  fixed 
kink  in  the  ureter,  and  when  the  social  and  eco- 
nomic status  of  the  patient  precludes  a  long  course 
of  treatment,  then  the  operation  of  kidney  suspen- 
sion, or  nephropexy,  is  indicated. 

There  is  no  absolutely  standardized  technique 
for  this  procedure.  The  ultimate  aim  of  all  of 
them  is  to  raise  the  kidney  to  a  higher  position 


and  make  it  anchor  itself  there  by  perinephric  fibro- 
sis, and  to  straighten  out  the  ureter  so  that  free 
drainage  is  established. 

The  following  technique  for  nephropexy  has  for 
one  of  us  (J.  D.  H.),  given  uniformly  good  results 
for  the  past  12  years.  The  mortality  has  been  nil. 
So  far  as  we  can  learn,  there  has  been  no  recur- 
rence of  symptoms  in  any  case  operated  upon.  In 
the  operation  here  described  the  capsule  is  stripped 
off  the  outer  two-thirds  of  the  kidney,  thereby  par- 
tially decapsulating  the  organ.  But,  patients  re- 
turning years  later  have  shown  no  impairment  in 
kidney  function,  and  in  many  cases  give  the  oper- 
ation credit  for  the  restoration  of  their  health  and 
are  very  grateful. 

Surgical  Procedure. — The  position  and  fixation 
of  the  patient  on  the  operating  table  is  very  im- 
portant, and  should  be  properly  attended  to  before 
the  operation  is  begun. 

The  incision  is  a  modified  type  of  Mayo  kidney 
incision.  It  is  not  carried  up  so  high  into  the  costo- 
vertebral angle  as  in  operations  for  other  purposes, 
but  is  continued  further  downward  in  order  better 
to  expose  the  ureter. 

The  fatty  capsule  is  opened  and  it  and  the  peri- 
renal fat  are  shoved  backward  and  downward  to 
add  support  to  the  kidney  from  below.  At  this 
point  it  is  important  to  free  the  ureter  of  all  its 
kinks  and  adhesions.  The  ureter  is  best  freed 
throughout  its  entire  course  (ureterolysis).  An 
examination  is  made  for  any  anomalous  blood  ves- 
sels which,  if  found,  are  ligated  and  divided. 

By  dissecting  the  skin  and  fascia  off  the  ribs  up 
to  about  the  tenth  rib,  or  higher  if  necessary,  suffi- 
cient exposure  can  be  obtained,  making  it  possible 
to  anchor  the  kidney  high  enough  entirely  to 
straighten  out  any  ureter.  This  may  sometimes 
best  be  accomplished  by  extending  an  incision  per- 
pendicularly to  the  original  kidney  incision,  from 
the  posterior  third  about  the  angle  of  the  ribs, 
thereby  relieving  skin  tension,  and  making  it  possi- 
ble to  pass  the  upper  kidney-fixation  sutures 
through  the  intercostal  muscle  above  the  twelfth 
rib. 

The  true  capsule  of  the  kidney  is  incised  along 
the  outer  border  of  the  cortex  to  within  an  inch  of 
each  pole.  This  incision  is  crossed  at  each  extrem- 
ity by  a  transverse  incision  through  the  capsule. 
The  capsule  is  now  bluntly  stripped  until  about 
two-thirds  of  the  renal  surface  is  exposed.  Six  su- 
tures of  heavy  chromic  catgut  are  placed  in  the 
capsule  as  mattress  sutures,  two  being  near  the 
superior  and  two  near  the  inferior  pole  of  the  kid- 
ney. The  sutures  are  left  long  and  clamped.  The 
kidney  is  now  replaced  and  the  ends  of  the  upper 
sutures  are  threaded  into  fairly  large  curved  nee- 
dles, and  passed   through   the   intercostal   muscles 


NEPHROPTOSIS— Highsmith  and  Albright 


April,  1936 


above  the  twelfth  rib,  or  in  certain  cases  the  elev- 
enth rib,  coming  out  beneath  the  reflected  skin  and 
fascia.  The  lower  sutures  are  passed  in  a  similar 
manner  from  above  downward  through  the  quadra- 
tus  lumborum  muscle.  The  sutures  are  tied  after 
all  of  them  are  placed  and  while  they  are  held  taut 
to  bring  the  denuded  cortex  of  the  kidney  in  close 
contact  with  the  wound  when  it  is  closed.  Drain- 
age is  usually  not  employed. 

The  choice  of  an  anesthetic  is  important.  We 
employ  spinal  anesthesia  routinely  as  it  affords 
better  muscular  relaxation  and  there  is  absence  of 
the  vomiting  and  straining  which  almost  always  fol- 
low the  administration  of  any  inhalation  anesthe- 
tic. 

Rest  in  bed  in  the  horizontal  position  or  with 
the  foot  of  the  bed  somewhat  elevated  is  imperative 
for  at  least  three  weeks  following  the  operation,  in 
order  to  allow  fixation  of  the  kidney  to  take  place. 
After  four  or  five  weeks  the  patient  may  be  out  of 
bed.  Ureteral  catheterization  and  retrograde  pyel- 
ography are  done  several  months  after  the  opera- 
tion to  ascertain  the  result  which  has  been  ob- 
tained. 

Case  Reoorts 
The  following  cases  have  been  selected  in  order  to  dem- 
onstate  several  of  the  varied  features  in  nephroptosis  which 
have  been  discussed  above.  They  are  purposely  presented 
in  brief,  and  roentgenograms  shown,  in  an  attempt  to 
bring  out  the  salient  points  in  each  case. 

Case  1. — A  white  girl,  24,  admitted  to  the  hospital  on 
December  11th,  1935,  gave  a  history  of  several  recent 
attacks  of  severe  right  kidney  colic,  considerable  loss  of 
weight  and. color  (hemoglobin  60%  and  red  cells  3,500,000) 
due  probably  to  improper  diet.  She  feared  she  had  a 
urinao'  stone,  but  cystoscopic  and  urographic  evidence 
proved  there  was  slight  ptosis  of  the  right  kidney  with  a 
looped  kink  of  the  ureter,  causing  retention  of  urine  in 
the  kidney  pelvis.  Ureteral  catheterization  relieved  her, 
but  the  x-ray  picture  showed  that  the  catheter  would  not 
pass  beyond  the  loop  in  the  ureter.  Nephropexy  was  se- 
riously considered.  However,  following  the  second  ureteral 
catheterization,  she  was  completely  relieved,  and  an  intra- 
venous urogram  made  eight  days  after  admission  showed 
the  kidney  had  slipped  back  to  a  higher  position  and  the 
kink  had  disappeared.  Since  that  time  she  has  been  treated 
by  repeated  ureteral  catheterization  and  the  wearing  of  a 
nephroptosis  support;  she  has  been  entirely  free  of  pain. 
The  anemia  is  being  successfully  overcome  by  proper  diet, 
iron  in  large  dosage,  and  concentrated  vitamin  prepara- 
tions. She  is  taking  exercises  to  strengthen  the  abdominal 
musculature.  It  is  believed  that  operation  will  not  be  nec- 
essary in  this  case. 

Case  2. — A  white  married  woman,  35,  came  to  the  hos- 
pital seeking  relief  from  pain  which  had  been  troubling 
her  for  three  or  four  years.  She  had  had  repeated  attacks 
of  sharp  cutting  pain  in  the  region  of  the  right  kidney 
and  in  between  the  attacks  a  dull  aching,  with  tenderness. 
The  pain  was  worse  after  she  had  been  standing  for  a 
while.  She  reported  dysuria,  frequency  of  urination — and 
nocturia.  She  had  lost  weight  and  was  considerably  run- 
down. The  pyelogram  showed  a  moderate  ptosis,  but 
there  was  an  acute  kink  in  the   ureter  of   the  watertrap 


variety  which  caused  obstruction  and  resulted  in  marked 
hydronephrosis.  Nephropexy  was  performed  in  May,  1935, 
and  since  that  time  the  patient  has  been  entirely  free  of 
pain. 

Case  3. — A  white  married  woman,  41,  came  in  with  a 
history  of  dull  aching  pain,  and  at  times  kidney  colic,  on 
the  right  side.  She  also  had  dysuria,  frequent  urination 
and  sometimes  hematuria.  These  symptoms  were  of  three- 
years'  duartion.  She  had  consulted  numerous  physicians 
but  had  obtained  no  permanent  relief.  Urography  demon- 
strated considerable  mobility  of  the  right  kidney.  Nephro- 
pexy was  performed  in  April,  1935.  Since  that  time  the 
patient  has  been  entirely  relieved. 

Case  4.- — A  white  girl,  16,  was  first  seen  by  us  at  the 
hospital  in  August,  1934,  at  which  time  she  stated  that 
for  two  months  she  had  been  suffering  with  dull  aching 
pain  in  the  right  kidney  region,  accentuated  at  times  by 
sharp  attacks  of  pain.  Urography  demonstrated  a  slight 
ptosis  with  rotation  of  the  kidney  causing  obstruction. 
Palliative  treatment  was  tried  but  results  were  not  satis- 
factory and  the  patient  was  being  made  miserable  by  the 
constantly  recurring  attacks  of  pain.  Finally,  in  April, 
1035,  a  nephropexy  was  performed.  Since  that  time  she 
has  been  reUeved  and  is  now  among  our  most  grateful 
patients. 

Case  S. — A  white  married  woman,  32,  was  admitted  in 
June,  1935,  complaining  with  pain  in  the  right  kidney  re- 
gion, dysuria,  loss  of  appetite,  indigestion  and  nervousness. 
Urography  demonstrated  a  very  movable  kidney,  with 
kinking  of  the  ureter  and  hydronephrosis.  Nephropexy 
was  performed  in  July,  1935,  and  since  that  time  the 
patient  has  been  entirely  relieved,  although  she  later  had 
to  return  for  removal  of  an  ovarian  cyst  which  was  giving 
trouble. 

Case  6. — A  white  married  woman,  20,  came  in  in  June, 
1935,  complaining  with  dull  aching  pain  in  the  right  kidney 
region  and  urinary  frequency.  The  symptoms  came  on 
following  the  birth  of  her  first  baby.  The  urograms 
showed  a  definitely  movable  kidney,  with  a  tortuous  and 
kinked  ureter  and  hydronephrosis.  A  nephropexy  was 
performed  in  July,  1935,  and  since  that  time  the  patient 
has  been  entirely  well. 

Case  7. — A  white  married  woman,  35,  gave  a  history  of 
having  severe  attacks  of  left  kidney  colic  for  10  years.  She 
cculd  be  relieved  by  ureteral  catheterization,  but  the  pain 
would  soon  recur.  One  feature  of  the  case  was  the  very 
severe  pain  which  even  morphine  in  large  dosage  would 
not  reUeve;  calcium  chloride  intravenously  was  quite  ef- 
fective several  times.  Urography  demonstrated  a  movable 
kidney  and  nephropexy  was  done  in  August,  1934.  Since 
recovering  from  the  operation  this  patient  has  been  entirely 
free  of  pain. 

Summary 

1.  Nephroptosis  has  an  interesting  history,  and 
the  radical  and  conservative  ideas  of  the  past  are 
gradually  converging  toward  a  rational  middle 
;,'round.  The  modern  concept  regarding  its  signiri- 
cance  and  treatment  is  made  possible  by  the  devel- 
opment and  extension  of  the  use  of  modern  meth- 
ods of  urologic  diagnosis. 

2.  The  etiology  includes  predisposing  causes,  a; 
age,  sex,  upright  posture  and  bodily  type;  and 
active  causes,  as  various  acute  and  repeated  chronic 
traumata,  and  perhaps  rapid  loss  of  weight. 


April,  1936 


N EPH ROPTOSIS—Hlghsmith  and  Albright 


197 


3.  The  characteristic  symptoms  of  dull  aching 
or  severe  attacks  of  pain  in  the  renal  areas,  gastro- 
intestinal disturbances,  psychotic  and  neurotic  re- 
actions and  vesical  symptoms  suggest  the  diagnosis, 
but  it  must  be  confirmed  by  urography.  Caution 
must  be  exercised  in  ruling  out  pathologic  changes 
in  other  organs  as  the  possible  source  of  the  symp- 
toms. 

4.  Non-operative  measures  may  at  times  suffice 
for  the  treatment,  but  nephrope.xy  is  often  indi- 
cated. 

5.  The  operative  technique  employed  by  the 
authors  is  described. 

6.  Seven  cases,  with  roentgenograms,  are  pre- 
sented. 

Bibliography 

1.  BiRDS.VLL,  J.  C:  Symptomatology,  diagnosis  and 
treatment  of  nephroptosis.    Penn.  Med.  Jl.,  Dec,  1933. 

2.  Braasch,  W.  F.:  Conservation  in  the  treatment  of 
movable  kidney.  //.  Am.  Med.  Assn.,  1932,  xcvin, 
613-15. 

3.  Bremerman,  L.  W.:  Movable  kidney.  III.  Med.  Jl., 
1028,  I.IV,  373-77. 

4.  Brown,  S.  T.:  Nephroptosis.  Jl.  Med.  Assn.  Ga., 
1934,  x.xni,  172. 

5.  DeLaney,  C.  O.:  Nephroptosis  with  especial  reference 
to  the  pathology  and  treatment.  South.  Med.  & 
Surg.,  1929,  xci,  8S2-S6. 

6.  HAiraioND,  T.  E.:  Treatment  of  movable  kidney. 
Lancet,  Lond.,  1926,  i,  358-59. 

7.  Lewis,  B.,  and  Carroll,  G.:  Clinical  evidence  on  the 
question  of  movable  kidney.  111.  Med.  JL,  1930,  Lvn, 
179-83. 

8.  Mathe,  C.  p.:  Movable  kidney.  Surg.,  Gynec.  &■ 
Obst.,  May,  1925,  605-22. 

9.  Morris,  H.  L.:  The  demonstration  and  significance 
of  nephroptosis  and  urinary  stasis.  Radiol.,  xvni, 
56-73. 

10.  Smith,  P.  G.,  McKm,  G.  F.,  and  Rush,  T.  W.; 
Nephroptosis.    Ohio  Med.  Jl,  1931,  xxvn,  27-30. 

11.  Thomas,  B.  A.:  Observations  on  the  diagnosis  and 
treatment  of  movable  kidney.  //.  Vrol.,  Bait.,  1929, 
xxn,  603-51. 

Discussion 

Dr.  J.  P.  Keotjedy,  Charlotte: 

Dr.  Highsmith  and  Dr.  Albright  have  given  a  very  com- 
prehensive and  thorough  study  of  this  question.  They 
have  very  rightly  emphasized  the  importance  of  a  careful 
diagnosis  prior  to  operative  treatment.  They  have  also 
referred  to  the  changed  attitude  toward  this  problem 
among  the  surgeons.  Shortly  after  the  operation  of 
nephropexy  was  established,  it  became  very  common,  and 
almost  any  patient  with  a  vague  abdominal  complaint 
who  happened  to  have  a  low  kidney  was  operated  upon. 
Naturally,  the  results  were  very  poor,  and  the  patients 
were  not  satisfied,  so  the  operation  fell  into  disrepute.  In 
fact,  one  Englishman  was  known  to  remark  that  a  dropped 
liidney  was  no  more  significant  than  the  dropped  letter 
A,  and  that  has  been  the  attitude  until  recently.  But  since 
the  development  of  pyelography,  and  particularly  the  use 
of  nonirritating  media,  we  get  a  lot  of  information  from 
the  pyelograms;  and,  with  the  development  of  intravenous 
pyelography,  it  is  possible  to  make  the  diagnosis  very 
much  more  accurately  now  than  previously. 


Persons  with  ptosis  of  the  kidney  may  be  divided  into 
three  groups.  In  the  first  group  are  those  in  whom  there 
are  no  symptoms;  in  the  second  group,  those  in  whom 
ptosis  is  so  severe  that  it  is  a  general  visceroptosis;  in 
the  third,  those  in  whom  there  are  kidney  symptoms.  The 
first  group  are  those  found  in  general  physical  examination. 
These  people  are  probably  better  off  if  not  told  that  they 
have  a  dropped  kidney.  In  the  second  group  the  treatment 
is  better  directed  toward  the  general  visceroptosis  rather 
than  to  the  ptosis  of  the  kidney.  Those  in  the  third  group 
require  complete  urographic  study  to  determine  whether 
the  symptoms  are  referable  to  this  condition. 

It  has  been  stated  that  there  are  three  reasons  for  un- 
satisfactory results:  first,  improper  selection  of  cases;  sec- 
ond, poor  technic;  third,  failure  to  free  the  ureter  wherever 
we  find  any  aberrant  blood  vessel  or  other  cause  for  ob- 
struction of  the  ureter,  at  the  time  of  operation. 

Dr.  Albright  has  very  properly  gone  into  the  selection 
of  the  cases.  One  thing  that  aids  in  the  selection  of  the 
cases  is  the  matter  of  the  emptying  time  of  the  kidney 
pelvis.  Most  cases  of  low  kidneys  that  are  producing 
symptoms  have  a  delayed  emptying  time.  A  kidney  may 
be  low  and  have  a  normal  emptying  time  and,  in  all  prob- 
ability, not  produce  any  symptoms. 

In  regard  to  the  operative  technic,  several  mistakes 
have  been  made.  In  times  past  it  was  the  custom  to  ex- 
plore the  kidney  and  pack  gauze  around  it,  in  order  to 
get  adhesions  to  form.  The  gauze  was  left  in  for  some 
time,  which  very  often  caused  infection.  Sutures  were 
put  through  the  kidney  substance,  which  caused  damage 
to  the  kidney. 

The  kidney  may  be  rotated  at  the  time  of  operation, 
which  will  cause  symptoms.  Also,  a  nerve  may  be  caught 
in  the  sutures,  which  will  cause  more  pain  afterward  than 
was  experienced  before  the  operation.  I  have  for  some 
time  used  the  technic  which  Dr.  Albright  describes,  strip- 
ping the  capsule  from  the  kidney  and  stitching  it  up  in 
place,  with  very  good  results.  More  recently  I  have  used, 
and  Uke  better,  an  operation  described  by  Deming,  of 
New  Haven,  in  which  he  does  not  strip  the  kidney  of  the 
capsule  at  all.  In  his  operation  he  frees  the  kidney  and 
the  kidney  pedicle,  frees  the  ureter  well  down  to  the  com- 
mon iliac  vessels,  and  then  pushes  the  kidney  high  up 
underneath  the  diaphragm — pushes  the  upper  pole  in  to- 
ward the  midline  and  the  lower  part  outward,  so  as  to 
give  good  drainage  to  the  lower  part  of  the  kidney  pelvis. 
Then  he  makes  a  hammock  or  sling  for  the  pelvis  by 
bringing  up  the  anterior  layer  of  the  perirenal  fascia,  to- 
gether with  the  extrarenal  fat,  and  tacks  that  to  the 
muscle,  and  fills  the  space  previously  occupied  by  the 
kidney  with  this  fatty  material  so  as  to  make  a  hammock 
or  sling  to  support  the  kidney. 

I  have  enjoyed  the  Doctors'  paper  and  trust  that  they 
will  give  us  further  reports. 

Dr.  Marion  H.  Wyman,  Columbia: 

I  should  lilie  to  ask  Dr.  .Albright  if  he  found  an  aber- 
rant vessel  or  a  fibrous  band.  I  interpret  that  as  being 
an  obstruction  at  the  pelviureteral  junction,  because  that 
pyclogram  is  bellied  out  towards  the  spinal  column.  In 
this  case  (showing  x-ray)  we  made  a  pre-operative  diag- 
nosis of  obstruction  at  the  pelviureteral  junction,  and  we 
left  that  kidney  in.  The  other  kidney  in  that  case  was 
abnormal.  We  handled  this  case  conservatively  and  got 
good  results. 

This  case  (showing  x-ray)  was  a  young  man  in  whom 
we  made  a  pre-operative  diagnosis  of  an  aberrant  vessel. 
Wc  did  not  find  it,  but  we  found  some  adhesions. 

We  think  that  in  any  type  of  operation  on  the  kidney 
we  ought  to  find  the  ureter  first,  follow  it  up,  and  not 


198 


NEPHROPTOSIS— Highsmith  and  Albright 


April,  1936 


handle  the  kidney  if  possible,  because  if  you  manhandle 
the  kidney  you  are  going  to  damage  it. 

The  best  case  we  had  was  in  a  young  lady  schoolteacher 
22  years  old.  This  girl  was  operated  on  by  a  general 
surgeon.  We  made  the  definite  diagnosis  and  wrote  it  out, 
so  there  would  not  be  any  argument  afterward.  She  had 
obstruction  at  the  pelviureteral  junction.  We  suggested  to 
this  surgeon  that  we  had  information  that  he  did  not 
have.    She  lost  a  kidney  that  she  should  not  have  lost. 

Dr.  Albright  and  Dr.  Kennedy  have  given  us  balanced 
discussion.  I  do  not  have  many  cases  in  which  I  think 
the  kidney  needs  to  be  fixed  up.  Something  else  is  usually 
responsible.  In  lots  of  these  cases  the  kidney  had  best  be 
left  in.  Certainly  the  urologists  save  many  more  of  them 
than  they  used  to. 

I  wish  to  congratulate  Dr.  Highsmith  and  Dr.  Albright 
upon  their  reports  of  these  cases. 

Dr.  AiBRiOHT,  closing: 

I  have  nothing  much  further  to  add.  I  realize  that  we 
can  not  always  say  positively  which  kidneys  should  be 
fixed  in  position.  I  think,  as  has  been  mentioned,  freeing 
the  ureter  of  its  kinks  and  freeing  the  ureter  of  its  adhe- 
sions and  looking  out  for  aberrant  blood  vessels  may  be 
the  most  important  thing.  It  may  be,  in  some  of  these 
cases,  that,  since  we  do  both,  the  operation  on  the  ureter 
is  what  gives  the  results  and  that  raising  the  kidney  to  a 
higher  position  is  nonessential.  I  just  do  not  know.  It  is 
a  matter  that  is  rather  hard  to  determine. 

We  do  not  go  out  of  our  way  to  look  for  these  movable 
kidneys.  It  is  a  mistake  to  keep  them  in  mind  too  much 
because  there  are  a  great  many  that  are  not  causing  any 
symptoms  and  the  patient  will  be  happier  in  the  long  run, 
as  well  as  the  doctor,  if  these  are  left  alone  and  nothing 
said  about  them. 


Nephrolithiasas  and  Bone  Disease 
(I.  R.   Sisk,  Madison,  in  Wise.   Med.  Jl.,  March) 

The  frequency  of  development  of  renal  calculi  in  patients 
suffering  with  severe  bone  injury  and  bone  disease  suggests 
a  relationship  between  these  conditions.  In  the.  literature 
are  numerous  references  to  this. 

We  recently  observed  in  the  Wisconsin  General  Hospital 
-S  patients  with  renal  calculi  which  developed  following 
severe  bone  injury.  Four  of  these  patients  in  the  hospital 
at  the  same  time  aroused  our  interest  in  the  subject. 

There  is  considerable  evidence  to  suggest  that  these  phos- 
phatic  stones  occurring  with  bone  disease  or  bone  injury 
are  likewise  caused,  at  least  in  part,  by  the  excessive  ex- 
cretion in  great  concentration  of  calcium  and  other  salts 
which  results  from  general  or  local  decalcification  of  the 
bones  with  elimination  of  the  salts  through  the  kidneys. 
That  the  disuse  of  the  skeletal  s\stem  occasioned  by  re- 
cumbency and  immobility  for  a  long  period  of  time  leads 
to  general  declarification  is  generally  acccepted  by  ortho- 
pedic surgeons. 

What  can  be  done  to  prevent  the  formation  of  renal 
calculi  in  patients  recumbent  or  immobilized  for  long  pe- 
riods of  time  or  with  destructive  bone  lesions?  Present 
knowledge  suggests: 

1.  The  greatest  movement  of  the  body  consistent  with 
appropriate  treatment  to  limit  decalcification. 

2.  An  acid-base  diet  and  ammonium  chloride  to  facili- 
tate the  elimination  of  calcium  salts  through  the  kidneys 
and  increase  the  solubility  of  these  salts  by  maintaining  a 
highly  acid  urine.  These  measures  may  also  prevent  certain 
infections  from  becoming  firmly  established  in  the  kidneys. 

3.  A  high  fluid  intake  to  dilute  the  urine. 

4.  Appropriate  treatment  for  renal  infections  when  pres- 
ent. 


-\   Survey  of  Urinary  Frequency  in  Women 
(J.   B.  Wear,  Madison,   in  Wise.   Med.   Jl.,  March) 

The  records  of  100  women  examined  by  the  urological 
department  for  urinary  frequency  were  investigated.  The 
obvious  cases  of  severe  pyelonephritis,  tuberculosis,  tumor, 
etc.,  were  not  included.  The  diagnoses  were:  pyelitis  of 
one  or  both  sides — 19 ;  early  tuberculosis — 1 ;  pelvic  stone — 
3 ;  ureteral  stricture — 5 ;  ptosis — 3.  In  18  of  these  61  cases 
the  bladder  was  normal  to  inspection. 

In  17  cases  the  trouble  was  found  to  lie  below  the 
bladder.  The  diagnoses  in  this  group  were:  urethral  stric- 
ture— 9;  urethritis — 5;  urethral  caruncle — 3.  In  6  of  these 
cases  the  bladder  was  normal  to  inspection. 

In  S  cases  the  bladder  was  the  primary-  seat  of  involve- 
ment. The  diagnoses  in  this  group  were:  trigonitis — 3; 
cystitis  with  cystocele — 1 ;  papilloma — 1 ;  stone — 1 ;  and 
bladder  irritability  due  to  applications  of  radium  to  the 
cervix — 2. 

In  11  cases  the  pathology  was  found  outside  the  urinary 
tract.  The  diagnoses  in  this  group  were:  uterine  fibroid — 
4 ;  pelvic  inflammation — 3  ;  cord  tumor — 1 ;  spina  bifida — 
2;  lack  of  training — 1. 

In  3  cases  we  could  find  no  cause  for  the  frequency. 

Failure  to  find  the  cause  is  due  to  lack  of  investigation 
in  most  cases. 


Promptness  in  County  Society  Meetings 
(Edi.   in   Jl.   Med.   Soc.   of  N.   J.,  March)  « 

A  memorial  volume  was  published  by  the  Orange  Moun- 
tain Medical  Society  in  1900,  in  honor  of  Dr.  WiUiam 
Pierson,  of  the  4th  generation  of  physicians,  and  President 
of  the  Medical  Society  of  New  Jersey,  as  were  his  father 
and  his  grandfather  before  him;  and  in  it  on  page  S  is 
the  record:  ''His  energy  and  promptness  were  illustrated 
by  his  gavel  calling  the  meetings  to  order  at  exactly  8 
o'clock,  and  by  their  adjournment  at  10  p.  m.  to  the 
minute." 

If  adherence  to  schedule  was  valuable  in  Dr.  Pierson's 
day,  it  has  a  still  greater  significance  in  these  times  o^ 
rapid  transit,  mental  as  well  as  physical. 

Promptness  in  conducting  a  meeting  of  a  county  medical 
society  is  a  virtue  which  condones  many  sins  of  omission 
and  commission.  An  announcement  on  a  program  is  a 
contract  which  officers  are  bound  to  carry  out  unless  they 
are  excused  by  the  members  who  come  together  in  response 
to  the  notice  of  the  meeting. 

Busy  doctors  apportion  their  time  by  schedule,  and  allot 
a  certain  amount  of  time  to  a  society  meeting.  They  ex- 
pect the  meeting  will  open  on  time  and  its  business  will 
be  transacted  so  early  that  they  may  listen  to  the  speaker 
of  the  evening  with  no  distracting  thoughts  of  engagement 
missed  through  needless  delays  in  the  meeting. 

The  guest  speaker  appreciates  the  value  of  an  early  hour 
for  his  address,  and  of  the  responsiveness  of  an  attentive 
audience  that  has  plenty  of  time  to  listen  to  him. 

Closing  a  meeting  on  time  is  equally  important  as  its 
prompt  opening.  Individual  members  can  control  the  clos- 
ing time  for  themselves,  for  they  can  walk  out  and  go  to 
the  grill  or  home. 

\  presiding  officer  need  have  no  fear  of  criticism  for 
his  promptness  in  opening  and  closing  a  meeting.  On  the 
oUier  hand,  his  promptness,  being  a  characteristic  with  a 
universal  appeal,  will  win  him  praise  in  greater  degree 
than  that  resulting  from  e.xpert  work  done  behind  the 
scenes. 


Chamouni,  the  celebrated  "Russian  Salamander,"  per- 
formed repeatedly  the  feat  of  entering  an  oven  with  a 
raw  leg  of  mutton  and  remaining  in  the  oven  until  the 
meat  was  well  baked. — Goidd  &  Pyle. 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Abnormal  Growth  From  the  Coccygeal  Region  of  a  Baby* 

W.  p.  TiMJMERMAN,  M.D.,  Batcsburg,  South  Carolina 


WHEN  we  speak  of  tumors  we  usually 
think  of  any  morbid  growth  from  some 
part  of  the  human  anatomy  which  is 
not  caused  by  inflammation  and  which  usually  is 
of  little  consequence  other  than  its  appearance. 

However,  there  are  very  many  varieties  and 
some  are  not  only  disfiguring  but  interfere  very 
materially  with  the  proper  functions  and  even  pro- 
duce fatality. 

The  one  which  I  shall  show  you  is  so  unusual 
that  I  desire  to  present  it. 

It  is  my  opinion  that  if  it  had  not  been  removed 
it  would  have  prevented  the  proper  activities  of  the 
child  and  probably  would  have  caused  its  death. 

Rare   Specimen 

Sunday,  the  Sth  of  January,  1936,  about  two  o'clock 
in  the  afternoon,  I  was  asked  by  a  Negro  man,  who  ap- 
parently had  imbibed  a  bit  too  freely,  to  visit  his  wife,  a 
few  miles  away,  who  had  given  birth  to  a  dead  baby  and 
who,  he  said,  was  ver\-  ill  and  suffering  greatly. 

Upon  my  arrival  at  the  house  where  the  woman  was, 
I  found  her  in  good  condition.  She  was  attended  by  a 
woman  and  her  surroundings  clean.  She  had  two  other 
living  healthy  children.  The  baby  was  alive  and  upon 
examination  I  found  it  to  be  a  girl  with  apparently  normal 
head,  face,  body  and  hmbs,  but  upon  removal  of  the 
diaper,  I  found  a  large  tumor  of  the  caudal  region  extend- 
ing from  just  posterior  to  the  anus  and  upward  with  a 
circumference  of  fifteen  inches.  Most  of  this  tumor  was 
covered  with  skin  which  seemed  taut,  but  a  space  of 
three  by  four  inches  was  covered  by  only  a  thin  membrane. 
Some  of  the  tumor  appeared  to  be  congested  blood  and 
ver\-  dark  and  some  blood  escaped  slowly,  continuously. 
There  appeared  to  be  turgid  blood  vessels  under  the  skin 
and  the  diagnosis  of  variegated  hematoma  was  made.  A 
circular  incision  was  made  through  the  skin  near  the 
junction  of  the  membranous  covering  and  the  mass  was 
dissected  and  removed  with  but  little  loss  of  blood.  The 
child,  you  will  recall,  was  only  a  few  hours  old.  It  be- 
came very  weak  but  rallied.  We  wrapped  it  in  hot  wet 
towels  and  refreshed  them  as  needed. 

I  wish  to  give  due  credit  to  Dr.  Keisler,  the  anesthetist, 
and  Dr.  Ballinger  who  so  ably  assisted  me.  Chloroform 
was  the  anesthetic  used.  Most  of  the  local  doctors  saw 
this  patient  and  can  tell  you  their  diagnoses  and  prog- 
noses. 

I  herewith  present  the  tumor  for  your  consideration. 

Specimens  of  the  tumor  were  sent  to  Dr.  K.  M.  Lynch, 
of  Charleston,  for  examination.     His  report  is: 

Received  three  masses  of  soft  white  tissue.  On  section 
they  contain  numerous  small  cyst-like  areas  which  are 
filled  with  clear  mucinous  material.     One  of  them  is  ex- 

'Presented  to  the  Tri-State  Medical  Associati 
lina,  February  17th  and  18th, 


tcnsivcly  infiltrated  with  blood.  It  appears  to  be  even 
partially  encapsulated.  The  tumor  has  a  varied  structure, 
containing  tissues  of  origin  from  all  the  primary  germinal 
layers.  Endometrium,  myometrium,  fallopian  tube,  ciliated 
epithelium,  cuboidal  epithelium,  stratified  epithelium,  sali- 
vary glands,  cartilage,  central  nervous  system  are  all  rep- 
resented. In  fact,  the  longer  one  looks  the  more  tissues  one 
can  identify.     Benign, 

Discussion 

Dr,  W,  W.  King,  Batesburg,  S,  C: 

I  wish  first  to  congratulate  Dr,  Timmerman  upon  his 
splendid  handling  of  this  case  and  his  excellent  results.  It 
was  my  good  fortune  to  be  present  at  this  operation  and 
to  have  seen  this  baby  several  times  since.  As  Dr,  Tim- 
merman  has  pointed  out,  the  sections  of  the  tumor  pre- 
sented the  characteristics  of  teratoma.  He  has  not  gone 
into  very  much  detail,  so  I  shall  mention  a  few  generalities. 
-As  you  know,  a  teratoma  is  a  tumor  composed  of  various 
tissues  and  organs  found  at  a  site  in  the  body  where  they 
do  not_  belong.  The  highest  type  of  teratoma,  of  course,  is 
fetus  in  fetu.  There  are  simpler  types,  however,  which 
make  up  the  general  group.  To  this  general  group  belong 
various  fetal  abnormalities,  such  as  double  monsters.  There 
are,  I  might  say,  two  types,  the  internal  and  the  external. 
In  the  external  group  we  may  have  fusion  of  two  embryos, 
one  of  which  has  reached  maturity  and  the  other  is  de- 
pendent upon  the  mature  embryo  for  its  livelihood.  The 
other,  to  which  I  think  this  belongs,  is  an  irregular  mass, 
usually  appearing  on  the  posterior  surface  of  the  chest, 
abdomen,  or  sacrum,  and  is  composed  of  quite  a  variety 
of  structures.  Of  course,  it  does  not  have  the  orderly  de- 
velopment, as  in  embry^os,  but  is  simply  a  mass  of  tissues. 
In  time  tumors,  malignant  or  benign,  may  develop  from 
teratoma. 

I  understand  later  some  pictures  will  be  shown,  develop- 
ing this  point.  I  wish  to  commend  Dr.  Timmerman  for 
his  prompt  handling  of  this  case. 

Dr.  E.  P,  Mallette,  Hendersonville: 

My  apology  to  the  society  for  coming  in  on  a  case  like 
this  is  that  I  saw  this  subject  on  the  program,  and  having 
some  pictures  of  a  case  having  some  features  in  common 
with  this  case,  I  thought  you  might  be  interested, 

I  will  just  say,  in  introduction,  that  I  was  walking  down 
the  street  and  saw  a  colored  boy  with  a  very  peculiar  back, 
I  said  to  him:  "What  is  the  matter  with  you,  my  boy?" 
He  said:  "I  have^a  tumor,"  So  I  took  him  to  my  office 
and  took  these  pictures  of  him.  That  was  sixteen  years 
ago, 

(Dr,  Mallette  then  showed  a  series  of  photographs,) 
Dr,  Tmoierman,  closing: 

I  have  nothing  to  say,  except  to  thank  the  gentlemen 
for  their  interesting  comments. 

I  might  say  that  since  then  I  have  seen  a  similar  tumor 
in  the  lumbar  region. 

of  the  Carolinas  and   Virginia,    meelinff  at   Coluniljia,    South  Caro- 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


Evaluation  of  Various  Treatments   for  Narcotic   Drug 
Addictions 

W.  C.  AsHWORTH,  M.D.,  Greensboro,  North  Carolina 


MANAGEMENT  of  morphine  habitues  in 
my  hands  is  based  on  an  experience  of 
more  than  a  thousand  cases,  and  added 
experience  more  and  more  convinces  me  that  every 
case  is  a  problem  unto  itself,  requiring  due  consid- 
eration to  personal  equation,  temperament  and 
idiosyncrasies.  We  cannot,  therefore,  adhere  to 
any  inflexible,  standardized  method  of  treatment 
with  any  more  degree  of  satisfaction  than  we  can 
have  a  standardized,  inflexible  method  of  treatment 
for  any  of  the  more  common  ailments.  We  cannot 
prescribe  for  our  narcotic  drug  patients  with  any 
degree  of  success  with  stock  prescriptions.  The 
treatment  should  be  individual,  and  outlined  in 
accordance  with  the  findings  of  a  careful  and  pains- 
taking examination. 

In  the  twenty-five  years  I  have  spent  in  this 
special  work  many  "treatments"  have  been  her- 
alded and  broadcast  as  "specifics"  for  the  morphine 
habit.  I  have  lived  a  sufficient  length  of  time  to 
observe  that  practically  all  of  these  "specifics" 
have  been  discarded,  which  is  conclusive  proof 
that  there  is  no  specific  cure  for  narcotic  drug  dis- 
ease. I  say  disease  advisedly,  since  every  chronic 
morphine  user  is  sick  physically,  nervously  and 
mentally,  notwithstanding  the  fact  that  we  cannot 
locate  any  definite  pathology.  One  of  the  first  so- 
called  specifics  to  be  exploited  was  known  as  Lipoi- 
dal  Substance,  put  out  by  a  chemist  named  Horo- 
witz. Lipoidal  Substance  was  soon  followed  by  a 
product  known  as  Narcosan,  also  discovered  and 
advertised  by  Mr.  Horowitz.  My  attention  has 
also  been  called  to  Rossium,  which  is  designated 
as  new  therapy  for  alcoholism  and  narcotic  addic- 
tion. Rossium  is  being  very  energetically  detailed 
and  advertised  to  the  medical  profession,  but  up 
to  the  present  time  I  have  not  known  of  any  case  of 
alcoholism  or  drug  addiction  responding  to  Ros- 
sium in  a  very  spectacular  manner.  It  is  unfor- 
tunate, if  the  drug  really  has  merit,  that  it  is  rec- 
ommended only  after  the  morphine  has  been  dis- 
continued, for  the  patient  needs  most  help  while 
abandoning  the  narcotic  drug.  I  have  recently  en- 
countered almost  insurmountable  trouble  when 
Dilaudid  patients  are  deprived  of  this  narcotic 
drug.  I  usually  find  it  necessary,  in  fact,  to  sup- 
plant the  Dilaudid  with  morphine  before  commenc- 
ing treatment  for  the  Dilaudid  habit. 

It  was  my  privilege  some  years  ago  to  be  in  a 
German  clinic  when  "twilight  sleep"  (Damersch- 
laf)  was  inaugurated,  or  first  used    in    childbirth. 


The  sleep  produced  by  scopolamine  and  morphine 
seemed  then  to  be  restful  and  almost  absolutely 
devoid  of  cyanosis  or  other  alarming  symptoms 
either  to  the  mother  or  the  new-born  child.  I  was 
so  much  impressed  with  the  action  of  scopolamine 
and  morphine  in  obstetric  cases  that  upon  my  re- 
turn home,  I  was  imbued  with  the  thought  that  if  a 
mother  could  have  painless  childbirth  under  the 
action  of  these  drugs,  it  would  be  an  invaluable 
treatment  for  the  relief  of  the  much-dreaded  symp- 
tom following  in  the  wake  of  the  withdrawal  of 
narcotic  drugs.  I  soon  discovered,  however,  that 
the  morphine  patient  is  not  analogous  to  the  pros- 
pective mother  whom  Nature  has  prepared  in  many 
ways,  especially  as  to  the  heart,  for  the  ordeal  of 
childbirth. 

It  is  useless  to  say  that  I  discontinued  the  scopo- 
lamine treatment  for  my  morphine  habitues,  since 
my  mortality  rate  increased,  and  I  was  almost  a 
nervous  wreck  myself  during  the  administration 
of  the  scopolamine  treatment,  since  a  large  per- 
centage of  my  patients  were  in  extremis,  as  evi- 
denced by  marked  cyanosis  and  all  the  symptoms 
of  heart  depression  as  a  direct  result  of  the  admin- 
istration of  the  scopolamine. 

Some  years  ago  I  had  a  very  dear  friend,  Dr. 
Petty,  of  Memphis,  who  was  a  very  strong  advo- 
cate of  the  scopolamine  treatment  for  narcotic  drug 
patients.  Dr.  Petty  wrote  very  voluminously  on 
the  subject,  but  some  years  before  his  untimely 
death  by  a  street-car  accident,  he  discontinued 
scopolamine  in  the  treatment  of  his  narcotic  pa- 
tients, because  his  mortality  was  steadily  increas- 
ing. 

The  safest  and  most  satisfactory  method  of  treat- 
ment is  the  tentative  Gradual  Reduction  method, 
coincident  with  the  administration  of  such  recon- 
structive nerve  tonics  and  substitutes  as  will  best 
enable  the  patient  to  abandon  the  narcotic  drug 
with  only  a  negligible  amount  of  discomfort.  I 
prescribe  pilocarpine  muriate,  1/20  grain,  and  es- 
erin  sulphate,  l/200th  grain,  three  to  four  times 
daily  for  the  relief  of  the  withdrawal  symptoms. 
Some  years  ago  this  prescription  of  eserin  and  pilo- 
carpine was  considered  almost  a  specific  for  mor- 
phinism; we  know  now  that  it  is  not  a  specific 
but  that  it  does  afford  much  relief.  I  have  also 
ascertained  that  gelseminine,  l/2Sth  grain,  is  of  in- 
estimable benefit  during  the  withdrawal  of  the 
narcotic  drug.  I  desire,  also,  to  call  the  attention 
of  the  profession  to  the  hypnotic  and  sedative  ef- 


April,  1936 


TREATMENTS  FOR  DRUG  ADDICTIONS— Ashworth 


201 


feet  of  apomorphine,  l,/20th  grain,  in  the  treat- 
ment of  narcotic  drug  patients,  for  I  am  fully 
mindful  of  the  fact  that  most  of  us  only  think  of 
apomorphine  as  an  emetic,  rather  than  as  a  sedative 
and  hypnotic  drug. 

Reconstruction  and  rehabilitation  must  be  given 
an  important  place  in  the  treatment.  The  average 
drug  patient  is  very  depleted,  therefore  the  treat- 
ment must  be  formulated  with  the  idea  in  mind  of 
supporting  the  vital  processes  in  every  way  possi- 
ble, rather  than  administering  depressing  drugs, 
especially  scopolamine  and  allied  heart  depressants. 

I  sometimes  administer  a  modified  Lambert  treat- 
ment with  a  reasonable  amount  of  satisfaction  pro- 
vided the  treatment  is  sufficiently  modified  to  make 
it  humane.  We  are  all  cognizant  of  the  fact  that 
belladonna  and  hyoscamine  have  diametrically  the 
opposite  effect  of  narcotic  drugs.  The  Lambert 
treatment,  however,  is  not  in  any  sense  a  specific, 
but  with  a  number  of  cases  is  of  decided  benefit  to 
the  patient.  I  desire  again  to  emphasize  and  re- 
emphasize  that  there  can  not  possibly  be  any 
general  formulated  prescription  for  narcotic 
patients,  but  on  the  other  hand,  as  stated  at 
the  onset  of  this  article,  every  case  is  a  defi- 
nite problem,  and  therefore  we  cannot  depend 
upon  any  treatment  which  is  not  outlined  in  ac- 
cordance with  the  needs  of  the  individual  patient 
as  revealed  by  a  painstaking  history  and  examina- 
tion. I  entertain  the  belief  that  some  time,  and 
I  hope  in  the  near  future,  some  serum  will  be  found 
which  will  antagonize  the  antibodies  of  morphine. 
Tolerance,  as  you  well  know,  is  established  by  the 
presence  of  antibodies,  which  Nature  develops  to 
counteract  the  morphine.  I  have  frequently  treat- 
ed patients  who  were  using  from  25  to  40  grains 
of  morphine  daily,  which  enormous  and  almost 
unbelievable  dosage  cannot  be  accounted  for,  ex- 
cept by  the  presence  of  the  antibodies  in  the  sys- 
tem of  the  patient.  The  withdrawal  symptoms  I 
think  are  due  to  the  fact  that,  when  the  morphine 
is  withdrawn,  these  antibodies  are  released  and 
become  disseminated  over  the  entire  system;  it  has 
been  ascertained  that  they  are  especially  irritating 
to  the  delicate  nerve  endings,  therefore  the  common 
and  very  painful  neuritis,  especially  of  the  extrem- 
ities. 

I  wish  to  emphasize  that  certain,  we  might  say, 
pathognomonic  symptoms,  which  so  far  we  have 
been  able  only  to  alleviate,  follow  as  the  day  follows 
the  night,  during  the  period  of  the  withdrawal  of 
the  narcotic  drug.  Individualization  is  the  sine 
qua  non  in  the  treatment  of  narcotic  drug  cases. 


UNDESIR.-iBLE     EFFECTS     FrOJI     THE     PROLONGED    USE     OF 

Various  Barbitur.vtes 
(C.   V^.  stone,  Cleveland,   in  Ohio   State    Med.  Jl.,  March) 

Barbituric  acid  derivatives  have  been  used  largely  for 
their  sedative  or  hypnotic  effects.  Among  those  so  em- 
ployed are  allonal,  amytal,  barbital  (veronal),  dial,  ipral, 
neonal,  pentobarbital  (nembutal),  phenobarbital  (luminal) 
and  phanodorn.  This  group  of  drugs  has  established  a 
useful  and  important  place  in  medicine. 

In  general  the  sodium  salts  are  more  active. 

Many  toxic  manifestations  have  been  seen,  some  with 
little  relation  to  the  size  of  the  dose,  but  usually  the  un- 
desired  symptoms  arose  as  a  result  of  long-continued  or 
of  heavy  dosage. 

The  systemic  toxic  manifestations  include  an  early  fall 
in  body  temperature  with  at  times  a  subsequent  rise  above 
normal.  There  is  a  general  vasodilation.  Respiration  is 
slow  and  shallow;  there  is  interference  with  the  respiratory 
reflex  and  a  tendency  to  pulmonary  edema  and  broncho- 
pneumonia or  death  by  respiratory  failure.  The  urine 
output  is  diminished  but  psp.  elimination  usually  is  not 
impaired.  Anorexia,  nausea,  epigastric  pain  and  diarrhea 
are  not  uncommon  toxic  symptoms. 

There  may  be  urticarial  wheals  or  scarlatiniform  or 
morbilliform  types  with  subsequent  desquamation.  Nys- 
tagmus is  quite  frequent.  Diplopia,  pupils  dilated — but 
in  severe  intoxication  they  may  be  contracted  and  immobile 
to  light,  or  show  inequality  and  irregularity.  Bulbar 
symptoms,  with  difficulty  in  swallowing,  loss  of  the  cough 
reflex,  and  disturbance  of  speech,  are  common.  The  speech 
may  be  merely  drawling  and  thick  or  be  wholly  unintelligi- 
ble.' 

As  a  rule  muscle  tone  is  diminished,  but  with  severe 
intoxication  there  is  increased  tonus.  Deep  reflexes  are 
diminished  or  absent,  and  the  superficial  reflexes  including 
the  corneal,  may  be  similarly  affected.  Tremors  are  fre- 
quently seen.    The  station  and  gait  are  unsteady. 

With  increasing  lethargy  and  mental  hebetude  the  sphinc- 
ters are  uncontrolled.  The  psychologic  effect  of  small  doses 
of  the  barbiturates  is  a  feeling  of  well-being  or  even  of 
exhilaration. 

In  the  treatment  of  the  toxic  symptoms  the  essential 
features  are  the  withdrawal  of  all  sedatives  and  hypnotics, 
supportive  stimulation  for  an  imminent  collapse  by  the 
use  of  strychnine  and  caffein,  and  adequate,  intelligent 
nursing  care. 

Barbiturics  should  be  employed  with  caution  in  obese 
and  debilitated  patients,  patients  with  arteriosclerosis,  myo- 
cardial disease  or  hypertension,  and  in  those  with  a  very 
low  blood  pressure,  with  respiratory  disease. 


The  terrible  manifestations  of  syphilis  recorded  by 
the  early  writers  probably  were  due  to  the  enormous  doses 
of  mcrcuiy  that  were  given. 


The  Blood  Cyanates  in  the  Treatment  of  Hypertension 
(M.  H.  Barker,  Chicago,  in  Jl.  A.  M.  A.,  March  7th) 
Forty-five  patients  with  hypertension  have  been  given 
sodium  or  potassium  thiocycanate  and  the  concentration 
of  the  cyanates  in  their  blood  has  been  followed.  The 
reduction  of  blood  pressure  and  the  relief  of  symptoms 
obtained  in  35  of  the  45  roughly  correspond  to  the  level 
of  the  cyanates  in  the  blood.  The  optimum  therapeutic 
level  would  seem  to  range  between  8  and  12  mg.  per  100 
c.c,  and  significant  toxicity  begins  to  appear  at  from  IS 
to  30  mg.  The  individual  tolerance  varies  greatly,  the 
different  levels  being  obtained  with  widely  varying  doses. 
The  cyanates  may  reach  hazardous  concentrations  very 
quickly  in  some  individuals,  so  that  the  administration  of 
the  thiocyanates  is  believed  to  be  dangerous  unless  con- 
trolled by  close  observation  and  blood  cyanate  determina- 
tions. 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


Hypertension — Cardiac   Hypertrophy — Nephrosclerosis* 

F.  Eugene  Zemp,  M.D.,  Columbia,  South  Carolina 


THIS  condition  begins  with  hyperpiesia  or 
essential  hypertension  and  should  not  be 
confused  with  the  hypertension  that  occurs 
in  glomerulotubular  nephritis,  in  tubuloglomerular 
nephritis,  or  with  the  kidney  of  tubular  nephritis 
or  nephrosis  or  of  passive  congestion. 

Physiology 
The  vasomotor  center  in  the  medulla  regulates 
the  tonus  of  the  vascular  musculature  by  impulses 
through  the  sympathetic  nerves  (vasomotor  fibres) 
to  the  vessels.  A  normal  blood  pressure  is  produced 
which  is  regulated  chiefly  by  contraction  and  re- 
laxation of  the  precapillary  arterioles  which  are 
quite  labile.  The  vasomotor  center  may  be  influ- 
enced by  direct  stimulation,  actual  or  through  the 
blood,  or  by  impulses  from  the  peripheral  nerves. 
The  latter  are  influenced  by  internal  or  external 
stimuli.  Severing  the  sympathetic  nerves  causes  re- 
laxation of  the  arterioles,  a  stimulation  causes  con- 
traction. 

Primary  Causes 
1)  Heredity. — O'Hare,  Walker  and  Vickers 
found  a  history  of  cardiovascular  disease  twice  as 
frequently  among  relatives  of  patients  with  hyper- 
tension as  among  relatives  of  controls.  The  studies 
of  our  own  Dr.  William  Allan  suggest  the  possi- 
bility that  hypertensive  cardiovascular  disease  may 
prove  to  be  a  dominant  unit  trait  and  one  is  not  yet 
justified  in  saying  that  it  is  wholly  or  partly  hered- 
itary. Ayman  studied  1,524  members  of  272  fam- 
ilies and  found  an  elevated  blood  pressure  in  45.5% 
of  the  children,  both  of  whose  parents  had  arterio- 
lar hypertension,  in  28.3%  of  those  with  one  parent 
so  diseased,  and  in  only  3.1%  of  those  with  both 
parents  normal.  F.  M.  Allen  speaks  of  the  inher- 
ited vulnerability  of  certain  individuals  to  this 
disease;  Elwyn  of  inherited  characteristics  of  the 
tissues  of  the  arterial  wall  and  of  the  vasomotor 
system  of  the  kidneys  and  their  reaction  to  ex- 
ternal stimuli.  Brown  attaches  importance  to  :  1) 
Hypersensitive  ancestry  causing  a  hyperreactabil- 
ity  of  the  vasomotor  system  to  various  internal 
and  external  stimuli.  A  central  abnormality  as  a 
hypertensitive  vasomotor  center  in  the  diencepha- 
lon  or  an  abnormal  peripheral  mechanism.  2) 
Embryological  malformation  of  the  cardiovascular 
system.  3)  Childhood  diseases,  scarlet  fever  in 
particular.  The  rash  is  a  capillary  phenomenon 
and  undoubtedly  some  damage  is  done  to  the  ca- 
pillaries by  the  action  of  the  bacteria  and  their 


toxins.  Acute  tonsillitis  and  measles  are  next  in 
importance.  4)  Foci  of  infection,  as:  abscessed 
teeth,  chronically  diseased  tonsils,  sinusitis,  otitis 
media,  prostatic  and  colon  infections,  etc.  The 
streptococcus  group  of  organisms  probably  do  more 
damage  to  the  vascular  system  than  any  of  the 
others.  S)  Syphilis  is  mentioned  because  of  its 
damage  to  the  vascular  system  but  plays  very  little 
part  in  hypertension.  6)  Endocrine  disturbances: 
Hypersupraadrenalism  with  its  specific  action  on 
the  vasomotor  system  plays  a  considerable  part. 
The  pituitary  gland  with  its  adrenalotropic  action 
is  now  being  studied  as  well  as  a  possible  renal 
hormone.  Sparks  recently  ruled  out  hyperactiva- 
tion  of  the  neurohypophysis  by  basophilic  cells  as 
a  cause.  Ovarian  dysfunction  at  the  menopause, 
tumors  of  the  adrenals  and  thyrotoxicosis  occasion- 
ally cause  an  increase  in  blood  pressure  but  are  not 
to  be  considered  as  causes.  7)  Disturbances  of 
the  sympathetic  nervous  system  by  intrinsic  fac- 
tors as  the  glands  of  internal  secretion,  especially 
the  adrenals;  and  extrinsic  factors,  as  various 
external  stimuli  (cold,  excitement,  worry,  work, 
tobacco,  etc.)  8)  Damage  by  certain  drugs  and 
chemicals  as  arsenic,  mercury,  etc.  9)  The  action 
of  a  pressor  substance  in  the  blood  stream.  Recent 
investigation  by  Walker  and  Bruner  is  against  this 
possibility. 

There  are  many  who  believe  that  this  condition 
arises  primarily  in  the  vascular  system  and  under 
this  heading  we  have:  1)  Arteriola-sclerosis  with 
obstruction  to  the  blood  flow  to  the  muscles  and 
viscera.  2)  Sclerosis  and  loss  of  elasticity  of  the 
aorta  and  great  vessels.  3)  Sclerosis  and  narrowing 
of  the  renal  arterioles.  4)  Spasm  of  the  smaller 
arteries  due  to  substances  in  the  blood  stream  as 
guanidine,  salt,  etc.  5)  Relative  overloading  of 
the  systemic  circulation.  6)  Increased  viscosity 
of  the  blood.  7)  Narrowing  of  the  arteries.  8) 
Swelling  of  the  capillary  endothelium  blocking  the 
lumen.  9)  Anatomical  changes  in  the  walls  of  the 
arteries  as  proliferation  of  the  endothelium.  10) 
Pressure  on  the  capillaries  from  surrounding  struc- 
tures as  in  edema.  11)  Sclerosis  and  narrowing  of 
the  arteries  supplying  the  pons  cerebri. 

Secondasy  Factors 

1)  Age — usually  in  middle  and  later  life:     67% 

in  6th  and   7th  decade,   17%   above   70,   16%   in 

Sth  decade,  4%  in  4th  decade,  1%  in  3rd  decade, 

^%  under  30.    2)  Sex — about  equal.    3)  Race — 

Carolinas   and   Virginia,    meeting  at   Coluniljia,    South   Caro- 


April,  1936 


CARDIAC  HYPERTROPHY— Zemp 


uncommon  in  Chinese,  Africans  and  other  tropicaJ 
peoples.  4)  Diet  and  obesity — overeating  espe- 
cially of  meats  and  salt.  5)  Individual  character- 
istics— temperamental,  high  strung,  emotional  and 
nervous.  6)  Occupation — professions  which  call 
for  undue  mental  and  physical  strain. 

It  seems  to  me  then  that  the  causes  may  be 
summed  up  as  two: 

1)  Inherited  characteristics  of  the  general  arte- 
rial system  and  the  autonomic  nervous  system  and 
their  response  to  intrinsic  and  extrinsic  factors. 

2)  Damage  to  the  capillary  bed  by  various 
bacteria,  especially  the  streptococci,  and  their  tox- 
ins. 

First  Stage — Benign — Presclerotic  or  Spastic. — 
Often  the  slight — 150  to  180  systolic — and  per- 
haps transitory  elevation  of  blood  pressure  is  dis- 
covered accidentally.  Frequently  there  is  palpita- 
tion, slight  dyspnea  on  exertion,  tinnitus,  vertigo, 
fullness  in  the  head,  nervousness  or  irritability. 
If  the  elevation  is  of  short  duration  there  is  no  en- 
largement of  the  heart  but  if  it  has  lasted  for  sev- 
eral years  there  is  some  hypertrophy.  There  are  no 
recognizable  changes  in  the  eye-grounds  or  kid- 
neys. 

The  cold  pressor  test  of  Brown  is  of  much  value 
in  this  stage  and  even  earlier  and  will  show  from 
three  to  ten  times  the  normal  reaction.  This  stage 
may  last  for  years  depending  largely  on  the  tempo 
of  the  disease  and  the  individual  response.  The 
other  stages  usually  progress  more  rapidly  but  also 
vary  with  the  tempo  and  the  response.  There  is  a 
blending  of  one  stage  into  the  next  but  each  is 
identified  by  special  findings. 

Second  Stage — Benign  —  Sclerotic.  —  Many  are 
the  symptoms:  dyspnea — the  most  frequent,  usually 
after  exertion  and  later  on  as  cardiac  asthma — 
palpitation,  tachycardia,  pain  or  more  of  a  sub- 
sternal tension,  headaches,  throbbing  or  fullness 
in  the  head,  visual  disturbance,  vertigo,  tinnitus, 
insomnia,  nervousness,  aphasia  (transient),  inter- 
mittent claudication,  monoplegia,  hemiplegia  (often 
transient)  and  angina  (spastic). 

There  is  a  slight  to  moderate  general  arterio- 
sclerosis with  moderate  hypertension — 180/90  to 
230/120.  The  heart  shows  moderate  hypertrophy 
especially  of  the  left  ventricle  forming  an  aortic 
configurated,  or  hypertensive  heart.  The  whole 
thoracic  aorta  is  slightly  dilated.  Reserve  power 
is  somewhat  diminished.  The  eye-grounds  usually 
show  some  arteriosclerosis  and  occasionally  early 
choroid-retinal  changes  or  angiospasm.  The  star- 
shaped  radiating  white  lines  of  degeneration  around 
the  macula  are  never  seen  in  this  stage.  Special 
tests  will  show  early  kidney  involvement,  benign 
nephrosclerotic  kidney.  The  urine  will  show  an 
increase  in   the  night   portion.     Albumin   may  be 


absent  or  present  as  a  faint  trace.  The  same  is 
true  of  casts.  The  IS-min  intravenous  psp.  test 
— the' most  accurate,  normal  2S,% — will  show  some 
impairment.  The  Van  Slyke  urea-clearance  test 
(normal  75  to  125%)  and  the  Lashmet-Newburgh 
concentration  test  (normal  1029)  will  both  show 
slight  to  moderate  impairment.  The  Volhard  wa- 
ter test  will  show  some  delay  in  the  excretion  time 
and  some  lessening  of  the  diluting  and  concentrat- 
ing powers  of  the  kidney.  Kidneys  unable  to  con- 
centrate above  a  specific  gravity  of  1020  we  can 
assume  are  becoming  involved;  if  unable  to 
concentrate  above  1015,  seriously  involved.  The 
blood  nitrogen  is  normal.  Teleroentgenogram  and 
orthodiagram  of  the  heart  will  show  moderate  in- 
crease in  its  diameters,  especially  of  the  left  ven- 
tricle and  of  the  aorta,  producing  an  aortic-con- 
figurated heart. 

The  electrocardiogram  usually  shows  a  left-axis 
deviation  and  sometimes  extrasystoles,  tachycardia 
and  evidence  of  myocardial  and  coronary  artery 
disease. 

Among  the  complications  are  monoplegia,  hemi- 
plegia, hemorrhages,  myocardial  decompensation, 
coronary  narrowing  and  angina  (spastic). 

Third  Stage — Malignant — Sclerotic  with  Renal 
Insttfficiency. — Dyspnea  is  marked  and  may  be- 
come orthopnea,  or  of  the  Cheyne-Stokes  or  the 
asthmatic  type.  Pain  may  vary  from  substernal 
tension  to  actual  pain  or  a  precordial  ache;  some- 
times anginoid — thoracic  or  abdominal.  Palpita- 
tion, vertigo  and  tinnitus  are  frequent  symptoms. 
Headaches  are  often  severe  and  throbbing.  There 
also  may  be  intermittent  claudication,  aphasia, 
insomnia,  disturbances  in  vision,  speech  and  mem- 
ory, and  mental,  nervous  and  gastrointestinal  symp- 
toms. 

General  arteriosclerosis  is  now  moderate  to  se- 
vere as  evidenced  by  the  changes  in  the  eye- 
grounds  and  palpable  arteries.  At  times  the  scler- 
osis shows  special  selection  for  the  arteries  of  the 
brain,  the  heart,  the  kidneys,  or  the  extremities. 
The  hypertension  is  moderate  to  severe — 220/120 
to  300/180.  It  often  becomes  a  fixed  pressure. 
There  is  marked  cardiac  hypertrophy  and  dilata- 
tion especially  of  the  left  ventricle  forming  an 
aortic  configurated  heart  of  a  greater  degree,  some- 
times a  mitralized-aortic  heart.  The  arch  of  the 
aorta  or  the  whole  thoracic  aorta  may  be  markedly 
dilated.  There  is  frequently  a  systolic  murmur 
at  the  apex  and  base  and  a  faint  diastolic  murmur 
at  the  base,  with  marked  accentuation  of  the  second 
aortic  sound.  Recently  I  observed  an  Austin  Flint 
and  Graham-Steel  murmur  in  a  young  man  28 
years  of  age  with  this  condition.  The  pulse  may 
have  a  gallop  rhythm,  pulsus  alternans  or  other 
irregularities.     Pulsation  in  the  neck  is  frequently 


CARDIAC  HYPERTROPHY— Zemp 


April,  1Q36 


seen  due  to  pushing  up  of  the  innominate  artery  or 
carotid  by  the  dilatation  of  the  aorta  and  left 
ventricle  and  auricle.  Hemorrhages  are  common 
from  the  nose,  stomach  or  rectum.  The  eye-grounds 
will  reveal  tortuosity  and  sclerosis  of  the  arteries, 
fullness  of  the  veins,  degenerative  changes  in  the 
retina  and  often  the  starshaped  radiating  lines 
around  the  macula,  hemorrhages,  edema  or  even 
choking  of  the  discs.  The  kidney  condition  has 
now  become  a  malignant  nephrosclerosis.  The  cells 
are  unable  to  secrete  because  the  vessels  are  unable 
to  supply  them.  Occasionally  we  find  a  mixed  type 
of  kidney  involvement.  The  urine  will  show  a 
faint  to  moderate  amount  of  albumin,  granular  and 
hyaline  casts  and  occasionally  red  blood  cells.  The 
psp.  test  will  show  marked  impairment — from  40% 
to  0  and  from  10%  to  0  by  the  IS-min.  method. 
The  Van  Slyke  urea-clearance  test  is  too  danger- 
ous to  do  as  it  will  only  be  about  10  to  25%.  The 
Lashmet-Newburgh  concentration  test  will  be  1015 
or  less.  The  Volhard  water  test  will  indicate  an 
advanced  involvement  of  the  kidneys  with  a  flexi- 
bility of  nine  points  or  less  and  marked  delay  in 
excretion.  If  the  kidneys  can  not  excrete  urine  of  sp. 
gr.  above  1010  they  are  severely  damaged.  Azote- 
mia is  usually  present  though  not  always  so.  The 
urea  nitrogen  of  the  blood  will  range  from  40  to  300 
mg.  per  100  c.c.  Creatinine  and  uric  acid  will 
show  a  proportionate  increase.  Teleroentgenogram 
and  orthodiagram  will  show  a  marked  increase  in 
the  diameters  of  the  heart  especially  of  the  left 
venticle  and  aorta,  forming  an  advanced  aortic- 
configurated  heart.  The  hilus  vessels  will  be  prom- 
inent and  if  decompensation  is  present  the  lungs, 
liver  and  other  organs  will  show  signs  of  passive 
congestion  or  free  fluid  in  the  pleural  cavity.  The 
electrocardiogram  will  show  a  left-axis  deviation  or 
evidence  of  chronic  myodegeneration,  arborization 
or  branch-bundle  block,  auriculo-ventricular  block, 
tachycardia,  auricular  flutter,  extrasystoles,  auricu- 
lar fibrillation,  coronary  artery  disease  or  occlu- 
sion. 

The  most  common  complication  is  cardiac  de- 
compensation; then  hemiplegia,  angina  or  coronary 
occlusion  and  uremia.  Hemorrhages,  gangrene  of 
extremities,  rupture  of  the  heart  and  terminial 
pneumonia  also  occur. 

Treatment 
1 )  Prophylactic  —  demands  recognition  and 
management  in  the  controllable  phases.  2)  Psych- 
ologic— profier  advice  and  handling  of  the  patient 
when  first  seen  which  varies  in  each  case.  3)  Rest 
and  relaxation — with  the  different  stages  from  one 
to  three  hours  a  day  to  complete  rest.  Avoidance 
of  mental  and  physical  strain  with  regulation  of 
hours  of  work,  exercise,  diversion,  vacations.  The 
patient  should  be  taught  how  to  relax  mind  and 


body.  4)  Diet — if  overweight  reduction  is  usually 
advisable.  Five  small  meals  may  be  preferable. 
The  food  should  be  chiefly  carbohydrate  and  fat, 
limiting  the  proteins  and  salt.  In  severe  cases 
proteins  are  governed  by  the  blood  nitrogen  and 
salt  is  usually  moderately  restricted.  Absolute  salt 
proscription  in  severe  cases  has  proven  beneficial 
in  some  cases.  S )  Water  should  be  taken  in  normal 
amounts,  coffee  and  other  caffein  products,  alco- 
holic beverages  and  smoking  are  best  avoided.  6) 
Care  of  the  bowels  by  proper  regulation  and  use 
of  saline  cathartics  as  indicated.  7)  Drugs  that 
have  been  most  helpful  are  the  sedatives,  pheno- 
barbital-sodium  and  calcium  bromide  in  particular, 
the  iodides,  nitrites,  theobrominine  and  theophyl- 
line groups.  Potassium  thiocyanate  is  of  some 
value  but  too  toxic  for  practical  purposes.  Bis- 
muth subnitrate  has  been  disappointing.  In  cer- 
tain complications  strophanthin,  digitalis,  caffein, 
coramine,  quinidine,  and  morphine  are  of  immense 
value.  8)  Deep  therapy  over  the  adrenals  and 
other  areas  have  been  disappointing. 

Surgical  Tre.atment  * 

Realizing  the  gravity  of  this  condition  the  sur- 
geon has  come  to  the  aid  of  the  medical  man.  Dur- 
ing the  past  four  years  considerable  progress  has 
been  made  which  involves  operations  chiefly  on  the 
sympathetic  nervous  system  and  the  adrenals.  The 
most  promising  results  have  been  obtained  by 
Brown,  Craig  and  Adson,  and  Peet.  Brown,  Craig 
and  Adson  advise  a  bilateral  resection  of  the  an- 
terior motor  roots  from  the  6th  thoracic  to  the 
2nd  lumbar  inclusive.  This  removes  all  the  sym- 
pathetic fibres  from  the  vessels  below  the  dia- 
phragm— more  than  75%  of  the  total  vascular  bed. 
Adson  has  been  able  to  produce  the  same  results 
recently  by  sectioning  the  splanchnic  nerves  and 
removing  the  first  and  second  lumbar  ganglia  with 
intervening  trunks.  He  has  also  combined  this 
operation  with  a  resection  of  half  of  the  adrenal 
glands.  Patients  selected  should  be  under  40  years 
of  age  with  hypertension  of  short  duration,  ade- 
quate kidney  function,  a  large  spastic  element  and 
a  serious  prognosis.  They  report  that  the  mean 
drop  in  the  systolic  pressure  has  been  44  mm.  of 
mercury,  in  the  diastolic  38  mm.  The  patients  are 
promptly  relieved  of  the  violent  headaches  and  car- 
diac discomfort  on  exertion.  Page  and  Heuer  also 
report  similar  results.  Peet  resects  the  greater  and 
lesser  splanchnics  and  the  dorsal  sympathetic  chain 
from  the  tenth  to  the  twelfth.  He  obtained  im- 
provement in  85%,  varying  from  relief  of  symp- 
toms to  complete  cures,  with  only  10%  not  bene- 
fited. DeCourcy  does  a  subtotal  adrenalectomy 
with  remarkable  benefit  to  the  general  condition 
and  reduction  of  the  systolic  and  diastolic  pres- 
sures.    In  some  cases  all  the  symptoms  were  re- 


April,  1936 


CARDIAC  HYPERTROPHY— Zemp 


205 


lieved.  Crile  denervates  the  adrenal  glands  in  early 
hypertension,  especially  in  young  people  or  when 
associated  with  hyperthyroidism,  which  seems  to 
correct  the  process  even  if  the  blood  pressure  is 
not  permanently  lowered.  The  latter  two  proce- 
dures are  not  without  danger  as  recently  reported 
by  Rogoff,  and  are  still  in  the  experimental  stage. 
They  should  not  be  attempted  until  results  are 
more  convincing  and  dangers  lessened.  Total  abla- 
tion of  the  thyroid  for  the  failing  heart  and  angina 
is  still  a  very  debatable  procedure. 

Bibliography 

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2.  Adson,  .Alfred  VV.:  Indications  for  Operations  on  the 
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7.  .\yman,  D.:  Heredity  in  Arteriolar  (Essential)  Hy- 
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26.  De  Courcy,  Joseph  L.,  De  Courcy,  Carroll,  and 
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27.  Editorial:  In  Defense  of  the  Adrenals.  J.  A.  M.  A., 
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29.  Freyberg,  R.  H.:  The  Choice  and  Interpretation  of 
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30.  Granger,  Arthur  Stanley:  The  Present  Conception 
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31.  HiNES,  Edgar  A.,  jr.:  Some  Recent  Concepts  Con- 
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32.  Ketterer,  Clarence  H.:  Essential  Hypertension. 
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33.  Lashmet,  F.  H.,  and  Neweurgh,  L.  H.:  An  Im- 
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35.  Page,  Irvine  H.,  and  Heuer,  George  J.:  A  Surgical 
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206 


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April,   1936 


in   Essential  Hypertension.     Arc.  Int.  Med.,  Vol.  52: 
57-65,  July,  1933. 

42.  White,  Marx  S.:  The  Status  of  Essential  Hyperten- 
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Discnssion 

Dr.  Malcolm  Mosteller,  Columbia: 

The  criticism  has  frequently  been  made  that  our  practice 
of  medicine  is  becoming  too  mechanical.  If  we  should 
allow  the  machines  to  make  the  sole  diagnosis  and  not 
just  co-operate  with  our  clinical  examination  and  findings, 
then  this  criticism  would  be  justified.  It  has  been  my  ex- 
perience that  the  average  physician  is  a  better  diagnosti- 
cian, both  at  the  bedside  and  in  his  office,  if  he  knows  that 
later  he  is  going  to  be  checked  up  by  the  laboratory  find- 
ings. Roentgenology  has  certainly  improved  our  diagnostic 
ability.  The  electric  cardiograph  has  increased  our  knowl- 
edge of  the  cardiac  muscle.  It  is  true  that  some  physicians 
in  our  midst  would  not  be  able  to  make  a  diagnosis  if  it 
were  not  for  the  laljoratory  findings,  but  the  average 
physician  is  much  better  able  to  make  the  diagnosis,  and 
the  student  of  medicine  always  uses  the  laboratory  to 
confirm  his  bedside  conclusions.  It  is  with  this  thought 
in  mind  that  I  present  some  of  the  more  common  findings 
in  Dr.  Zemp's  paper. 

Here  are  two  x-ray  films,  presenting  the  more  common 
findings  in  the  heart.  First  is  shown  the  marked  enlarge- 
ment of  the  heart,  especially  to  the  left,  and  the  transverse 
diameter  of  the  heart  is  considerably  larger  than  it  should 
be.  In  addition,  there  is  a  mild  passive  pulmonary  con- 
gestion. This  is  a  more  common  finding  in  the  series  of 
passive  cases  which  Dr.  Zemp  has  described  to  us.  In  the 
second  case  is  shown  marked  enlargement  of  the  heart, 
with  passive  pulmonary  congestion,  but  the  enlargement  of 
the  heart  is  to  the  right  as  well  as  to  the  left. 

Dr.  a.  Iz.«d  Josey,  Columbia: 

I  appreciate  very  much  being  here  today  and  having  an 
opportunity  to  say  a  few  words  about  this  paper.  Dr. 
Zemp  has  presented  to  us  an  important  condition  that 
afflicts  a  great  number  of  people,  probably  an  increasing 
number.  The  etiological  factors  in  hypertension  remain  as 
much  as  mystery  today  as  they  were  when  the  blood- 
pressure  apparatus  was  first  devised  and  people  began  rec- 
ognizing the  condition  and  assigning  high  blood  pressure 
as  a  cause  of  so  many  of  our  ills.  As  I  understand  it,  the 
primary  type  is  much  more  common.  Among  the  second- 
ary causes  of  hypertension,  the  first  thing  that  comes  to 
mind,  of  course,  is  glomerular  nephritis  following  focal 
infections  or  following  scarlet  fever.  The  hypertension 
seen  accompanying  thyroid  hyperfunction  and  adrenal  tu- 
mors may  also  be  classed  among  the  members  of  the  second 
group. 

As  for  primary  hypertension,  it  seems  to  be  very  difficult 
to  determine  the  different  factors  as  to  their  cause  and 
effect;  that  is,  to  determine  the  difference  between  the 
effects  of  hypertension  and  the  cause  of  hypertension.  In 
all  probability  we  are  prone  to  consider  the  kidney  and 
the  kidney  lesion  entirely  too  much  as  a  cause  of  hyper- 
tension. I  think  pathologists  have  led  us  into  the  fault 
of   assigning   the   effects   of   hypertension   as   the  cause  of 


hypertension.  We  have  all  sat  around  at  the  autopsy  of 
some  man  dying  of  hypertension  with  the  pathologist 
showing  no  interest  at  all  in  the  enlarged  heart.  He  gets 
down  to  the  kidneys,  slices  them  open,  and  says:  "There, 
gentlemen,  is  the  cause."  To  my  mind  those  are  the  effects 
of  hypertension. 

There  is  a  current  idea,  also,  that  hypertension  is  a 
compensative  phenomenon  depending  upon  lowered  kidney 
function  or  dysfunction. 

We  have  coronary  occlusion  and  recovery  and  maintain 
a  much  lower  pressure  over  a  period  of  months  or  even 
years  without  showing  evidence  of  renal  insufficiency.  It 
appears  to  me  that  the  fields  of  investigation  as  to  the  etiol- 
ogical factors  of  hypertension  should  be  developed  further 
by  the  physiologist  rather  than  by  the  pathologist.  I  think 
we  shall  learn  more  if  we  get  them  more  interested  in  it. 
Certainly  during  the  last  several  years  the  neurovascular 
surgeon  has  taught  us  considerable  about  hypertension, 
and  his  experiments  have  pointed  to  etiological  factors 
away  from  the  kidney.  I  do  not  consider  that  extensive 
surgical  procedures  will  be  the  ultimate  relief  in  hyperten- 
sion, but  certainly,  as  experimental  operations,  they  are 
going  to  teach  us  a  great  deal.  With  our  minds  focused 
on  the  kidneys  as  the  etiological  factor,  our  therapy  is 
focused  in  that  direction.  Quite  frequently  Dr.  Zemp  and 
I  will  meet  in  the  halls  of  the  hospital  and  discuss  whether 
a  patient  with  a  pressure  of  200  or  210  should  have  salt 
herring  for  breakfast.  That,  of  course,  depends  upon  the, 
amount  of  secondary  damage  that  has  occurred  to  the 
kidney. 

The  "secondary  results  of  hypertension  seem  to  me  to 
depend  upon  the  ability  of  the  vascular  system  to  with- 
stand the  punishment  which  hypertension  gives  it.  As  to 
arteriosclerosis,  we  become  more  and  more  skeptical  year 
after  year  as  to  its  being  an  etiological  factor.  It  is  a 
degenerative  disease  which  may  be  accompanied  by  a  mod- 
erate 0  reven  a  low  pressure. 

This  is  an  extremely  interesting  subject ;  it  has  been  and 
will  be  for  years  to  come,  in  all  probability.  It  is  far 
from  any  solution  at  all,  and  it  is  a  subject  to  which  we 
should  devote  a  considerable  amount  of  thought.  The 
treatment  in  the  past  has  been  far  from  adequate  and  we 
should  follow  the  newer  lines  of  thought,  as  developed  by 
these  experimental  surgeons  from  the  pathological  and  the 
physiological  standpoint. 

Again  I  wish  to  say  I  enjoyed  the  paper  very  much. 

Dr.  J.  Bolling  Jones,  Petersburg: 

I  did  not  come  to  this  meeting  with  any  thought  at  all 
of  discussing  this  paper.  However,  I  am  struck  by  the 
paper  itself  in  one  way  and  a  remark  made  by  a  gentle- 
man in  the  discussion  in  another  way.  After  years  of  work 
I  have  about  come  to  the  conclusion  that,  from  an  arterial 
standpoint,  how  long  we  live  is  practically  determined  be- 
fore we  are  bom.  In  other  words,  I  am  convinced  that 
heredity  plays  by  far  the  most  important  part  in  the 
development  of  hypertension.  The  gentleman  who  led  the 
discussion  made  the  remark  that  the  physician  who  relies 
upon  the  history  and  the  physical  examination,  as  against 
the  laboratory  findings,  is  a  better  diagnostician  than  the 
man  who  relies  on  the  laboratory  findings  as  against  the 
other  two.  We  all  have  a  tendency  to  rely  too  much  on 
laboratory  findings  in  making  a  diagnosis.  The  history  - 
and  physical  findings  are  vastly  more  important.  For 
instance,  take  the  electrocardiogram,  which  is  purely  and 
simply  a  laboratory  technical  product.  I  should  like  to 
know  how  many  men  in  this  audience  could  at  all  inter- 
pret the  pictures  that  are  presented  to  us  as  the  electrocar- 
diographic readings.    They  are  all  Dutch  to  me. 

If  you  will  pardon  a  personal  mention,  some  six  years 


April,  1936 


CARDIAC  HYPERTROPHY— Zemp 


207 


ago  I  was  feeling  bad  in  a  general  way,  with  some  dis- 
tress in  my  chest ;  and  just  at  that  time  a  fellow  physician 
was  taken  violently  ill  with  a  distinct  coronary  occlusion. 
This  led  me  to  take  him  to  a  distinguished  diagnostician. 
In  carrying  him  over  there  and  using  the  electrocardiograph 
on  him,  I  sunggested  to  the  technician  that  she  make  a 
reading  on  me.  In  a  few  days  the  report  came  back  that 
the  doctor  patient's  cardiogram  was  perfect  and  that  mine 
was  about  all  wrong.  This,  of  course,  caused  more  alarm 
on  the  part  of  my  wife  than  it  did  on  my  part;  neverthe- 
less, it  occasioned  the  summoning  of  a  son  from  far-away 
Boston  for  a  conference  and  a  consultation  of  other 
diagnosticians  to  dear  up  the  matter.  On  further  study  it 
was  definitely  determined  that  I  had  a  perfect  reading  and 
that  the  other  fellow  was  going  to  die.  So,  gentlemen,  we 
should  take  into  consideration  the  history  and  the  physical 
findings  as  well  as  the  laboratory  studies  in  coming  to  a 
correct  diagnosis. 

Dr.  William  Allan,  Charlotte: 

Dr.  Zemp  has  given  us  a  thorough  review  of  the  most 
frequent  and  most  perplexing  problem  that  we  have  to 
deal  with  in  medicine.  The  first  thing  that  comes  into  our 
heads  is,  where  did  this  thing  come  from?  Of  course,  like 
evcrj'thins  else,  it  is  either  acquired  or  inherited.  So  far, 
I  do  not  believe  anyone  has  shown  that  the  air  we  breathe 
or  the  liquor  we  drink  or  the  food  we  eat  has  anything  to 
do  with  the  hypertensive,  cardiovascular  problem.  Also, 
no  one  has  shown  that  it  is  inherited — simply,  I  think,  be- 
cause not  enough  work  has  been  done  on  it.  Nobody  in 
the  world,  I  think,  has  a  better  change  to  work  out  this 
problem  than  we  have  here  in  the  rural,  rather  non-migra- 
tory population  such  as  we  have  in  the  Carolinas  and  Vir- 
ginia. So  that  problem,  I  think,  should  be  worked  out 
here  rather  than  in  the  big  cities. 

Dr.  E.  J.  G.  Beardsley,  Philadelphia: 

A  time  comes  in  a  man's  life  when  he  is  very  much 
more  interested  in  the  progress  of  his  students  than  in  his 
own  progress.  I  was  fortunate  enough  to  have  Dr.  Zcmp 
as  a  pupil.  I  am  not  so  sure  that  he  was  fortunate  to 
have  me  as  a  teacher.  We  taught  him  as  much  as  we 
knew,  but  not  as  much  as  he  knows. 

There  is  one  point  in  the  paper  that  I  hoped  Dr.  Zemp 
was  going  to  enlarge  on.  From  the  psychological  stand- 
point, I  wish  that  the  blood-pressure  apparatus  had  never 
been  discovered.  Of  the  evil  that  it  does  in  our  daily  lives 
I  do  not  think  we  can  judge,  but  that  we  do  harm  in  an 
effort  to  go  good  there  is  no  doubt  whatever.  I  am  for- 
tunate enough  to  see  a  great  many  sick  doctors,  and  I 
think  from  the  sick  doctors  one  can  learn  a  great  deal 
about  the  psychology  of  lay  patients,  because  they  are  no 
longer  doctors  when  they  become  ill;  they  are  just  plain 
sick  individuals,  and  they  come  with  a  sense  of  fear  that 
is  far  more  potent  for  ill  than  is  the  pathology  which  they 
present.  So  I  should  like  to  point  out  to  the  young  mem- 
bers of  this  Tri-State  Association  (not  to  the  older  mem- 
bers, who  know  it  as  well  as  I  know  it  myself,  if  not  bet- 
ter) that  to  tell  a  patient  he  has  a  hypertension  is  never 
going  to  do  him  any  good  whatever  and  is  invariably  go- 
ing to  do  him  harm  if  he  has  a  mind.  One  sees  it  every 
day  in  one's  consulting  room.  They  will  come  in  and  tell 
you  just  how  many  fractions  of  a  per  cent,  of  hypertension 
they  have,  and  they  go  to  sleep  with  it  in  their  minds 
and  wake  with  it  in  their  minds.  My  own  view,  and  I 
am  sure  the  view  of  every  man  here,  is  that  we  are  to  be 
of  use  to  our  patients.  How  are  we  to  be  of  the  best  use 
to  our  patients?  By  eliminating  fear  as  best  we  may. 
Dr.  Zemp's  paper  shows  how  little  we  know  of  the  real 
underlying  cause.     I  am  of  the  opinion  with   Dr.  Boiling 


Jones,  that  heredity  is  90  per  cent,  of  the  problem.  If  I 
might  live  that  long — and  I  have  every  intention  of  doing 
so— I  should  like  to  hear  a  paper  from  Dr.  Zemp  30  years 
from  now.  That  paper  of  30  years  from  now  will  be  an 
entirely  different  paper  from  this  of  today.  It  must  be  so, 
if  life  teaches  us  anything.  He  is  interested  now  in  the 
mechanics;  30  years  from  now  he  will  be  less  interested 
in  the  mechanics  and  more  interested  in  the  patient's  men- 
tal reactions.  I  am  inclined  to  discourage  the  use  of  the 
blood-pressure  apparatus  except  for  the  doctor's  mental 
growth.  It  has  done  much  to  increase  the  growth  of  fear. 
You  can  have  your  blood  pressure  taken  in  the  big  cities 
in  the  10-cent  stores;  they  have  an  attendant  there  to  do 
it  without  charge.  The  evil  it  has  done  is  incalculable. 
So  I  am  going  to  beg  my  pupil.  Dr.  Zemp,  not  to  tell  his 
patients  their  blood  pressure,  and  I  am  going  to  tell  him 
that  the  patient  who  assumes  the  air  of  having  no  fear  is 
the  one  that  has  the  greatest  fear  in  his  heart. 

Dr.  Marion  H.  Wyman,  Columbia: 

I  worked  out  a  family  for  Dr.  Heyward  Gibbes  about 
ten  years  ago,  when  he  was  working  on  the  subject  of 
heredity  and  hypertension.  This  family  consisted  of  the 
father  and  mother,  five  girls  and  two  boys.  Two  girls 
were  first,  then  a  boy,  then  three  girls  came,  and  the  other 
boy  was  the  youngest  in  the  family.  At  that  time  the 
youngest  boy  was  22  and  the  oldest  girl  was  approaching 
40.  The  mother  and  father  had  moderate  hypertension; 
their  readings  were  less  than  200,  somewhere  from  160  to 
180.  It  was  not  alarming.  Every  member  of  the  family 
had  hypertension,  even  to  the  youngest  boy.  I  kept  de- 
tailed records  of  that  family.  The  youngest  boy  was  a 
veteran,  and  we  had  wonderful  records  of  him.  He  finally 
died  of  renal  insufficiency.  The  oldest  daughter  had  a 
reading  of  over  300 — higher  than  our  machine  would  re- 
cord. Dr.  Gibbes'  studies  proved  conclusively  that  the 
whole  family  had  hypertension. 

Dr.  Zemp,  closing: 

I  suppose  one  reason  why  I  have  been  so  interested  in 
this  subject  is  because  practically  every  member  of  my 
family  on  my  father's  side — my  aunts  and  uncles — all  have 
this.  I  am  sure  that  when  we  say  it  is  hereditary  we 
almost  have  the  cause  completely  right  there. 

I  wish  to  thank  these  gentlemen  for  their  very  kind  dis- 
cussion and  Dr.  Beardsley  for  his  very  good  advice. 


M.\TCHiiS  A  Cause  of  Astiema 
(Jos.  Biederman,  Cincinnati,  in  Ohio  State  Med.  Jl.,  Mar.) 

This  patient  had  an  asthmatic  seizure  from  inhaling  the 
fumes  of  the  safety  match  (red  phosphorous)  and  also 
from  the  fumes  of  the  household  match  (sesquisulphide  of 
phosphorous).  ' 

Another  patient  having  an  asthmatic  seizure  upon  in- 
haling the  fumes  of  matches  was  found  to  be  sensitive  to 
the  red  phosphorous,  the  chlorate  of  potash  and  the  sequi- 
sulphide  of  phosphorous.  This  patient  upon  avoiding, 
among  other  things,  the  fumes  of  matches  has  also  been 
entirely  free  from  asthma.  I  have  been  surprised  at  the 
frequency  of  the  match  as  a  cause  of  asthma  after  once  I 
began  to  watch  out  for  it. 

The  common  match  is  demonstrated  to  be  a  cause  of 
asthma.  Since  matches  are  in  such  common  usage  it  is 
wise  to  think  of  these  substances  as  possible  offenders 
when  treating  asthmatic  patients.  The  difference  between 
the  successful  and  unsuccessful  treatment  of  a  patient  may 
depend  on  whether  or  not  he  is  taught  how  to  light  a 
match. 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


More  About  Prostatic  Resection 

F.  A.  Ellis,  M.D.,  Salisbury,  North  Carolina 


0 


UOTING  Pedersen,  New  York,  in  March, 
1936,  Urologk  &  Cutaneous  Review. 


"Like  even'  other  progress  in  Medicine,  that  of  pros- 
tatic surgery  has  not  ceased.  Its  path  is  not  a  Roman 
highway,  straight,  broad,  and  smooth.  Quite  to  the  con- 
trary, it  is  a  rural  dirt  road  rough  with  uncertainties, 
narrow  with  errors  and  devious  with  byroads  to  various 
techniques." 

How  truly  is  this  applicable  to  the  progress  of 
surgery  in  general,  and  not  merely  to  prostatic 
surgery!  During  my  student  days,  the  late  Dr. 
John  B.  Deaver  would  discuss  gallbladder  drainage 
vs.  gallbladder  removal;  we  have  had  the  pros  and 
cons  of  perineal  prostatectomy  vs.  suprapubic  well 
drilled  into  us;  only  recently  I  read  a  reprint  on 
whether  the  stump  of  an  appendix  should  be  buried 
in  the  wall  of  the  cecum  or  not  buried  after  an 
appendectomy. 

The  answer  to  many  questions  in  surgery  is 
derived  by  taking  all  the  good  points  gained  in  the 
experience  of  others  and  reaching  some  definite 
deductions. 

Electrical  resection  of  the  prostate  has  clearly 
emerged  from  many  of  its  misunderstandings  and 
condemnations  and  is  capable  of  standing  on  its 
own  feet.  In  reality  it  is  a  "new  deal"  for  a  vast 
majority  of  prostatics. 

Lewis  and  Carroll,  in  "Prostatic  Resection  With- 
out the  Moonlight  and  the  Roses,"  January,  1933, 
Urologk  &  Cutaneous  Review,  lists  the  difficulties 
encountered  by  the  leading  urologists  of  the  United 
States  in  the  course  of  their  resection  work.  These 
difficulties  are  presented  more  in  the  nature  of 
criticisms  of  resection  and  it  is  well  to  briefly  ana- 
lyze a  few  of  them. 

Criticism  No.  1 — Failure  of  Relief  with  Repe- 
tition One  or  More  Times.  This  criticism  ceases 
toi4)e  a  criticism  in  the  hands  of  one  who  is  ex- 
perienced and  skillful  in  urological  instrumentation. 
Dr.  Theodore  Davis,  of  the  Crowell  Clinic  of  Char- 
lotte, 44  miles  distant,  the  hot-bed  of  electrical 
resection,  handles  prostatic  enlargement  of  one- 
plus  to  four-plus  with  comparatively  few  repeats. 
The  criticism  is  more  or  less  a  compliment  in  dis- 
guise to  resection.  It  shows  that  the  majority  of 
urologists  stand  for  conservatism.  One  can  always 
go  back  later  and  resect  more  tissue,  but  none  can 
be  replaced  if  too  much  has  been  over-enthusiasti- 
cally  removed.  The  repeat  subjects  the  patient 
to  comparatively  little  risk.  Knowing  what  I  have 
gathered  from  the  experiences  of  doing  prostatec- 


tomy and  later  resection,  I  would  choose  resection 
even  though  there  would  possibly  be  a  repeat. 

Criticism  No.  II — Excessive  Hemorrhage,  Pri- 
mary and  Secondary.  Hemorrhage  can  be  guarded 
against  by  careful  coagulation  after  each  cut.  One 
must  be  the  master  of  hemorrhage  at  all  times, 
controlling  it  in  a  careful  methodical  manner  even 
though  this  is  time-consuming.  If  the  patient  is 
properly  prepared  with  catheter  drainage,  allowing 
time  for  shrinkage  of  prostate,  the  chances  of  ex- 
cessive primary  hemorrhage  are  greatly  lessened. 
As  to  secondary  hemorrhage,  if  the  work  of  resec- 
tion has  been  done  in  a  skillful  manner,  as  in  other 
surgery  properly  done,  the  operator  simply  has  to 
put  his  trust  in  a  Higher  Power,  hoping  that  there 
will  be  no  secondary  bleeding.  If  this  occurs,  an 
attempt  can  be  made  to  evacuate  the  bladder  of 
clots  and  then,  through  an  operating  cystoscope, 
to  find  and  coagulate  the  bleeding  points. 

Criticism  No.  Ill — Infection,  Local  and  Sys- 
temic. Any  surgery  has  the  possibilities  of  infec- 
tion. The  vast  majority  of  prostatics  with  obstruc- 
tion are  already  infected  locally.  Careful  prelimi- 
nary treatment  with  catheter  drainage  and  heavy 
doses  of  urotropin  and  urinary  acidifiers  prior  to 
resection  and  continued  afterward  will  be  a  mate- 
rial aid. 

I  have  discussed  the  most  important  of  these 
difficulties  or  criticisms  that  are  directed  toward 
prostatic  resection.  There  are  innumerable  others; 
but  many  are  unjust,  and  most  of  them  are  more 
applicable  to  open  prostatectomy  than  to  resection. 
Then  again,  we  have  to  realize  that  resection  was 
attempted  by  any  number  of  men  with  varying 
qualifications  for  such  a  procedure.  This  is  a 
highly  technical  operation  and  can  only  be  safely 
entrusted  to  those  men  that  are  experienced  and 
skillful  in  cystoscopic  instrumentation. 

Resection  is  one  of  the  greatest  contributions 
in  the  progress  of  urological  surgery.  It  changes 
materially  the  whole  outlook  on  life  to  the  sufferers 
from  prostatic  hypertrophy.  It  promises  less  risk, 
less  postoperative  pain,  and  a  greatly  shortened 
hospitalization — the  latter  an  important  economic 
factor.  In  our  enthusiasm  let  us  not  lose  sight  of 
the  fact  that  most  prostatic  cases  are  well  advanced 
before  they  seek  relief.  In  fairness  to  resection, 
they  need  just  as  careful  study  and  preliminary 
treatment  as  they  do  for  prostatectomy.  Their 
nervous  systems  have  suffered  from  broken  rest; 
their  cardiovascular  systems  have  been  damaged; 
and  there  are  varying  degrees  of  impaired   func- 


April,  1936 


PROSTATIC  RESECTION— Ellis 


tioning  of  the  kidneys.  They  are  unstable  elderly 
individuals  and  always  an  atenipt  should  be  made 
to  get  them  in  a  more  stable  condition  before  any 
prostatic  surgery  is  attempted. 

With  only  one  exception — early  malignancy  of 
the  prostate — there  is  just  one  definite  indication 
for  prostatectomy  or  resection,  and  that  is  obstruc- 
tion of  urination  with  residual  urine.  If  there  is 
no  residual  urine,  then  prostatic  resection  is  not 
indicated  even  though  the  prostate  is  felt  to  be 
enlarged.  All  that  resection  offers  is  a  more  com- 
plete emptying  of  the  bladder.  I  mention  this  be- 
cause I  fear  that  there  are  resections  done  when 
there  is  no  indication,  just  as  there  are  needless 
removals  of  ovaries  and  appendices. 

Preliminary  treatment  is  best  carried  out  in  bed 
with  in-dwelling  catheter  rather  than  by  intermit- 
tent catheterization.  By  this  method  the  urethra 
and  bladder  are  rendered  tolerant  to  the  catheter. 
This  tolerance  is  very  important  because  an  in- 
dwelling catheter  is  imperatively  needed  postoper- 
atively. The  bladder  is  kept  completely  emptied, 
thereby  relieving  any  back  pressure  on  the  kid- 
neys. Frequent  lavage  of  bladder  can  be  easily 
and  frequently  done.  Forced  urinary  output  can 
be  carried  off  with  no  effort  on  the  part  of  the 
patient.  With  rest  in  bed  and  an  in-dwelling 
catheter  it  is  most  impressive  to  see  how  the  blood 
pressure  settles  down  to  stability,  edema  disap- 
pears, heart  action  becomes  slower  and  stronger, 
blood  chemistry  approaches  normal,  and  the  patient 
appears  brighter  with  greatly  improved  morale. 
Und;r  catheter  drainage  the  prostate  diminishes 
remarkably  in  size,  thus  materially  lessening  the 
amount  of  tissue  that  has  to  be  resected.  It  may 
take  only  a  few  days  to  accomplish  all  this,  or  it 
may  take  weeks.  Only  when  the  most  favorable 
condition  obtainable  for  that  particular  patient  is 
reached  should  resection  be  done. 

Low  spinal  anesthesia  is  the  anesthesia  of  choice. 
Properly  done  it  gives  a  perfect  block  of  pain. 
Its  effect  lasts  long  enough  to  complete  most  re- 
sections. However,  this  method  necessitates  the 
presence  of  an  assistant  to  watch  for  any  sudden 
drop  in  blood  pressure  and  be  prepared  to  combat 
it  w:th  a  loaded  hypodermic  of  ephedrine  or  adre- 
nalin. The  operator  also  has  to  be  ever  mindful 
of  tl.e  fact  that  spinal  anesthesia  renders  the  blad- 
der insensitive  to  over-distention  with  irrigation 
fluid. 

T!ie  operation  of  resection  requires  a  definite 
working  visual  knowledge  of  the  anatomy  of  the 
posterior  urethra  and  bladder  neck.  Great  care 
has  to  be  exercised  that  all  cutting  be  posterior 
to  the  verumontanum;  otherwise,  there  may  be 
injury  or  complete  destruction  of  the  sphincter 
muscle     leading     to     postoperative     incontinence. 


Bringing  away  enough  tissue  to  give  a  definite 
tunneling  effect  adequately  removes  the  obstruct- 
ing part  of  the  prostate.  Sometimes  the  median  lobe 
has  to  be  leveled  off,  while  at  times  part  of  both 
lateral  lobes  have  to  be  removed.  Any  small  intra- 
urethral  lobes,  if  overlooked,  will  defeat  the  func- 
tional results  of  resection.  After  all  resections 
there  is  a  definite  shrinkage  of  the  remaining  por- 
tion of  the  prostate.  This  is  probably  due  to  a 
release  of  tension  within  the  prostatic  capsule  and 
dehydration.  The  average  resection  with  excellent 
control  of  all  bleeding  points  can  be  accomplished 
within  an  hour. 

Postoperative  recovery  is  usually  swift  and  un- 
complicated. There  is  comparatively  little  shock. 
Nausea  is  a  rarity  and  the  patient  can  usually 
partake  of  a  full  regular  diet  almost  immediately. 
Postoperative  pain  is  insignificant  as  compared 
with  open  operations  on  the  prostate.  There  are  no 
dressings  or  urinary  leakage  to  contend  with.  The 
only  necessary  details  that  have  to  be  carried  out 
are  frequent  irrigations  through  the  in-dwelling 
catheter  to  prevent  its  blockage  by  blood  clot 
and  this  usually  is  necessary  only  for  the  first  48 
hours.  On  an  average  of  five  days  after  resection 
the  in-dwelling  catheter  can  be  removed  and  in 
90  per  cent,  of  cases  the  patient  can  void  freely 
with  no  difficulty. 

Conclusions 

1.  Prostatic  resection  is  a  "new  deal"  for  pros- 
tatics.  Its  limitations  are  governed  largely  by  the 
ability  and  skill  of  the  operator. 

2.  Morbidity  and  hospitalization  are  greatly 
shortened — an  important  economic  factor. 

3.  Mortality  is  practically  nil  in  the  hands  of 
those  capable  of  doing  resection. 

4.  The  operation  requires  the  same  careful  pre- 
liminary preparation  as  that  of  prostatectomy. 

5.  Patients  rightfully  demand  resection  in  pref- 
erence to  prostatectomy.  The  most  cons:rvative 
and  reluctant  clinic  toward  resection  in  the  East 
is  now  doing  resection  in  50  per  cent,  of  its  cases 
of  prostatic  obstruction. 

— Wallace  Building 


Is  Phenolphthalein  Harmful? 

(Prof.   Zoltan    v.    Vaniossy,   Ruda  Past,    in   Amer.   Jl.    Dig. 

Dis.   &    Nutri) 

I  introduced  this  la.\ative  in  1902  on  the  basis  of  animal 
experiments,  on  observations  on  myself  and  my  asociates 
and  also  on  its  clinical  trial  in  a  great  many  adults  and 
children.  I  made  the  statement  then,  and  I  still  believe 
so  today,  that  phenolphthalein  is  harmless. 

There  are  about  20  instances  cited  where  some  general 
disturbance  has  been  attributed  to  the  use  of  phenolph- 
thalein. I  consider  most  of  these  reports  as  not  definitely 
proven.  Assuming  that  the  reported  reactions  are  due  to 
phenolphthalein,  it  still  shows  that  considering  the  enor- 
mous number  of  doses  consumed,  such  reactions  are  so  few 
as  to  be  negligible. 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


Surgical   Observations 

A  Column  Conducted  by 

The  Staff  of  the  Davis  Hospital 
Statesville,  N.  C. 


Vaginitis  of  Infancy  and  Childhood 

A.  HiNSON,  M.D. 


The  vagina  at  birth  is  lined  by  a  modified  strati- 
fied squamous  epithelial  covering,  is  3  to  6  cells 
deep,  and  is  easily  injured  and  quite  susceptible 
to  invasion  by  many  types  of  organisms. 

At  puberty  the  so-called  female  sex  hormone  is 
elaborated  by  the  maturing  follicle  having  been 
activated  by  the  secretion  from  the  anterior  pitui- 
tary body.  The  action  of  this  hormone  is  wide- 
spread. Along  with  the  development  of  the  female 
sex  characteristics,  the  epithelial  cells  lining  the 
vaginal  canal  proliferate  rapidly  and  approach  the 
character  of  true  stratified  squamous  epithelium. 
The  desquamating  epithelial  cells  from  the  pre- 
pubertal canal  are  small,  rounded  with  granular 
cytoplasm  and  large  deeply-staining  nuclei  which 
make  up  a  greater  portion  of  the  cell  substance. 
The  cells  after  puberty  are  flattened  and  pale; 
many  have  no  nuclei,  and  the  nuclei  present  are 
pale  and  shrunken  and  stain  poorly. 

The  vagina  is  highly  susceptible  to  the  gonococ- 
cus  before  puberty;  after  puberty  the  thickened 
cornined  epithelium  presents  a  wellnigh  impassable 
barrier.  The  infecting  organism  then  turns  to 
greener  pastures  which  are  found  in  the  less  re- 
sistant accessory  structures,  the  nabothian,  Bartho- 
lin's and  Skene's  glands.  In  view  of  this  change 
and  the  fact  that  adolescent  vaginitis  often  sub- 
sides with  the  beginning  of  menstruation,  a  new 
approach  has  been  made  to  the  treatment  of  in- 
flammation of  the  infant  vagina. 

A  thorough  history  and  physical  examination  are 
necessary  for  the  diagnosis  of  the  type  of  inflam- 
matory process.  Only  too  often  we  are  able  to 
clear  up  the  origin  of  the  infection  by  a  careful 
examination  of  a  parent  or  nurse. 

It  is  usually  difficult  to  examine  these  children 
properly,  as  the  inflamed  vulva  are  quite  sensitive. 
Placed  on  the  back  with  assistants  holding  the  legs 
flexed  on  the  thighs,  the  examiner's  thumbs  placed 
just  behind  and  lateral  to  the  vaginal  orifice  with 
the  fingers  braced  against  the  outer  surface  of  the 
thighs,  strong  pressure  in  the  direction  of  the  table 
depresses  the  perineal  body  and  exposes  the  orifice 
of  the  hymen  allowing  the  introduction  of  a  small 
swab  for  smears,  hanging  drops  and  cultures.  The 
vulva  should  first  be  cleansed  with  a  mild  antisep- 
tic solution  such  as  boric  acid.  If  the  swab  is  taken 
from  the  vulva  the  contaminating  organisms  will 
often  make  an  accurate  diagnosis  impossible.    The 


search  for  the  proper  end-result  of  female  sex  hor- 
mone therapy  will  also  be  clouded  as  the  tjrpe  of 
cell  found  on  the  vulva  is  similar  to  that  of  an 
adult's  vaginal  smear. 

A  gram  stain  may  be  sufficient  evidence  for  the 
physician  but  the  legal  profession  seems  to  think 
the  organisms  should  be  cultured.  This  is  an  al- 
most impossible  task  at  times.  I  was  able  to 
culture  the  organisms  in  about  25  per  cent,  of 
the  cases  clinically  diagnosed  gonorrheal  vaginitis. 

A  hanging  drop  should  reveal  the  presence  of 
trichomonas  vaginalis.  In  the  presence  of  a  thick, 
frothy,  whitish  discharge  and  a  fier\'  red  mucous 
membrane  with  areas  of  punctate  hemorrhage,  a 
single  negative  examination  should  not  be  consid- 
ered as  final.  A  discharge  that  is  negative  one  day 
may  be  teeming  wth  organisms  24  hours  later. 
Douches  and  antiseptics  often  cause  a  temporary 
disappearance  of  the  trichomonas  from  the  dis- 
charge. 

The  treatment  of  trichomonas  vaginitis  in  chil- 
dren who  have  not  reached  puberty  is  difficult.  At 
times  the  condition  responds  rapidly  to  a  cleansing 
douche,  drying  and  the  application  of  an  arsenical 
such  as  stovarsol.  Often  one  such  treatment  suf- 
fices, but  the  recurrences  are  many.  In  chronic 
cases  the  bladder  and  urine  should  be  examined  as 
a  possible  source  of  the  reinfection.  Small  amounts 
of  stovarsol,  5  grains  to  SO  c.c,  instilled  into  the 
bladder  at  2-  to  3-day  intervals  will  usually  aid 
in  clearing  up  the  resistant  cases. 

To  judge  from  the  literature,  trichomonas  vagi- 
nitis may  be  cured  with  anything  from  a  yeast  cake 
to  cauterization  of  the  cervix.  The  efficacy  of 
either  is  yet  to  be  decided.  The  organisms  thrive 
in  a  vagina  with  a  pH  of  4  to  7,  yet  simple  alkaline 
douches  will  seldom  eradicate  the  organisms  from 
the  vagina  for  more  than  24  hours.  The  presence 
of  slender,  highly-motile  organisms  denotes  an 
acute  or  highly  resistant  infection.  The  sluggish, 
rounded  type,  difficult  at  times  to  distinguish  from 
pus  cells,  are  usually  susceptible  to  almost  any 
type  of  therapy. 

One  physician  effected  cures  with  injections  of 
female  sex  hormone.  Endocrine  therapy  is  often 
improperly  given  as  in  this  instance.  There  is 
small  cause  for  wonder  at  the  bad  name  it  has 
received  because  of  such  untimely  application. 

A  rare  type  of  infantile  vaginitis,  but  one  that 
is  usually  fairly  easy  to  diagnose,  is  that  caused 
by  the  diphtheria  bacillus.  The  yellow  necrotic 
membrane  and  presence  of  the  organism  should 
make  the  diagnosis  simple.  The  treatment  is  sim- 
ple hygienic  measures  and  diphtheria  antitoxin. 

The  physician  has  long  been  prone  to  label  any 
woman  with  a  discharge  as  having  gonorrhea.  The 
child  and  even  the  infant  has  not  been  immune  to 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


this  blanket  diagnosis.  Much  suffering  and  domes- 
tic unrest  has  resulted.  Only  recently  was  this 
demonstrated  by  the  case  of  a  little  girl  of  45^ 
years  with  a  bloody  discharge  since  the  age  of 
two.  The  frantic  parents  had  been  to  no  less  than 
five  physicians  and  had  received  five  different  kinds 
of  treatment.  Two  of  these  are  reported  to  have 
positively  stated  that  the  child  had  a  gonorrheal 
vaginitis.  .A  close  examination  revealed  a  metallic 
foreign  body  almost  completely  embedded  in  the 
anterior  vaginal  wall.  It  was  badly  corroded  but 
a  window  in  one  side  helped  identify  it  as  a  part 
of  a  lipstick  container.  The  removal  of  this  re- 
sulted in  a  prompt  subsidence  of  the  discharge. 

Through  an  endoscope  of  the  Kelly  tj'pe  even 
the  smallest  vagina  and  cervix  may  be  inspected. 
Water  dilatation  may  be  useful,  as  the  hymen  will 
usually  hug  the  outer  surface  close  enough  to  cause 
ballooning-out  of  the  folds  of  the  vaginal  mucosa. 
General  anesthesia  may  be  indicated  and  while  the 
knee-chest  posture  is  not  imperative,  it  is  an  aid 
if  the  child  is  old  enough  to  cooperate. 

Gonorrhea  in  the  female  child  has  long  been  a 
difficult  disease  to  treat.  With  the  advent  of  fe- 
male sex  hormone  therapy,  a  great  advance  has 
been  made.  Out  of  a  series  of  83  cases  complaining 
of  Icukorrhea  14  were  unmistakably  gonorrheal,  as 
proved  by  the  discharge  containing  gram-negative 
intracellular  diplococci.  Repeated  cultures  made 
routinely  in  all  of  these  cases  were  positive  in  only 
four  cases.  Even  these  cultures  were  not  always 
positive.  Smears  and  cultures  were  taken  three 
times  a  week  for  the  first  two  weeks  and  afterwards 
every  seven  days. 

The  preparation  used  in  the  treatment  of  these 
cases  was  .'\mniotin  Oral  (E.  R.  Squibb  &  Son), 
starting  with  75  to  100  rat  units — 2  to  3  times 
daily  in  orange,  grapefruit  or  tomato  juice.  Occa- 
sionally it  was  taken  on  a  piece  of  bread.  (Corn 
oil  solution.)  In  two  cases  gelatin  pessaries  were 
used  but  these  are  of  value  only  in  older  children, 
the  size  preventing  their  use  in  infants.  At  the 
middle  of  the  second  week  there  was  a  change  in 
the  type  of  cell  seen  in  the  smears.  There  was  a 
flattening  out  of  the  epithelial  cells  and  a  loss  of 
staii  ing  properties  of  the  nuclei.  The  pus  cells 
and  gonococci  gradually  disappeared  and  the  flat- 
tened cells  of  the  stratified  squamous  epithelium 
were  predominating.  The  change  was  complete  in 
every  case  in  15  to  16  days. 

In  two  cases  the  gonococci  were  present  for  three 
weeks  but  they  had  disappeared  in  most  at  the 
end  of  two.  Abrupt  cessation  of  all  medication  at 
this  time  often  precipitated  a  recurrence  within  2 
to  3  weeks.  It  was  then  found  to  be  much  better 
to  continue  the  medication  in  smaller  doses.  From 
75  to  100  rat  units  daily  by  mouth  was  found  to 


be  sufficient  to  main  the  adult  type  of  cell  in  the 
vaginal  secretion.  When  all  medication  was  stop- 
ped the  cells  did  not  revert  to  the  infantile  type 
for  2  to  4  weeks.  It  is  best  to  continue  the  medi- 
cation in  small  doses  for  2  to  3  months. 

Of  the  14  cases  treated  9  responded  beautifully 
in  10  to  14  days  without  recurrence.  The  sudden 
clearing-up  of  all  symptoms  was  something  new  in 
the  treatment  of  gonorrhea  in  children.  There 
were  no  local  medications  except  for  daily  cleansing 
of  the  external  genitals  with  boric-acid  solution. 
Thin  pads  with  a  little  boric-acid  powder  were  worn 
next  to  the  skin.  This  helped  to  prevent  excoria- 
tion. The  mothers  were  told  not  to  expect  ajiy 
result  for  2  to  3  weeks. 

In  three  of  the  cases  recovery  took  place  after 
three  weeks,  in  two  after  a  month-and-a-half.  In 
these  cases  the  practice  of  continuing  the  therapy 
for  several  months  had  not  been  instituted.  They 
did  clear  up  after  several  weeks  more  of  treatment, 
however. 

If  larger  doses  of  female  sex  hormone  are  given, 
there  will  be  a  generalized  desquamation  of  the 
vaginal  epithelium  causing  a  white,  caseous  dis- 
charge. This  is  often  the  cause  of  much  needless 
worry  on  the  part  of  the  mother  and  perhaps  the 
physician.  A  smear  will  demonstrate  the  cause 
and  a  smaller  dosage  eliminate  the  result. 

This  therapy  was  carried  out  on  10  cases  of  non- 
gonorrheal  vaginitis.  The  offending  organisms  were 
mixed  in  most  cases.  Micrococcus  catarrhalis,  sta- 
phylococcus aureus  and  streptococci  were  found 
oftener  than  any  other. 

In  three  cases  the  only  organisms  were  the  long 
gram-positive  rods  of  Doderlein.  These  are  rarely 
found  in  the  infantile  vagina.  Only  five  of  these 
responded  to  this  type  of  therapy,  but,  with  added 
topical  applications  of  mild  silver-nitrate  solutions 
through  the  endoscope,  the  results  were  very  good. 
Irrigations  with  mild  antiseptics  have  a  definite 
place  here. 

While  the  cases  reported  are  too  few  to  justify 
any  lasting  conclusions,  the  evidence  so  far  tends 
to  show  that  an  almost  specific  type  of  therapy  for 
gonorrheal  vaginitis  in  children  has  been  found. 


Intravenous  Sucrose  as  a  Diuretic 

(J.    G.    Strohm    &    S.    B.    Osgood,    Portland,    in    Nor'wes. 
Med.,  Mar.) 

For  relieving  anuria  in  postoperative  urologic  patients, 
in  2  such  cases  in  which  intravenous  glucose,  caffeine  so- 
dium benzoatc  and  alkali.s  have  proved  ineffective,  50% 
sucrose  (Lilly)  in  repeated  intravenous  doses  of  20  to  SO 
c.c.  produced  startling  diuresis. 

Ten  experiments  showed  the  normal  urinary  output  of 
dogs  to  be  more  than  doubled  during  the  period  immedi- 
ately following  sucrose  administration.  Wc  are  hoping  to 
publish  later  the  detailed  report  of  our  investigations. 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


DEPARTMENTS 

UROLOGY 

For  this  issue,  N.  O.  Benson,  M.D.,  Lumberton,  N.  C. 


Unusually  Laege  Hydrocele  With 
Inflatvdmatory  Changes 
My  reason  for  reporting  this  case  is  the  unusual- 
ly large  hydrocoele,  persisting  over  a  long  period  of 
time,  with  inflammatory  changes  that  caused  a 
marked  thickening  of  the  tunica  vaginalis,  and  also 
because  of  the  simulance  to  a  complete  indirect  in- 
guinal hernia. 

A  colored  man,  aged  45,  came  to  my  office  on  June  ISth, 
1934,  complaining  of  a  swelling  of  the  scrotum,  and  of 
being  ruptured.  There  was  nothing  in  the  family  history 
which  seemed  contributory.  The  patient  had  gonorrhea 
when  a  boy,  with  anterior  symptoms  only.  He  gives  no 
history  of  syphilis. 

In  1923  patient  says  that  he  ruptured  himself  on  the 
right  side  when  he  was  trying  to  upright  an  overturned 
log-cart.  Though  what  he  believes  to  be  a  hernia  has 
increased  in  size,  it  was  always  reducible  until  four  months 
ago.  The  increase  in  the  size  of  the  scrotum  has  been 
more  rapid  during  the  past  four  months,  but  the  patient 
was  inconvenienced  in  no  other  way.  He  says,  "it  gets 
in  my  way,  in  more  ways  than  one."  A  month  before 
coming  to  see  me  an  abscess  formed  at  the  bottom  of  the 
scrotum  on  the  right  side  which  ruptured  spontaneously  a 
few  days  ago,  draining  only  a  small  amount  of  pus.  The 
patient  then  went  to  see  a  doctor,  who  further  opened  the 
abscess  and  obtained  about  a  pint  of  pus.  Patient  has  no 
symptoms  referable  to  the  urinary  tract.  Bowels  are  nor- 
mal.   Appetite  good. 

The  patient  is  fairly  well  developed  and  in  no  appar- 
ent pain.  Examination  is  negative  except  as  follows:  Ab- 
domen— scars  over  lower  portion  and  over  thighs,  from  a 
burn  in  babyhood.  Left  inguinal  region  normal.  Right 
inguinal  region — the  external  ring  is  larger  than  normal 
and  is  filled  with  a  soft  mass  which  extends  into  the  scro- 
tum. Genitals — the  penis  is  of  fair  proportions,  no  scars 
or  discharge,  supported  by  the  'scrotum.  The  scrotum 
measures  18  by  23  cm.,  the  right  side  larger  than  the 
left;  on  the  left  is  a  soft,  translucent,  fluctuatmg  mass  8 
by  13  cm.  The  testicle  is  indefinitely  palpable  but  does 
not  feel  to  be  enlarged,  the  epididymis  and  vas  are  appar- 
ently normal.  Palpation  of  the  right  side  of  the  scrotum 
reveals  a  firm,  resistant  yet  slightly  fluctuating  mass,  whose 
surface  is  slightly  irregular;  a  definite  impulse  is  noted  on 
coughing;  no  scrotal  contents  palpable,  and  light  is  not 
transmitted.  At  the  base  of  the  scrotum  on  the  right  side 
is  an  abscess  8  cm.  in  diameter,  from  which  is  draining 
thick  yellowish  pus.  By  rectal  examination,  the  prostate 
is  smaller  than  normal,  the  left  side  smaller  than  the  right. 
The  surface  of  the  entire  gland  is  slightly  irregular,  and 
there  is  first-degree  induration  throughout  the  entire  gland. 
There  are  no  lateral  adhesions,  and  the  median  furrow  and 
notch  are  normal.  The  seminal  vesicles  are  normal  in 
shape  and  size,  but  are  slightly  indurated,  on  both  sides. 
The  secretion  obtained  by  prostatic  massage  is  normal. 
Urine  collected  for  two-glass  test — contents  of  both  glasses 
clear,  examination  negative.     Wassermann  blood  test   xxx. 

On  June  16th,  the  patient  was  sent  to  the  Baker  Sana- 
torium where  the  abscess  was  dressed  daily.  In  eight  days, 
during  which  time  the  abscess  drained  freely,  there  was  a 
definite  decrease  in  the  size  of  the  right  side  of  the  scro- 


tum, and  there  was  definite  fluctuation  on  the  right  side 
of  the  scrotum,  though  no  light  was  transmitted.  A  hypo- 
dermic needle  was  carefully  introduced  into  the  right  side 
of  the  scrotum,  and  a  dark  brown  fluid  was  obtained;  a 
large  needle  was  substituted  and  700  c.c.  of  this  fluid  was 
aspirated,  with  marked  decrease  in  the  size  of  the  scrotum. 
An  attempt  to  examine  the  scrotal  contents  of  the  right 
side  failed,  because  the  scrotal  coverings  felt  to  be  1  or  l}/2 
cm.  thick. 

On  June  27th,  under  ether  anesthesia,  a  bottle  operation 
was  performed  for  the  hydrocele  on  the  left  side  and  the 
wound  closed;  then  an  incision  was  made  over  the  right 
inguinal  region  extending  to  the  upper  part  of  the  scrotum, 
the  cord  located,  sheath  separated,  cord  clamped,  cut  and 
ligated  with  No.  2  chromic  catgut  and  the  sheath  sutured 
over  the  proximal  stump.  The  skin  incision  was  then 
carried  over  to  the  median  rape  and  down  excising  the 
abscess  on  the  lower  part  of  the  scrotum,  then  back  up 
the  posterior  side  of  the  scrotum  along  the  midline  to  the 
starting  point.  All  contents  of  the  right  scrotum  were  re- 
moved. The  external  inguinal  ring  was  closed  with  No.  2 
chromic  interrupted  sutures.  The  skin  edges  were  approxi- 
mated by  interrupted  silkworm  sutures.  Two  cigarette 
drains  were  placed,  one  at  each  end  of  the  incision.  Con- 
valescence was  uneventful  and  the  patient  was  discharged 
twelve  days  after  operation  and  back  at  work  three  weeks 
after  operation. 

At  the  e.xtemal  inguinal  ring  there  was  a  slight  bulging 
of  the  parietal  peritoneum,  but  no  evidence  of  the  intestines 
ever  having  gone  into  the  scrotum.  The  specimen  removed 
was  an  oval  sac  measuring  10  by  22  cm.,  whose  walls  were 
from  1  to  1>^  cm.  thick.  The  skin  was  not  adherent  to 
the  sac.  The  inner  lining  of  the  sac  was  a  muddy  brown, 
with  numerous  nodular  growths  from  2  to  7  cm.  in  diam- 
eter. The  testicle  was  present  in  the  lower  portion  defi- 
nitely adherent  to  the  wall  of  the  sac.  The  epididymis 
was  not  found.  Sections  were  taken  from  the  testis  no- 
dules and  wall  of  the  sac.  Report  on  them  is  as  follows: 
"Grossly  it  is  impossible  to  make  out  any  structures  of 
the  testis.  The  masses  are  hard  and  pale,  but  in  two  of 
them  we  find  circumscribed  dark  yellow  and  brown  masses. 
By  the  general  appearance  one  gains  the  impression  that 
these  masses  are  growing  and  invading  the  surrounding 
tissue.  Paraffin  section:  Shows  little  normal-appearing  tis- 
sue. There  is  a  great  deal  of  necrosis  present  and  a  pe- 
culiar infiltration  of  leukocytes,  some  of  which  are  plasma 
cells,  and  others  of  which  contain  brownish-yellow  pig- 
ment. There  are  foreign  body  giant  cells  which  contain 
cholesterol  crystals.  The  whole  thing  is  more  than  likely 
due  to  syphilis,  in  the  opinion  of  Dr.  Forbus,  but  this  is 
not  certain  from  histological  examination.  Diagnosis: 
Chronic  inflammatory  tissue  in  relation  to  epididymis." 

There  is  little  doubt  but  that  the  inflammatory 
changes  were  caused  by  syphilis.  I  believe  that 
the  impulse  noted  on  coughing  was  due  to  the  in- 
complete inguinal  hernia,  transmitting  the  impulse 
through  the  fluid  of  the  hydrocoele  to  the  thickened 
tunica  vaginalis,  thus  simulating  a  complete  hernia. 


School  and  college  girls  and  young  matrons  (E.  D. 
Barringer,  in  Med.  Woman's  Jl.,  Mar.),  with  all  false  mod- 
esty thrown  to  the  winds,  and  none  of  the  real  article  to 
take  its  place,  discuss  glibly  over  the  teacups  all  the  facts 
of  life,  sex  relations,  syphilis  and  gonorrhea  alike.  There 
is  a  perfect  orgy  of  obtaining  this  knowledge — some  of  it 
scientific,  some  good,  plenty  of  it  unreliable  and  truly  vic- 
ious. 


April,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


HOSPITALS 

R.  B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  Editor,  Greensboro,N.  C. 


For  Whom  Are  Hospitals  Built? 

All  will  agree  that  hospitals  are  built  for  the 
good  of  humanity.  There  are  those  who  act  at 
times  as  thouc;h  the  hospitals  were  built  solely  for 
them,  regardless  of  what  group  they  happen  to  fall 
in. 

Let  us  analyze  the  attitude  of  a  doctor  of  a 
certain  type  by  making  rounds  with  him.  He 
comes  in  and  is  met  by  a  courteous  nurse  who 
is  ready  and  willing  to  assist.  He  first  looks  over 
the  charts  of  his  patients  and,  not  infrequently, 
begins  on  a  rampage  of  destructive  criticism  con- 
cerning the  nurses'  work.  He  does  not  take  into 
consideration  the  fact  that  he  is  making  early 
morning  rounds,  and  that  all  treatment  given  with- 
in the  last  hour  could  not  yet  have  been  properly 
charted.  There  are  many  baths  to  be  given,  much 
special  morning  treatment  and  other  extra  duties, 
such  as  fixing  flowers  in  the  patients'  rooms,  or 
giving  information  to  an  interested  relative  as  to 
what  kind  of  a  night  the  patient  has  spent.  His 
patient  or  some  other  patient  is  in  the  midst  of  a 
bath  or  being  given  an  enema  or  a  douche,  and 
he  can  not  see  a  patient  at  the  particular  moment. 
The  wrong  kind  of  a  doctor  complains  about  this. 
He  visits  the  next  patient  who  possibly  has  had  a 
bad  night.  Patients  will  have  bad  nights  no  mat- 
ter where  they  are.  The  doctor  complains  that  the 
hospital  is  not  giving  good  service  to  this  patient, 
when  he  knows  that  the  night  before  the  patient 
came  into  the  hospital  he  was  called  two  or  three 
times  over  the  telephone,  and  that  was  one  of  the 
reasons  for  admitting  her.  And,  so  on  from  the 
beginning  to  the  end  of  his  rounds  the  doctor  as- 
sumes the  air  that  the  hospital  was  intended  to 
make  his  work  easier,  to  lighten  his  responsibility, 
and  to  increase  his  income,  and  in  general  conduct- 
ing himself  as  though  the  hospital  was  built  and 
operated  solely  for  his  benefit. 

To  understand  what  is  in  the  minds  of  some 
nurses  one  has  only  to  visit  with  them  a  while  up 
and  down  the  halls  of  a  hospital.  They  go  about 
their  work  as  if  it  were  a  burden.  The  object  which 
them  is  to  get  through  with  waiting  on  a  patient  as 
quickly  as  possible  and  not  to  make  the  patient 
as  comfortable  as  possible.  The  foremost  thought 
in  their  minds  is  to  so  systematize  their  nursing 
service  that  they  will  answer  as  few  summonses 
as  possible,  rub  as  few  backs  as  possible,  give  as 
few  baths  as  possible,  and  tidy  up  as  few  rooms 
as  few  times  as  they  can  get  by  with.  And,  while 
they  may  not  be  definitely  grouchy  with  patients, 
the  atmo.sphere  around  them  is  impregnated  with 
the  air  of  indifference  and  lack  of  interest  for  the 


welfare  of  the  patients.  As  the  day  wears  on  their 
attitude  grows  worse  and  because  a  patient  has 
pulled  on  his  or  her  light  several  times  within  the 
last  few  hours  these  t3TDes  of  nurses  complain  of 
the  patients  being  so  hard  to  do  anything  for.  This 
is  the  type  of  nurse  who  when  called  by  a  physi- 
cian to  come  on  duty  asks  as  the  first  question, 
"Is  the  patient  in  the  hospital?"  This  is  as  much 
as  to  say  that  the  hospital  is  built  to  make  nursing 
easier,  and  she  prefers  her  patients  to  go  there. 

Let  us  now  consider  visitors  who  stream  in  and 
out  of  hospitals,  morning,  noon  and  night.  To  be 
sure  there  are  many  of  them  who  do  not  fall  into 
the  class  that  we  will  describe.  There  are  a  few, 
however,  who  insist  upon  coming  to  visit  sick  rela- 
tives or  friends  without  regard  for  visiting  hours. 
If  they  are  not  let  in  promptly  they  complain  about 
what  they  have  to  do  during  the  regular  visiting 
hours,  and  how  they  can  not  come  during  those 
times. 

There  there  are  those  creatures  who  when  their 
friend  or  relative  is  recuperating  and  apparently 
out  of  danger  persist  in  laughing  and  talking  at 
the  top  of  their  voices,  or  turning  a  radio  on  so 
loud  that  it  can  be  heard  three  or  four  rooms  dis- 
tant. When  one  passes  by  the  door  he  would 
think  there  is  a  general  frolic  going  on  rather  than 
an  orderly  visit  to  a  sick  person.  These  thought- 
less visitors  sit  on  the  beds  and  some  will  lie  down 
across  them.  They  smoke  cigarettes  and  drop  the 
ashes  all  over  the  linen  and  the  floor.  If  there  is 
another  patient  in  the  same  room  they  make  him 
definitely  worse  by  their  visit  and  conduct.  This 
t)T5e  of  visitor  assumes  the  attitude  that  the  hos- 
pital is  run  for  the  benefit  of  visitors  so  that  they 
might  have  a  pleasant  and  enjoyable  evening.^ 
Definite  visiting  hours  are  as  much  a  part  of  good* 
hospitalization  as  is  medicine  and  treatment. 

The  last  group  of  people  we  want  to  describe  is 
that  made  up  of  patients.  A  patient  is  not  in  the 
hospital  for  pleasure  or  pastime.  He  is  there  be- 
cause of  illness,  weakness  and  pain.  Physically 
and  financially  he  is  at  a  low  ebb,  and  often  men- 
tally as  well. 

What  if  patients  are  impatient  at  times?  Who 
would  not  be  under  similar  circumstances?  What 
doctor,  nurse  or  visitor  always  has  a  sweet,  cheer- 
ful disposition  when  sick  and  suffering,  with  income 
stopped  and  expenses  mounting  daily?  Unless 
those  who  work  for  and  with  these  patients  are 
going  to  realize  why  a  patient  is  brought  to  a  hos- 
pital, then  they  need  not  expect  to  render  the  best 
service  or  possess  a  cooperative  spirit. 

If  patients  will  get  well  quicker  in  the  hospital; 
if  patients'  lives  are  saved  at  the  hospital;  if  dis- 
ease and  injury  are  better  borne  by  having  good 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  19.36 


hospital   care — then,   is   that   not    the   real   reason 
why  hospitals  are  built? 


GENERAL  PRACTICE 

WiNGATE  M.  Johnson,  M.D.,  Editor,  Winston-Salem,  N.  C. 


Narna  Darrell 

This  is  the  title  of  a  novel  by  Dr.  Beverley 
Tucker,  just  off  the  press  of  the  Stratford  Com- 
pany, of  Boston  ($2.50).  That  it  is  of  absorbing 
interest  is  proved  by  the  fact  that  I  read  the  last 
third  of  it  while  jolting  over  the  weather-beaten 
road  between  here  and  Raleigh,  while  my  wife 
dodged  as  many  of  the  gullies  and  pits  as  she  could 
without  any  advice  from  me. 

The  book  might  be  called  a  study  in  heredity. 
In  strong,  swift  strokes  one  picture  after  another 
is  drawn.  Beginning  in  the  iirst  chapter  with  the 
conquest  of  the  Britons  by  the  Romans  under  Ju- 
lius Csesar,  the  first  Narna  is  presented,  and  forms 
a  love  match  with  a  Roman  centurion,  Lucius. 
Centuries  later  another  Lucius,  surnamed  x\ldbryht, 
of  the  Saxon  kingdom  of  Wessex,  refused  to  lead 
an  army  against  the  Saxon  kingdom  of  Kent  be- 
cause he  was  in  love  with  another  Narna,  daughter 
of  the  King  of  Kent.  Instead,  he  went  over  to 
that  kingdom,  organized  a  force  there  to  fight 
against  his  former  ruler,  and  married  Narna.  At 
first  successful  in  battle,  later  he  was  defeated  by 
the  armies  of  Wessex  and  killed  in  the  fight.  Narna 
stabbed  herself  rather  than  be  taken  by  the  crown 
prince  of  Wessex,  but  her  daughter,  also  named 
Narna,  survived. 

The  thread  of  romance  is  woven  through  the 
signing  of  Magna  Carta,  in  which  another  Lucius 
Aldbryht — this  one  a  knight — splayed  a  prominent 
part  and  gained  another  Narma  as  a  bride.  Then 
it  is  taken  up  when  a  Narna  Southworth  volun- 
teered to  go  on  the  shipload  of  fair  maidens  des- 
tined to  be  wives  for  the  planters  of  Virginia,  and 
found  her  Lucius,  with  the  more  modern  surname 
of  Albright. 

Successive  generations  of  lovers  of  the  same 
name  and  of  the  same  hereditary  traits  are  traced 
through  the  early  colonial  days,  the  American  Rev- 
olution, and  the  Civil  War  down  to  the  very  pres- 
ent, through  the  Great  Depression  and  even  for  a 
half  century  into  the  future  of  the  next  generation. 
One  of  them  was  made  Governor  of  Virginia,  an- 
other a  United  States  Senator. 

In  all  the  Luciuses  and  Narnas  are  found  the 
same  strong  hereditary  traits:  courage,  tolerance, 
love  of  justice,  devotion  to  duty,  and  leadership. 
The  objection  may  be  made  that  the  action  in  the 
book  moves  so  swiftly,  and  character  after  charac- 
ter is  presented  so  rapidly  that  it  is  difficult  to 
grasp  and  retain  in  memory  the  individuals  in  it. 


I  think,  however,  that  Dr.  Tucker's  aim  was  to 
present  a  type  that  ran  true  to  form  for  successive 
generations;  and  in  this  he  has  succeeded  admira- 
bly. I  can  commend  it  unreservedly  as  a  strong, 
gripping,  inspiring  book,  that  leaves  one  better  for 
having  read  it.  Not  the  least  of  its  charm  are  the 
philosophic  asides  interjected  at  intervals  by  the 
author.  And  to  the  lover  of  poetry  the  epilogue, 
"Narna — Goddess  by  the  World  Forgot,"  is  a  beau- 
tiful prose  poem  that  will  bear  reading  over  and 
over. 


Recently  a  patient  of  mine  was  sent  to  a  dis- 
tinguished neuro-surgeon  for  an  opinion  and  possi- 
bly a  nerve  injection.  She  returned  without  the 
injection,  but  with  the  following  story  which  is  too 
good  to  keep.  After  she  had  been  kept  in  the 
hospital  for  several  days,  being  subjected  to  all 
sorts  of  examinations,  her  ultramodern  youngest 
daughter  caught  the  great  man  by  his  coat  sleeve 
as  he  was  hurrying  down  the  corridor,  out  of  the 
invalid's  room.  With  a  stamp  of  her  foot,  she 
demanded,  "Doctor,  I  want  to  know  what  in  the 
hell  is  the  matter  with  my  mother! "  Looking  down' 
upon  her  from  his  much  superior  height,  he  replied, 
"Well,  young  lady,  if  you  want  an  honest  answer — 
damned  if  I  know!" 


rEDIATRICS 

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


State  Medical  Society  Meeting,  IMay  4th  to 
6th 

Attractions  in  and  about  Asheville: 

The  Biltmore  Estate,  including  the  mansion  of 
the  late  George  Vanderbilt,  is  now  open  to  visitors. 
A  nominal  fee  is  charged  for  the  tour,  which  re- 
quires an  entire  afternoon.  The  trip  is  concluded 
by  an  inspection  tour  of  the  certified-milk  dairy, 
which  is  part  of  the  estate.  A  separate  trip  to  the 
dairy  can  be  arranged  for  which  no  charge  is  made. 
The  best  time  for  this  trip  is  the  late  afternoon 
when  the  milking  is  done.  Admission  permits  to 
the  dairy  and  tickets  for  the  Estate  tour  are  ob- 
tained at  the  office  of  the  Biltmore  Estate  in  Bilt- 
more. 

The  Asheville  Medical  Library  is  located  in  the 
Arcade  Building,  across  the  street  from  the  conven- 
tion headquarters,  no  more  than  150  steps  from  the 
front  door  of  the  hotel.  We  are  proud  of  our 
library  of  nearly  1,500  volumes. 

In  Biltmore  Forest  are  Biltmore  Forest  Country 
Club  and  Golf  Course  and  some  of  our  finest  resi- 
dences. On  the  way  through  the  forest  stop  to  see 
the  hand-carved  wood  work  at  the  Artisans'  Shop 
and  the  hand-wrought  silver  at  the  Dodge  Silver 
Shop  just  across  the  street. 


AprU,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


21S 


If  you  are  interested  in  mountain  handicraft,  the 
Allanstand  Cottage  Industries  Shop  may  be  found 
in  the  center  of  the  shopping  district. 

Two  boys'  schools  with  exceptional  features  are 
located  near  the  city.  Asheville  School  for  Boys  is 
just  a  few  miles  beyond  the  city  limits  via  West 
Asheville.  On  this  trip  a  visit  to  the  Middlemount 
Gardens  greenhouses  will  be  enjoyed  by  all  lovers 
of  flowers.  Be  sure  to  see  the  orchid  garden  while 
there.  Asheville  Farm  School  is  one  of  America's 
high-standing  schools  of  Progressive  Education.  It 
is  located  east  of  the  city. 

Six  theaters,  4  golf  courses  and  a  skeet  range  are 
ready  to  entertain  those  visitors  who  enjoy  that 
type  of  recreation. 

For  our  visitors  who  can  remain  over  for  a  few- 
days  following  the  convention,  a  trip  to  Chimney 
Rock  (a  full  day's  trip),  to  the  top  of  Mt.  Pisgah 
(full  day),  or  a  trip  through  the  Great  Somky 
Mountains  National  Park  (either  one,  two  or  three 
days)  offer  scenery  comparable  to  the  most  beau- 
tiful to  be  found  anywhere  in  the  world. 

The  members  of  Buncombe  County  Medical  So- 
ciety, as  hosts,  are  anxious  to  be  of  service  in  every 
possible  capacity  to  our  guests.  In  addition  this 
editor  offers  the  facilities  of  his  offices  to  all  who 
wish  to  avail  themselves  of  them,  at  101  Haywood 
St.,  directly  behind  the  Battery  Park  Hotel. 

Gleanings  From  Here  and  There 

If  Hellin's  Law  of  80s  holds  true  for  quintuplet 
births  as  it  does  for  twin,  triplet  and  quadruplet 
births,  then  the  chance  of  quintuplets  is  the  result 
of  80x80x80x80— once  in  every  40,960,000  births. 

Definitions:  A  little  boy:  a  noise  with  dirt  on 
it.  A  Pink  Tea:  Gibble,  Gabble,  Gobble,  Git.  (O. 
W.  Holmes.) 

Changing  a  child's  handedness  not  only  may  re- 
sult in  stammering,  but  cause  cross-eyes  as  well. 

No  proof  or  sworn  statement  is  required  when 
registering  a  birth  in  England. 

Hippocrates  is  responsible  for  the  idea  that  the 
8-month  baby  is  less  likely  to  survive  than  the  7- 
month.  [Hippoc  must  have  had  a  vein  of  sardonic 
humor.  Or  maybe  he  failed  to  notice  that  pretty 
nearly  all  7-month  babies  are  firstborns. — /.  M. 
N.] 

In  England  more  than  200,000  babies  of  wealthy 
families  do  not  live  at  home  but  in  fashionable 
baby  hotels  where  they  are  taken  at  birth. 

Cure  of  scurvy  by  lemon  juice  was  noted  as 
early  as  1745. 

Before  the  discovery  of  antitoxin  45%,  of  cases 


of  diphtheria  ended  in  death.  Are  we  so  terribly 
modern  today?  How  many  children  did  you  pro- 
tect against  diphtheria  today,  this  week  or  this 
month? 

It  would  be  interesting  to  know  the  virus  that 
is  responsible  for  a  particular  epidemic  of  colds 
and  to  know  whether  or  not  that  virus  is  responsi- 
ble for  a  high  incidence  of  otitis  media.  I  have 
opened  more  bulging  ear  drums  in  the  past  two 
weeks  than  I  have  opened  all  year.  Empyema  acts 
similarly.  It  seems  to  follow  pneumonias  of  cer- 
tain years.  I  have  seen  very  few  cases  of  empyema 
this  past  year. 

During  the  early  days  of  the  World  War,  the 
British  soldiers  were  not  compelled  to  accept  ty- 
phoid fever  inoculations.  It  was  the  great  Osier 
who  exhausted  himself  in  lecturing  successfully  to 
the  soldiers  on  the  advantages  of  the  inoculations. 

We  must  not  forget  that  children  develop  ty- 
phoid fever.  It  is  today  a  relatively  rare  disease 
in  our  large  cities  but  still  too  common  in  the 
country  sections  of  our  State.  It  is  only  because 
of  the  past  inoculation  campaigns.  We  must  con- 
tinue to  carry  on.  The  State  will  vaccinate  free 
of  charge  or  you  can  do  it,  collect  for  your  services 
and  show  the  parents  that  you  are  alert  to  the 
preservation  of  the  health  of  the  children  under 
your  care. 

Favorite  irritants: 

The  baby  has  an  "acid  rash." 

Won't  the  baby  have  a  fever  if  its  bowels  don't 
move  every  day? 

Why  doesn't  castor  oil  help  the  baby  to  fight 
the  cold,  the  stool  after  the  oil  works  is  full  of 
mucus?  (Did  you  ever  see  a  castor-oil  stool  that 
was  not  full  of  the  irritating  effects  of  the  oil- 
mucus?). 

Won't  the  baby  be  cross-eyed  if  he  takes  a  sun 
bath? 

I  didn't  think  the  baby  would  drink  such  nasty 
stuff  as  kerosene. 


CLINICAL  CHEMISTRY  &  MICROSCOPY 

C.  C.  Carpenter,  B.A.,  M.D.,  F.A.C.P.,  Editor 
WaUe  Forest,  N.  C. 


The  Incomplete  Autopsy 
Dltring  the  last  few  years,  and  more  particu- 
larly during  the  last  year,  the  public,  the  insurance 
companies  and  the  courts  have  come  to  not  rely 
on  incomplete  information  concerning  the  cause  of 
death  and  use  the  autopsy  more.  For  that  reason 
in  almost  every  locality  at  times  the  general  phy- 
sician is  called  upon  to  do  an  autopsy.    The  lab- 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1036 


oratories  receive  material  from  these  autopsies  in 
large  quantities  for  a  completion  of  the  study, 
which  would  include  a  chemical  or  microscopical 
examination  or  both.  This  material  is  received  in 
every  conceivable  way  and  the  most  convenient 
material  at  hand  is  likely  to  be  sent  without  a 
consideration  of  the  location  of  the  fatal  lesion. 
These  incomplete  autopsies  often  make  it  neces- 
sary to  exhume  the  body  months  later  for  a  com- 
plete examination.  This  writer  would  not  argue 
that  the  general  physician  should  not  attempt  to 
do  an  autopsy  but  would  suggest  that  he  inform 
himself  concerning  the  procedure  and  methods  of 
collecting  material.  Obviously,  in  the  autopsy,  as 
well  as  hysterectomy,  the  man  who  is  more  experi- 
enced and  has  made  a  special  study  of  the  proce- 
dure should  be  more  competent.  In  the  case  of 
a  hysterectomy,  the  inexperienced  would  not  at- 
tempt it  because  of  the  likelihood  of  error,  death 
and  suit.  These  dangers  are  not  so  likely  when 
one  performs  an  operation  on  the  dead  body,  but 
the  error  may  be  even  greater  in  the  hands  of  the 
inexperienced. 

History :  The  history  of  the  case  is  as  important 
as  it  is  in  arriving  at  a  diagnosis  during  life.  Ma- 
terial coming  to  the  laboratory  is  seldom  accom- 
panied by  a  history.  The  assumption  seems  to  be 
that  if  the  lesion  or  toxic  substance  is  present  that 
is  final  and  no  other  deductions  need  be  drawn. 
This  is  untrue.  More  than  one  lesion  usually  exists 
and  the  clinical  record  will  serve  to  differentiate 
the  more  important  one  in  the  production  of  death. 
In  the  same  way,  symptoms  may  be  similar  and 
produce  an  entirely  different  lesion.  One  would 
hardly  assume  that  all  patients  complaining  of 
acute  abdominal  pain  will  show  the  lesion  in  the 
abdomen  but  that  symptom  would  call  attention 
to  the  abdomen  and  demand  explanation  if  the 
lesion  is  found  elsewhere.  The  manner  of  death  is 
important.  A  patient  may  fall  and  break  a  limb 
but  the  cause  of  the  fall  may  be  found  to  be  acci- 
dental in  the  common  sense  of  the  term,  cerebral 
or  cardiac.  Death  occurs  in  a  good  many  cases  in 
which  the  cause  is  determined  by  the  elimination 
of  other  possibilities.  In  drowning  we  have  many 
so-called  positive  signs,  but  in  the  absence  of  other 
lesions  capable  of  producing  death  the  lack  of  these 
signs  does  not  prove  that  it  was  not  a  case  of 
drowning.  Death  from  apoplexy  or  angina  pectoris 
would  not  be  suspected  in  the  relatively  young 
individual.  However,  this  occasionally  happens 
and  a  history  pointing  in  that  direction  would  aid. 

Poisons:  It  is  common  practice  when  people  die 
following  the  ingestion  of  some  particular  substance 
to  remove  the  stomach  and  send  it  with  its  con- 
tents to  a  laboratory  for  toxicological  examination 
without  any  suggestion  of  the  suspected  material. 


Whenever  possible,  a  history  of  the  material  in- 
gested, the  duration  of  symptoms,  the  presence  of 
other  symptoms  and  the  manner  of  death  should 
be  given.  One  would  not  suspect  strychnine  in 
death  following  prolonged  coma;  neither  would 
one  be  justified  in  thinking  of  morphine  if  the 
patient  died  in  convulsions.  We  should  also  realize 
that  the  stomach  and  its  contents  may  not  contain 
the  toxic  substance,  as  many  toxins  are  stored  or 
liberated  through  other  organs.  The  stomach  is  of 
little  value  in  determining  death  from  alcoholism. 
The  alcohol  is  found  principally  in  the  brain  and 
cerebro-spinal  fluid.  Fluid  removed  by  spinal 
puncture  is  of  more  value  in  determining  this  type 
of  death  than  the  stomach.  Therefore,  one  should 
properly  select  the  material  to  be  sent  in  suspected 
poison  cases  according  to  the  poison  in  question. 
It  is  always  desirable,  when  possible,  to  send  a 
portion  of  the  material  that  has  been  ingested. 

External  Examination:  This  should  be  made 
with  great  care.  The  presence  or  absence  of 
wounds,  the  state  of  the  pupils,  the  color  of 
the  skin  and  the  degree  of  rigor  and  livor  mortis 
are  among  the  more  important  things.  The  same 
as  in  the  case  of  a  physical  examination  during  life, 
it  is  advisable  to  follow  a  certain  procedure  in  order 
not  to  overlook  things  of  material  importance.  It 
is  a  good  practice  to  begin  at  the  top  of  the  head 
and  go  down  in  the  external  examination ;  and  when 
examination  of  the  interior  is  started,  follow  the 
reverse  order  for  the  cavities  (peritoneal,  pleural 
and  pericardial),  taking  the  organs  again  from 
above  down  after  examination  of  the  cavities  has 
been  completed.' 

Internal  Examination:  In  all  cases  all  of  the 
organs  should  be  examined  completely.  Many  times 
the  laboratory  receives  portions  of  various  organs 
that  have  been  removed  by  simply  opening  the 
body  and  cutting  out  a  piece.  The  important  lesion 
may  be  at  a  distance  from  the  portion  removed.  At 
times  a  permission  cannot  be  obtained  for  a  complete 
autopsy  but  unless  this  is  true  no  organ  should  be 
omitted.  One  should  remember  that  after  the  body 
is  buried  it  is  too  late  to  look  at  things  that  might 
have  been  seen  at  the  time  of  the  autopsy. 

Records:  Careful  record  should  be  made  of 
everything  observed.  This  record  does  not  neces- 
sarily include  a  diagnosis  of  the  lesion  but  a  de- 
scription of  its  appearance,  location  and  size. 
There  is  no  reason  to  attempt  to  carry  in  one's 
mind  these  important  details  when  it  can  be  so 
easily  written.  The  description  cannot  be  made  as 
accurately  at  any  other  time  as  at  the  time  of  the 
examination.  It  is  very  common  to  have  material 
come  into  the  laboratory  on  which  a  history  is  re- 
quested and  the  physician  states  that  he  believes 
the  lesion  was  of  a  certain  type  and  location  but 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


217 


is  not  certain.  This  same  indefinite  opinion  may 
be  taken  into  court  and  there  it  is  found  to  be  of 
little  value. 

This  discussion  is  not  given  with  the  idea  of 
encouraging  the  inexperienced  to  do  autopsies  but 
every  physician  is  called  on  at  times  to  make  this 
examination  and  by  little  time  and  study  he  will 
be  able  to  materially  improve  the  value  of  his  ex- 
amination and  the  impression  he  makes  in  court. 


PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 
Pitt  County  Health  Officer 


The  Preschool   E.xamin.mion 
Who  Should  Make  it? 

The  season  is  again  here  for  the  preschool  clinic, 
that  is,  the  examination  of  children  who  will  be 
beginners  next  fall. 

There  are  two  questions  which  naturally  arise 
in  the  physician's  mind  concerning  this  examina- 
tion: First,  is  it  necessary?  Second,  who  should 
do  it? 

As  to  the  first  question.  All  who  believe  in  the 
annual  health  check-up,  all  who  believe  in  preven- 
tive medicine,  will  agree  that  the  preschool  exam- 
ination is  necessary.  Necessary,  not  only  for  the 
sake  of  the  health  of  the  child  per  se,  but  also  for 
its  relationship  to  the  child's  school  progress. 

As  to  the  second  question.  We  believe  the  an- 
swer is,  the  examination  should  be  done  by  the 
family  physician,  the  one  who  knows  the  child  and 
his  hereditary  traits. 

As  we  see  it,  the  only  possible  sound  reason  for 
the  examination  being  done,  at  present,  by  the 
health  officer  is,  that  the  demonstration  period,  in 
some  localities,  has  not  passed. 

Of  course,  there  is  another  reason  which  some, 
particularly  the  school  people,  believe  to  be  a  sound 
reason  for  the  health  officer  making  the  examina- 
tion, and  that  is  that  the  State  has  a  compulsory 
educational  law  and  for  its  (the  State's)  own  pro- 
tection, the  child  should  have  a  preschool  health 
examination.  And  they  further  argue  that,  since 
the  health  officer  is  an  employe  of  the  State  (the 
State  pays  a  part  of  the  health  officer's  salary) 
then  the  State  has  a  right  to  require  that  the  health 
officer  make  these  examinations. 

I  agree  that  where  the  State  pays  for  the  child's 
education,  it  is  basically  sound  that  it  not  only 
require  a  preschool  health  examination,  but  it 
would  be  good  business  to  go  a  step  farther  and 
require  the  correction  of  the  remediable  defects 
which  tend  to  interfere  with  the  child's  normal 
school  progress. 

I  believe,  however,  that  all  work  should  be  done 
by  the  private  practitioner  and  dentist  and  the  ex- 


pense borne  by  the  parent,  where  the  parent  is  able, 
and  where  the  parent  is  not  able,  then  by  the  local 
or  State  Governmental  unit. 

The  local  welfare  department  would  determine 
who  can  and  who  cannot  pay. 

The  only  part  the  local  health  department  should 
play  in  this  work  is  that  of  provifing  nursing  ser- 
vice for  home  visits  and  follow-up  work  in  the  case 
of  the  indigent  child. 

If  the  tide  now  moving  towards  socialized  medi- 
cine can  be  stemmed  for  a  while,  that  is,  long 
enough  for  the  Government  and  the  various  Foun- 
dations to  awaken  to  the  fact  that  in  fostering  so- 
cialized medicine  they  are,  in  the  long  run,  render- 
ing a  disservice  to  the  public,  then  preschool  exam- 
inations and  other  types  of  clinics  conducted  by 
health  officers  and  other  salaries  physicians  will  be 
abandoned. 

This  awakening,  however,  will  not  come  until 
organized  medicine  asserts  itself  through  the  legis- 
lative halls. 


RADIOLOGY 


Wright  Clarkson,  M.D.,  and  .^i.len  Barker,  M.D., 
Editors,  Petersburg,  Va. 


Roentgen  Therapy  in  Dermatology 
The  dermatologic  conditions  in  which  roentgen 
therapy  has  proved  valuable  are  too  numerous  to 
permit  detailed  discussion  here,  and  therefore  only 
a  few  of  the  more  common  diseases  will  be  con- 
sidered. Some  of  the  skin  diseases  in  which  roent- 
gen therapy  has  proved  efficacious  are:  acne  vul- 
garis, fungus  infections  (dermatophytoses),  ecze- 
ma, neurodermatitis,  verrucae,  lichen  planus,  su- 
perficial lesions  of  lupus  vulgaris,  psoriasis,  furun- 
cles and  carbuncles,  keloids,  and  epitheliomata. 
It  is  understood  that  in  conjunction  with  roentgen 
therapy  various  constitutional  and  local  remedies, 
as  the  specific  condition  may  require,  must  be 
applied,  but  space  does  not  permit  a  discussion  of 
these  at  this  time. 

Acne  vulgaji-is,  a  diseasje  cojisisting  of  come- 
dones, papules,  pustules  or  nodules,  usually  super- 
imposed on  an  oily  skin,  responds  well  to  75  to 
100  r  administered  at  two-week  intervals  for  a 
total  of  eight  applications.  Should  even  a  slight 
erythema  occur  during  treatment,  the  applications 
must  be  stopped  until  the  reaction  subsides,  and 
then  resumed  cautiously  with  smaller  doses.  In 
such  cases  the  use  of  1  mm.  aluminum  as  a  filter 
helps  prevent  further  reactions.  For  permanent 
and  satisfactory  cures  in  this  disease  proper  con- 
stitutional measures  must  be  used  in  combination 
with  roentgen  therapy. 

Dermatophytoses  include  those  eczematous  erup- 
tions produced  by  the  trichophyton  or  epidermo- 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


phyton,  and  good  results  usually  follow  three  to 
five  applications  of  150-200  r  when  used  in  con- 
junction with  proper  fungicides,  but  recurrences 
are  common,  and  further  treatment  must  be  given 
with  caution. 

Eczema,  a  term  used  to  cover  a  wide  group  of 
dermatologic  conditions — many  of  unknown  eti- 
ology— usually  responds  well  to  two  or  three  doses 
of  100  r,  but  recurrences  are  common  and  treat- 
ment must  not  be  continued  too  long.  The  etiolo- 
gical factor  must  be  discovered  and  removed  if 
permanent  results  are  to  be  expected. 

Neurodermatitis  in  its  acute  stages  responds  well 
to  a  few  fractional  doses,  but  in  the  chronic  stages 
with  lichenification  larger  doses  are  necessary  to 
produce  results. 

Verrucae  when  only  a  few  lesions  are  present 
may  successfully  be  treated  by  carefully  shielding 
the  surrounding  normal  skin  and  applying  900  to 
1000  r  to  the  local  lesions.  When  the  lesions  are 
numerous,  one  should  resort  to  several  fractional 
doses  given  at  one-week  intervals. 

Lichen  planus  in  many  instances  responds  well 
when  treated  in  the  acute  stages,  but  the  hyper- 
trophic lesions  are  radioresistant  and  radiation 
therapy  is  practically  useless.  Langer^  has  re- 
ported good  results  by  treatment  over  the  sympa- 
thetic ganglia  corresponding  to  the  regions  of  nerve 
distribution.  At  the  present  time  we  have  a  pa- 
tient whom  we  are  treating  in  this  manner  and 
marked  regression  of  the  lesions  has  occurred  with- 
out any  local  therapy. 

Lupus  vulgaris  often  shows  rapid  improvement 
with  fractional  doses  of  roentgen  therapy  given  at 
two-week  intervals.  If  the  lesions  are  deep  or  large 
ulcers  are  present,  filtration  with  3  mm.  of  alumi- 
num seems  to  give  better  results.  In  the  treatment 
of  this  disease  one  cannot  hope  to  produce  a  per- 
manent cure  unless  the  same  constitutional  meas- 
ures as  employed  in  pulmonary  tuberculosis  are 
used  in  conjunction  with  radiation. 

Psoriasis  is  a  chronic  disease  characterized  by 
frequent  intermissions  and  exacerbations,  and  it 
usually  recurs  at  intervals  during  the  patient's  en- 
tire life.  Since  there  is  a  very  definite  limit  to 
the  amount  of  roentgen  irradiation  one  can  receive, 
it  is  wise  if  possible  to  avoid  irradiation  in  such 
chronic  diseases,  and  to  rely  on  constitutional  and 
local  remedies.  In  certain  cases  the  lesions  about 
the  face  and  hands  may  be  treated  for  cosmetic 
reasons,  but  treatment  must  not  exceed  the  limits 
of  skin  tolerance.  Usually  two  or  three  treatments 
are  sufficient.  If  there  is  no  response  to  this  num- 
ber, further  treatment  is  useless  and  may  be  dan- 
gerous. Rosh^  in  1934  reported  encouraging  re- 
sults by  roentgen  treatment  to  the  sympathetic 
nervous  system.     High-voltage  roentgen  rays  were 


applied  to  the  spine  at  those  levels  corresponding 
to  the  nerve  supply  of  the  affected  regions.  The 
method  deserves  further  trial. 

The  great  value  of  roentgen  irradiation  in  the 
treatment  of  furuncles  and  carbuncles  has  been 
known  for  several  years,  and  results  in  a  large  \ 
majority  of  these  cases  are  so  phenomenal  that 
failure  to  give  the  patient  the  benefit  of  irradiation 
therapy  approaches  negligence.  Some  of  the  poor 
results  occasionally  seen  may  probably  be  attrib- 
uted to  too  large  doses.  Whereas  many  radiologists 
and  dermatologists  administer  as  much  as  300  r 
in  one  dose,  our  experience  indicates  that  a  dose 
of  80  to  100  r  (1/5-1/4  erythema  dose)  filtered 
through  3  mm.  of  aluminum  gives  much  better  re- 
sults, and  the  dose  may  be  repeated,  if  necessary, 
in  four  to  five  days.  A  third  application  is  seldom 
necessary. 

Keloids  and  keloidal  scars  are  best  treated  by 
irradiation.  Surgery  is  contraindicated,  unless  used 
in  conjunction  with  preoperative  and  postoperative 
irradiation,  as  the  lesions  always  recur.  The 
younger  the  keloid  or  keloidal  scar,  the  more  radio- 
sensitive the  tissue;  thus,  the  smaller  the  doses  an9 
the  fewer  the  treatments  required  to  produce  re- 
sults. Most  of  these  lesions  require  several  months 
to  disappear  and  the  older  ones  a  year  or  more. 
While  the  majority  of  authors  have  advised  the 
administration  of  doses  equivalent  to  80  or  90 
per  cent,  of  an  erythema  dose,  Hodges^  has  shown 
that  results  are  just  as  good  when  using  only  200- 
250  r  (SO  to  60  per  cent,  of  erythema  dose)  un- 
filtered  irradiation  every  five  to  six  weeks.  Any 
method  of  radiation  therapy  which  gives  as  good 
results  with  small  doses  as  with  larger  ones  is 
always  preferable. 

The  therapy  of  various  types  of  epitheliomata 
is  so  varied  and  complicated  that  its  discussion  is 
deferred  to  a  later  communication. 

Space  permits  only  mention  of  some  otlrer  less 
common  skin  diseases  in  which  roentgen  therapy  is 
a  valuable  procedure,  but  brevity  does  not  mean 
that  this  therapeutic  agent  is  less  valuable  in  these 
than  in  those  already  described.  A  few  are  as  fol- 
lows: blastomycosis,  actinomycosis,  mycosis  fun- 
goides,  acne  rosacea,  hyperidrosis,  granuloma  an- 
nulare, seborrheic  dermatitis  and  pyogenic  gran- 
ulomata. 

In  applying  irradiation  for  dermatologic  condi- 
tions, as  in  other  diseases,  one  must  constantly 
keep  in  mind  the  total  dose  administered,  and  the 
cumulative  effects  of  irradiation,  particularly  when 
fractional  doses  are  administered  at  frequent  inter- 
vals. In  general,  a  safe  rule  to  follow  when  treat- 
ing large  skin  areas  is  to  avoid  giving  more  than 
a  total  of  two  skin-erythema  doses  in  any  one 
course  of  treatment,  and  this  amount  must  be  given 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


only  in  fractional  doses  over  a  period  of  not  less 
than  ten  to  sixteen  weeks.  With  the  average  pa- 
tient it  is  safe  to  give  50  to  65  r  (1/8-1/6  erythema 
dose)  weekly  for  a  period  of  ten  to  twelve  weeks, 
or  80-100  r  (1/5-1/4  erythema  dose)  at  ten-day 
intervals  for  a  total  of  eight  doses.  However,  it 
should  be  emphasized  that  each  case  presents  an 
individual  problem.  Any  sign  of  skin  sensitivity 
demands  a  reduction  in  dosage  and  a  longer  inter- 
val between  treatments. 

In  undertaking  the  roentgen  treatment  of  any 
disease  it  is  wise  to  recall  that  roentgen  ray  is  a 
powerful  agent,  which,  improperly  used,  is  capable 
of  producing  as  much  damage  as  good.  Therefore 
it  is  not  intended  to  infer  that  roentgen  therapy  is 
a  simple  procedure,  or  to  encourage  its  use  by  those 
not  thoroughly  familiar  with  its  administration. 

Radiologists  have  long  considered  it  dangerous 
to  produce  an  erythema  during  the  treatment  of 
benign  skin  conditions.  The  operator  who  persist- 
ently produces  an  erythema  over  a  large  skin  area  in 
the  treatment  of  these  conditions  will  sooner  or 
later  find  himself  confronted  with  irreparable  skin 
damage. 

Since  the  universal  adoption  of  the  international 
roentgen,  r,  as  a  unit  of  measurement,  and  the 
manufacture  of  accurate  dosimeters,  the  uninten- 
tional production  of  a  skin  erythema  usually  de- 
notes either  carelessness  or  ignorance  on  the  part 
of  the  operator.  Clinical  experiments^  have  shown 
that  with  medium-sized  fields,  400  r,  measured  in 
air,  will  produce  a  pale,  pink  skin  reaction  which 
appears  a  few  days  following  application  and  per- 
sists for  about  two  weeks.  The  intensity  of  the 
erythema  is  largely  dependent  on  the  quality  of 
the  radiation,  the  type  of  skin  and  the  location 
and  size  of  the  areas  treated.  Of  the  tensions  and 
quality  of  irradiation  most  frequently  used  in 
dermatology,  i.e.,  100  kv.  unfiltered,  and  132  kv. 
filtered  through  3  mm.  of  aluminum,  it  has  been 
shown  that  400  r  of  the  former  produces  the  deeper 
erythema.  It  is  also  well  known  that  variations 
in  the  size  of  the  area  treated  may,  because  of 
increased  back-scattering  with  large  areas,  cause  a 
marked  increase  in  the  total  skin  dosage  even 
though  the  same  number  oj  roentgen  units  is  given. 
Therefore,  as  the  skin  area  increases  we  must  re- 
duce the  number  of  roentgens  applied  to  the  area 
in  order  to  avoid  an  erythema.  Unless  one  has  a 
thorough  understanding  of  these  facts,  he  should 
avoid  the  use  of  roentgen  therapy  in  any  disease. 

In  conclusion,  it  is  important  to  emphasize  that 
in  using  roentgen  therapy  all  factors  must  be  ac- 
curately known.  In  addition  to  kilovoltage,  mil- 
liamperes,  time,  filter  and  distance,  the  actual  r 
output  of  the  particular  tube  in  use  must  be  care- 
fully determined,  either  by  ionization  measurements 


or  by  the  actual  erythema  time,  the  latter  being 
dependent  on  the  size  of  the  area  treated.  A  change 
in  tubes  demands  a  new  output  determination,  as 
the  amount  of  radiation  from  a  new  tube  may  be 
almost  100  per  cent,  more  than  from  an  old  one, 
and  different  tubes,  whether  new  or  old,  vary  con- 
siderably in  their  output. 

References 

1.  Langer,  H.:  Roentgen  Treatment  Over  Vegetative 
Nerve  Centers  or  Ganglia  in  Diseases  Presenting  Symp- 
toms of  Disturbances  of  the  Vegetative  Nervous  Sys- 
tem. Am.  Jl.  Roenl.  &  Rad.  Therapy,  Dec.,  1932,  28, 
747-763. 

2.  RosH,  R.:  Irradiation  in  tlie  Treatment  of  Psoriasis. 
Am.  Jl.  Roent.  &  Rad.  Therapy,  July,  1934,  32,  82-86. 

3.  Hodges,  F.  M.:  Radiation  Therapy  of  Keloid  and 
Keloidal  Scars.  .4m.  //.  Roenl.  &  Rad.  Therapy,  Feb., 
1934,  31,  238-243. 

4.  Andrews,  G.  C,  and  Braestrup,  C.  B.:  Skin  Ery- 
thema Dose  in  Terms  of  Roentgens  in  Superficial  Ther- 
apy. Am.  Jl.  Roenl.  &■  Rad.  Therapy,  May,  1933,  29, 
663-666. 


CARDIOLOGY 

For  this  issue,  Elias  Faison,  M.D.,  Charlotte,  N.   C. 


Rheumatic  Fever 

The  earliest  description  of  this  disease  appeared 
prior  to  the  middle  of  the  Seventeenth  Century; 
probably  the  best  description  up  to  SO  years  ago 
was  that  given  by  Sydenham  in  1776.  In  1778 
David  Pitcairn  published  an  excellent  description 
of  rheumatic  heart  disease.  Dillon  and  Gramshaw 
in  the  years  1850  and  1853,  respectively,  used  the 
term  rheumatic  carditis  in  the  title  of  published 
articles.  Stokes,  in  1853,  said  rheumatic  fever  does 
not  necessarily  exist  with  arthritis,  and  observed 
that  the  heart  lesion  may  precede  that  of  the 
joints. 

The  age  incidence  is  usually  from  5  to  15  years 
with  females  more  susceptible  than  males.  The 
poorer  classes  in  urban  and  industrial  centers  are 
more  often  invaded  than  well-to-do  members  of 
society.  The  familial  incidence  resembles  closely 
that  of  tuberculosis.  Numerous  epidemics  have 
occurred  in  families,  institutions,  barracks,  etc^  It 
is  definitely  more  common  in  temperate  climates; 
to  satisfy  himself  on  this  score  Coburn  transported 
10  active  cases  from  New  York  to  Porto  Rico.  In 
3  months  they  were  symptom-free  and  in  6  months 
clinically  well.  The  symptoms  recurred  in  some 
instances  upon  returning  to  New  York. 

During  the  World  War  5%  of  the  entire  draft 
were  excluded  because  of  heart  disease.  Insurance 
statistics  show  that  from  2  to  2^%  of  the  entire 
population  have  heart  disease.  Statistics  of  the 
Presbyterian  Hospital  in  New  York  show  that  1 
out  of  12  patients  coming  to  autopsy  has  typical 
lesions  of   rheumatic   disease.     Of  the  two   most 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


common  causes  of  heart  disease — syphilis  and 
rheumatic  fever — the  latter  is  responsible  for  2 
cases  to  the  former's  1. 

Just  as  in  tuberculosis,  in  rheumatic  fever  there 
is  one  t3rpical  lesion  which  changes  in  character 
according  to  the  anatomical  site.  This  lesion  is 
the  submiliary  nodule  or  Aschoff  body — at  times 
barely  visible  but  usually  invisible  to  the  naked 
eye  and  found  in  the  endocardium,  myocardium, 
pericardium,  periarticular  tissue  of  the  joints, 
synovial  membranes,  subcutaneous  tissue,  vascular 
system,  brain  and  meninges,  and  perhaps  even  in 
the  skeletal  system. 

The  rheumatic  nodule  consists  of  a  center  of 
necrotic  material  which  is  composed  mostly  of 
collagen,  around  which  are  grouped  the  large  en- 
dothelial cells  of  Aschoff  with  one  or  more  vesicu- 
lar nuclei  and  a  basophilic  cytoplasm.  It  is  thought 
that  these  cells,  which  constitute  the  most  charac- 
teristic feature  of  the  lesion,  are  derived  from  the 
histiocytes.  These  giant  cells  are  not  unlike  those 
of  Hodgkin's  disease.  Lymphocytes  and  plasma 
cells  are  next  seen  with  few,  or  at  times  numer- 
ous, polymorphonuclears.  Finally  and  somewhat 
dependent  upon  the  location  with  regard  to  the 
amount  a  fibroblastic  proliferation  is  always  pres- 
ent. In  other  words,  the  rheumatic  virus  stimu- 
lates a  specific  histological  reaction  which  manifests 
itself  by  a  submiliary  nodule  encountered  in  most 
and  probably  all  tissue,  and  according  to  its  an- 
atomical location  is  classed  as  a  degenerative  or 
exudative  lesion. 

The  etiological  agent  in  this  disease  has  not 
been  definitely  established.  Streptococci,  viruses 
and  allergins  are  accused.  It  is  generally  agreed 
that  it  is  an  infectious  disease  and  Fraser  believes 
that  he  confirms  this  by  reporting  3  cases  in  which 
Aschoff  bodies  were  found  in  the  superior  medias- 
tinal lymph  nodes,  and  another  case  of  rheumatic 
pneumonia  with  Aschoff  bodies  in  the  bronchial 
nodes.  Thus,  he  concludes,  the  causative  virus 
passes  from  the  infected  area  to  the  blood  stream 
by  way  of  the  lymph  channels. 

Wolfe  studied  360  cases  of  rheumatic  heart  dis- 
ease and  believes  that  the  course  of  rheumatic  fever 
is  similar  to  that  of  tuberculosis  in  that  it  continues 
active  for  months  or  years  and  by  self-limitation 
becomes  quiescent  or  arrested.  Most  of  his  cases 
manifested  the  disease  by  fleeting  aching  muscles 
and  joints,  choreiform  movements  and  twitchings, 
and  growing  pains.  More  than  20%  had  abdomi- 
nal symptoms  such  as  cramps,  capricious  appetites, 
occasional  vomiting,  and  in  some  cases  enuresis. 
Tonsillitis  and  pharyngitis  were  very  common. 
Fourteen  patients  developed  pleurisy;  one,  rheu- 
matic pneumonia.  Wolfe  believes  that  an  inactive 
case  of  rheumatic  disease  may  be  reactivated  by  an 


acute  infection  such  as  pharyngitis,  tonsillitis,  etc. 
Of  this  study  he  says,  "watching  this  group  we 
saw  a  composite  picture  which  definitely  proved 
the  importance  of  universal  recognition  by  the  pro- 
fession as  well  as  the  laity,  that  pharyngitis,  grow- 
ing pains,  tonsillitis,  chorea,  polyarthritis,  peri- 
endo-  and  myocarditis  are  manifestations  of  active 
rheumatic  disease  and  that  several  of  these  mani- 
festations frequently  coexist." 

Among  the  chest  complications  are  rheumatic 
pleurisy  and  pneumonia.  The  incidence  of  the  lat- 
ter following  rheumatic  lesions  elsewhere  is  prob- 
ably in  the  neighborhood  of  2%.  The  pathology 
consists  of  an  acute  inflammation  of  the  lungs  with 
consolidation  not  necessarily  of  the  lobar  type. 
The  inflammation  usually  is  of  an  interstitial  peri- 
vascular exudate  of  large  endothelial  cells  identical 
with  those  found  in  the  Aschoff  bodies.  In  most 
of  the  cases  hemorrhage  and  fibrinous  exudate  are 
quite  prominent.  There  are  not  as  many  poly- 
morphonuclear cells  as  seen  in  pneumonia  due  to 
pneumococcus;  therefore  there  is  not  the  evidence 
of  necrosis  and  suppuration  as  accompanies  pyo^ 
genie  infection  and  likewise,  gray  hepatization,  ab- 
scess and  empyema  are  not  encountered  except 
through  secondary  infection.  The  sjrmptoms  are 
different  from  those  caused  by  the  pneumococcus 
and  much  less  spectacular.  There  is  no  chill  and 
very  little  cough;  the  sputum  is  scanty,  tenacious 
and  occasionally  blood-streaked.  The  respiratory 
rate  is  elevated  only  slightly  and  the  temperature 
irregular.  The  rales  are  decreased  and  not  as 
intense. 

Of  recent  years  clinicians  have  attempted  to 
establish  periarteritis  nodosa  and  rheumatic  fever 
as  one  and  the  same  disease.  Freiberg  and  Gross, 
in  1934,  reported  4  cases  of  periarteritis  nodosa 
associated  with  acute  rheumatic  fever  with  autopsy 
findings  and  the  presence  of  Aschoff  bodies.  This 
unusual  disease  presents  an  atjqjics.l  and  protean 
clinical  picture  which  consists  of  a  febrile  illness 
resembling  a  general  infection,  kidney  symptoms 
suggesting  nephritis,  abdominal  symptoms  which 
would  suggest  an  acute  intraabdominal  complica- 
tion and  joint  symptoms  indicative  of  rheumatic 
fever.  They  conclude  that  the  association  of  the 
diseases  and  the  simultaneous  occurrence  of  symp- 
toms of  each  make  it  probable  that  rheumatic  fever 
is  a  common  cause  of  the  vascular  lesions  termed 
periarteritis  nodosa. 

Until  1931  only  65  to  70  cases  of  angina  pectoris 
caused  by  rheumatic  fever  were  reported.  In  1933 
Eakin  reported  a  case  in  a  girl  of  14  years  with 
autopsy  revealing  an  invasion  of  the  coronary  ves- 
sels by  the  specific  rheumatic  tissue. 

There  are  numerous  reports  in  the  literature  of 
laparatomies  performed  with  a  preoperative  diag- 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


221 


nosis  of  pathological  appendix,  only  to  find  a  nor- 
mal appendix  and  the  true  nature  of  the  disease 
discovered  later  by  a  discernible  heart  lesion.  No 
doubt  rheumatic  fever  has  caused  appendiceal  trou- 
ble just  as  it  has  caused  acute  pericarditis,  pleurisy, 
pneumonia,  peritonitis,  enteritis,  arthritis,  etc. 

It  may  be  concluded  that  rheumatic  fever  is  not 
merely  an  infectious  disease  with  an  affinity  for 
the  heart  and  vascular  system,  but  also  a  disease 
that  is  capable  of  invading  our  entire  structure. 
On  the  other  hand,  one  is  compelled  to  conclude 
that  very  little  is  known  about  this  disease,  and 
until  more  work  has  been  done  we  will  have  to 
content  ourselves  with  an  attempt  at  earlier  recog- 
nition and  treatment  by  more  prolonged  absolute 
rest. 


ORTHOPEDIC  SURGERY 

0.  L.  Miller,  M.D.,  Editor,  Charlotte,  N.  C. 


Disturbance   of    Growth   in   Long    Bones   as 

Result  of   Fractures  That  Include  the 
Epiphysis — of  Clinical  and  Medico- 
Legal  Interest 

A  FEW  YEARS  ago  I  had  occasion  to  treat  a  pa- 
tient who  had  unequal  development  of  the  bones  of 
the  right  forearm.  The  ulna  had  grown  more  than 
an  inch  longer  than  the  radius,  giving  sharp  radial 
deviation  to  the  wrist  and  hand — a  rather  ugly  and 
unhandy  deformity.  The  patient  was  a  girl  IS 
years  of  age  who  had  sustained  a  fracture  in  the 
distal  end  of  the  radius  some  12  years  before.  The 
fracture  had  united  with  the  injured  bone  in  ex- 
cellent alignment,  but,  due  to  damage  in  the  epi- 
physis, growth  arrest  had  occurred  causing  the  de- 
formity to  develop  at  the  wrist.  This  girl  and  her 
family  had  contended  for  12  years  that  the  de- 
fomity  resulting  from  her  injury  was  due  to  neg- 
lect on  the  part  of  a  doctor.  This  latter,  of  course, 
was  anything  but  true.  The  deformity  was  due  to 
disturbance  of  growth  resulting  from  trauma  in  an 
epiphysis. 

Compere,  in  an  article  recently  appearing  in  the 
Journal  of  the  A.  M.  A.,  discusses  the  clinical  and 
medico-legal  aspects  of  fractures  in  long  bones  in- 
volving an  epiphysis.  He  states  that  the  import- 
ance of  the  growth  cartilage  of  the  long  bones  has 
been  emphasized  by  embryologists  and  anatomists, 
but  the  ease  with  which  growth  may  be  arrested 
as  the  result  of  infection  that  injures  the  cartilage 
plate  or  by  direct  violence  is  not  always  appreci- 
ated by  those  who  are  called  on  to  treat  the  lesions 
of  the  extremities  of  growing  children. 

One  observer  has  stated  that  trauma  is  the  most 
frequent  cause  of  disturbances  of  growth  in  bones. 
He  further  states  that  the  greatest  growth  activity 
is  localized  in  the  cartilage  columns  on  the  meta- 


physeal side  of  the  epiphyseal  cartilage  plate  and 
that,  after  the  destruction  of  this  portion  of  the 
growth  cartilage,  length  growth  practically  ceases. 

A  review  of  fractures  treated  in  the  University 
of  Chicago  Clinics  revealed  that  35%  of  all  the 
fractures  that  had  been  treated  in  these  clinics  oc- 
curred in  children  14  years  of  age  or  younger,  and 
that  14%  of  the  fractures  in  children  involved  the 
growth  epiphysis. 

Of  the  fractures  in  children  that  involved  the 
growth  cartilage  and  were  seen  before  deformity 
had  occurred  and  followed  for  more  than  sLx 
months  with  roentgen  examinations,  18  or  19  cases 
(95%)  showed  growth  disturbances. 

Growth  disturbance  from  fractures  near  the  ends 
of  the  long  bones  in  children  are  more  common 
than  is  generally  recognized  and  the  clinician  should 
be  reserved  in  his  prognosis  in  the  cases  of  such 
fractures. 


HUMAN  BEHAVIOR 

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


Protoplasm,  Heredity,  Immortality 
Not  only  the  moving  finger  writes,  but  the  hu- 
man being  as  an  entity  is  busily  engaged  from  birth 
till  death  in  writing — and  in  writing  autobiogra- 
phy. For  all  instincts  and  emotions  and  intellect- 
ual states  manifest  themselves  in  action — or,  in  re- 
pression. Every  mortal  lives  his  life — there  should 
be  a  sexless  referring  pronoun — but  no  human  can 
write  his  life  in  its  entirety.  Life,  even  an  obscure 
one,  is  too  big  for  that,  and  too  complex.  And  no 
one  can  see  self  with  detachment,  nor  write  of  self 
otherwise  than  protectingly.  Little  of  the  historical 
writing  is  classed  as  autobiographical;  but  all  writ- 
ing is  more  or  less  autobiographical,  in  the  sense 
that  it  is  self-revealing.  Style  and  content  are  as 
characteristic  of  the  individual  as  the  handwriting. 
Not  many  families  of  eminence  maintain  their 
prestige.  Blood  will  tell,  but  the  principal  thing 
it  proclaims  is  that  it  must  be  attended  to.  It 
seems  to  be  as  difficult  for  a  family  to  keep  itself 
above  the  common  plane  of  humanity  as  for  a 
wave  to  continue  to  hold  its  elevation  above  the 
surrounding  sea.  Recession  would  seem  to  be  an 
inherent  tendency  in  living  things.  I  know  few 
historic  families  that  have  held  their  station.  I 
have  been  told  that  the  majestic  intellect  of  Jona- 
than Edwards  survives  in  many  of  his  descendants. 
The  Adams  family  in  New  England  is  still  intel- 
lectual— and  that  means  more  than  being  intelli- 
gent. In  North  Carolina  the  Battle  and  the  Gra- 
ham families  retain  their  mental  vigor.  But  I 
think  that  remark  can  be  made  of  few  other  old 
families  in  that  state. 

Here  in  Virginia  many  individuals  identify  and 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


magnify  themselves  by  appeal  to  a  family  tree  and 
a  coat  of  arms.  The  maker  of  history  is  the  acorn 
from  which  the  tree  springs.  He  is  interested  in 
previsioning,  rather  than  in  retrospection.  But 
members  of  many  old  families  continue  to  make 
their  contributions  to  history,  not  only  in  this  an- 
cient Commonwealth,  but  in  many  other  states  of 
the  Union.  We  still  know  too  little  of  the  proper- 
ties of  protoplasm,  but  we  do  know  that  through  it 
are  transmitted  those  qualities  that  distinguish  and 
differentiate  individuals  and  families.  Protoplasm 
is  the  only  vehicle  that  transports  hereditary  traits. 
Only  through  protoplasm  is  life  made  immortal.  It 
is  the  pathway  along  which  all  life  travels  from 
the  antedeluvian  mists  into  an  ever-approaching 
future.  Birth  and  life  and  death  are  only  different 
scenes  on  the  protoplasmic  film.  In  a  mere  speck 
of  it  inheres  the  redness  of  the  rose,  the  green  of 
the  grass,  the  modesty  of  the  violet,  the  fragrance 
of  the  hyacinth — the  beauty  of  woman,  the  courage 
of  man,  the  majesty  of  the  intellect. 

Time  may  have  no  existence.  It  may  constitute 
only  a  necessity  of  thought.  It  may  exist  only  in 
speech.  One,  two,  three  years  ago — I  do  not  know 
— but  the  day  was  done,  when  Dr.  Beverley  Ran- 
dolph Tucker  placed  in  my  hands  a  bulky  manu- 
script with  the  request  that  I  submit  it  to  my 
judgment.  Even  when  four  o'clock  of  the  next 
morning  had  come  I  experienced  difficulty  in  turn- 
ing from  it  to  Morpheus.  What  an  unusual  and 
magnificent  experience  I  was  having!  Dr.  Tucker 
had  taken  me  to  a  place  of  detachment  from  which 
I  could  look  so  far  into  the  past  that  I  could  view 
the  invasion  of  Britain  by  Julius  Caesar  and  his 
legions,  and  from  which  I  could  see  also  far  into 
the  future  of  our  own  country.  Xarna  Darrell,  for 
that  is  the  title  of  the  historic  novel,  is  a  continu- 
ing account  of  our  civilization  here  in  America 
from  its  origin  in  those  far-distant  days  in  ancient 
England.  The  story  is  daring  in  conception  and 
dramatic  in  presentation. 

Is  Frank  R.  Stockton  ever  spoken  of  any  more? 
What  am  I  trying  to  recall?  Do  I  remember  cor- 
rectly? Or  is  the  Grand  Vizier  of  the  Two-Horned 
Alexander  only  a  dream?  But  Stockton  created 
an  individual  who  had  lived  from  the  beginning  of 
man  life  on  and  on  and  on  up  to  the  author's  own 
time,  without  ageing,  and  he  had  associated  with 
all  those  of  consequence,  and  his  e.xperiences  and 
reminiscences  spun  themselves  out  into  an  engaging 
tale. 

The  unexpected  approach  of  the  Roman  navy 
prevented  the  voluntary  sacrifice  of  the  life  of 
Narna,  a  savage  but  lovely  blonde  beauty  of  an- 
cient Britain.  She  stood  upon  the  cliff  high  above 
the  sea  awaiting  the  command  of  the  Druid  priests 
to  plunge  into  the  waves  as  an  offering  to  the  sun 


god.  But  the  god  was  to  go  unappeased.  The 
Roman  vessels  appeared;  soldiers  clambered  ashore. 
Narna  stood  alone.  Priests  and  people  fled  into  the 
forests.  Narna  and  Lucius,  a  Roman  officer,  loved 
at  sight.  They  lived  happily,  but  briefly.  War- 
fare terminated  their  lives.  But  Narna  left  a  little 
Lucius.  And  for  succeeding  generation  after  gen- 
eration— in  Britain,  in  Virginia,  and  in  other  states 
of  the  Union — there  was  a  golden -haired,  alluring 
Narna,  and  a  dark,  intellectual,  courageous,  domi- 
nating Lucius.  And  that  is  the  story;  and  a  splen- 
did, romantic,  adventurous,  joyous,  tragic,  catas- 
trophic, loving,  glamorous,  majestic,  solemn,  ludi- 
crous, pathetic,  angelic,  human,  god-like  account 
it  is  of  mortals — high,  low,  mediocre,  common, 
unknown.  But  every  single  one  of  the  many  Nar- 
nas  had  in  her  the  qualities  of  the  Mother  of  God 
and  every  Lucius  had  in  him  those  attributes  that 
caused  him  to  stand  head  and  shoulders  above  the 
human  herd.  Narna  Darrell  is  a  mighty  book. 
There  is  majesty  and  grandeur  in  the  sweep  and 
the  scope  of  it.  It  is  a  tale  wisely  and  brave  told. 
Only  a  physician  could  have  written  it.  Only, a 
believer  in  the  potency  of  heredity  and  the  fact  of 
human  immortality  could  have  conceived  it.  Only 
the  member  of  an  ancient  and  a  puissant  and  dig- 
nified and  a  wholesome  and  a  tolerant  family  could 
have  formulated  it.  One  does  not  read  it  without 
sensing  that  the  author  from  earliest  childhood  had 
heard  the  brave  tales  of  gallant  men  and  gracious 
women;  the  glory  of  life  and  the  dignity  of  death. 

Dr.  Tucker  is  the  Lucius  of  many  Luciuses.  In 
Britain,  in  Bermuda,  in  Virginia,  in  .America,  the 
family  is  old,  filled  with  honours,  yet  prolific  and 
powerful.  Few  whose  names  occupy  places  in  Vir- 
ginia's solemn  and  tragic  story  are  unrelated  to  this 
powerful  clan.  Their  procreative  protoplasm  has 
in  it  that  which  vitalizes  and  individualizes.  And 
that  is  the  story  of  the  book,  too;  the  worth  and 
the  immortality  and  the  god-likeness  of  the  indi- 
vidual. Blood  will  tell!  Who  doubts  it?  But  it 
should  declare  itself  in  the  aristocracy  of  intelli- 
gence and  courage  and  tolerance  and  love  and  in 
appreciation  of  beauty  and  wholesomeness  and  in 
duty  to  self  and  to  others  and  to  God. 

I  have  not  for  many  a  day  been  so  thrilled  by 
the  printed  page.  The  volume  may  be  had  in  Bos- 
ton of  the  Stratford  Company  for  $2.50.  You  will 
enjoy  the  exchange. 

The  True  Physician 
Even  a  remark  may  epitomize  the  individual. 
At  a  medical  meeting  not  long  ago  there  was  con- 
siderable discussion  about  the  therapeutic  value  of 
rest,  and  of  the  mechanisms  through  which  the 
patient  might  be  placed  in  that  blessed  state.  Even 
when  it  is  not  an  insult,  a  mere  question  may  be 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


a  disturber  of  the  peace.  Some  one  asked  what 
rest  is.  That  simple  interrogatory  released  an 
immense,  but  not  enlightening,  verbalization. 
Finally,  Dr.  Wingate  Memory  Johnson,  perhaps 
as  the  result  of  unseen  prodding,  for  he  is  a  shy 
man,  suggested  that  rest  and  comfort  are  practi- 
cally sj'nonymous  conditions;  that  where  pain  or 
discomfort  is  there  can  be  no  rest.  Straightway  I 
thanked  God  for  placing  in  our  midst  a  wise  man 
who  had  the  capacity  to  symbolize  his  opinions  in 
few  and  simple  words.  And  that  is  the  greatest 
gift  of  all  gifts.  There  are  sensible  people,  many 
of  them,  perhaps,  who  have  no  skill  either  in  the 
selection  or  in  the  neighborly  arrangement  of  words. 
And  for  that  reason  somewhat  of  a  barrier  exists 
betwixt  them  and  other  mortals.  But  the  indi- 
vidual who  is  gifted  in  the  use  of  language  has 
free  access  to  the  minds  of  all  mortals. 

No  other  procedure  is  so  provocative  of  sound 
thinking  as  persistent  practice  in  the  attempt  to 
set  forth  in  plain  and  lucid  language  one's  obser- 
vations and  opinions.  Not  long  ago  I  told  Dr. 
Beverley  R.  Tucker,  one  of  the  facultates  of  the 
Medical  College  of  Virginia,  that  the  medical  stu- 
dents in  that  ancient  institution  should  be  annually 
encouraged  by  someone  skilled  in  the  activity  to 
begin  simultaneously  with  their  treatment  of  the 
sick  to  record  their  observations — and  occasionally 
to  publish  them  in  a  medical  journal.  For  no 
other  mortal  is  permitted  to  have  those  intimate 
and  sacred  acquaintances  with  the  doings  and  the 
yearnings  of  our  fellow-creatures  as  we  physicians. 
Are  we  sufficiently  appreciative  of  that  hallowed 
privilege?  I  doubt  it.  Every  physician,  even  that 
one  unskilled  in  the  use  of  the  pen,  could  write  a 
best  seller,  where  the  revelations  of  his  professional 
experiences  not  violative  of  sacred  confidences.  The 
best  seller  only  fabricates  such  experiences. 

Once  I  heard  a  thoughtful  physician,  although  a 
psychiatrist,  say  that  heredity  is  only  the  crystalli- 
zation in  the  individual  of  ancestral  experiences. 
The  remark  pestered  me,  because  I  have  been  un- 
able either  to  accept  it  or  to  reject  it.  But  some 
force  that  we  speak  of -as  heredity  must  be  at  work. 
All  who  labour  with  vegetable  life  are  now  busy 
exhibiting  their  belief  in  its  existence  and  potency. 

There  are  writing  people.  And  Samuel  Johnson 
was  not  the  only  writing  Johnson,  though  he  was 
probably  the  most  famous  member  of  that  numer- 
ous family.  For  a  long  time  Charity  &  Children 
has  come  each  week  into  my  home,  and  I  always 
read  it.  That  little  publication  is  the  official  organ 
of  the  splendid  orphanage  maintained  at  Thomas- 
ville  in  North  Carolina  by  the  Baptist  people.  The 
late  Archibald  Johnson  was  for  many  years  the 
editor.  He  was  endowed  with  a  thinking  mind, 
and  with  the  capacity  to  formulate  in  simple,  clear 


and  appealing  language  what  he  thought  about 
things  and  people.  He  had  the  requisite  degree  of 
courage  to  make  his  language  his  servant.  His 
son  is  Gerald  W.  Johnson,  once  an  editorial  writer 
of  the  Greensboro  Daily  News,  once  the  professor 
of  journalism  in  the  University  of  North  Carolina, 
and  now  an  editorial  contributor  to  the  Evening 
Sun  of  Baltimore.  And  in  between  times  he  has 
given  us  Andrew  Jackson,  John  Randolph,  and 
others  and  other  things.  The  Biblical  Record- 
er of  Raleigh  is  the  journal  of  the  Baptist  Church 
in  North  Carolina.  And  for  a  longer  period  than  I 
can  remember  it  has  been  one  of  the  mightiest  and 
most  beneficent  influences  in  that  great  state.  For 
a  long  time  its  editor  was  the  late  Dr.  Livingston 
Johnson.  Archibald  Johnson's  pen  is  moved  in 
Baltimore  by  the  hand  of  his  son  Gerald;  the  pen 
of  Livingston  Johnson  is  held  by  the  fingers  of  his 
son,  Dr.  Wingate  M.  Johnson,  in  Winston-Salem. 
Who  doubts  either  the  influence  of  heredity,  or  the 
fact  of  human  immortality? 

If  you  read  Southern  Medicine  &  Surgery,  Hy- 
geia,  Harper's,  or  the  Atlantic  Monthly,  you  have 
met  Dr.  Johnson  in  those  pages.  The  writing  per- 
son who  reaches  Harper's  or  the  Atlantic  is  as  fully 
arrived  in  authorship  as  the  politician  has  succeed- 
ed who  becomes  a  member  of  the  Presidential 
Cabinet.  But  Dr.  Johnson  is  no  professional  writer. 
He  writes  neither  for  money  nor  for  fame.  Per- 
haps he  cannot  help  it.  It  may  be  a  form  of  mental 
itch.  When  Thomas  Carlyle  was  asked  to  name 
the  most  satisfying  experience  he  replied  untar- 
dily:  to  scratch  the  place  that  itches. 

I  have  no  desire  to  reduce  your  plutocracy.  But 
I  suggest  that  you  transmit  $L75  of  it  at  once  to 
MacMillan's  for  a  copy  of:  The  True  Physician, 
by  Dr.  Wingate  M.  Johnson.  If  you  are  a  young 
physician  you  will  discover  that  the  medical  college 
did  not  teach  you  all  about  the  practice  of  medi- 
cine, and  that  wrestling  with  diseases  constitutes 
a  small  part  of  that  titanic  and  continuing  engage- 
ment; if  you  are  no  longer  young  you  will  experi- 
ence the  comfort  of  learning  that  you  can  still  add 
to  your  professional  development. 

I  was  glad  to  read  in  the  very  first  chapter  that 
the  physician  should  have  a  certain  brave  disre- 
gard of  public  opinion,  and  a  fine  contempt  for 
so-called  authority,  and  that  the  broom  with  which 
he  dusts  down  cobwebs  from  his  own  mind  should 
be  always  within  easy  reach.  A  chapter  is  devoted 
to  the  happy  days  of  interneship;  another  to  the 
importance  of  the  type  of  professional  work  and 
the  best  location  for  it;  and  the  fourth  chapter 
carries  sound  and  practical  advice  about  the  office 


SOUTHERN  MEDICINE  AND  SURGERY 


AprU,  1936 


set-up,  living  quarters,  attention  to  office  hours, 
and  how  to  deal  with  dopers,  dead  beats,  those 
who  have  procreated  beyond  the  walls  of  wedlock, 
and  the  best  use  to  make  of  the  too-much  leisure 
time.  Succeeding  chapters — there  are  twelve  of 
them  in  all — have  to  do  with  the  medical  man  as 
student,  as  citizen,  as  business  man,  as  a  witness 
in  court,  and  with  the  constant  risk  he  runs,  unless 
careful  and  terribly  honest,  of  becoming  entangled 
in  the  law — that  made  by  God  as  well  as  that 
formulated  by  man.  The  doctor  is  a  human  being, 
contrary  to  sometimes-encountered  opinion,  and  he 
must  needs  give  thought  to  that  personal  aspect  of 
himself.  The  last  section  of  the  volume  is  an 
elaboration  of  the  hope  that  the  young  doctor  will 
continue  to  be  a  reading  man,  and  Dr.  Johnson 
makes  out  a  list  of  sixteen  books  that  he  himself 
enjoys.  To  that  list  I  should  add:  Bacon's  and 
Montaigne's  essays;  Uncle  Remus;  Alice  in  Won- 
derland; The  Rubaiyat  of  Omar  Khayyam;  The 
Confession  of  Faith;  and  The  True  Physician.  The 
latter  book  will  help  the  doctor  to  understand  how 
he  can  get  along  more  comfortably  and  more  help- 
fully with  the  sick  person;  with  well  people;  with 
the  past,  through  the  medium  of  books;  with  the 
future,  through  honest,  fruitful  activity;  and  with 
himself,  by  knowing  himself  better.  Every  physi- 
cian should  constitute  Plato's  conception  of  a  true 
physician.  Dr.  Johnson  does  that  as  a  good  family 
doctor  in  Winston-Salem;  as  a  good  citizen;  and 
as  a  writer  who  inspires  his  readers  to  try  to  live 
more  nearly  as  he  lives. 


THERAPEUTICS 

Frederick  R.  Taylor,  B.S.,  M.D.,  F.A.C.P.,  Editor 
High  Point,  N.  C. 


High  Spots  From  the  New  Chapters  of  the 
Oxford  Loose-leaf  Medicine 

A  new  group  of  chapters  was  recently  published 
for  the  Oxford  Loose-leaf  Medicine.  Drs.  Crowe 
and  Baylor  of  Johns  Hopkins  have  a  new  chapter 
on  Infections  of  the  Upper  Air  Passages  and  Their 
Relation  to  General  Systemic  Disorders.  It  is  a 
valuable  and  greatly  needed  chapter,  as  this  subject 
had  not  previously  been  adequately  covered  in  the 
Oxford  System. 

Drs.  Castle  and  Minot  have  a  colossal  treatise 
of  200  pages  on  The  Anemias  replacing  a  smaller 
chapter  on  the  subject  by  Dr.  Minot.  It  is  so 
exhaustive  as  to  be  exhausting  to  read,  but  is  about 
the  last  word  on  the  subject  to  date.  The  subject 
of  the  anemias  seems  so  complex  after  reading  this 
chapter  that  a  mere  internist  feels  as  if  no  one  but 
a  hematologist  could  handle  an  anemic  patient 
properly,  if  he  takes  the  chapter  too  seriously! 
There   are   two   interesting   and    important    tables 


showing  the  proper  dosage  of  substances  used  in 
the  treatment  of  the  anemias  which  we  will  abstract 
here. 

Approximate    Daily  Amounts   of   Substances   Necessary  to 

Produce    Maximal     Reticulocyte    Responses    in 

Pernicious    Anemia 


Substance 


Liver  or  kidney  

Desiccated   hog   stomach- 
Liver  extracts 


Weight  or 
Volume 

Prepared 
„_  400  gm. 
-—    30     gm. 


Route  of 
Administration 


Aqueous   concentrate 65      c.c. 

Precipitate  95%   alcohol,  frac- 
tion  "G" 27      gm. 

Dilute  solution  of  fraction  "G"      2     c.c. 
Concentrated  solution  of  frac- 
tion   "G"    (commercial). 


Intramuscular 


Liver-stomach    preparation    4.5  gm.    Oral 

Intramuscular  treatment  may  be  given  once  a 
week  using  7  times  the  dose  shown  as  the  daily 
optimum.  The  authors  point  out  that  the  most 
economical  method  of  treatment  is  the  intramuscu- 
lar, and  note  that  it  is  a  strange  thing  that  we  give 
the  patient  instructions  how  to  give  himself  in- 
sulin, a  drug  that  has  grave  dangers  in  overdosage* 
while  we  rarely  do  so  with  regard  to  intramuscular 
liver  preparations,  though  it  is  impossible  to  do 
harm  with  any  ordinary  overdose  of  such  prepara- 
tions, and  they,  like  insulin,  have  to  be  taken  over 
a  very  long  period  of  time.  Where  economy  is 
essential,  patients  should  be  given  a  potent  prep- 
aration of  liver  extract  for  intramuscular  use  and 
trained  to  give  it  to  themselves. 

Approximate    Daily   Amounts  of   Substances   Necessary   to 

Produce    Maximal    Hemoglobin    Production    in 

Hypochromic  Anemia 

Weight  or        Route  of 
Volume    Administration 

Prepared 

6.0    gm.     Oral 

0.19  gm.     Intramuscular 


Substance 

Ferric  Ammonium   Citrate 

Ferrous     Carbonate      (Blaud's 

pills) , 

Ferrum  reductum 

Ferrous   sulphate 


4.0    gm.    Oral  « 
3.0    gm.      " 
0.8     gm. 


Liver,   concentrated  water  ex- 
tract    45.0    c.c.      " 

Liver,    70%    alcohol    insoluble  » 
fraction 12       gm.      " 

The  above  dosage  is  for  "idiopathic"  hj'po- 
chromic  anemias.  In  hypochromic  anemias  du3  to 
chronic  blood  loss,  half  the  above  dose  or  less  may 
prove  of  maximal  effect,  so  far  as  iron  preparations 
go,  and  the  liver  preparations  are  not  recommended 
for  ordinary  use  in  these  anemias.  It  would  thus 
appear  that  ferrous  sulphate  is  the  preparation  of 
choice  in  the  iron  group  for  oral  use,  and  ferric 
ammonium  citrate  for  intramuscular  use.  In  gen- 
eral, oral  therapy  is  to  be  preferred  when  giving 
iron. 

Dr.  Montgomery  of  the  Mayo  Clinic  has  a  new 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


chapter  on  Mycosis  Fungoides,  Lymphoblastoma 
of  the  Skin,  and  Allied  Conditions  as  General  Dis- 
eases that  covers  an  interesting,  though  distressing 
group  of  conditions. 

Dr.  E.  B.  Vedder  of  George  Washington  Univer- 
sity has  made  a  very  careful  and  thorough  revision 
of  his  chapter  on  Beri-beri  and  Epidemic  Dropsy. 

By  far  the  most  important  chapter  in  this  group, 
from  the  present  writer's  viewpoint  is  the  new 
chapter  on  Amebiasis  by  Col.  Craig  of  Tulane. 
There  is  so  much  that  is  new  and  important  in  it, 
that  it  is  hard  to  select  from  the  material.  Col. 
Craig  has  worked  out  a  dependable  complement 
fixation  test  for  amebiasis.  He  emphasizes  the 
point  that  amebic  dysentery  is  merely  one  mani- 
festation of  amebiasis,  and  that  most  amebiasis 
patients  do  not  have  dysentery,  but  are  either 
carriers  or  have  merely  vague  gastrointestinal 
symptoms.  He  makes  the  startling  statement  that 
about  10  per  cent,  of  the  inhabitants  of  the  United 
States  have  amebiasis,  though  only  a  small  fraction 
of  these  have  amebic  dysentery.  Chlorine  water 
"sterilization"  does  not  destroy  Endamocba  histo- 
lytica. Infected  water  must  be  boiled  to  be  safe. 
Actively  motile  forms  of  Endamoeba  histolytica  do 
not  transmit  the  disease  to  healthy  persons  with 
normal  hydrochloric  acid  concentration  in  the 
stomach,  as  the  acid  destroys  the  parasite.  Only 
the  cysts  are  infective  to  such  persons.  Hence  the 
actively  sick  patient  with  amebic  dysentery  is  safe 
to  work  with,  whereas  the  cyst  carrier,  often  devoid 
of  symptoms,  is  a  public  menace.  Emetin  and 
other  ipecac  preparations  fail  to  cure  about  85  per 
cent,  of  cases.  They  should  not  be  used  to  cure, 
but  only  to  quickly  relieve  dysentery  or  to  treat 
early  liver  abscess.  Even  then,  1  grain  a  day  for 
12  days  is  the  amount  recommended,  which  should 
not  be  exceeded.  Other  drugs  are  far  more  effective 
in  curing,  notably  chiniofon  (yatren),  carbarsone, 
and  vioform.  The  first-  and  last-named  drugs  are 
iodine-containing,  and  very  safe.  Carbarsone  is 
an  arsenical  and  the  safest  of  that  group  of  drugs, 
acetarsone  being  more  toxic.  For  carriers,  3  or  4 
four-grain  pills  of  chiniofon  three  times  a  day  are 
recommended,  keeping  up  the  treatment  for  10 
days.  The  whole  course  may  be  repeated  after  a 
week's  rest  if  necessary.  If  chiniofon  fails,  a  4- 
grain  capsule  of  carbarsone  may  be  given  twice 
daily  for  10  days,  watching  the  patient  for  signs 
of  arsenic  intolerance.  Or  vioform  may  be  used, 
giving  4  grains  three  times  daily  for  10  days,  rest- 
ing a  week,  and  repeating  the  course.  When  acute 
dysentery  or  liver  abscess  requires  emetin,  it  should 
be  given  hypodermically,  rather  than  by  mouth. 
Many  other  drugs  have  been  recommended,  but 
Craig  sticks  pretty  closely  to  the  above  program. 
Dr.  Strong  of  Harvard  has  an  interesting  new 


chapter  on  Onchocerciasis,  a  disease  of  certain  parts 
of  Africa,  Guatemala  and  Mexico. 

The  present  writer  has  a  new  chapter,  really  a 
continuation  of  a  previous  one,  on  Unusual  Dis- 
eases and  Symptom  Complexes  Not  Discussed  Else- 
where in  the  System.  The  new  group  of  diseases 
include  Atrophy  of  the  Gray  Matter  of  the  Brain 
(Arnold  Pick's  Disease,  Alzheimer's  Disease),  Pro- 
gressive Centrolobar  Sclerosis  (Pelizaeus-Merz- 
bacher Disease,  Schiller's  Disease,  etc.).  Von 
Gierke's  Glycogen  Disease,  Progressive  Hypertro- 
phic Polyneuritis,  Ileus  With  Transient  Renal  In- 
sufficiency (Wakefield-Mayo-Bargen  syndrome). 
Hereditary  Arthrodysplasia  with  Dystrophy  of  the 
Nails,  and  Hypertelorism. 

Von  Gierke's  glycogen  disease  is  perhaps  the 
most  interesting  condition  of  this  group.  There  are 
three  types — the  hepatorenal,  the  cardiac  and  a 
vague  cerebral  type.  The  hepatorenal  type  is  the 
most  frequent,  though  the  disease  is  rare,  only 
about  15  cases  having  been  reported  in  the  litera- 
ture. In  that  type  there  is  an  enormous  liver 
without  marked  jaundice,  without  ascites  or  en- 
gorged veins,  etc.  The  disease  begins  usually  in 
infancy  or  early  childhood.  The  liver  or  heart, 
and  often  also  the  kidneys,  become  much  enlarged 
due  to  the  deposition  and  "fixation"  of  glycogen 
in  them.  Ketonuria  is  usually  present  without 
glycosuria  or  starvation  or  any  of  the  usual  causes 
of  ketonuria,  and  there  is  a  strong  odor  of  acetone 
on  the  breath  as  a  rule.  Injection  of  adrenalin  fails 
to  mobilize  the  "fixed"  glycogen,  hence  it  does  not 
raise  the  blood-sugar  level — a  very  diagnostic  test. 
There  is  no  effective  treatment  for  the  disease. 


INTERNAL  MEDICINE 

W.  Bernard  Kinlaw,  M.D.,  F.A.C.P.,  Editor  Pro  Tern, 
Rockv  Mount,  N.  C. 


Acute  Abdominal  Disease  Simulating 
Coronary  Occlusion 
The  diagnosis  of  coronary  occlusion  has  been 
quite  popular  during  the  past  few  years,  and  rightly 
so.  Even  now,  after  many  reports  of  cases  and 
with  much  in  the  literature  about  the  condition, 
one  cannot  help  but  feel  a  little  proud  when  he 
makes  the  correct  diagnosis.  Every  textbook  and 
all  papers  or  lectures  discuss  how  easily  coronary 
occlusion  may  be  mistaken  for  some  acute  abdom- 
inal condition,  but  there  has  been  a  noticeable 
absence  of  articles  dealing  v/ith  the  subject  of  acute 
abdominal  disease  being  mistaken  for  coronary  oc- 
clusion. About  two  years  ago  I  saw  one  such  case 
and  just  recently  I  have  seen  three  others.  Coro- 
nary occlusion  was  suspected  in  all  four.  Barker, 
Wilson  and  Coller  reported  four  cases  in  the  Amer- 
ican Journal  oj  the  Medical  Sciences  in  August, 
1934.    Two  were  due  to  gall  bladder  disease,  one 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


to  perforation  of  a  gastric  ulcer  and  in  the  fourth 
there  was  a  combination  of  cholelithiasis  and  coro- 
nary disease.  There  were  three  cases  of  mesenteric 
thrombosis  and  one  of  acute  pancreatitis  in  the 
four  that  I  had  observed.  The  latter,  a  man  of 
38  years  but  appearing  at  least  45,  was  admitted 
at  10  p.  m.,  having  had  an  onset  with  acute  epi- 
gastric pain  16  hours  before.  There  was  some 
pain  under  lower  sternum,  and  he  had  been  short 
of  breath.  After  morphine  he  vomited  several 
times  during  the  day.  .'\t  the  onset,  coronary  oc- 
clusion was  suspected,  but  as  the  case  progressed 
the  referring  doctor  thought  it  was  most  likely  an 
abdominal  condition  but  wanted  an  electrocardio- 
gram to  answer  the  question  in  his  mind  that  it 
might  be  a  case  of  coronary  thrombosis.  There 
was  nothing  even  suspicious  of  occlusion  in  either 
of  the  four  leads.  He  was  in  a  very  critical  condi- 
tion and  died  six  hours  after  admission  to  the  hos- 
pital. Post-mortem  examination  revealed  a  very 
extensive  acute  pancreatitis.  Surgery  could  not 
have  saved  this  patient  had  he  been  operated  on 
early,  in.  the  day. 

An  interesting  point  in  one  of  the  cases  of  mesen- 
teric thrombosis  was  that  his  intense  pain  was 
nearly  relieved  by  the  inhalation  of  amyl  nitrite, 
which  caused  the  physician  to  wonder  if  he  was 
dealing  with  angina  pectoris.  The  diagnostic 
point  was  that  he  had  been  suffering  with  acute 
pain  for  over  three  hours  when  the  nitrite  was 
given.  This  duration  would  surely  exclude  angina; 
and  the  pain  of  coronary  occlusion  would  not  be 
relieved  by  the  nitrites,  whereas  spasm  of  the  eso- 
phagus or  other  portion  of  the  gastrointestinal  tract 
may,  and  usually  will,  be  relieved  by  this  drug. 
Rigidity  soon  appeared,  and  he  was  operated  on 
and  a  very  extensive  mesenteric  thrombosis  found. 
The  usual  outcome  followed  within  24  hours. 

At  the  onset  of  these  cases  it  may  be  very  diffi- 
cult to  diagnose  the  trouble,  and  error  is  easily 
made.  Serial  electrocardiograms  are  helpful  and 
necessary.  If  the  first  one,  using  all  four  leads,  is 
not  typical  of  the  condition,  a  tracing  made  a  few 
hours  later  will  give  a  hint  that  the  trouble  is 
above  the  diaphragm.  The  surgeon  naturally  wor- 
ries about  coronary  disease  in  every  acute  upper- 
abdominal  pain  in  patients,  especially  men  past 
37.  If  a  very  severe  pain  in  the  abdomen  is  due 
to  coronary  occlusion,  there  will  nearly  always  h; 
some  substernal  pain  also  and  some  early  alteration 
in  pulse — features  not  seen  early  in  the  abdominal 
case.  The  leukocyte  counts  usually  go  up  higher 
and  faster  in  the  abdominal  conditions  and  the 
many  other  differences  are  known,  but  it  is  not  the 
purpose  here  of  differentiating  between  the  two 
conditions. 

There  can  be  a  similarity  early  after  onset  when 


surgical  activity  may  be  necessary  if  the  disease  is 
below  the  diaphragm,  and  masterly  inactivity  if 
above.  iMany  surgeons  have  operated,  expecting 
to  find  an  acute  process  in  the  abdomen,  and  later 
see  the  patient  present  typical  signs  of  coronary 
occlusion.  In  cases  that  the  medical  man  believes 
to  be  coronary  occlusion  with  pain  in  the  abdo- 
men, a  surgical  consultant  will  be  very  helpful  as 
his  fingers  will  detect  rigidity,  rebound  tenderness 
and  other  signs  of  the  acute  abdominal  disease 
more  quickly  than  will  those  of  his  medical  col- 
leagues. A  check  on  each  other  with  an  argument, 
if  necessary,  is  often  very  helpful  to  the  patient. 


SURGERY 

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


The  Treatment  of  Peritonitis 
Peritonitis  may  be  a  complication  of  so  many 
lesions  and  so  many  infectious  diseases  that  almost 
any  physician  may  be  called  upon  to  treat  it  in 
his  work.  It  is  always  a  serious  condition  with  a 
guarded  prognosis  and  an  uncertain  outcome.  Ifs 
course  and  termination  depend  upon  the  lesion  or 
disease  which  it  complicates,  upon  the  resistance 
of  the  patient,  upon  the  virulence  of  the  infecting 
organism  and,  by  no  means  least,  upon  the  treat- 
ment. Any  localized  pus  pocket  or  abscess  should 
be  drained  surgically  at  which  time  the  primary 
focus  or  lesion,  such  as  a  gangrenous  appendix, 
should  be  removed  if  possible. 

A  fundamental  principle  in  the  treatment  of  any 
inflammation  is  rest.  This  is  best  obtained  in  peri- 
tonitis by  the  repeated  administration  of  morphine 
so  as  to  keep  the  respiration  below  IS  per  minute. 
-A-dults  should  be  given  ^4  grain  every  3  hours  if 
respirations  are  IS  or  above.  Old  people  do  not 
tolerate  morphine  well;  it  has  a  cumulative  effect. 
The  position  of  the  old  should  be  changed  often 
and  if  there  is  no  contraindication  use  a  back-rest 
to  lessen  the  danger  of  lung  congestion  and  h\'pos- 
tatic  pneumonia.  Children  tolerate  morphine  well. 
Septic  patients  require  more  of  the  drug  for  full 
physiological  effect  than  do  normal  individuals.  It 
is  difficult  to  impress  upon  the  nurse  the  absolute 
necessity  for  adequate  morphine  in  cases  of  peri- 
tonitis. Contrary  to  the  old  teaching,  physiologists 
have  demonstrated  on  lower  animals  that  the  mus- 
cular tone  of  the  gut  is  increased,  not  decreased, 
by  morphine. 

Complete  rest  of  the  gut  can  be  maintained  only 
by  keeping  it  empty.  Nothing,  not  even  water, 
should  be  given  by  mouth.  This  should  be  ex- 
plained carefully  to  the  patient  and  to  the  family 
in  language  they  can  understand  so  that  their  full 
cooperation  may  be  had;  otherwise  they  are  apt  to 
become  resentful   as  the  patient   remains   '.vithout 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


227 


food  day  after  day.  It  should  be  realized,  however, 
that  an  empty  stomach  is  much  more  conducive  to 
comfort  and  to  safety  than  a  full  one  which  is  not 
in  condition  to  digest  food. 

Cathartics  cause  active  peristalsis  and  are  deadly 
in  peritonitis.  Evacuation  by  enema  is  safe.  A 
rectal  tube  left  in  place  affords  a  vent  for  gas. 

Nausea  and  spitting  up  regurgitated  gastric  and 
intestinal  contents  are  distressing  symptoms  of 
peritonitis.  Repeated  lavage  leaving  the  stomach 
empty  after  each  washing  gives  great  relief.  For 
very  ill  patients  an  indwelling  duodenal  tube  passed 
through  the  nose  is  often  life-saving.  Through  it 
the  to.xic  gastric  contents  may  be  removed  at  will 
without  the  ordeal  of  passing  the  tube.  It  allows 
the  escape  of  gas  and  prevents  distention. 

Fluid  should  be  given  in  maximum  quantity  to 
prevent  dehydration  and  to  promote  the  elimination 
of  toxins.  By  giving  it  as  normal  salt  solution 
demineralization  of  the  tissues  is  prevented.  It 
may  be  given  by  vein  or  my  hypodermoclysis, 
either  of  which  may  be  supplemented  by  proctocly- 
sis. Acutely  toxic  patients  should  be  given  3  or  4 
liters  (about  a  gallon)  of  fluid  a  day. 

Glucose  provides  a  readily  assimilable  carbohy- 
drate food  that  maintains  tissue  needs  admirably. 
By  it  both  acidosis  and  starvation  are  prevented  so 
that  patients  may  be  kept  in  fairly  good  condition 
for  2  weeks  or  more.  It  may  be  given  in  a  vein 
but  is  well  tolerated  under  the  skin  in  5  per  cent, 
solution.  When  repeated  administration  is  neces- 
sary it  is  best  given  in  normal  salt  solution  by 
continuous  intravenous  drip  given  through  an  in- 
dwelling needle  or  cannula.  Ochsner  advises  the 
addition  to  the  solution  of  enough  insulin  to  bal- 
ance the  glucose  given.  He  has  found  by  experi- 
ment that  this  preserves  the  muscular  tone  of  the 
intestine,  whereas  glucose  without  the  insulin  de- 
presses it. 

In  this  editorial  we  have  outlined  the  treatment 
of  peritonitis  which  we  have  found  effective  in 
practice.  No  originality  is  claimed  but  we  feel 
sure  that  if  the  details  are  followed  as  suggested 
Nature  will  be  materially  aided  in  localizing  or 
overcoming  the  infection.  Peritonitis  is  usually 
self-limited  and  in  a  few  days  in  favorable  cases 
resolution  begins. 


PSYCHIATRy  IN  THE  GENERAL  PRACTICE  07  MeDICINE 
(C.  N.  Sarlin,  Tucson,  In  Souwes.  Med.,  Mar.) 
_  Psychiatric  problems  are  not  limited  to  obvious  emo- 
tional and  mental  difficulties.  Many  patients  suffer  from 
psychogenic  disturbances  manifested  in  the  form  of  physi- 
cal symptoms.  Marital  problems  cause  many;  compulsive 
acts^  are  noted.  One  washes  continuously  to  overcome  in- 
fection; one  woman  suffers  from  the  obsessive  fear  that 
she  is  going  to  kill  her  children. 

The  patient  frequently  recognizes  the  causative  factor  as 
absurd  and  yet  it  is  out  of  control  of  his  reasoning.     One 


will  seek  situations  upon  which  to  express  anxiety  caused 
by  factors  of  which  he  is  totally  unaware. 

The  psychopathic  individual's  behavior  stamps  him  as 
abnormal  although  he  manifests  no  symptoms  in  the  usual 
sense  of  the  term.  Many  alcohohcs  and  drug  addicts  be- 
long in  this  class. 

The  treatment  of  the  psychoses  excepting  cases  of  pare- 
sis is  still  woefully  inadequate. 

The  medical  profession  as  a  whole  has  not  recognized 
that  drug  addiction  and  chronic  alcoholism  are  psychiatric 
problems  in  persons  needing  thorough  psychiatric  re-educa- 
tion— difficult  to  apply,  time-consuming,  and  not  always 
successful.  As  a  result  these  patients  are  treated  as  moral 
outcasts. 

Perhaps  because  of  the  medical  profession's  own  inade- 
quacy in  the  treatment  of  the  psychoneuroses,  it  has  taken 
an  attitude  almost  of  censure. 

Beginning  to  permeate  the  medical  profession  is  the  fact 
that  unhappiness,  so-called  nervousness,  and  mild  states  of 
depression,  frequently  resulting  from  maladjustments  in 
marital  problems,  are  psychogenic  in  origin. 

One  patient  e.xpresses  his  difficulties  in  emotional  fonn 
whereas  another  converts  his  problems  into  physical  symp- 
toms. 

No  man  practicing  medicine  can  dismiss  the  problem  of 
the  hysteric.  There  is  hysterical  blindness  and  contracture 
of  visual  fields.  Aphonia,  vertigo,  sinus  conditions,  nervous 
indigestion,  anorexia,  vomiting,  pain,  diarrhea,  and  consti- 
pation may  be  hysterical  phenomena. 

Women  insisting  upon  repeated  gynecological  treatments, 
or  complaining  of  pelvic  pain,  backache,  dysmenorrhea 
and  amenorrhea — all  this  may  be  psychogenic. 

Eneuresis  is  almost  always  a  psychoneurotic  symptom. 
We  have  all  seen  bedwetting  continuing  late  into  childhood 
almost  miraculously  cured  by  removal  of  adenoidal  tissue. 
The  cure  was  not  directly  from  the  removal  of  lymphoid 
tissue,  but  in  the  psychological  reactions  associated  there- 
with. 

Incipient  pulmonary  tuberculosis  is  frequently  confused 
with   the  hypochondriacal  symptoms   of   the   neurasthenic. 

Chronic  appendicitis  and  adhesions  are  diagnoses  which 
all  too  frequently  represent  the  desire  of  these  patients  to 
be  operated  upon. 

Labeling  a  patient  hysteric  solves  no  problems.  Many 
hysterics  do  not  wish  to  be  cured  despite  their  protesta- 
tions to  the  contrary. 

Many  clinicians  of  repute  emphasize  the  psychogenic 
factor  in  mucous  colitis,  gastric  ulcer,  hyperthyroidism, 
asthma  and  so-called  allergic  states. 

There  are  three  groups  of  psychiatric  patients.  The 
first  have  obvious  nervous  and  mental  symptoms.  The 
second  present  varying  and  bizarre  complaints  without 
demonstrable  organic  pathology.  The  last  group  present 
unquestioned  organic  pathology  resulting  from  psychogenic 
causes  and  can  be  completely  cured  only  by  proper  treat- 
ment of  the  psychic  factors. 


The  Teaching  of  PnARMAcor.ocy 
(Wm.  deB.  MacNider,  Chapel  HUl,  in  Jl.  Assn.  Amer 
Med.  Colleges,  March) 
The  teaching  of  the  bulk  of  pharmacological  information 
depends  very  largely  on  the  personality  of  the  instructor. 
The  amount  should  not  be  large.  The  presentation  should, 
of  course,  be  from  an  experimental  point  of  view,  employ- 
ing, first,  normal  tissues,  and  later  a  scattering  of  experi- 
mentally induced  pathological  states  in  which  chemical 
action  may  be  studied  for  the  purpose  of  emphasizing  the 
influence  of  such  changes  on  drug  action.  It  is  only 
through  this  type  of  instruction,  which  in  certain  instances 
may  finally  be  carried  to  the  bedside,  that  a  scientific 
therapeutics  can  be  developed. 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  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 
Eye,  Ear  and  Throat  Hospital  Group         Charlotte,  N.  C. 
Orthopedic   Surgery 

O.  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. 

Obstetrics 

Henry  J.  Lancston,  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 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 -- Albemar.e,  N.  C. 

Cardiology 

Clyde  M.  Gilmore,  A.B.,  M.D .  Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Enneti,  M.D Greenville,  N.  C. 

Radiology 

Allen  Barker,  M.D.        I     _ Petersburg,  Va. 

Wright  Clarkson,  M.D. ) 


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. 


For  Asserting  Ourselves  in  Elections 

The  Annual  Meeting  of  the  Medical  Society  of 
the  State  of  North  Carolina  is  only  two  or  three 
weeks  off.  In  his  president's  page  in  this  journal's 
issue  for  March,  President  Paul  H.  Ringer  came 
out  for  a  measure  that  we  have  been  advocating 
all  along,  and  which  we  earnestly  hope  he  will 
urge  upon  the  Society  in  his  presidential  address. 
This  is  the  matter  of  seeing  that  ^ledicine  has 
proper  representation  in  the  General  Assembly  of 
the  State. 

As  President  Ringer  says,  there  are  many  diffi- 
culties in  the  way  of  doctors  accepting  such  office; 
but,  as  he  goes  on  to  say,  we  can  "select  as  our 
representatives  individuals  who  will  be  favorably 
disposed  to  the  desires  and  objectives  of  the  medi- 
cal profession."  And  he  urges  that  doctors  through- 
out the  State  take  individual  and  collective  action 
in  ascertaining  in  advance  the  attitude  of  would-be 
representatives  in  both  Houses;  and  then  we  have 
only  to  agree  on  proper  candidates  and  work  daily 
for  their  election. 

You  may  depend  on  it,  the  person  who  puts  it 
out  that  politics  are  too  dirty  for  decent  folks  to 
have  anything  to  do  with  is  one  who  finds  them 
just  dirty  enough  for  him;  and  that  his  eagerness 
to  keep  decent  people  from  exercising  all  their 
political  rights  has  its  origin  in  his  and  his  associ- 
ates desire  to  keep  politics  dirty. 

Remember,  too,  that  primary  elections  are 
usually  the  deciding  ones  with  us.  Get  the  candi- 
dates' statements  witnessed — preferably  signed — 
and  make  sure  the  statements  are  definite  and  to 
the  point. 

An  editorial  in  an  alert  and  energetic  State  med- 
ical journal  just  off  the  press,  under  the  title 
"Lick  'Em  in  the  Primaries,"'  tells  us  that  the 
great  majority  of  the  county .  medical  societies  in 
that  State  have  committees  to  look  after  such 
work;  and  it  quotes  "a  real  student  of  Indiana 
politics" — a  Hoosier  Aus  Watts,  probably — as  au- 
thority for  the  statement  that  the  doctors  of  In- 
diana, acting  together,  can  get  anything  they  want 
and  stop  anything  they  do  not  want,  in  the  State 
Legislature.  That's  just  what  we  have  said,  times 
without  number,  about  the  doctors  of  North  Caro- 
lina; but  it  can  not  be  done  by  going  fishing  on 
election  day,  or  in  any  other  way  than  b}'  (1) 
finding  out  what  men  stand  for,  (2)  agreeing  on 
candidates,  and  then  (3)  giving  these  candidates 
the  votes  and  the  full,  vigorous  and  enthusiastic 
support  of  every  one  oj  us. 

It  is  well  to  remind  that  members  of  Congress 
are  to  be  chosen  this  year,  and  that  there  are  some 
circumstances  appertaining  to  this  case  of  special  j 


1.     Journal  Indiana  State  Medical  Journal,  Apr. 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


229 


concern  to  doctors  as  doctors,  in  addition  to  those 
which  concern  us  as  citizens. 

Reports  in  the  daily  papers  from  Government 
hospitals  of  how  such  and  such  a  sick  Cabinet 
Member,  Senator  or  Representative  was  getting 
along  aroused  our  interest  as  to  why  said  politician 
was  not  in  a  private  hospital  paying  his  own  way, 
as  a  tax-paying  citizen  with  a  fourth  the  income 
of  the  tax-eating  politician  must  pay. 

A  letter  of  inquiry  despatched  to  Washington 
brought  prompt  and  pertinent  response.  By  chance 
it  happened  that  only  very  recently  the  Washing- 
ton Herald  made  an  investigation  and  reported  the 
result  in  its  issue  for  IMarch  ISth:  or,  maybe  it 
was  not  by  chance;  probably  the  Herald's  interest, 
like  our  own,  was  elicited  by  the  numerous  reports 
of  cheap  politicians  who  had  landed  high-priced 
jobs  practically  forcing  their  way  into  hospitals 
the  Government  had  provided  for  employees  who 
receive  small  salaries  and  whose  hospital  care  is 
part  of  their  meager  pay,  often  to  the  exclusion  of 
those  for  whom  the  hospitals  were  provided. 

Quoting  the  Herald: 

"Congress  has  a  medical  racket  of  its  own. 

The  same  Congressmen  who  cut  the  medical  appropria- 
tion for  the  District  to  a  point  deemed  dangerous  by 
noted  physicians  are  benefited  by  a  hospital  racket  which 
assures  the  $10,000-a-year  pubHc  servants  medical  atten- 
tion at  a  figure  far  below  what  any  ordinary  citizen  of 
Washington  could  hope  for  or  expect. 

For  Congressmen,  high  officials,  and  White  House  secre- 
taries. Naval  Hospital  is  wide  open.  For  war  veterans  it 
is  shut  tight. 

If  the  ordinary  citizen  of  Washington  wanted  a  private 
room  in  a  hospital,  with  bath,  food,  medical  attention, 
nurses  and  attendants,  it  would  cost  between  .$10  and  $15 
a  day.  But  if  a  member  of  Congress  wants  the  same 
service,  he  pays  $3.75  a  day  at  Naval  Hospital.  And 
between  50  and  60  Congressmen  are  "guests"  at  Naval 
Hospital  every  year.  At  this  moment,  there  are  three 
members  at  Naval  Hospital — Representative  Alfred  D. 
Beiter  and  William  D.  Thomas  of  New  York  and  Repre- 
sentative John  Kee  of  West  Virginia. 

The  situation  at  Naval  Hospital  may  be  brought  to  a 
head  by  a  bill  introduced  by  Representative  Rankin,  chair- 
man of  the  Committee  on  Veterans,  which  says: 

'Notwithstanding  any  provision  of  law  to  the  contrary, 
in  no  event  shall  \'eterans'  Administration  facilities  be 
used  for  furnishing  medical  and  hospital  care  to  persons 
not  eligible  for  such  care  under  the  laws  providing  relief 
for  veterans.' 

This  law  (which  representative  Rankin  submitted  as  a 
request  bill  from  a  veterans'  organization)  is  directed  at 
the  practice  of  sending  CCC  workers  and  employes  of  the 
Post  Office  Department  to  veterans'  hospitals  and  charging 
it  all  to  the  expense  of  the  Veterans  Administration. 

But  secondly,  it  is  directed  at  the  high  Government  offi- 
cials who  sojourn  at  Naval  Hospital,  it  was  admitted. 
The  Veterans  Administration  pays  almost  $300,000  a  year, 
according  to  the  1937  budget,  to  Naval  Hospital. 

Every  enlisted  man  and  officer  of  the  Navy  also  pays 
20  cents  a  month  towards  Navy  hospitals.  When  those 
outside  the-  Navy  go  there,  they  are  eating  into  these 
funds. 


Pity  the  poor  Congressman,  when  he  becomes  ill! 

In  the  Capitol  is  a  complete  medical  center,  under  the 
direction  of  Dr.  George  W.  Calver,  who  holds  the  rank  of 
captain  in  the  Medical  Corps  of  the  Navy. 

Dr.  Calver  has  three  assistants.  Altogether,  those  en- 
trusted with  the  health  of  those  who  work  on  Capitol 
Hill  get  $20,600  a  year,  including  expenses. 

But  that's  only  the  start  of  it.  A  Congressman  leaves 
the  floor  and  visits  Dr.  Calver,  saying  he  doesn't  feel  well. 
Dr.  Calver  looks  him  over,  and  remarks  that  a  few  days 
in  a  hospital  would  help. 

But  the  Congressman  isn't  sent  to  Emergency,  or  Gar- 
field, or  Georgetown.  At  these  hospitals,  he  would  be 
charged  full  fare  for  a  room  and  bath  and  the  attention  a 
Congressman  wants.  Dr.  Calver  gets  him  into  Naval 
Hospital,  where  war  veterans  can't  go.  He  gets  them  in 
at  $3.75  a  day.  At  most  other  hospitals,  all  you  get  is  a 
bed  in  a  ward  for  that  figure. 

Organizations  of  war  veterans  remember  how  Represen- 
tative John  "Honest  John"  McDuffie  fostered  the  economy 
act  which  shut  veterans  out  of  Army  and  Navy  hospitals. 
They  also  remember  that  Representative  McDuffie  was 
one  of  the  first  "New  Deal"  patients  in  Naval  Hospital. 
The  strain  of  putting  across  the  economy  act  sent  him 
there.     That  was  in  July,  1933. 

Capt.  G.  C.  Thomas,  the  hospital  medical  director,  says 
that  no  Congressmen  are  allowed  in  the  hospital  "unless 
there  is  room."  They  must  be  recommended,  he  says,  by 
the  Secretan,'  of  the  Navy.  Congressmen  who  have  been 
at  the  hospital  say  the  only  recommendation  necessary 
comes  from  Dr.  Calver — that  he  has  complete  authority 
to  send  a  member  of  Congress  to  the  hospital. 

Meanwhile,  veterans'  organizations  point  out  that  for  a 
veteran  to  enter  a  hospital,  he  must  take  a  "pauper's 
oath." 

What,  they  ask,  does  a  Congressman  take?" 

The  answer  is — for  9  out  of  every  10  of  them — 
everything  he  can  get. 

"They  must  be  recommended,  he  says,  by  the 
Secretary  of  the  Navy."  Now,  it  so  happens  that 
about  the  time  this  was  written  the  Secretary  of 
the  Navy,  himself,  fell  in  a  bathroom  and  was 
taken — where?  To  the  Navy  Hospital,  for  the 
support  of  which  20  cents  a  month  is  taken  out 
of  the  meager  pay  of  every  jack-tar  wearing  the 
uniform  of  the  U.S.!  How  much  out  of  the  $15,000 
salary — with  prerequisites — of  the  Secretary  goes 
to  support  the  Naval  Hospital? 

There's  not  a  particle  of  evidence  of  any  inten- 
tion on  the  part  of  the  framers  of  the  fundamental 
law  that  tax-paid  doctors  and  tax-supported  hos- 
pital beds  should  be  at  the  disposal  of  ailing  poli- 
ticians— or  even  statesmen,  if  any  such  there  be 
in  the  lot. 

Nearly  two  years  ago,  the  Medical  Society  of 
the  District  of  Columbia  made  dignified  and  ener- 
getic protest  against  these  practices,  sending  copies 
to  the  President  and  each  member  of  his  Cabinet, 
to  the  Superintendents  of  the  Government  Hos- 
pitals in  Washington  and  other  proper  officials, 
and  to  the  American  Medical  Association.  We  do 
r.ot  know  whether  anything  v/as  done;  evidently 
nothing  effective.   To  allow  these  officials  to  sponge 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  193 


on  Government  hospitals  and  doctors  is  to  acqui- 
esce in  an  outrageous  misappropriation  of  tax  funds 
and  grievous  injustice  to  the  other  hospitals  and 
private  doctors  in  Washington. 

Then,  there  are  the  matters  of  burying  Congress- 
men, and  perhaps  others,  who  die  in  office,  at  the 
expense  of  the  people;  and  of  voting  the  widow — 
or  widower,  we  suppose — of  a  deceased  member 
the  neat  flat  bonus  of  $10,000.  Do  you  ask,  how 
can  they  do  that?  Simply  enough.  Some  body  of 
men  had  to  be  entrusted  with  the  power  to  make 
special  appropriations  of  funds.  It  probably  never 
crossed  the  mind  of  even  one  of  the  framers  of  the 
Government  that  any  Congress  would  ever  be  so 
constituted  as  to  make  possible  the  perpetration 
of  such  outrages;  but,  if  it  had,  it  would  hardly 
have  not  been  feasible  to  specifically  forbid  every 
possible  thing  that  ingenuity  can  devise  for  getting 
greedy  hands  into  the  public  treasury.  Something 
had  to  be  left  to  common  honesty. 

We  would  love  to  see  the  ^Medical  Society  of  the 
State  of  North  Carolina  take  action  on  all  these 
matters,  in  its  meeting  two  weeks  from  now. 

As  to  the  Washington  matters;  we  can  back  up 
the  doctors  and  hospitals  of  the  District;  we  can 
request  the  records  of  the  Congressmen  and  Sena- 
tors who  are  paid  to  represent  us  in  Congress  and, 
if  satisfactory  records  are  not  forthcoming,  make 
the  facts  public  and  work  to  send  new  men  to 
Washington;  and,  as  to  the  "funeralizing" — so  dear 
to  the  hearts  of  our  colored  friends,  as  well — we 
can  reduce  that  item  of  cost  to  a  minimum  by 
always  electing  to  Congress  the  youngest  and 
healthiest  candidate. 


Public  Health  Teaching  on  The  Hill 
An  event  of  far-reaching  importance  is  the  estab- 
lishment at  Chapel  Hill  of  a  Division  of  Public 
Health.  It  is  important  to  the  University,  to  the 
State  Board  of  Health  and  to  North  Carolina  ^led- 
icine — most  of  all  to  the  people  of  the  State  and 
Section. 

In  1935,  on  the  initiative  of  Dean  C.  S.  Man- 
gum,  the  Medical  School  of  the  University  planned 
courses  of  study  in  Public  Health  Administration 
to  meet  urgent  needs  for  trained  workers  in  this 
field.  To  this  end  the  facilities  of  the  School  of 
Medicine,  the  School  of  Engineering  and  the  State 
Board  of  Health  were  coordinated,  and  these  agen- 
cies so  immediately  concerned  with  problems  of 
public  heatlh  gave  an  excellent  course  of  instruc- 
tion to  a  gratifying  number  of  students. 

In  this  year  this  course  has  been  developed  into 
a  Division  of  Public  Health  under  the  direction  of 
the  renowned  Dr.  M.  J.  Rosenau,  for  many  years 
Professor  of  Preventive  Medicine  and  Hygiene  at 
Harvard.     The  University  has  been  approved  by 


the  United  States  Public  Health  Service  as  the 
center  for  the  training  of  health  officers  for  Inter- 
state Sanitary  District  No.  2,  extended  from  Dela- 
ware to  Florida,  to  carry  out  the  provisions  of  the 
Social  Security  Act  for  training  public  health  per- 
sonnel. .\  Field  Demonstration  Unit  has  been 
established  in  a  nearby  bi-county  unit  in  coopera- 
tion with  a  conveniently  near  city-county  health  de- 
partment. 

Short  courses  best  adapted  to  qualify  physicians 
for  public  health  work  constitute  the  main  objec- 
tive. Students  in  the  Division  of  Public  Health 
may  take  courses  in  other  departments  of  the  Uni- 
versity for  which  they  can  meet  entrance  require- 
ments. It  would  seem  wise  to  offer  a  course  in 
applied  psychiatry  as  a  part  of  the  teaching  in  this 
Division  of  Public  Health;  that  this  action  would 
be  promotive  of  the  public  health  and  saving  of  the 
public  purse  to  a  degree  that  is  little  appreciated. 

.\11  these  things  are  very  pleasing  to  this  journal. 
We  need  more  instruction  in  public  health  matters 
and  we  need  it  from  a  conveniently  near  point  and 
at  a  conveniently  low  cost.  There  is  need,  too, 
that  the  University  of  North  Carolina  be  brought 
into  more  intimate  touch  with  the  daily  lives  of 
the  people  of  North  Carolina;  and  this  activity  of 
the  Medical  School  should  serve  as  a  real  begin- 
ning, for  every  man  and  woman  and  child  of  us 
will  be  touched  frequently  by  the  influences  of 
the  public  health  teachings  at  Chapel  Hill. 

We  would  like  to  see  other  University  activities 
which  would  reveal,  daily,  that  the  institution  of 
higher  learning  for  which  a  group  of  good  and 
wise  men  chose  the  beautiful  setting  of  the  hill 
beyond  Morgan  Creek  on  which  the  Church  of 
England  had  erected  a  chapel,  is  earnestly  endeav- 
oring to  be  useful  to  all  the  people  of  the  State. 

As  an  evidence  of  such  a  purpose  and  a  step 
toward  its  realization,  this  journal  proposes  that, 
from  now  on,  the  Board  of  Visitors  of  the  Univer- 
sity of  North  Carolina  be  chosen  so  as  to  be  repre- 
sentative of  the  people  of  the  State;  i.e.,  that  far- 
mers, manufacturers,  ministers,  doctors,  teachers, 
merchants,  lawyers  and  so  on  be  elected  to  this 
Board  in  the  same  ratio  as  they  make  up  the  pop- 
ulation of  the  State. 

This  journal  is  proud  of  the  University.  It  has 
confidence  in  its  President  and  its  Faculty  and 
deplores  and  opposes  the  warfare  so  persistently 
waged  against  some  one  or  more  of  these.  With 
a  Board  of  Visitors  representative  of  the  people 
the  University  could  be  brought  into  the  homes  of 
the  State;  its  citizens  would  come  to  know  the 
University  and  think  of  it  as  something  more  than 
headquarters  for  a  football  squad;  they  would  get 
something  tangible  for  what  they  pay  toward  the 
University's  maintenance;  and  so  they  would  be 
ready  to  rally  to  repel  assaults  made  upon  it. 


April.   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


The  Western  X.  C.  Sanatorium  for  the 
Tuberculous 

Several  years  ago  a  Negro  in  one  of  the  Eastern 
counties  was  arrested  and  put  in  jail.  It  was 
soon  discovered  that  he  was  infected  with  tuber- 
culosis and  the  sheriff  of  the  county  was  confronted 
with  the  problem  of  his  care.  There  being  no 
facilities  for  taking  care  of  tuberculous  patients 
in  his  county  the  sheriff  carried  the  Negro  to  the 
State  Sanatorium  and  asked  that  he  be  admitted 
there.  The  sheriff  was  kindly,  but  firmly,  informed 
by  Dr.  P.  P.  McCain  that  there  was  no  room,  and 
that  he  could  not  be  admitted  for  some  time,  as 
there  was  a  waiting  list  of  about  400  who  were 
asking  admission.  As  the  sheriff  traveled  the  long 
weary  road  back  home,  he  had  to  listen  to  the 
never-ending  moans  and  sobs  of  the  disappointed 
Negro.  His  heart  was  touched  and  he  then  re- 
solved that  if  he  ever  had  an  opportunity,  he 
would  work  for  the  provision  of  additional  accom- 
modations at  the  Sanatorium  or  an  additional  san- 
atorium. This  opportunity  came  when  he  was 
elected  as  the  Representative  of  his  county  in  the 
Legislature. 

So  it  happened  that  Representative  E.  A.  Ras- 
berry,  in  the  1935  North  Carolina  General  As- 
sembly, fathered  a  bill  which  called  for  an  appro- 
priation of  $250,000  for  the  purchase  of  a  suitable 
site  in  the  western  part  of  the  State,  and  an  addi- 
tional $50,000  for  equipment  and  maintenance 
during  the  first  year.  This  bill  received  the  full- 
hearted  support  of  Senator  L.  L.  Gravely  of  the 
Senate  Committee  on  Appropriations.  Upon  the 
passage  of  the  bill  and  selection  of  the  site,  the 
Federal  Government  appropriated  $245,454.54, 
making  a  total  of  nearly  $550,000  to  be  expended 
in  the  purchase  of  site,  buildings  and  equipment. 

A  commission,  headed  by  Hon.  Kemp  D.  Battle, 
was  appointed  to  select  the  site.  After  viewing 
some  40  possible  locations,  this  commission  select- 
ed a  site  of  196  acres,  12  miles  from  Asheville  and 
two  miles  from  Black  ^Mountain  facing  upon  High- 
way No.  70. 

A  more  ideal  spot  could  not  have  been  found.  It 
lies  upon  a  large,  level  plateau  2,800  feet  above  sea 
level,  overlooking  the  beautiful  Swannanoa  valley, 
affording  an  unobstructed  view  of  the  majestic 
Craggy  range  of  the  Appalachians  to  the  north, 
and  of  the  soft  contours  of  the  Blue  Ridge  to  th; 
South.  It  is  close  to  the  Southern  Railway,  per- 
mitting the  construction  of  a  siding  if  desired.  It 
is  just  across  the  Swannanoa  from  the  State  Test 
Farm,  permitting  the  utilization  of  the  products  of 
this  farm.  An  eight-inch  main  from  the  City  of 
Asheville's  water  supply  passes  through  the  prop- 
erty as  does  the  main  sewer  line  of  the  Swannanoa 
District. 


Plans  calling  for  the  construction  of  a  400-bed 
hospital  having  been  prepared,  on  March  11th 
ground  was  broken  for  the  construction  of  the  first 
unit  consisting  of  a  200-bed  wing,  an  administra- 
titon  building,  a  laundry  and  a  power  plant. 

The  management  of  the  institutiton  is  vested  in 
a  Board  of  Trustees,  whose  members  are:  L.  L. 
Gravely,  E.  A.  Rasberry,  Dr.  Thurman  Kitchin, 
Dr.  J.  R.  Terry,  Mrs.  Max  Payne,  Robert  M. 
Hanes,  Laurie  McEachern,  R.  L.  Harris,  Dr.  J.  W. 
jNIcGehee  and  U.  L.  Spence. 

In  its  report  the  commission  selecting  the  site 
stated  that  Asheville  and  its  vicinity  have,  for  the 
past  50  years,  been  recognized  as  the  center  for 
the  treatment  of  tuberculosis  in  the  South,  and  that 
they  were  influenced  in  their  selection  because  of 
the  proximity  of  the  U.  S.  Veterans'  Hospital  at 
Oteen  where  the  Government  has  an  investment  of 
more  than  $3,000,000  in  an  institution  which  has 
proved  to  be  one  of  the  most  successful  of  similar 
units  in  the  country.  The  availability  of  nearby 
specialists,  both  medical  and  surgical,  was  also  an 
important  consideration. 

—L.  G.  BEALL.  Black  Mountain. 


Obituary 

Dr.  Southgate  Leigh 

In  the  meeting  of  the  Tri-State  Medical  Associa- 
tion held  at  Columbia  two  months  ago  Dr.  Leigh 
took  an  active  part.  Particularly  noteworthy  it  is 
that  through  his  interest  and  activity  committees 
were  appointed  for  looking  further  into  the  causa- 
tion and  cure  of  two  diseases  over  which  we  have 
gained  little  control.  A  month  later  he  lay  dead. 
To  the  very  last  he  was  doing  the  full  part  of  a 
good  doctor,  concerned  that  he  neglect  no  oppor- 
tunity to  advance  the  cause  of  health  and  healing. 

The  resolution  of  his  own  County  Medical  So- 
ciety sets  forth  some  details  of  his  eventful  life 
and  something  of  his  achievements  and  the  esteem 
in  which  he  was  held: 

Your  committee  notes  with  deep  sorrow  the 
passing  of  our  esteemed  fellow  member.  Dr.  South- 
gate  Leigh.  The  community  of  Tidewater  Virginia 
and  the  medical  profession  at  large  has  lost  one 
of  its  most  distinguished  members. 

The  Leighs  have  been  in  Tidewater  Virginia  for 
generations,  but  Dr.  Leigh  was  born  in  Lynch- 
burg, May  21st,  1864,  because  his  father,  who  was 
in  the  Confederate  Army,  was  stationed  at  Lynch- 
burg at  that  time.  He  returned  to  Norfolk  at 
the  close  of  the  war,  where  he  has  resided  ever 
5i:;cc.  He  attended  a  Norfolk  school  under  th.: 
instruction  of  Mr.  Gait,  and  from  there  entered 
the  University  of  Virginia,  from  which  he  received 
his   medical   degree   in    1888.      Following   this,   he 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  10,%6 


entered  Columbia  University  College  of  Physicians 
and  Surgeons,  where  he  received  the  degree  of 
Doctor  of  Medicine  after  a  competitive  examina- 
tion. In  1889  he  entered  Mt.  Sinai  Hospital  and 
served  an  internship  of  two-and-a-half  years.  After 
completing  his  internship,  he  went  to  the  Clinics 
of  Europe,  doing  post-graduate  work  in  Vienna 
and  specializing  in  obstetrics  and  gynecology.  Re- 
turning from  abroad,  he  went  back  to  Mt.  Sinai 
Hospital  and  engaged  in  special  work  with  Dr. 
Gerster  regarding  antisepsis.  In  1893  he  returned 
to  his  home  in  Norfolk,  Virginia,  where  he  took  up 
the  practice  of  medicine  and  surgery,  to  which  he 
gave  the  very  best  that  was  in  him  and  soon  at- 
tained a  high  standing  among  his  colleagues. 

Realizing  the  need  for  a  private  hospital  in 
Tidewater  Virginia,  he  built  the  Sarah  Leigh  Hos- 
pital, which  was  opened  in  1903,  and  of  which  he 
has  been  chief  surgeon,  president  and  owner.  This 
hospital  has  served  the  city  of  Norfolk,  Tidewater 
Virginia  and  eastern  North  Carolina  since  its  open- 
ing. 

Dr.  Leigh's  career  in  his  profession  has  been  a 
brilliant  one.  He  has  given  unstintingly  of  his 
time  and  energy  to  the  advancement  of  medical 
and  surgical  science  and  to  the  service  of  the  med- 
ical profession  and  the  public  generally.  He  con- 
sistently stood  for  all  that  was  best,  both  for  the 
profession  and  the  public.  He  lived  the  life  laid 
down  by  the  oath  of  Hippocrates  and  these  princi- 
ples carried  him  to  the  zenith  of  his  chosen  profes- 
sion. He  reached  the  same  high  pinnacle  in  com- 
munity work  and  Norfolk  will  long  miss  his  civic 
efforts.  He  gave,  with  the  utmost  abandon,  of  his 
time,  energy  and  worldly  goods. 

He  became  deeply  interested  in  surgery  and  no 
matter  what  encouraging  reports  of  new  methods  of 
treatment,  his  were  always  along  conservative  lines. 
His  early  training  and  practice,  combined  with  his 
many  innate  faculties,  soon  developed  in  him  a 
high  degree  of  efficiency  as  a  surgeon.  In  later 
years  he  became  deeply  interested  in  cancer  educa- 
tion and  cancer  control. 

He  was  a  member  of  numerous  medical  societies, 
president  of  several  and  a  past  president  of  the 
Norfolk  County  Medical  Society.  He  was  one  of 
the  founders  of  the  American  College  of  Surgeons 
and  has  been  a  member  of  the  Board  of  Governors 
of  the  College. 

The  sudden  death  of  Dr.  Leigh  was  a  great 
shock  to  the  entire  community  and  his  passing  is 
mourned  by  countless  grateful  patients,  friends  and 
devoted  colleagues  and  co-workers.  He  leaves  a 
wife  and  four  children. 

Be  it  resolved,  that  in  the  death  of  Dr.  South- 
gate  Leigh  the  Norfolk  County  ]\Iedical  Society 
has  sustained  an  irreparable  and  distressing  loss. 


Be  it  further  resolved,  that  a  page  in  the  minute 
book  of  this  society  be  set  aside  and  dedicated  to 
his  memory  and  that  a  copy  of  these  resolutions, 
with  expression  of  our  deepest  sympathy,  be  pre- 
sented to  his  family  and  to  the  Virginia  Medical 
Monthly. 

Dr.  Leigh  became  a  member  of  the  Tri-State 
Medical  .Association  soon  after  its  organization  in 
1898;  and,  after  serving  on  various  committees 
and  holding  practically  every  other  office  within 
the  gift  of  the  Association,  was  chosen  president 
for  the  fiscal  year  which  terminated  with  the  meet- 
ing in  Wilmington  in  1914. 

It  is  significant  that  his  presidential  address 
urges  the  importance  of  cancer  education,  while  he 
clearly  saw  that  progress  would  be  slow  and  te- 
dious; and  that,  22  years  later,  we  see  him  at  Co- 
lumbia, with  faith  unshaken,  proclaim  with  the 
same  high  courage  that  we  must  keep  right  on  till 
this  menace  to  the  evening  of  life  is  destroyed. 

Dr.  Leigh  was  a  good  doctor  and  a  good  citizen 
because  he  believed  in  ^ledicine,  he  believed  in 
other  doctors  and  he  believed  in  himself;  and  be- 
cause he  was  an  eager  and  earnest,  yet  joyous, 
student  to  the  end. 


NEWS  ITEMS 


Infant  mortality  and  obstetrics  were  subjects  of  discus- 
sion at  the  quarterly  meeting  of  the  First  Disteict  Med- 
ic.-u.  Society  held  at  Edenton,  Feb.  27th  in  the  Hotel  Jo- 
seph Hewes.  .-Vbout  40  medicos  from  the  .\lbemarle  were 
in  attendance  and  listened  attentively  to  addresses  by  Dr. 
P.  H.  Ringer,  Dr.  L.  B.  McBrayer,  Dr.  Frank  Garris  of 
Lewiston,  Bertie  County  Health  Officer,  read  a  paper  on 
infant  death  statistics,  and  Dr.  Cola  Costello  of  Windsor 
talked  on  Surgical  Obstetrics.  Dr.  L.  P.  Williams  of 
Edenton,  the  district  secretary,  reported  that  the  next 
quarterly  gathering  would  be  in  Elizabeth  City  in  May 
or  June. 

The  C.\TAWBA  \'.ALLEY  Medic.al  SOCIETY  held  its  regular 
meeting  March  10th  at  the  North  State  Hotel,  Lincolnton, 
X.  C.  Dr.  Douglas  Hamer,  jr.,  of  Lenoir,  presided,  .^fter 
the  banquet,  Dr.  L.  C.  Todd,  of  Charlotte,  gave  an  inter- 
esting and  instructive  talk  on  Allergy.  The  next  meeting 
will  be  in  Morganton  on  May  12th.  The  following  com- 
mittee was  appointed  to  make  arrangements  for  that  meet- 
ing: Dr.  J.  B.  Helms,  Dr.  J.  B.  Riddle,  Dr.  J.  W.  Vernon. 
L.  A.  Cro'diell,  jr.,  M.D.,  Sec. 


Buncombe  County  Medic.u.  Society,  regular  meeting 
held  the  evening  of  March  16th  at  the  Asheville  Medical 
Librarj-,  Arcade  Building,  at  8  o'clock,  President  Parker 
in  the  chair,  49  members  present. 

The  chairman  recognized  Dr.  Julian  Moore,  who  wel- 
comed the  society  to  the  Library  and  urged  the  members 
to  browse  around  after  the  meeting  and  see  of  what  the 
library   consisted. 

Dr.  H.  H.  Briggs,  jr.,  spoke  on  The  Fundus  Oculi,  Its 
Relation  to  General  Diseases,  illustrated  by  several  pictures 
of  the  fundus  in  systemic  diseases.  Discussion  by  Drs. 
L.  M.  Griffith,  W.  R.  Johnson,  Tennent,  and  by  the  es- 
sayist. 


1 


April.  1Q36 


SOUTHERN  MEDICINE  AND  SURGERY 


Eli  Lilly  and  Company 

FOUNDED     i  8  7  6 

^Makers  of  CMedichml  Products 


LJiahdcs  mellitus  was  liiscovmd  in  this  six-year-old  child  during  an  attack 
oj  acidosis  eight  days  before  these  photographs  were  made.  At  the  time  oj  the 
picture  she  was  sugar-Jree  on  three  doses  of  Jnsutin  daily  and  had  already 
mastered  the  technic  of  Jnsidin  administration. 


THE   PROSPECTS   OF  A  DIABETIC   CHILD 

ll'ithoiit  Jnsidin  With  Insulin 

1.  Hunger     Sufficient  food 

2.  Stunted  growth Normal  growth 

3.  Irregular  school  attendance   ....  Normal  mental  development 

4.  Coma  and  death      Freedom  from  fear 

5.  Fear  of  the  needle Development  of  self- 

discipline  and  persistence 

The  history  of  Insulin  is  "one  of  the  most  triumphant  and  thrilling 
stories  in  all  the  history  of  medicine." 

ILETIN  (INSULIN,  LILLY) 
The  First  Insulin  Commercially  Available  in  the  United  States 
TIME-TRIED       '       PURE       '       STABLE       >■       UNIFORM 


Prompt  Jlttetition  Qiven  to  Professional  Jncfuiries 

PRINCIPAL    OFFICES    AND    LABORATORIES,    INDIANAPOLIS,    INDIANA,    U.S.A. 


Please   Mention   THIS  JOURNAL  When   Writing  to   Advertisers 


234 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1P36 


Dr.  Kutscher  of  the  Committee  on  Arrangements  for 
the  coming  State  Med.  Soc.  session  here  in  May  spoke  of 
the  good  response  for  exhibit  space  from  our  commercial 
houses.  He  urged  our  individual  members  to  get  up  an 
exhibit  for  the  State  meeting. 

The  secretary  presented  the  application  for  membership 
of  Dr.  Carey  L.  Harrington  for  election,  and  by  unanimous 
vote  Dr.  Carrington  was  elected  a  member. 

The  resignations  of  Drs.  Geo.  H.  B.  Terry,  John  C. 
George  and  Grover  C.  Godwin  of  the  Oteen  Med.  Staff 
were  brought  up.  Dr.  Moore  moved  that  the  resignations 
of  these  physicians  be  accepted  with  regrets.  Sec.  and 
carried. 

Dr.  C.  C.  Orr  thanked  the  society  for  the  telegram  of 
congratulations  to  him  on  Feb.  17th. 

Dr.  Kutscher  brought  up  the  matter  of  our  press  run- 
ning adv.  of  the  Chiropractors  in  our  city,  such  adv.  being 
false  and  untrue.  Dr.  McCall  spoke  of  our  hospitals  here 
sending  in  news  items  to  our  papers  with  the  name  of  the 
hospital  involved  stated  in  the  items.  After  much  discus- 
sion Dr.  Ringer  made  a  motion  that  the  entire  matter  be 
referred  to  a  committee  to  wait  upon  the  business  manager 
of  the  daily  press  and  report  back.     Sec.  and  carried. 

Regular  meeting  of  Bunxojmbe  County  Medico  Socie- 
ty, .\sheville,  evening  of  .\pril  6th,  Pres.  Parker  in  the 
chair,  6b  members  present,  2  visitors — Miss  Mashbum  of 
the  Librarj-  .Assoc,  and  Dr.  EUer  of  Pittsburgh. 

Committee  on  Arrangements  for  State  Meeting,  Dr. 
Ward,  chr.,  made  a  verbal  report  of  the  activities.  An- 
other meeting  to  be  held  this  week  and  prospects  of  a  big 
meeting  in  May  were  good. 

Committee  appointed  to  wait  upon  the  business  manager 
of  the  Citizen-Times  in  regard  to  false  adv.  by  the  chiro- 
practors, reported  progress  and  report  would  be  made  at 
the  next  society  meeting. 

Under  the  head  of  the  paper  of  the  evening  the  society 
was  addressed  extemporaneously  by  Dr.  E.  G.  Ballenger  of 
.Atlanta  on  The  Diagnosis  and  Treatment  of  Everyday 
Genito-Urinary  .Affections.  The  essayist,  introduced  by 
Dr.  T.  R.  Huffines,  spoke  of  the  importance  of  establishing 
free  and  open  drainage  in  all  affections  and  conditions 
affecting  these  parts. 

Dr.  J.  W.  Williams  spoke  of  the  offer  of  free  time  on 
the  radio  for  the  City  Health  Department  and  his  desire  to 
utilize  the  time.  He  wished  to  know  the  attitude  of  the 
medical  society.  Dr.  Ward  spoke  on  the  importance  of 
the  doctors  participating  in  a  planned  program  of  radio 
broadcasts.  Dr.  Moore  moved  the  matter  be  referred  to 
our  Committee  on  Publicity  for  study  and  the  outhne  of  a 
program  of  broadcasts.  Seconded  by  Cocke  and  carried 
unanimously. 

(Signed)     M.  S.  Broun,  M.D.,  Sec. 


afternoon  program  consisted  of  presentation  of  chnical 
cases  at  Rex  Hospital  and  a  pathological  conference  at 
Mary  Elizabeth  Hospital.  Dr.  Ivan  Procter,  President  of 
the  Society,  entertained  at  a  buffet  luncheon. 


Regular  dinner  meeting  of  the  Guilford  County  Med- 
ical Society,  .April  2nd,  Dr.  J.  W.  Tankersley,  president 
of  the  association,  presiding.  Dr.  William  D.  Stroud,  Phila- 
delphia, spoke  on  Coronary  Disease. 


Randolph  CouNxy  (N.  C.)  Medical  Society  met  at  i 
p.  m.,  March  9th,  at  Randolph  Hospital,  Asheboro.  Dr. 
W.  L.  Lambert,  vice  president,  presided  in  the  absence  of 
Dr.  C.  S.  Tate,  president,  who  was  dangerously  ill  at  his 
Ramseur  home.  Paper  of  Dr.  Rudd  of  Greensboro  read 
by  the  secretary.  Dr.  C.  C.  Hubbard's  paper  on  Syphilis 
was  postponed  until  the  April  meeting.  Dr.  Mathison, 
who  lately  moved  to  Asheboro,  was  received  as  a  member. 
Dr.  W.  L.  Lambert  showed  an  interesting  clinical  case. 

Adjourned  to  meet  at  Asheboro  on  the  2nd  Monday  in 
.April  at  3  p.  m. 

Reported  by  Dr.  C.  C.  Hubbard,  Farmer. 


From  Dr.  A.  E.  Baker,  jr.,  Charleston 

.An  engagement  of  wide  social  interest  recently  announc- 
ed in  Camden  is  that  of  Miss  Charlotte  Boylin  Salmond 
to  Dr.  Joseph  Woods  Brunson,  of  Ridge  Spring.  Mis; 
Salmond  received  her  education  at  the  Hugh  Morson 
School,  Raleigh,  N.  C,  her  former  home,  and  later  studied 
voice  in  the  studio  of  Mrs.  Henr\-  Bellamann  in  New  York. 
Doctor  Brunson  was  graduated  from  the  Citadel,  '30,  and 
from  the  Medical  College  of  South  Carolina,  '34,  serving 
his  interneship  at  Roper  Hospital.  The  wedding  will  take 
place  in  June  at  Grace  Episcopal  Church,  Camden. 

Dr.  and  Mrs.  J.  G.  Halford  of  Johnson  celebrated  the 
fifteenth  anniversary  of  their  wedding  by  a  dinner  party 
of  intimate  friends. 

Dr.  and  Mrs.  Rice  B.  Harmon  of  Lexington  announc; 
the  birth  of  a  son,  Rice  Boozer  Harmon,  jr. 

Dr.  Julian  T.  Coggeshall,  60,  died  at  his  home  at 
Darlington  March  3rd,  after  an  illness  of  several  days  with 
pneumonia. 


At  the  meeting  of  the  Wake  County  (N.  C.)  Medical 
Society  April  9th,  Dr.  Emil  Novak  of  Johns  Hopkins 
spoke  on  The  Endocrines  in  Gynecological  Practice.     The 


.At  a  recent  meeting  of  the  Federation  of  Societies  for 
Experimental  Biology,  Dr.  Willl\m  deB.  M.^cNider  was 
elected  to  represent  the  American  Pharmacological  Society 
on  the  National  Research  Council  for  a  period  of  three 
years.  The  Federation  is  composed  of  the  following  socie- 
ties: American  Physiological,  .American  Biochemical,  .Amer- 
ican Pharmacological,  and  American  Pathological. 


Dr.  John  W.  Ervln  (Med.  Col.  of  Va.  'ii),  native  of 
Morganton,  N.  C,  has  returned  to  his  native  town  for 
the  practice  of  his  profession.  Since  graduation  Dr.  Ervin 
has  served  on  the  staffs  of  the  Worcester  (Mass.)  City 
and  State  Hospitals. 


Dr.  Ramon  Suarlz,  San  Juan,  Puerto  Rico,  recently 
visited  Dr.  William  Branch  Porter  at  his  home  in  Rich- 
mond. He  addressed  the  students  at  the  Medical  College 
of  Virginia. 


Dr.  T.  M.  Parkins,  coroner  of  Staunton.  Va..  since 
1011,  has  been  appointed  by  city  council  as  Health  Offi- 
cer of   Staunton  to  succeed   Dr.  J.   Fairfax   Fulton. 


Dr.  William  H.  Nelson  and  Dr.  John  D.  Kerr  have 
been  added  to  the  staff  of  the  Sampson  County  Health 
Department. 


Dr.  Thomas   G.  Faison   (Med.   Col.   Va.  32)    has  been 
appointed    full-time    Health    Officer    of    Hertford    County, 

N.  C. 


Dr.  John  B.  Buxlard,  Richmond,  resumed  his  practice 
on  March  1st,  with  offices  at  1614  Monument  avenue. 


Deaths 

Dr.  Francis  H.  Beadles,  63,  specialist  in  dermatology, 
died  of  a  heart  ailment  on  March  26th  at  his  home  in 
Richmond.     For  two  score   years  or  so   Dr.   Beadles  had 


April,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


235 


THEY   LOOK  ALIKE...  THEY  TASTE  ALIKE 

but  v/ha\  a  difference  in  calories! 


THAT'S  what  Klim  does.  Adds  336  cal- 
ories to  a  plate  of  Cream  of  Chicken  soup 
— without  appreciably  changing  its  appear- 
ance, taste  or  bulk. 

For  Klim  is  simply  powdered  whole  milk 
— all  the  food  value  of  milk  in  only  l-i  the 
volume.  It  can  easily  be  added  to  dozens 
of  staple  dishes  in  the  cooking — giving 
the  patient  a  concentrated  diet  far  more 
varied  and  pleasing  than    is   possibL       ^ff'Sm^r. 
with  sweetish,  cloying  "invalid  drinks.'' 


Klim,  moreover,  places  little  added  tax  on 
the  patient's  digestive  system — since  the  dry- 
ing process  actually  makes  it  more  digestible 
than  fluid  milk. 

Send  for  the  booklet  "Reinforced  Diet 
Recipes" — 70  ways  to  get  more  food  value 
into  a  patient's  diet  with  Klim.  As  many 
copies  as  you  need  will  be  sent  for 
distribution  to  your  patients.  No  read- 
ing matter  contrary  to  profes- 
sional ethics  is  included. 


KLIM 


The  Borden  Company 

Dept.  000,  350  Madison  Avenue.  New  York  City 
Please   send    me    copies   of   the   booklet   **Rein- 
forced  Diet  Recipes  with  Klim." 

M.D. 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1036 


practiced    dermatology    and    during    much    of    that    time 
taught  this  subject  in  the  Medical  College  of  Virginia. 


Dr.  E.  A.  de  Bordenhave,  62,  died  at  Raiford's  Hospital, 
Franklin,  Va.,  ."^pril  6th,  after  an  illness  of  many  months. 
He  was  graduated  from  the  Medical  College  of  Virginia  in 
ISQQ  and  had  been  in  enjoyment  of  a  large  practice  at 
Franklin  for  36  years. 


Dr.  Raleigh  Martin  Shelton,  65  (University  of  Va.  '97), 
March  15th  at  his  home  at  Unionville,  Va.,  after  brief 
illness  of  pneumonia.  A  native  of  Pittsylvania  County. 
Dr.  Shelton  practiced  medicine  in  both  Pittsylvania  and 
Brunswick.  He  moved  to  Unionville,  Orange  County,  in 
1927. 


Dr.  James  Braxton  McKee,  76  (Vanderbilt  '91),  died  at 
his  home  at  Glade  Springs,  Va.,  March  18th.  Dr.  McKee 
had  been  a  practicing  physician  for  52  years. 


Dr.  Samuel  I.  Conduff,  62  (P.  &  S.,  Balto.,  '98),  long  a 
practitioner  in  Roanoke,  Va.,  died  at  the  University  of 
Virginia  Hospital  March  18th. 


Dr.  Joseph  W.  Duguid,  64  (Maryland  '93),  after  30 
years  of  practice  at  Dover,  N.  C,  died  at  his  home  March 
19th. 


Our  Medical  Schools 


Medical  College  or  Vikcinta 


of  Chicago.  The  dissertation  requirements  were  satisfied 
with  a  paper  on  The  Effect  of  Physical  Training  on  Blood 
Volume,  Hemoglobin,  Alkali  Reserve  and  Osmotic  Resist- 
ance of  Erythrocytes. 

The  ex-internes  of  the  Hospital  Division  of  the  college 
held  their  annual  reunion  March  20th. 

The  honorary  degree  of  Doctor  of  Science  will  be  award- 
ed Dr.  Lawrason  Brown  of  Saranac  Lake,  New  York,  at 
the  commencement  exercises,  June  2nd. 


Dr.  Harvey  Haag,  Professor  of  Pharmacology,  present- 
ed a  paper  on  Studies  of  the  Persistence  of  Action  of 
Various  Digitalis  Substances  at  the  Federation  of  Ameri- 
can Biological  Societies  at  Washington  March  25th  through 
March  28th ;  Dr.  Ernst  Fischer,  Associate  in  Physiology, 
on  The  .Action  of  a  Single  Vagal  Volley  and  the  Depend- 
ence of  its  Chronotopic  Effect  on  the  Rythmic  Mechan- 
ism of  the  Pacemaker. 

Others  of  the  college  staff  to  the  Washington  convention 
Dr.  J.  C.  Forbes,  Dr.  Frank  L.  Apperly,  Dr.  John  E.  Davis 
and  Dr.  Rolland  J.  Main. 

Promotions  on  the  major  faculty  for  the  session  1936- 
37  are  as  follows: 

Dr.  RoUand  J.  Main  from  Assistant  Professor  of  Physi- 
ology to  Associate  Professor. 

Dr.  WilUam  D.  Suggs  from  Associate  in  Obstetrics  to 
.'\ssistant  Professor. 

Dr.  Lawther  J.  Whitehead  from  Associate  in  Radiology 
to  Assistant  Professor. 

Dr.  W.  L.  Peple,  resigned,  was  made  Emeritus  Professor 
of  Clinical  Surgery. 

Dr.  S.  F.  Bradel  from  Assistant  Professor  of  Crown  and 
Bridge  Prosthesis  and  Dental  Metallurgy  to  Associate  Pro- 
fessor. Doctor  Bradel  was  also  reappointed  superintendent 
of  the  dental  infirmary. 

Dr.  C.  W.  Morhart  from  Associate  in  Prosthetic  Dentis- 
try to  Assistant  Professor. 

Miss  Lulu  K.  Wolf  from  Assistant  Professor  of  Nursing 
to  Associate  Professor. 

Miss  Aileen  Brown  from  Associate  in  Nutrition  and 
Cookery  to  Assistant  Professor. 

Dr.  A.  M.  Wash,  in  addition  to  his  associate  professor- 
ship of  dental  radiology,  exodontia  and  anesthesia,  was 
made  Associate  Professor  of  Oral  Surgery. 

John  Emerson  Davis  was  awarded  a  Ph.D.  degree  in 
Physiology   at   the   spring   convocation    of    the    University 


Wake  Forest 

Dr.  William  deB.  MacNider,  Kenan  Research  Professor 
of  Pharmacology  of  the  University  of  North  Carolina  Med- 
ical School,  addressed  the  Marshall  Medical  Society  on 
February  29th,  on  Tissue  Resistance. 

Dr.  Thurman  D.  Kitchin  and  Dr.  George  Mackie  ad- 
dressed the  Lenoir  County  Medical  Society  in  Kinston  at 
their  annual  meeting  on  March   13th. 

An  oil  painting  of  Dr.  Thurman  D.  Kitchin,  President 
of  the  College  and  Dean  of  the  Medical  School,  done  by 
E.  Barnard  Lintott,  famous  English  artist,  has  been  com- 
pleted and  hung  in  the  Medical  Library.  This  was  made 
possible  through  contributions  by  a  few  intimate  friends 
of  the  Medical  School. 


Duke 

On  February  24th  and  25th,  Dr.  Edward  R.  Baldwin, 
Director  of  the  Edward  L.  Trudeau  Foundation  for  Re- 
search and  Teaching  in  Tuberculosis,  lectured  to  the  fac- 
ulty and  students  on  The  History  of  Tuberculosis  Re- 
search in  America. 

The  following  seniors  recently  were  elected  to  member- 
ship in  the  Alpha  Omega  Alpha  honorary  medical  frater- 
nity:  George  T.  Harrell,  jr.,  and  Joseph  B.  Stevens. 


University  of  Virginia 


At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  February  17th,  Dr.  Afred  Chanutin  spoke  on 
the  subject  of  Some  Clinical  Aspects  of  Lipid  Metabolism. 

Dr.  James  Angus  Doull,  Professor  of  Hygiene  and  Pub- 
lic Health  at  Western  Reserve  University,  visited  the  Med- 
ical School  on  February  27th. 

On  March  2nd,  Dr.  Arnold  Rice  Rich,  Associate  Profes- 
sor of  Pathology  at  Johns  Hopkins  University,  gave  the 
mid-year  .Alpha  Omega  .Alpha  lecture,  speaking  on  the 
subject  Immunity  in  Tuberculosis. 

Dr.  H.  S.  Diehl,  Dean  of  Medical  Sciences  and  Head  of 
the  Department  of  Preventive  Medicine  and  Student  Health 
Service  at  the  University  of  Minnesota,  was  a  recent  visi- 
tor. 

For  the  third  consecutive  year  the  Edward  N.  Gibbs 
Prize  of  the  New  York  Academy  of  Medicine  was  awarded 
to  Dr.  .Alfred  Chanutin,  Professor  of  Biochemistry.  The 
stipend  of  the  award  is  to  be  applied  to  a  continuation  oJ 
research  on  kidney  diseases. 

On  February  24th  and  25th,  Dr.  Edward  R.  Baldwin, 
Director  of  the  Edward  L.  Trudeau  Foundation  for  Re- 
search and  Teaching  in  Tuberculosis,  lectured  to  the  fac- 
ulty and  students  on  The  History  of  Tuberculosis  Research 
in  America. 

The  following  seniors  recently  were  elected  to  member- 
ship in  the  Alpha  Omega  .Alpha  honorary  medical  frater- 
nity:  George  T.  Harrell,  jr.,  and  Joseph  B.  Stevens. 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society   on   March    23rd,   Dr.   M.   Ehrenstein,   of   the   De- 


April,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


i»^ 


i/rw 

IN  *OS5  AND  THROAT  DISEASES 


He 


Lot.  thick  applications  of  AnliphlogisHue 
—  applied  to  the  neck  and,  li  necessary,  en 
tirely  covering  the  nect  irom  ear  to  ear— ore 
of  undisputed  aid  in  effecting  a  reduction  of 
irLflcnntnation  and  congestion  in  the  pharyn- 
geal and  laryngeal  tissues. 

By  providing  continuous  moist  heal  for  any- 
where from,  twelve  to  twenty-lour  hours,  Anti- 
phlogistine  produces  local  arterial  hyperemia 
. . .  thus  hastening  the  destruction  of  the  organ- 
isms causing  the  infection  cmd  accelerating 
the  processes  of  repair.  Antiphlogistine  also 
pcy?e-sses  jjifiigesic  and  it-laxing  properlif;s. 
It  is  absolutely  non-toxic  and  non- irritating. 

In  nose  and  throat  diseases  such  as  those 
pictured  . . .  and  in  nuTierous  other  conditions 
. . .  Antiphlogistine  has  been  recommended  for 
many  years  with  uniformly  favorable  results. 
A  sample  of  this  plastic  dressing,  together  with 
Uterature,  will  be  sent  you  on  request. 


THE  DENVER  CHEMICAL  MFG.  CO. 

163  VARICK  STREET,  NEW  YORK,  N.  Y. 


Please  Mention  THIS  JOURNAL  When  Writing  to  Advertisers 


SOUTHERN  MEDICINE  AND  SURGERY 


April,   1936 


ELIXIR    DIGESTENZYME 


/ 

?^=3 

f 

■I 

"leESTlizvi*^ 

^ 

Contains  the  active  enzymes  and  acids  of  diges- 
tion— Pepsin,  Veg.  Ptyalin,  Pancreatine,  Lactic 
and  Hydociiloric  acid — combined  in  similar  pro- 
portions as  they  exist  in  the  human  system. 
These  digestive  agents  comprise  the  principal 
known  substances  employed  by  nature  in  the 
preparation  of  food  for  assimilation. 

It  is  a  valuable  aid  in  Dyspepsia,  and  diseases 
i'lising  from  imperfect  digestion.  Also  partic- 
ularly valuable  in  many  forms  of  Diarrhoea,  and 
Vomiting  in  Pregnancy. 

Dosage 

Twn  teaspoonfuls  to  one  tablespoonful  after  each 
meal. 

How   supplied 

n  Pints  and  gallons  to  Physicians  an:l  druggists. 


Burwell  &  Dunn  Company 

Manufacturing    Ph  :;■;.'.•<; fis/s 
CHARLOTTE,     N.  C. 

Sampbs  sent  to  any  Physician  in  the  U.  S.  on  request. 


partment  of  Physiology,  read  a  paper  on  Gonadotrophic 
Factors  and  Sex  Hormones. 

Dr.  William  M.  Moir,  of  the  Department  of  Pharma- 
cology, read  a  paper  on  The  Influence  of  Age  and  Sex 
on  the  Repeated  .Administration  of  Sodium  Pentobarbital 
to  Albino  Rats,  during  the  meetings  of  the  Federation  of 
American  Societies  for  Experimental  Biology  in  Washing- 
ton on  March  27th. 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  March  30th,  Drs.  W.  H.  Parker  and  E.  P. 
Lehman  spoke  on  the  subject  Studies  on  Head  Injuries. 

The  following  were  recent  visitors  at  the  Medical  School: 
Dr.  Frank  P.  Knowlton,  Professor  of  Physiology,  Syracuse 
University;  Dr.  Elliott  C.  Cutler,  Mosely  Professor  of 
Surgery,  Harvard  Medical  School;  Dr.  Dayton  J.  Edwards, 
Associate  Professor  of  Physiology,  Cornell  University  Med- 
ical College;  Dr.  William  C.  Rose,  Professor  of  Physiol- 
ogical Chemistry,  University  of  Illinois. 

Dr.  Alfred  Chanutin  and  Dr.  Stephen  Ludewig  present- 
ed a  joint  paper  on  The  Influence  of  Liver  Damage  on 
the  Blood  Lipids  before  the  Section  on  Biochemistr\-  of 
the  Federation  of  American  Societies  for  Experimental  Bi- 
ology on  March  27th. 

At  the  meetings  of  the  American  .Association  of  Anatom- 
ists at  Duke  University  on  .April  9th  to  11th,  Dr.  C.  C. 
Speidel  read  a  paper  on  The  Formation  and  Metamorphosis 
of  the  "retraction  cap  of  injury"  of  Striated  Muscle  Fibers 
in  Living  Frog  Tadpoles;  Dr.  J.  E.  Kindred  read  a  paper 
on  an  Interpretation  of  the  Secondary  Lymphoid  Nodule 
in  Lymph  Nodes  of  the  Albino  Rat;  Dr.  H.  E.  Jordan 
was  chairman  of  a  Round  Table  Conference  on  Lympho- 
cytes, Macrophages  and  Fibroblasts. 

Dr.  Maximillian  Ehrenstein,  of  the  Department  of  Physi- 
ology, formerly  a  member  of  the  faculty  of  the  University 
of  Berlin,  was  awarded  one  of  the  Vant  Hoff  Prizes  of  the 


Royal   Academy   of  Science  of  Amsterdam   in   recognition 
of  his  work  on  the  alkaloids  of  tobacco. 

On  April  2nd,  Dr.  Lawrence  T.  Royster  spoke  before  the 
Institute  of  Medicine  at  the  Community  Hospital  in  Farm- 
ville,  Virginia. 


BOOK  REVIEWS 


SYNOPSIS  OF  CLINICAL  LABORATORY  METH- 
ODS, by  W.  E.  Bray,  B.A.,  M.D.,  Professor  of  CHnical 
Pathology,  University  of  Virginia;  Director  of  Clinical 
Laboratories,  University  of  Virginia  Hospital.  Thirty-two 
illustrations,  11  color  plates.  The  C.  V.  Mosby  Company, 
St.  Louis,  1936.     ?3.75. 

In  this  little  book  will  be  found  nearly  every- 
thing of  recognized  value  on  the  subject,  condensed 
and  arranged  so  as  to  be  of  the  greatest  usefulness. 
Dr.  Bray  teaches  medical  students,  trains  labora- 
tory technicians  and  conducts  a  clinical  laboratory. 
Among  the  general  rules  put  down  on  the  lirst 
page  of  the  text  is:  Avoid  unnecessary  requests, 
for  these  are  bad  for  the  morale  of  the  laboratory 
staff,  and  waste  time  and  material.  Examinations 
likely  to  prove  of  value  in  various  cases  are  listed 
discriminatingly.  This  book  will  not  only  inform  a 
doctor  when  and  how  to  make  laboratory  deter- 
minations; it  will  encourage  him  to  make  them. 

A  TEXTBOOK  OF  SURGERY,  by  American  Authors. 
Edited  by  Frederick  Christopher,  B.S.,  M.D.,  F.-^.C.S., 
.Associate  Professor  of  Surgery  at  Northwestern  University 


April.   1036 


SOUTHERN  MEDICINE  AND  SURGERY 


Inetrazol 


'^cd^ 


INJECT  I  or  2  ampules  Metrazol  as  a  restorative 
in  circulatory  collapse  and  shock,  respiratory 
distress,  deep  anesthesia,  and  in  morphine  and 
barbiturate  poisoning.  For  circulatory  stimulation 
in  the  emergencies  of  pneumonia  and  other  over- 
whelming infections,  and  in  congestive  heart  failure, 
give  I 'A  to  3  grains  Metrazol  three  times  a  day. 

METRAZOL     (pentamethylentetrazol)  Councll  Accepted 

Uniform  dosage:   I  Ampule  (l  cc.)  =  I  Tablet  =  1^2  grain  Metrazol  Powder. 


BILHUBER-KNOLL  CORP.  154 ogdenave.  jersey ciry. N.J. 


Medical  School;  Chief  Surgeon,  Evaniton  (Illinois)  Hos- 
pital. 1608  pages  with  1340  illustrations  on  730  figures, 
l^hiladclphia  and  London:  IF.  B.  Saunders  Company,  1036. 
Cloth,  SIO.OO  net. 

The  preface  promises  concise  pressntatio  i  with 
a  maximum  of  authority,  and  the  promise  is  lived 
up  to.  The  preponderance  among  the  authors  of 
associate  and  assistant  professors  over  professors- 
and-heads-of-departments  in  no  way  negatives  the 
statement  as  to  authority;  for  the  full-time  pro- 
fessor idea  has  put  many  a  poor  doctor  over  a 
whole  lot  of  good  ones,  many  a  neophyte  over  a 
dozen  of  veterans. 

Only  tried-and-proven-worthy  things  are  includ- 
ed. The  reader  is  not  confused  with  a  cloud  of 
witnesses. 

.\mong  the  distinguishing  features  are:  the  fact 
that  there  is  section  on  the  bursae;  what  to  do  for 
corns  and  calluses;  the  section  on  fractures  and 
that  on  dislocations  are  independent  of  the  section 
on  orthopedic  surgery;  a  kind  word  for  injection 
treatment  of  hernia;  the  statement  that  treatment 
of  peptic  ulcer  is  primarily  medical;  Dr.  Dean 
Lewis"  ranging  himself  on  the  side  of  those — 
mostly  medical  men — who  say  of  chronic  appendi- 
citis, "There  is  no  such  pathologic  entity";  the 
statement  that  for  most  cases  of  stricture  of  the 
ureter  of  long  standing  the  tubercle  bacillus  is 
responsible;    and  the  excellent  practical  directions 


F'OR 


PAIN 


The  majority  of  the  phy- 
sicians in  the  Carolinas 
are  prescribing  our  new 


tablets 


AND 


751 


Analgesic  and  Sedative     ^  Pf.*'  _  5  parts       I  part 
Aspirin   Phenacetin   Caffeln 


We  will  mail  professional  samples  regularly 
m'th  nur  compliments  if  you  desire  them. 
Carolina   Pharmaceutical    Co..    Clinton,   S.    C. 


as  to  chronic  prostatitis:  but  we  think  Theodore 
Davis  worthy  of  mention  along  with  others  named 
as  contributors  to  transurethral  surgery. 

Among  the  nigh  200  authors  of  this  work  are 
noted  Dr.  A.  Stephens  Graham  of  the  Medical 
College  of  Virginia,  and  Dr.  Deryl  Hart  of  the 
Duke  Medical  School. 

If  a  more  attractive  or  more  informative  book 
on  any  branch  of  Medicine  has  come  out  in  recent 


SOUTHERN  MEDICINE  AND  SURGERY 


April,  1936 


years  the  fact  has  escaped  our  attention.     Here  is 
reliable  clear  instruction  on  everyday  problems. 


THE  1Q3S  YEAR  BOOK  OF  GENERAL  THERAPEU- 
TICS, edited  by  Beiujard  Fantus,  M.S.,  M.D.,  Professor 
of  Materia  Medica,  Pharmacology  and  Therapeutics,  Uni- 
versity of  Illinois  College  of  Medicine;  Member,  Revision 
Committee  of  the  United  States  Pharmacopeia  and  of  the 
National  Formulary  Revision  Committee;  Director  of 
Therapeutics,  Cook  County  Hospital.  The  Year  Book  Pub- 
lishers, Inc.,  Chicago.    $2.25,  postpaid. 

The  introduction  gives  intimations  of  advances 
in  the  treatment  of  hernia,  that  "diabolic  neuritis" 
is  a  vitamin-B  deficiency,  that  powdered  stomach 
is  obtaining  more  recognititon  in  pernicious  anemia, 
that  better  methods  have  been  evolved  of  treating 
poisoning  with  certain  common  aspects,  that  cod- 
liver  oil  is  a  good  wound  dressing,  and  a  lot  more 
to  interest  and  instruct.  Iso-alcoholic  elixir,  com- 
presses, gargling,  and  local  medication  through  all 
the  external  openings  of  the  body  are  treated  of. 
The  book  praises  here,  condemns  there,  and  now 
and  then  is  neutral. 

Its  arrangement  is  convenient  and  its  content 
valuable. 

In  addition  to  drug  therapy,  general  technic  is 
detailed  and  antipathogen  therapy,  immunization, 
treatment  by  fever,  blood  transfusions,  special 
diets,  posture,  rest,  work,  heat,  radiant  energy  and 
electro-  and  psychotherapy. 


ABC  OF  THE  ENDOCRINES,  by  Jennie  Gregory, 
M.S.,  Foreword  by  Carl  G.  Hartman,  Department  of  Em- 
bryology, Carnegie  Institution  of  Washington.  The  Wil- 
liams &  Wilkins  Co.,  Baltimore,  1935.     $3.00. 

The  matter  on  each  gland  and  its  relationship 
to  the  others  is  set  forth  in  charts  and  graphs.  Thus 
the  essentials  of  the  subject  are  presented  in  a 
wayy  that  makes  it  possible  to  fix  these  essentials 
firmly  in  the  mind  within  a  very  short  time.  The 
reviewer  is  impressed  with  the  boldness  and  clever- 
ness of  the  idea  and  predicts  success  for  it. 


EXAMINATION  OF  THE  PATIENT  AND  SYMPTO- 
M.ATIC  DIAGNOSIS,  by  John  Watts  Murray,  M.D., 
with  274  illustrations;  2nd  edition.  The  C.  V.  Mosby  Co., 
St.  Louis.     1936.     $10.00. 

This  book  was  planned  and  written  to  help  the 
doctor  practicing  general  medicine  to  make  the 
most  use  of  history,  symptoms,  signs  and  physical 
findings.  It  does  not  teach  that  a  "complete"  ex- 
amination should  be  made  in  every  case,  but  that 
whe.i  the  patient  presents  himself  the  physician 
ascertains  by  the  history  the  extent  of  the  exam- 
ination necessary. 

The  arrangement  is  novel  and  the  change  is  in 
the  way  of  improvement.  Symptoms  are  analyzed, 
particularized,  classified,  differentiated  and  com- 
pared just  as  a  thoughtful  doctor  does  in  actual 
practice. 


The  author  is  a  country  doctor,  the  only  doctor 
in  a  village  of  less  than  200  persons.  He  has  first- 
hand knowledge  of  the  problems  of  a  doctor  who 
has  to  depend  largely  on  himself;  he  has  learned 
much  about  how  to  solve  these  problems;  and  he 
passes  this  knowledge  on  in  plain,  attractiv.;  form. 


YOUR  HAY  FEVER,  by  Oeen  Durham,  Chief  Botan- 
ist, .Abbott  Laboratories,  North  Chicago,  with  an  introduc- 
tion by  Morris  Fishbein  and  a  chapter  on  treatment  by 
SAiiUEL  M.  Feinberg,  M.D.,  F.A.C.P.  The  Bobbs-Merrill 
Company,  Indianapolis  and  New  York  City.     1936.     $2.00. 

At  once  the  reader  is  struck  with  the  fact  that 
this  medical  book  is  written  by  a  man  not  a  doctor 
of  medicine.  On  looking  further,  it  will  be  seen 
that  this  does  not  mean  that  the  author  is  one  in- 
experienced in  his  subject.  Hay  fever  is  of  all 
medical  subjects,  perhaps,  the  one  on  which  is 
most  needed  the  light  that  can  be  shed  by  an  in- 
vestigator not  directly  engaged  with  patients  with 
dripping  noses  and  smarting  eyes.  Whether  you 
be  doctor  or  patient  in  this  serio-comic  episod;  of 
life,  you  will  find  between  these  covers  much  to  in- 
form and  entertain. 


AMERICAN  CHAMBER  OF  HORRORS:  The  Truth 
-About  Food  and  Drugs,  by  Ruth  deForest  Lamb.  Illus- 
trated with  photographs.  Farrar  and  Reinhart,  Inc.,  New 
York  City.     1936. 

The  book  centers  on  the  attempt  to  pass  the 
Copeland  Bill  as  an  improved  Food  and  Drugs  act 
and  the  opposition  of  many  manufacturers  and 
dealers.  It  explains  many  of  the  difficulties  of 
enforcement  of  the  plain  intent  under  the  present 
laws  and  gives  graphic  accounts  of  many  of  the 
dangers  which  beset  us.  Both  sides  of  the  argu- 
ment are  presented  and  many  exposures  of  noto- 
rious and  dangerous  frauds  are  set  before  the 
reader. 

From  this  book  one  may  learn  that  eyelash  dye 
may  produce  blindness,  and  "harmless"  hair  re- 
mover may  paralyze;  and  one  may  be  reminded  of 
all  the  callous  selfishness  of  manufacturers  of  rem- 
edies to  "cure"  tuberculosis,  cancer,  diab;tes, 
Bright 's  disease  and  everything  else.  One  may  get 
more  information  on  Crazy  Crystals,  Pinkh:;m's 
Compound  and  Vick's  Vapo-Rub — and  learn  how 
lightly  at  least  one  of  our  "philanthropists"  re- 
gards the  truth,  and  how  eagerly  a  North  Carolina 
U.  S.  Senator  aligns  himself  with  the  enemies  of 
those  who  are  striving  for  a  Food  and  Drugs  Act 
that  will  protect. 


First  baseball  diamond  in  the  world.  .At  Cooperstown, 
N.  Y.,  is  the  original  ball  field,  laid  out  in  1839  by  .Abner 
Doubleday. — Med.  Pocket  Quart. 


Automobiles  are  streamlined  to  gratify  the  eye;  but  the 
other  end  is  not  neglected:  we  are  now  offered  streamlined 
rectal  suppositories. 


April,  1936 


PROFESSIONAL  CARDS 


GENERAL 


Nalle  Clinic   Building 


THE  NALLE 

Teleplione~i-2Ul  (Ij  no 
General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics 

EDWARD  R.  HIPP,  M.D. 

Traitmatic  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.  ADAMS,  M.D. 

Diseases  of  Intants  &  Children 

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


High  Point,  N.  C. 


BURRUS  MEMORIAL  HOSPITAL,  INC. 

(Miss  Gilbert  Muse,  R.N.,  Supt.) 
General  Surgery,  Internal  Medicine,  Proctology,  Ophthalmology,  etc..  Diagnosis    Uroloev 


Fedtatrics,  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  ^-  ^-  Bonner,  M.D.,  F.A.C.S. 


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,  e.xcept   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.  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.  Dentist 

A.  W.  ScHEER  X-ray  Technician 

Miss  Etta  Wade  Clinical  Pathologist 


Please  Mention  THIS  JOURNAL  When   Writing  to   Advertiser* 


PROFESSIONAL  CARDS 


April,  1036 


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   Buildinc  Charlotte 


ORTHOPEDICS 


J.  S.  GAUL,  M.D. 

ALONZO  MYERS,  M.D. 

ORTHOPEDIC  SURGERY  and 

ORTHOPEDIC  SURGERY  and 

FRACTURES 

FRACTURES 

Professional   Buildinjr                     Charlotte 

Professional  Building                    Charlotte 

HERBERT  F.  MUNT.  M.D. 


FRACTURES 
ACCIDENT  SURGERY  and  ORTHOPEDICS 


Nissen  Building 


Winston-Saleni,  N.  C. 


EYE,  EAR,  NOSE  AND  THROAT 


AMZI  J.  ELLINGTON,  M.D. 

Diseases  of  the 
EYE,  EAR,  NOSE  AND  THROAT 

PHONKS:     Office  992— Residence   761 
Burlington  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 


I 


April,   1936 


PROFESSIONAL  CARDS 


NEUROLOGY  and  PSYCHIATRY 


AV.  C.  ASHWORTH,  M.D. 

W.  CARDWELL,  M.D. 

NERVOUS  AND  MILD  MENTAL 

DISEASES 

ALCOHOL  AND  DRUG  ADDICTIONS 

Glenwood    Park    Sanitarium,    Greensboro 


Wm.  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  Telep!,one5~3-7101-i-7102 

STAFF 
Andrew  J.  Cro\vell,  M.D.  Claude  B.  Squires,  M.D. 

Raymond  Thompson,  M.D.         Theodore  M.  Davis,  M.D. 


Dr.  Hamilton  McKay  D,    r^I^^^j  j^^^^^ 

DOCTORS  McKAY  and  McKAY 

Praclice  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         Arkansa.s 


C.  C.  MASSEY,  M.D. 

Diseases  of  the  Rectum  &  Colon 

Professional  Bldg.  Charlotte 


Please   Mention   THIS  JOURNAL  When  Writing  to  Advertiser 


PROFESSIONAL  CARDS 


April,  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 


Physician  Wants  Assistant  in  Genera!  Practice,  who  is  also  highly  qualified 
Ear,  Nose,  Throat  operator.  Age  28-35.  Good  personality.  References, 
full  particulars  and  photograph  first  letter.  Salary  or  percentage.  North 
Carolina  license.    Address:  PHYSICIAN,  care  this  Journal. 


THE  EDITING  OF  MEDICAL  P.'\PERS 

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  &  SURGERN'. 


Please   Mention   THIS  JOURNAL  When   Writing   to   Advertisers 


Journal 

of 

SOUTHERN  MEDICINE   &  SURGERY 


Vol.  XCVIII 


Charlotte,  N.  C,  May,  1936 


No.  5 


What  Constitutes  An  Interesting  Case? 

The  Proper  Study  of  Mankind  is  Man— Pope 
Paul  H.  Ringer,  A.B.,  M.D.,  F.A.C.P.,  Asheville,  North  Carolina 


MEMBERS    OF   THE    MEDICAL    SOCIETY    OF    THE 
STATE  OF  NORTH  CAROLINA,  AND  GUESTS: 

IT  is  with  a  deep  feeUng  of  pleasure  that  I 
preside  at  this  meeting  today  and  stand  before 
you  clothed  with  the  office  of  chief  executive 
of  the  Medical  Society  of  the  State  of  North  Caro- 
lina. That  it  is  a  source  of  pride  to  me  to  have 
been  elected  to  this  office  is  but  natural.  The 
deepest  feeling  of  gratification  that  I  have  experi- 
enced, however,  is  due  to  the  fact  that  my  col- 
leagues, the  men  whom  I  have  known  and  with 
whom  I  have  worked  for  thirty  years,  have  con- 
sidered me  worthy  of  selection  for  this  position. 
The  possession  of  the  confidence  and  respect  of 
fellow-physicians  is  the  greatest  prize  that  can  be 
won,  and  I  deem  myself  undeservedly  fortunate  in 
having  received  this  evidence  of  the  well-wishings 
and  friendship  of  my  associates  in  the  practice  of 
medicine  throughout  the  boundaries  of  our  com- 
monwealth. 

For  the  past  five  or  six  years  presidents  of  medi- 
cal societies  the  country  over  have  felt  that  there 
was  but  one  subject  on  which  they  should  address 
their  fellow-members  on  those  occasions  when  it 
behooved  them  to  do  so;  namely,  Medical  Econom- 
ics. So  much  has  been  written  on  the  various 
phases  of  this  general  topic  that  many  are  getting 
very  tired  of  it—myself  among  others.  My  address 
to  the  House  of  Delegates,  delivered  yesterday 
evening,  had  necessarily  to  concern  itself  with  the 
business  of  the  Medical  Society  of  the  State  of 
North  Carolina,  in  which  naturally  medical  eco- 
nomics played  a  major  part.  In  my  address  today, 
however,  I  was  very  anxious  to  get  away  from  the 
business  end  of  medicine  and  to  consider  a  more 
scientific  phase.  I  did  not  wish  to  choose  a  subject 
too  technical  or  one  too  specialized.     I  wished  to 

ethf'lDse^"""'"  »^<i'"«ss  to  the  Medical  Society  of  the  State 


select  a  topic  that  would  appeal  to  all  physicians, 
irrespective  of  any  particular  branch  of  practice. 

Doctors  never  gather  together  that  one  of  them 
does  not  say  "I  had  an  interesting  case  the  other 
day" — and  then  the  bout  is  on  and  "interesting 
cases"  are  swapped  as  are  stories  in  a  Pullman 
smoking  compartment.  The  topic  upon  which  I 
wish  to  dwell  this  morning  is:  "What  Constitutes 
an  Interesting  Case?"  The  approach  to  the  ques- 
tion can  be  many-sided — the  answers  can  be  equally 
varied. 

If  one  has  talked  with  colleagues  and  has  read 
reports  of  interesting  cases  in  the  literature,  one 
must  be  struck  with  two  factors  that  predominate; 
first,  rarity;  and  second,  incurability.  Often  the 
most  important  and  convincing  element  in  the  en- 
tire report  of  the  interesting  case  is  the  protocol  of 
the  necropsy.  Does  this  state  of  affairs  mean  that 
ordinary  treatable  and  curable  cases  are,  therefore, 
uninteresting?  Let  us  consider  awhile  the  elements 
that  go  to  make  up  an  interesting  case. 
The  object  of  medicine  is  three-fold: 

1.  Prevention — eradication  of  disease 

2.  Prophylaxis — protection   from   existing  dis- 
ease 

3.  Cure 

Once  a  "case"  of  any  sort  is  seen  it  obviously 
belongs  to  class  3.  Consequently,  the  primary  ob- 
ject of  the  practice  of  medicine  lies  in  class  3  and 
consists  in  the  proper  administration  of  successful 
therapy.  Therefore,  the  final  goal  of  all  medicine 
and  surgery  is  therapy.  But  we  must  realize  that 
adequate  therapy  is  unavailable  in  the  absence  of 
accurate  diagnosis;  therefore,  the  two  legs  upon 
which  rest  the  practice  of  medicine  and  surgery  are 
diagnosis  and  treatment.  No  one  realizes  better 
than  myself  what  platitudes  I  have  just  uttered; 

of  North  Carolina,  at  its  meeting  in  Asheville,  May  4th- 


WHAT  CONSTITUTES  AN  INTERESTING   CASE?— Ringer 


May,   1936 


they  seemed  necessary,  however,  for  the  further  de- 
velopment of  the  subject  concerning  which,  as  far 
as  I  can  discover,  very  httle  has  been  written.  My 
friend,  Dr.  W.  R.  Houston,'  now  of  Austin,  Texas, 
wrote  a  brief  paper  on  this  matter  in  the  China 
Medical  Journal  some  twelve  years  ago.  That  is 
practically  the  only  reference  to  interesting  cases 
in  the  abstract  that  I  can  find  in  medical  literature. 

The  interesting  case  is  primarily  one  that  offers 
therapeutic  possibilities,  using  the  words  in  the 
broadest  sense.  Therapy  must  include  both  treat- 
ing the  disease  the  patient  has  and  treating  the 
patient  that  has  the  disease.  Most  diseases  are 
not  in  themselves  particularly  interesting  to  treat. 
The  things  that  stimulate  the  physician  are  the  in- 
teraction upon  one  another  of  the  particular  condi- 
tions from  which  the  patient  is  suffering,  and  the 
particular  type  of  pjersonality  that  is  being  affected 
by  the  presence  of  somatic  pathology. 

Throughout  life  in  general  it  is  true  that  the 
things  we  know  best  we  find  most  interesting.  Thus, 
the  firmer  the  grasp  we  can  secure  upon  all  phases 
of  a  given  patient's  condition,  the  greater  interest 
will  that  patient  evoke.  Many  of  us,  in  fact  most 
of  us,  do  not  get  to  the  bottom  of  all  that  a  patient 
can  present  because  we  find  it  practically  impossible 
to  give  the  necessary  time  to  ferreting  out  details 
which,  when  put  together,  may  fill  in  an  important 
gap.  It  takes  time  to  consider  body,  mind  and 
spirit.  It  takes  patience  to  discover  behavior  char- 
acteristics, family  skeletons,  inferiority  complexes, 
thought  transferences,  various  conditions  that  the 
patient  himself  wishes  to  conceal — it  takes  far  more 
time  and  patience  than  it  does  to  make  a  careful 
routine  physical  examination  and  to  have  done,  or 
do,  the  necessary  laboratory  work.  But  painstak- 
ing inquiry  and  tireless  investigation  will  often 
bring  to  light  a  combination  of  facts  that  will  turn 
the  patient  that  promises  to  be  a  bore,  and  perhaps 
a  nuisance,  into  a  genuinely  "interesting  case." 

"Interesting  cases"  are  both  born  and  made. 
Those  that  are  born  come  under  the  head  of  "rare" 
or  "unusual"  and,  as  previously  stated,  are  fre- 
quently incurable.  There  is  a  certain  thrill  in 
making  a  diagnosis  of  subacute  bacterial  endocard- 
itis or  of  pulmonary  carcinoma;  but  when  that  is 
done,  what  next?  Merely  the  scientific  attitude  of 
waiting  for  proof  at  the  autopsy  table,  coupled  with 
a  sense  of  futility  and  frustration  and  a  sort  of 
wonder  as  to  how  it  is  and  why  it  is  that  we  so 
often  come  to  a  dead  end  and  are  left  baffled  and 
helpless  and  hopeless.  Then  it  is  that  we  feel 
keenly  the  vain  pleading  of  the  patient's  loved  ones: 
"Doctor,  isn't  there  something  you  can  do?"  How 
many  times  have  we  heard  this,  and  how  equally 
many  times  have  we  turned  away  with  a  lump  in 
our  throats  because  we  could  not  bear  to  have  to 


tell  the  young  wife  or  the  aging  mother  or  the  des- 
perate father  that  in  truth  we  could  do  nothing! 
The  en,d  of  these  "interesting  cases"  is  sad  indeed 
and  makes  all  of  us  realize  our  pitiful  limitations. 

The  interesting  case  that  is  "made"  is  quite  an- 
other proposition.  Here  is  found  a  challenge  to 
the  physician — not  the  challenge  of  life  versus 
death,  but  the  challenge  of  health  versus  sickness, 
of  economic  solvency  versus  penury  and  depend- 
ence, of  joy  and  gladness  versus  gloom  and  wretch- 
edness. Surely  this  is  a  challenge  worthy  to  be 
met  and  accepted.  As  a  matter  of  fact,  it  is  the 
bounden  duty  of  every  physician  to  meet  and  to 
accept  it.  Unless  he  does  so  to  the  best  of  his 
ability  he  is  derelict  in  the  discharge  of  his  profes- 
sional obligations,  and  in  the  acceptance  thereof  he 
will  experience  a  sense  of  happiness  and  of  gratifi- 
cation which  nothing  else  can  give. 

-As  a  sub-title  to  this  address,  I  have  selected  a 
well-known  line  of  Alexander  Pope:  "The  property 
study  of  mankind  is  man."  This  statement  applies 
most  particularly  to  the  medical  profession:  We 
all  know  that  one  of  the  great  lures  of  our  calling 
resides  in  the  fact  that  we  see  human  nature  bare— ^ 
in  the  raw;  that  we  discover  things  that  no  other 
class  of  men  discover;  that  we  are  the  recipients 
of  confidences  never  given  to  others;  that  we  carry 
about  in  our  memories  damning  proofs  of  guilt  and 
evidences  of  the  highest  type  of  heroism;  and  we 
also  know  that  all  these  evidences  that  we  receive 
serve  to  make  the  "interesting  case." 

I  would  not  have  you  feel  that  I  am  pleading 
that  every  case  should  be  an  interesting  one — I 
have  practiced  medicine  too  long  to  think  that.  I 
do  feel,  however,  that  all  too  often  we  physicians 
fail  in  not  trying  to  place  ourselves  in  the  position 
of  the  patient — an  individual  who  comes  to  us  for 
relief  of  symptoms.  Whether  these  symptoms  are 
of  organic  or  of  functional  origin  or  both,  is  up  to 
us  to  decide;  but  irrespective  of  their  etiology,  they 
exist;  and  because  of  their  etiology,  the  therapeutic 
management  must  vastly  vary.  It  is  in  the 
evaluation  of  the  etiological  factor  in  the  symp- 
tomatology and  in  the  consequent  adequate  appli- 
cation of  rational  and  understanding  therapy  that 
we  doctors  make  or  break  our  reputations. 

Naturally  the  viewpoints  of  physicians  will  differ. 
The  ones  accustomed  to  seeing  acute  illness  will 
not  walk  in  exact  step  with  those  whose  professional 
life  consists  of  constant  contact  with  chronic  suf- 
ferers. The  management  of  the  case  of  lobar  pneu- 
monia is  far  removed  from  that  of  pulmonary  tuber- 
culosis, and  the  attitude  adopted  toward  the  case 
of  perforated  gastric  ulcer  is  vastly  different  from 
that  assumed  in  the  case  of  diabetes.  All  four  of 
these  examples  are,  however,  "interesting  cases" — 
the  acute  medical  and  surgical  emergencies  chosen 


May,  1936 


WHAT  CONSTITUTES  AX  INTERESTING   CASE?— Ringer 


as  examples  are  intensely  interesting  over  a  brief 
period  of  time,  at  the  end  of  which  the  patient  is 
either  dead  or  definitely  convalescent.  The  two 
chronic  medical  examples  exemplify  conditions  for 
which  the  patient  must  be  supervised  for  years 
and  toward  which  a  totally  different  approach  is 
necessary.  The  environment,  social  and  domestic 
struggles,  etc.,  are  of  no  importance  in  the  acute 
emergencies;  they  loom  large  in  the  chronic  condi- 
tions. What  makes  the  tuberculous  case  interest- 
ing? In  part,  the  local  pathological  condition,  its 
improvement  or  the  reverse;  in  part,  the  effect  of 
surgical  procedure  in  influencing  the  diseased  proc- 
ess; but  most  of  all  the  reaction  of  the  personality 
to  the  new  environment,  the  psychic  struggle  that 
is  going  on,  the  combination  of  resignation  and 
will-to-win,  the  character-building,  that  accompany 
every  recovery.  Why  is  the  diabetic  interesting? 
Partly  because  of  the  diet  he  can  accept,  of  the 
gradual  increase  in  carbohydrate  tolerance,  in  the 
feasibility  as  time  goes  on  to  decrease  insulin  dos- 
age, in  the  evidences  of  general  betterment  or,  in 
other  cases,  of  gradual  metabolic  failure.  Surely 
these  are  all  sources  of  interest,  but  there  are  oth- 
ers. The  personal  enthusiasm  of  the  patient  in 
seeking  to  understand  his  own  condition;  his  im- 
mense concern  over  his  diet;  his  self-control  in  the 
presence  of  temptation;  his  mastery  of  a  new  world 
composed  of  carbohydrates,  proteins,  fats  and  cal- 
ories— his  occasional  diabetic  jags  when  he  "breaks 
training"  and  suffers  in  consequence;  in  short,  the 
reaction  of  his  entire  personality  to  the  soulless 
demands  of  a  decreased  metabolic  ability  and  a 
consequent  lifelong  adaptation  to  a  changed  mode 
of  life. 

Xo  one  who  has  listened  to  the  outpourings  of 
the  soul  of  a  tuberculous  patient  with  his  mem- 
ories of  the  past,  fear  of  the  present  and  hope  for 
the  future  can  consider  such  an  individual  as  any- 
thing but  an  "interesting  case";  nor  can  anyone 
who  has  run  the  gamut  of  emotions  with  a  diabetic 
(many  of  them,  to  be  sure,  purely  dietetic)  fail  to 
realize  that  in  the  laying  bare  of  the  human  ele- 
ment and  of  the  human  spirit  that  sustains  the 
diseased  body  rest  the  groundworks  of  the  inter- 
esting case.  These  examples  have  been  chosen  as 
types.  They  may  be  varied  to  suit  the  individual 
taste  and  experience. 

Probably  the  most  difficult  patient  to  excite  in- 
terest is  the  "chronic  incurable" — the  individual 
whose  prognosis  is  absolutely  bad  and  whose  out- 
come depends  not  upon  "if"  but  upon  "when," 
which  is  best  exemplified  in  the  man  or  woman  of 
sixty-odd  exhibiting  symptoms  due  to  hyperten- 
sion. Here  is  where  the  true  physician  or  surgeon 
must  expend  himself  to  his  uttermost.  A  serious 
illness  of  his  own  is  a  real  boon  to  the  doctor.    He 


then  sees  the  reverse  of  the  coin  with  whose  obverse 
he  is  so  familiar,  and  he  gets  the  viewpoint  of  the 
symptom-conscious  and  of  the  bedridden;  the  one 
who  is  "looking  up,"  whereas  the  doctor  is  always 
"looking  down."  I  am  sure  that  in  our  busy  days 
we  often  fail  to  fully  appreciate  just  how  much 
visits  with  us  mean  to  our  patients  or,  sad  to  say, 
the  reverse.  I  know  that  I  have  left  a  sick  bed 
with  the  feeling  that  my  visit  had  been  of  real 
value,  even  though  no  change  in  treatment  had 
been  made;  and,  alas,  I  also  know  that  I  have 
frequently  gone  out  of  a  patient's  room  realizing 
that  my  visit  had  been  mechanical  and  perfunctory. 
The  patient,  that  day  at  least,  had  not  been  an 
"interesting  case";  but  the  interest  inherent  in  pa- 
tients is,  in  the  vast  majority  of  instances,  depend- 
ent upon  what  we  put  into  the  visit  rather  than 
what  we  get  out  of  it. 

All  of  which  brings  us  inevitably  to  a  considera- 
tion of  the  science  and  of  the  art  of  medicine.  We 
could  not  do  without  the  science,  which  has  as  its 
cornerstone  the  diagnosis  and  treatment  of  disease; 
nor  could  we  do  without  the  art,  on  which  depends 
our  estimate  of  the  patient  and  our  management 
of  his  personality;  and  while,  because  of  the 
science,  many  cases  are  intrinsically  interesting,  be- 
cause of  the  art  almost  every  case  can  present  some 
absorbingly  intriguing  phase. 

In  his  presidential  address  before  the  Tn  S!ite 
Society  of  the  Carolinas  and  Virginia  in  1932,  Dr. 
Beverley  R.  Tucker,-  of  Richmond,  stated:  "It  is 
the  ability,  I  take  it,  not  only  to  see  the  fact  or 
the  truth  of  medical  science  but  to  play  one's 
knowledge,  both  acquired  and  intuitive,  through 
the  imgination  around  about,  back,  above,  below, 
and  ahead  of  the  fact  or  truth;  that  constitutes 
the  art  of  medicine."  Elaborated,  this  statement 
implies  that  the  broader  the  education  of  the  phy- 
sician, the  more  adequately  he  can  solve  the  prob- 
lems presented.  The  statement  quoted  is  that  of  a 
neurologist  and  psychiatrist — it  were  well  if  many 
of  us  were  more  neurologically-  and  psychiatrically- 
minded.  Which  of  us  fails  to  see  so-called  "neu- 
rotics"? How  many  of  us  after  dealing  with  them 
for  awhile  turn  away  from  them,  dubbing  them 
"nuts"  and  consigning  them  and  their  ailments  to 
limbo!  Yet,  they  represent  an  element  of  suffering 
humanity — the  point  is  to  get  the  key  to  the  lock. 
Here  the  physician  with  the  larger  aspect,  with  the 
greater  extra-medical  knowledge,  with  the  broader 
humanitarian  culture,  will  be  the  most  apt  to  suc- 
ceed. Too  often  these  unfortunates  need  but  a 
sympathetic  personality  that  has  some  grasp  (in- 
adequate it  may  be,  but  patients  put  up  wonder- 
fully with  our  imperfections)  upon  that  which  holds 
their  interest  in  life:  it  may  be  art,  chemistry,  relig- 
ion, architecture,  ceramics,  poetry,  politics  or  what 


WHAT  CONSTITUTES  AN  INTERESTING   CASE?— Ringer 


May,   1936 


have  you? — but  somehow,  somewhere,  there  must  be 
reached  a  point  of  contact  between  the  physician 
and  the  patient  suffering  from  functional  disease, 
or  even  between  the  physician  and  the  patient 
suffering  from  organic  disease  with  a  functional 
overflow.  Here  it  is  that  the  broad-minded  versa- 
tile practitioner  will  find  a  "receptor"  where  his  less 
fortunate  colleague  will  not. 

The  type  of  man  that  enters  medicine  with  the 
art  as  well  as  the  science  (and  I  again  quote  Dr. 
Tucker)  "sees  through  and  around  about  the  pa- 
tient and  becomes  'en  rapport'  with  the  whole  sit- 
uation, including  the  conscious  or  objective  and  the 
subconscious  or  subjective;  with  a  faculty  for  the 
retrospective  and  a  clinical  instinct,  he  goes  to  the 
root,  or,  more  often,  to  the  roots,  of  the  malady; 
he  has  the  indicated  laboratory  work  done  and  he 
interprets  it  in  relation  to  the  particular  human 
being  he  is  treating;  he  allows  for  technical  errors 
and  watches  for  incongruous  findings;  he  contem- 
plates, meditates,  and  brings  to  bear  upon  the 
diagnosis  his  knowledge,  his  experience,  and,  un- 
wittingly perhaps,  his  imagination.  Then,  and  then 
only,  he  arrives  perhaps  with  great  rapidity,  at  a 
tentative  solution  or  at  a  definite  conclusion.  He 
is  much  more  apt  to  be  right  than  wrong,  and  if  he 
is  wrong,  he  is  usually  not  far  wrong,  and  he  soon 
puts  himself  back  on  the  right  track.  Now,  and 
not  until  now,  he  applies  his  real  therapy,  and  his 
treatment  is  not  routine  but  resourceful.  He  re- 
members that  the  best  medicine  is  frequently  ad- 
ministered not  in  a  pill  or  in  a  teaspoon  but  by 
sympathetic  understanding  and  safe  advice." 

The  words  of  Dr.  Tucker  will  apply  well  to  some 
patients  that  many  of  us  see  and  to  many  patients 
that  some  of  us  see.  Why  have  I  quoted  these 
sentences?  Because  in  their  essence  they  give  to 
us  the  principles  upon  which  is  built  the  "interest- 
ing case."  If  we  can  look  upon  our  patients  other 
than  those  that  come  to  us  in  an  acute  surgical 
or  medical  emergency  or  those  that  present  the  true 
"rarities"  of  medicine:  I  repeat,  if  we  can  look 
upon  our  patients  that  come  to  us  day  in  and  day 
out  with  the  breadth  of  vision  and  the  imaginative 
concept  supported  by  Dr.  Tucker,  then  truly  shall 
we  discover  again  and  again  "interesting  cases"; 
and  in  the  discovery  thereof  we  will  be  stimulated 
and  rewarded. 

The  inherent  quality  of  the  "interesting  case"  is 
the  presentation  of  a  problem  to  be  solved.  Some 
of  these  problems  are  so  simple  and  obvious  that 
they  stick  out  like  a  sore  thumb;  some  are  more 
subtle,  be  they  organic  or  functional,  but  still  there 
is  enough  on  the  surface  to  urge  us  to  further  in- 
quiry; still  others,  and,  I  am  sure,  by  no  means  a 
small  group,  present  at  first  sight  no  elements  of 
interest  but  appear  dull,  colorless  and  drab.     It 


takes  the  artist  as  well  as  the  scientist  in  medicine 
to  unravel  these  patient-problems.  We  lose  so 
much  when  we  fail  in  our  own  minds  to  dramatize 
medicine — what  a  drama  it  presents  I  "The  proper 
study  of  mankind  is  man" — and  man  in  his  reac- 
tions to  disease,  to  heredity,  to  environment,  to 
success,  to  failure,  to  happiness,  to  sorrow,  to  ex- 
ultation, to  fear;  do  not  the  consideration  of  all 
these  factors  constitute  the  practice  of  medicine, 
and  is  there  not  drama  in  each  element?  All  of 
us  in  our  offices  have  had  dramas  unrolled  before 
us — the  whole  gamut  of  what  is  presented  upon 
the  stage — tragedy,  naked  and  stark;  comedy,  both 
high  and  low;  farce,  at  times,  melodrama  not  in- 
frequently. Why  do  we  so  often  fail  to  grasp  the 
significance  of  the  presentation  of  the  whole  pic- 
ture, in  its  relationship  to  the  functional  and  somatic 
complaints,  of  those  whose  role  is  a  major  or  a 
minor  one  in  the  play  of  human  emotions  that  is 
depicted  to  us  in  narration  or  more  often  in  uncon- 
scious acting  as  we  talk  with  our  patient?  Yes! 
there  is  drama  in  medicine  and  its  appreciation  and 
interpretation  are  potent  forces  in  diagnosis. 

The  ability  to  dramatize  is  a  real  gift  and  tends« 
to  get  one  away  from  that  standardization  which 
is  so  ingrained  in  this  country.  The  late  Dr.  C. 
Jeff  Miller,^  of  New  Orleans,  had  this  to  say: 
"Perhaps  the  most  characteristic  aspect  of  Ameri- 
can civilization  today  is  the  trend  toward  stand- 
ardization, and  American  medicine  has  become  in- 
fected with  the  same  virus.  We  have  standardized 
our  hospitals  and  our  medical  schools,  and  our  pa- 
tients are  in  all  respects  the  better  for  it.  We 
have  standardized  our  laboratory  methods  and  our 
medical  and  surgical  therapeutics,  and  our  patients 
are  in  many  respects  the  better  for  it.  But  we  are 
in  a  very  great  danger — I  do  not  use  the  word 
lightly — of  standardizing  ourselves  and  them,  and 
we  are  both  the  worse  for  it.  There  is  a  limit  to 
the  value  of  standardization,  and  I  greatly  fear  that 
we  have  reached  it.  I  know  that  it  would  profit  us, 
and  I  am  sure  that  it  would  not  lessen  our  scientific 
efficiency,  to  be  more  personal  and  more  human  in 
our  relationships,  to  regard  as  something  more  than 
cases  and  symptom-complexes  the  ailing  men  and 
women  who  turn  to  us  for  aid." 

Dr.  ]\Iiller  is  pointing  us  toward  the  art  of  medi- 
cine and  indicating  plainh'  that  man  cannot  be 
standardized  and  that  the  study  of  man  in  relation 
to  his  environment  cannot  be  governed  by  any  hard 
and  fast  rule.  It  is  by  having  no  inelastic  yard- 
stick that  one  so  often  gets  at  the  heart  of  things, 
and,  when  the  entire  situation  is  viewed  in  a  pano- 
ramic way,  out  crops  the  interesting  case! 

Sir  William  Osier  once  said  that  to  treat  patients 
without  reading  medical  literature  is  like  sailing 
an  uncharted  sea;   but  to  read  medical  literature 


May,   1936 


WHAT  CONSTITUTES  AN  INTERESTING   CASE?— Ringer 


and  not  treat  any  patients  is  like  not  going  to 
sea  at  all.  It  is  thus  with  the  science  and  the  art 
of  medicine.  To  have  science  without  the  art  is 
not  conducive  to  success;  to  have  the  art  without 
the  science  is  dangerous  to  those  that  are  to  be 
treated,  though  one  sees  many  successful  practi- 
tioners who  get  along  on  an  absolute  minimum  of 
the  science.  They  know  people — "the  proper  study 
of  mankind  is  man,"  and  because  of  their  art  they 
help  enormously.  -And  again,  what  is  this  Art  of 
Medicine  that  to  so  many  is  a  will-o-the-wisp  ever 
sought  and  ever  fleeing?  Dr.  Walter  C.  Alvarez,'' 
who  always  writes  so  delightfully,  has  defined  it  in 
such  simple  terms  that  I  must  quote  him.  He  says: 
"What  is  this  Art?  I  should  say  that  it  is  the 
knack  of  dealing  with  the  patient  in  such  a  way  as 
to  gain  his  confidence,  his  respect  and  his  liking: 
it  is  the  knack  of  inspiring  him  with  the  feeling  that 
here  at  last  is  a  man  who  understands  his  case  and 
will  cure  him:  it  is  the  knack  of  keeping  his  trust 
even  when  things  go  wrong,  when  health  and  com- 
fort do  not  return,  and  when,  perhaps,  as  is  the 
case  with  many  illnesses,  things  continue  to  go  from 
bad  to  worse;  and  it  is  the  knack  of  making  the 
patient  comfortable  and  of  adjusting  the  prescribed 
treatment  to  his  particular  idiosyncrasies  of  mind 
and  body."  The  physician  who  has  these  qualities 
so  well  pointed  out  will  give  much  of  himself  to 
his  patients,  will  receive  much  from  them  and  will 
find  himself  surrounded  by  "interesting  cases." 

And  so,  finally,  we  are  as  it  were  turned  back 
upon  ourselves,  forced  to  introspection,  self-analysis 
and  self-evaluation.  We  are  forced  to  realize  that 
we  are  not  a  guild  apart,  set  away  with  our  x-ray 
and  our  laboratory  and  our  technical  terms  in  a 
water-tight  compartment;  but  that,  on  the  contrary, 
we  are  part  and  parcel  of  this  great  flow  of  hu- 
manity, specialists  in  one  of  the  branches  of  biology, 
particularly  qualified  to  do  certain  things,  discover 
certain  things,  deduce  certain  things:  specially  qual- 
ified to  diagnose  and  treat  disease,  and  specially 
qualified,  if  we  have  the  right  approach,  to  aid 
suffering  men  and  women  over  the  rough  places  oi 
life,  to  restore  a  certain  number — thank  God  a  large 
number — to  health  and  vigor;  and  specially  qual- 
ified to  stand  by  and  ease  and  comfort  those  whos; 
lot  it  is  to  land  upon  that  shore  from  whose  bourn: 
no  traveler  returns.  In  so  doing  we  reach  heights 
which  no  others  can  scale  and  we  plumb  depths 
which  no  others  can  reach. 

1  hope  that  all  of  you  have  read  Ian  Maclaren"s 
".■\  Doctor  of  the  Old  School."  If  you  have  not, 
you  have  a  rare  treat  in  store  for  you.  it  ends  with 
the  funeral  of  the  well-beloved  Doctor  MacLure 
in  the  presence  of  practically  the  entire  population 
of  the  village  oi  Drumtochty  and  the  glens  there- 
about.    The  minister,  Dr.   Davidson,  has  selected 


the  te.xt  to  be  placed  upon  his  tombstone;  it  is: 
"Greater  love  hath  no  man  than  this,  that  a  man 
lay  down  his  life  for  his  friends."  Objection  is 
made  to  this  by  one  of  those  present  because  the 
doctor  "didna  mak  mair  profession  o'  releegion." 
Then  Lachlan  Campbell  speaks  up  and  says: 
"'When  William  MacLure  appears  before  the  Judge, 
He  will  not  be  asking  him  about  his  professions, 
for  the  doctor's  judgment  has  been  ready  long  ago; 
and  it  iss  a  good  judgment,  and  you  and  I  will  be 
happy  men  if  we  get  the  like  of  it." 

"It  iss  written  in  the  Gospel,  but  it  iss  William 
MacLure  that  will  not  be  expecting  it." 

"W^hat  is't  Lachlan?"  asked  Jamie  Soutar,  eager- 
ly. The  old  man,  now  very  feeble,  stood  in  the 
middle  of  the  road,  and  his  face,  once  so  hard,  was 
softened  into  winsome  tenderness: 

"Come  ye  blessed  of  My  Father  *  *  *  *  i  was 
sick,  and  ye  visited  Me." 

— 213  Arcade  Building 

References 

1.  Houston,  W.  R.:  Interesting  Cases.  China  Medical 
Journal,  1924. 

2.  Tucker,  B.  R.:  Presidential  Address  Tri-State  Medical 
.'Association  of  the  Carolinas  and  Virginia,  1932,  South- 
ern Medicine  &  Surgery,  March,  1932. 

3.  Miller,  C.  J.:  Surgery,  Gynecology  and  Obstetrics, 
Feb.  15th,  1931. 

4.  Alvarez,  W.  C:  Minnesota  Medicine,  14:227,  March, 
1931. 


Malincering 
(A.    p.    Seltzer,    Phila..    in    Med.    Rec,    Mar.    18th) 

Malingering  in  man  may  be  a  fabric  of  entire  untruth 
or  it  may  have  a  slight  background  of  fact.  Three  main 
groups  are:  those  of  normal  mentality,  the  degenerate  and 
the  hysteric;  easy  access  to  medical  literature  is  a  factor. 

Where  the  doctor  is  known  to  examine  all  cases  thor- 
oughly, malingerers  are  few. 

Difficulty  of  hearing  is  a  favorite  complaint.  Test:  If 
a  normal-hearing  person  be  stroked  first  with  a  clothes 
brush,  then  the  palm  of  the  hand  along  the  back  of  the 
coat,  the  test  person  can  tell  whether  it  is  the  brush  or 
not.  But  if  at  the  same  time,  the  examiner  passes  the 
brush  down  his  own  coat,  the  normal  hearing  person  is 
usually  unable  to  tell  whether  it  is  the  brush  or  the  hand. 
But  if  the  test  person  is  deaf,  he  can  always  judge  correct- 
ly, because  the  sense  of  hearing  is  not  a  disturbing  factor. 

Severe  change  in  the  drumhead  does  not. always  mean 
loss  of  hearing,  and  absolute  deafness  may  exist  with  com- 
pletely normal  drum. 

In  simulation  referred  to  muscles  and  joints,  it  should 
be  borne  in  mind  that  voluntary  muscles  can  be  controlled 
only  within  certain  limits  and  that  their  electrical  behavior 
is  not  dependent  upon  the  will.  Also,  all  voluntary  mus- 
cular effort  sooner  or  later  leads  to  fatigue.  Many  persons 
by  autosuggestion  can  cause  secretion  of  lachrymal  glands, 
dilation  of  pupils  and  similar  changes. 

It  reflects  on  the  individual  doctor  also  on  the  profession 
2S  a  whole,  to  diagnose  a  suspect  as  malingerer  because  his 
symptoms  are  slight,  and  later  to  have  him  return  a  well- 
marked  case  of  lateral  sclerosis,  or  some  other  disease 
equally  serious.  The  physician  should  be  a  keen  diagnos- 
tician, and  if  in  doubt,  willing  to  seek  the  advice  of  some- 
one who  has  had  more  special  training  and  experience 
with  the  question  involved. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,   1936 


Report  of  General  Lymphadenitis  in  a  Diphtheria  Case* 

A.  E.  TuRMAN,  M.D.,  Richmond,  Virainia 


SERUM  SICKNESS  following  the  administra- 
tion of  therapeutic  serum  after  an  interval  of 
several  days  is  so  relatively  common  that  it 
is  usually  to  be  expected  and  as  a  rule  we  explain 
to  the  patient  or  his  family  at  the  time  of  serum 
administration  that  the  patient  will  probably  ex- 
perience an  attack  of  the  hives  and  the  usual  asso- 
ciated symptoms  several  days  later.  The  family  is 
thus  prepared  for  what  will  probably  develop  and 
understand  that,  aside  from  the  more  or  less  pro- 
nounced discomfort,  there  is  no  cause  for  appre- 
hension. 

Acute  anaphylactic  shock  immediately  following 
the  therapeutic  administration  of  serum  is  fortu- 
nately quite  rare.  This  may  be  very  severe,  even 
rapidly  fatal.  According  to  the  literature  it  occurs 
chiefly  in  allergic  individuals,  especially  those  with 
history  of  asthma.  For  this  reason  it  is  important 
always  to  question  the  patient  prior  to  serum  ad- 
ministration, regarding  past  allergic  manifestations, 
family  history  of  allergy,  and  especially  regarding 
any  evidence  on  the  patient's  part  of  sensitivity  to 
horses,  horse  dander  and  horse  serum.  It  is  equally 
important  to  inquire  whether  the  patient  has  ever 
previously  received  any  injection  of  serum. 

There  is  a  reaction  intermediate  between  serum 
sickness  and  anaphylactic  shock  as  described  above, 
a  phenomenon  described  as  accelerated  serum  sick- 
ness. This  occurs  within  the  first  24  or  48  hours 
after  serum  administration  and  partakes  in  varying 
degree  of  the  nature  of  anaphylactic  shock  or  serum 
sickness.  If  it  occurs  soon  it  resembles  more  a 
mild  anaphylactic  shock.  If  it  does  not  occur  until 
the  second  day  it  resembles  more  the  true  delayed 
serum  sickness.  The  accelerated  reaction  is  gener- 
ally considered  as  a  delayed  anaphylactic  shock, 
due  to  previous  serum  sensitization,  milder  in  its 
symptoms  than  acute  shock  because  the  patient  is 
not  as  highly  sensitized. 

The  following  case  is  interesting  and  it  would 
appear  to  be  rather  unusual  in  that  an  accelerated 
reaction  occurred  in  a  boy  in  whom  there  was  no 
previous  allergic  history  whatsoever. 

Case    Report 

.\  white  boy,  aged  13,  became  acutely  ill  in  the  latter 
part  of  November  with  an  upper  respiratory  tract  infection 
and  temperature  102.  Although  there  was  no  typical 
membrane  in  the  throat  I  took  a  swab  for  culture  which 
was  reported  as  positive  for  diphtheria.  At  10  o'clock  the 
following  morning  the  boy  received  20,000  units  of  diph- 
theria antitoxin  in  the   right  rectus  muscle.     Three  hours 

•Presented  to  the  Tri-State  Medical  Association  of  the  Carolinas  and  Virginia,    meeting  at  Columbia,    South  Caro- 
linii,  February  17th  and  18th.     Read  by  Dr.  F.  M.  Routh,  the  author  being  kept  at  home  by  sickness. 


later  he  had  generalized  lymph-gland  enlargement,  extreme 
malaise  and  photophobia.  After  several  hours  his  condi- 
tion gradually  improved.  Within  a  few  days  he  was  up 
and  about,  feeling  fine. 

Seven  days  after  receiving  the  antitoxin  he  suddenly 
experienced  an  attack  of  serum  sickness  with  giant  urticaria, 
extreme  restlessness,  photophobia,  lymph-gland  enlarge- 
ment, swelling  of  the  tongue  and  temperature  104.  The 
reaction  was  very  acute  and  required  two-hourly  injections 
of  adrenahn  for  a  total  of  13  doses.  After  six  or  eight 
doses  he  gradually  improved  although  the  illness  lasted  a 
total  of  three  days. 

This  was  followed  by  a  complete  recovery ;  but  on  Jan- 
uary 19th,  about  two  months  later,  he  was  taken  suddenly 
ill  for  no  apparent  reason  with  a  high  fever  {t.  104), 
malaise,  rhinorrhea,  cervical  lymphadenitis,  but  no  urti- 
caria. This  acute  illness  lasted  ten  or  twelve  hours  follow- 
ing which  the  temperature  dropped  suddenly  to  normal. 
There  has  been  no  recurrence. 

He  was  a  seven-months  baby,  had  had  the  usual  diseases 
of  childhood,  tonsillectomy  at  the  age  of  four,  never  had 
anything  that  his  mother  could  call  even  similar  to  hay- 
fever,  asthma,  urticaria,  eczema,  allergic  headaches  or  indi-, 
gestion.  He  had  not  been  subject  to  any  form  of  indiges- 
tion. He  had  ridden  horses  considerably  and  had  never 
bothered  in  any  way  by  their  proximity.  He  had  had  no 
food  idiosyncrasy.  At  age  three  he  had  fallen  several 
stories  on  to  the  pavement  and  had  fractured  his  skull. 
Several  years  later  he  had  suffered  another  skull  fracture 
but  recovery  was  complete  on  both  occasions  and  at  no 
time  had  he  received  tetanus  or  other  antitoxin.  His 
mother  was  certain  that  he  had  never  received  a  previous 
injection  of  horse  serum.  The  only  injection  of  any  sort 
that  he  had  had  was  typhoid  vaccine,  administered  two 
years  before  the  onset  of  the  present  illness. 

Careful  questioning  revealed  an  absolutely  negative  fam- 
ily history  for  allergy. 

Following  the  attack  in  January  the  patient  was  sub- 
jected to  very  complete  allergic  studies.  He  was  found 
definitely  sensitive  to  the  following  foods:  Spinach,  tomato, 
apple,  asparagus,  cherry,  blackberry,  pear,  apricot,  rasp- 
berri',  onion,  sweet  potatoes,  strawberry,  garlic.  He  did 
not  react  to  any  of  the  pollens  with  which  he  was  tested. 
The  only  inhalant  allergen  to  which  he  gave  a  definite 
positive  reaction  was  orris  root.  The  reaction  to  horse 
dander  was  plus  minus  or  borderline. 

Horse  serum  diluted  100  times  reacted  two-plus  following 
intracutaneous  test. 

There  are  two  points  of  special  interest  in  this 
case:  a)  the  accelerated  reaction  in  an  individual 
apparently  nonallergic,  and  b)  the  episode  of  Jan- 
uary 19th. 

It  is  a  matter  of  rather  general  knowledge  that 
occasionally  serum  sickness  may  occur  recurrentlj- 
as  many  as  three  or  four  times,  at  approximately 
weekly  intervals,  following  a  single  serum  injection. 
So  far  as  I  have  been  able  to  determine  a  recurrent 
reaction  two  months  after  serum  administration, 
with  no  interv'ening  reactions  for  at  least  six  weeks 


GENERAL  LYMPHADENITIS  IN  DIPHTHERIA—Turman 


has  not  been  described.  Of  course  there  is  no  way 
in  determining  whether  the  episode  of  January  19th 
was  another  delayed  serum  reaction  or  not.  At 
that  time  there  was  no  renewed  exposure  to  horse 
serum,  or  horse  emanation.  At  the  present  time 
he  is  positive  by  skin  test  to  horse  serum.  Unfor- 
tunately there  is  no  way  of  knowing  whether  this 
reaction  would  have  been  positive  prior  to  the 
original  antito.xin  injection  or  in  the  interval  be- 
tween the  illness  of  November  and  that  of  January. 
Without  further  corroborative  evidence  it  seems 
safest  to  conclude  that  the  January  illness  was 
entirely  unrelated  to  serum  sensitization,  although 
the  very  short  duration  (10  or  12  hours)  is  rather 
suggestive  of  some  curious  acute  allergic  episode. 

The  major  interest  in  this  case  centers  about  the 
accelerated  serum  sickness  or  delayed  anaphylactic 
reaction  occurring  in  a  boy  who  is  presumably  not 
allergic.  Later  he  was  found  to  react  to  several 
allergens  and  foods  and  one  inhalant;  but  none  of 
the  substances  to  which  he  gave  positive  skin  reac- 
tions caused  symptoms  in  his  case.  The  only  really 
strong  reaction  was  to  horse  serum,  which  was  two- 
plus  even  though  diluted  one  hundred  tim;s  whih 
the  remainder  were  one-  or  two-plus  at  most,  con- 
centrated. 

The  procedure  now  generally  recommended  as 
precautionary  prior  to  the  administration  of  hors; 
serum  or  antitoxin  consists  in  careful  questioning 
concerning  personal  and  family  allergic  history  as 
outlined  above,  followed,  in  questionable  cases,  and 
in  cases  of  previous  serum  administration,  by  pre- 
liminary testing  for  serum  sensitization.  This  is 
done  either  by  dropping  a  drop  of  the  serum  into 
the  ocular  conjunctiva  and  watching  for  the  char- 
acteristic conjunctival  reaction  which  puts  in  its 
appearance  within  five  to  ten  minutes,  or  by  the 
skin  test.  Either  concentrated  serum  or,  preferably, 
a  dilute  of  1  to  10  may  be  used.  In  the  skin  test, 
the  other  procedure  of  choice,  the  scratch  reaction 
is  performed  first  and  if  this  is  negative  intracu- 
taneous test  is  done.  If  the  skin  test  or  conjunc- 
tival reaction  is  negative  or,  better  if  both  are  neg- 
ative, one  may  safely  proceed  with  serum  treatment. 
Otherwise  one  must  consider  desensitization  or  the 
use  of  some  other  type  of  serum  such  as  goat 
serum. 

The  case  herein  reported  ernphasizes  the  desir- 
ability of  preliminary  skin  and  conjunctival  tests 
even  in  the  absence  of  an  allergic  history,  as  a  pre- 
cautionary measure.  While  this  case  eventuated  in 
recovery,  one  reacting  more  strongly  might  have 
fared  otherwise. 


Note. — Dr.  W.  A.  Browne  co-operated  in  manaKement  of 
this  case.  Dr.  Warren  T.  Vaughan  made  the  allergic 
studies. 

— 20  West  Grace  Street. 


Discussion 

Dr.  Foster  M.  Routh,  Columbia: 

This  is  a  very  important  subject  to  those  who  see  many 
patients  requiring  serum  administration. 

I  have  never  seen  just  such  a  case  as  this.  The  probable 
explanation  of  the  recurring  attacks  is  from  the  protein  in 
the  horse  serum.  Just  why  it  should  pick  out  different 
times  to  present  this  reaction  is  a  question  nobody  can 
answer.  Fortunately  for  the  patients  and  the  profession, 
anaphylactic  shock,  that  we  see  frequently  in  laboratorj' 
animals,  does  not  often  occur  in  human  beings,  and  it  is 
much  rarer  now  since  the  manufacturers  have  been  able  to 
concentrate  their  serum,  which  is  considerably  safer  than 
it  was.  We  never  know,  however,  just  when  we  are  likely 
to  be  faced  with  one  of  these  reactions. 

A  mother  called  me  one  night  and  said  that  her  child, 
three  years  of  age,  had  been  spurred  by  a  rooster  and 
asked  me  what  she  had  better  do.  I  told  her  she  had 
better  bring  the  child  up  to  see  me  the  next  morning.  This 
child  had  a  penetrating  wound  near  the  shoulder  blade  an 
inch  deep.  I  took  a  syringe  and  cleansed  the  wound,  then 
injected  a  very  small  amount  of  horse  serum  in  the  skin, 
preparatory  to  giving  a  dose  of  tetanus  antitoxin.  In  five 
minutes  the  child  began  to  scratch,  I  gave  the  child  five 
minims  of  adrenalin  and  waited  half  an  hour;  then  I  in- 
jected under  the  skin  0.1  c.c.  of  horse  serum,  waited  an- 
other half  hour,  and  gave  0.2  c.c.  It  was  about  lunch  time 
then,  so  I  let  them  go  to  lunch.  When  they  came  back, 
later  in  the  afternoon,  the  child  had  no  signs  of  urticaria, 
so  I  gave  the  rest  of  the  antitoxin. 

Now,  did  I  desensitize  this  child  to  the  effect  of  this 
serum?  I  don't  know  whether  I  did  or  not.  But  certainly 
it  is  a  rather  interesting  thing,  and  the  point  that  we  all 
want  to  take  back  with  us  is  that  we  have  an  opportunity 
to  determine,  in  the  majority  of  cases,  whether  we  shall 
have  a  reaction  or  not. 

Dr.  James  T.  Wolfe,  Washington: 

I  have  been  interested  in  work  on  asthma  for  a  great 
many  years.  The  allergists  seem  to  have  gotten  control  of 
this  aspect  of  medicine,  more  because  of  the  apathy  of 
the  general  profession  than  for  any  other  reason,  and  their 
lack  of  real,  scientific  study  of  asthma,  .\dams,  of  Glasgow, 
years  ago  (I  think  in  1905)  reported  that  allergic  manifesta- 
tions have  a  toxic  base.  In  other  words,  allergic  manifesta- 
tions depend  on  the  toxic  state.  Dixon,  of  England,  reported 
that  asthma  is  caused  by  imbalance  between  the  sympathetic 
and  the  vagus.  Ordinarily  the  sympathetic  is  the  dilator 
of  the  bronchial  tubes  and  the  vagus  is  the  constrictor, 
and  it  is  upset  of  this  evenly  maintained  balance  which 
causes  asthma.  The  suprerenal-gland  secretion  controls  the 
function  of  the  sympathetic  nervous  system.  '  Phillips,  of 
Miami,  has  proved  some  of  this  work,  and  Hazeltine,  of 
Chicago,  has  proved  Phillips'  work.  We  need  investigative 
work  by  real  students  of  asthma — I  do  not  mean  allergists ; 
I  have  never  yet  heard  allergists  say  how  allergy  performs 
anything,  how  it  brings  about  constriction  of  the  bronchial 
tubes.  Allison,  of  New  York,  published  last  year  a  paper 
the  sum  and  substance  of  which  is  this — that  allergy  is  an 
endocrine  neurogenic  disturbance  due  to  a  faulty  combining 
of  the  serum  globulin  with  the  foreign  protein.  A  man 
eats  strawberries;  there  is  a  faulty  combining  of  the  end- 
products  of  digestion  of  the  strawberries  with  the  serum 
globulin;  and  he  breaks  out  with  hives.  Another  man  cats 
strawberries;  there  is  no  faulty  combining,  and  he  does  not 
break  out  with  hives.  My  point,  in  reason,  is  to  decry 
this  blind  classing  of  asthma  with  allergy,  because  it  has 
not  been  brought  out.  It  has  been  proved  that  stimulation 
of  the  nerve  fibers  will  cause  constriction  of  the  bronchial 


GENERAL  LYMPHADENITIS  IN  DIPHTHERIA— Turman 


May,  1936 


tubes.     A  positive  skin  test  means  only  that  the  skin  is 
sensitive,  it  probably  has  nothing  to  do  with  asthma. 

Dr.  Routh,  closing; 

Mr.  President,  I  appreciate  Dr.  Wolfe's  discussion.  I  do 
not  think  anybody  knows  what  allergy  is.  If  we  did  know 
what  allergy  is,  we  would  all  be  able  to  do  a  great  deal 
more  for  a  certain  part  of  our  population  than  we  are  able 
to  do  at  the  present  time.  When  a  man  begins  to  do 
allergy  work,  pretty  quickly  he  begins  to  get  results  that 
are  spectacular,  and  the  average  allergist  becomes  too  en- 
thusiastic about  it.  I  heard  a  doctor  read  a  paper  a  short 
time  ago  on  allergy,  and  immediately  after  that  meeting  an 
obstetrician  said  to  me:  "Well,  the  allergists  are  claiming 
the  explanation  of  everything  we  know  about  now  except 
pregnancy."  That  is  a  mistake.  It  is  a  mistake  for  any- 
body to  take  a  patient  and  work  this  patient  out  from  an 
allergic  standpoint  and  not  consider  certain  constitutional 
factors  that  might  have  part  in  this.  For  instance,  in  one 
case  I  relieved  a  patient  completely  of  asthma  by  the  ex- 
traction of  a  tooth.  Now,  you  gentlemen  have  all  seen 
this.  I  have  seen  a  patient  get  a  remission  of  asthma 
following  a  gallbladder  operation.  Once  I  read  a  paper 
entitled:  "Is  Septic  Endocarditis  Preventable,"  based  on 
the  report  of  this  case  in  which  tooth  extraction  relieved 
the  asthma.  This  patient  came  back  to  me  two  years  later 
with  marked  sensitiveness  to  some  foods  and  pollens.  By 
the  elimination  of  those  she  was  relieved.  When  you  get 
results  like  that  following  skin  tests,  you  have  got  to  realize, 
Doctor,  that  there  is  something  to  skin  tests. 

We  do  not  know  what  allergy  is;  we  know  it  is  an 
imbalance  of  some  kind.  There  are  a  great  many  allergic 
people.  Some  of  you  here  doubtless  would  be  upset  by 
some  foods  or  other  substances,  but  you  have  allergic 
equilibrium.  My  approach  to  these  people  at  this  time  is 
this:  They  are  sensitive  to  a  lot  of  things,  and  as  they 
grow  older  they  become  sensitive  to  more  things.  You 
have  to  tell  them  the  truth — if  you  will  leave  these  foods 
to  which  you  are  specifically  sensitive  out  of  your  diet, 
and  eliminate  other  things  that  you  are  specifically  sensitive 
to,  for  a  period  of  time,  then  you  can  take  these  things  up 
again.  And  that  happens  invariably.  In  other  words,  it  is 
a  question  of  load,  and  I  explain  it  to  them  in  this  way. 
Allergy  is  very  much  like  electricity.  We  do  not  know 
what  it  is,  but  we  can  harness  it  and  make  it  useful.  We 
can  do  exactly  the  same  thing  in  medicine.  We  can  harness 
it  and  make  use  of  it  and  relieve  the  patients  of  a  number 
of  very  uncomfortable  things. 


results  may  be  expected  both  in  regard  to  the  specific  effect 
and  to  less  severe  serum  reactions. 

At  least  two  cities  have  established  serum  centers  for  the 
distribution  of  convalescent  serums. 

Measles  convalescent  serum  is  useful  in  phophylaxis  and 
it  should  be  given  to  give  a  modified  attack  of  measles  so 
that  the  patient  will  become  actively  immune.  Apparently 
there  is  good  evidence  that  scarlet  fever  convalescent  serum 
is  of  value  in  prophylaxis  and  in  treatment. 

Statistics  are  quoted  frequently  as  to  the  greatly  lowered 
incidence  of  typhoid  fever  in  the  World  War  but  it  must 
not  be  forgotten  that  other  sanitary  conditions,  which  may 
have  been  important  factors  also  were  in  effect  during  the 
World  War.  In  civil  practice  we  continue  to  be  confronted 
by  a  considerable  number  of  typhoid  vaccine  failures  oc- 
curring under  conditions  in  which  it  had  been  hoped  that 
protection  would  have  been  afforded. 

It  may  be  possible  to  prepare  a  more  effectively  immun- 
izing antigen  against  typhoid  fever  but  apparently  none  oi 
these  has  convinced  our  militar>'  authorities,  whose  opinion 
we  regard  so  highly,  particularly  in  relation  to  typhoid 
vaccine,  that  a  change  should  be  made  from  the  Rawlings 
strain,  which  has  been  used  so  extensively. 

Rabies  vaccine  always  should  be  given  following  dog  bite 
unless  there  is  reasonable  evidence  that  the  animal  was  not 
in  the  transmissible  stage  of  rabies  at  the  time  of  biting. 
Occasionally  a  case  of  rabies  develops  even  when  the  vaccine 
is  used  under  the  most  favorable  conditions.  Reduction  of 
the  incidence  of  rabies  in  those  actually  exposed  to  1%  is' 
about  all  that  experience  enables  one  to  e.xpect.  Much  more 
infrequent  than  the  failure  of  treatment  is  the  occasional 
case  of  postvaccinal  or  treatment  paralysis.  Neither  fear  of 
failure  of  treatment  or  of  paralytic  complication  is  ever  a 
contraindication  to  Pasteur  treatment  in  one  known  to  be 
exposed  to  rabies. 

As  to  the  advisability  of  the  immunization  of  dogs  by 
rabies  vaccine  the  evidence  is  rather  inconclusive. 

Vaccines  against  poliomyelitis  reported  definite  serological 
immunity.  The  efficacy  and  the  safety  of  these  products 
will  be  shown  only  by  clinical  experience. 

Pertussis  vaccine,  Sauer,  has  promise  of  being  a  valuable 
agent  in  the  prevention  of  whooping-cough. 

Smallpox  vaccine  is  responsible  for  the  practical  elimina- 
tion of  a  disease  which  was  one  of  the  most  dread  afflic- 
tions of  mankind  a  few  centurys  ago. 


The  Sx.-iTus  of  Serums  and  Vaccines  in  General 

Pr.\ctice 

(W.  G.  Workman,  Washington,   D.  C,  in  Ohio  State  Med. 
J  I.,  April) 

There  is  no  reasonable  doubt  that  excellent  results  follow 
the  injection  of  a  sufficient  dose  of  antitoxin  early  in  the 
course  of  diphtheria.  The  best  method  of  diphtheria  pro- 
phylaxis available  is  the  administration  of  alum-precipitated 
toxoid  to  all  susceptible  children  at  from  six  months  to  one 
year  of  age. 

It  must  be  an  uncomfortable  feeling  for  a  physician  to 
observe  the  development  of  tetanus  in  a  patient,  whose 
injury  he  had  treated  without  the  prophylactic  administra- 
tion of  antito.xin.  Antitoxin  is  eliminated  in  about  12  days 
end  the  injection  should  be  repeated  if  there  is  persistent 
infection  or  if  a  secondary  operation  is  necessary. 

A  tetanus  toxoid  on  the  market  has  distinct  promise  of 
usefulness  in  selected  groups  of  individuals  exposed  to 
more  than  the  usual  risk  of  tetanus. 

.\ntistreptococcus  products  of  much  higher  potency  are 
now  being  produced  and  it  would  appear  that  much  better 


Morbus  J  obi:   Job  Patriarch,  the  Patron  Saint  of 
Syphilis 

(Librarian;  Special  Assistant  to  Officer  in  Charge;  Editor 
of    Index. Cat.,   Army   Med.    Lib..    Washington,    in 
Urol.  &  Cuta.    Rev.,  April) 

At  the  end  of  the  15th  century,  when  it  had  been  recog- 
nized as  a  general  systemic  disease,  in  addition  to  its 
thousand  other  designations,  syphilis  became  known  as  the 
disease  of  St.  Fiacre,  St.  Roch,  St.  Mevins,  etc.  Job,  with 
his  skin  disease  and  patient  suffering,  was  the  verj-  person 
to  appeal  to  the  fancy  of  the  people.  No  wonder  that 
among  the  popular  terms  of  syphilis  we  find  also  the  ex- 
pression "Job's  disease"  in  several  German,  Italian,  and 
French  15th  century  chronicles,  poems  and  other  historical 
documents. 

What  Job's  disease  really  was  is  a  matter  of  speculation. 
Job,  a  tribal  chief  of  wealth  and  fortune,  was  a  very  pious 
man.  Opinions  differ  as  to  whether  he  was  a  Jew  or 
Gentile.  Some  say  that  he  was  one  of  the  servants  of 
Pharaoh;  others  say  that  he  was  an  Edomite  sheik.  He 
was  living  in  Uz,  a  part  of  the  Arabian  Desert,  inhabited 
by  the  son  of  Abraham  and  Keturah.  Bloch  (1901)  holds 
that  Job  had  chronic  eczema. 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Pellagra* 

Beverley  Randolph  Tucker,  M.D.,  Richmond,  Virginia 


IX  this  brief  paper  I  shall  only  take  up  a  few 
additional  notes  on  pellagra  which  have  been 
gathered  since  my  recent  publications. 

My  work  on  pellagra  has  led  me  to  believe  that 
there  is  a  strong  possibility  that  the  the  disease 
may  be  of  virus  origin;  that  both  the  cutaneous 
and  gastrointestinal  lesions  are  in  all  probability 
trophic  from  the  cord  and  posterior  spinal  sympa- 
thetic ganglia;  that  the  Goldberger  theory  of  the 
causation  of  pellagra  has  been  an  important  contri- 
bution as  to  a  contributory  cause  of  the  disease, 
but  that  it  does  not  explain  the  neuropathology; 
and  that  pellagra  was  more  common  in  this  country 
during  the  "fat"  years  of  prosperity  preceding  the 
depression  than  it  was  during  the  "lean"  years  of 
the  depression.  Various  charts  are  shown,  portray- 
ing the  result  of  investigation  and  examination  of 
two  brains,  sLx  cords  and  two  sympathetic  spinal 
ganglia. 

Since  discussing  the  above  facts,  I  have  made 
some  study  as  to  the  distribution  of  pellagra  in 
countries  in  which  the  poorer  classes  of  people  sub- 
sist chiefly  on  a  pellagra-inviting  diet. 

From  a  personal  interview  with  Dr.  William  B. 
Porter,  of  Richmond,  who  has  investigated  pellagra 
in  the  Island  of  Porto  Rico,  it  is  found  out  that 
about  90  per  cent,  of  the  seven  hundred  and  some 
odd  thousands  of  Porto  Ricans  subsist  on  a  diet 
containing  chiefly  salt  cod,  rice  and  beans,  and  that 
pellagra  on  this  island  is  extremely  rare. 

Dr.  Pardo-Castello,  of  Havana,  writes  me  that 
there  was  a  small  outbreak  of  pellagra  in  1913; 
since  then  only  a  few  sporadic  cases  have  been 
seen,  and  these  chiefly  in  alcoholics.  He  says  the 
average  diet  in  the  labor  class  in  Cuba  includes 
polished  rice,  dry  beans,  jerked  beef,  corn  meal, 
very  little  milk,  practically  no  butter,  fruit  or  vege- 
tables, except  sweet  potatoes  and  some  of  the  native 
tubers. 

Dr.  W.  H.  Pott,  physician  at  St.  Luke's  Hospital, 
Shanghai,  tells  me  that  in  the  various  provinces  of 
China  most  of  the  coolie  class  live  on  what  could 
be  considered  pellagra-inviting  diet  and  that  pel- 
lagra is  a  very  rare  condition  in  China,  hardly  pre- 
senting a  problem. 

In  a  paper,  "Pellagra  in  Egypt,"  by  H.  Wilson, 
M..\.,  iM.D.,  Professor  of  Physiology,  Faculty  of 
Medicine,  Cairo,  it  is  learned  that  pellagra  in 
northern  Egypt  is  quite  a  common  disease,  espe- 
cially   around    Alexandria,    whereas    in    southern 


Egypt  the  disease  is  much  rarer.  This  he  thought 
was  due  to  a  difference  in  the  cereals  eaten  by  the 
northern  and  southern  Egyptians. 

It  has  also  been  found  out  that  pellagra  in  India 
is  much  more  common  along  the  coast  than  it  is 
in  the  interior,  and  this  is  also  attributed  to  a  dif- 
ference in  the  cereals. 

In  the  Sudan  and  in  Turkey  there  have  been  out- 
breaks of  pellagra. 

It  is  my  belief  that  if  a  restricted  diet  were  the 
only  cause  of  pellagra  the  variation  in  these  coun- 
tries would  not  be  so  pronounced  and  that  it  is 
more  rational  to  account  for  some  kind  of  place 
infection,  making  the  disease  more  common  in  cer- 
tain of  these  areas  of  restricted  diet  than  in  others. 
My  work  in  this  subject  has  led  me  not  to  dogmatic 
conclusions  but  to  the  belief  that  the  whole  subject 
should  be  reopened  by  a  properly  financed  commis- 
sion and  by  adequate  restudy. 


•Presented  to  the  Tri-State 
lina,  February  17th  and  18th. 


Discussion 

Dr.  Charles  F.  Williams,  Columbia: 

I  am  sure  all  of  us  have  been  impressed  with  Dr.  Tuck- 
er's statement  that  he  has  arrived  at  no  dogmatic  conclu- 
sion. I  have  known  something  of  the  work  that  Dr. 
Tucker  has  been  doing  for  the  past  year  or  two  in  pellagra, 
and  I  know  that  all  of  us  who  know  him  know  he  is 
seeking  the  truth.  He  has  made  a  very  careful  statistical 
study  which  is  rather  hard  for  us  to  controvert. 

Dr.  Tucker  has  no  statistics  with  reference  to  our  own 
state.  I  do  not  know  whether  that  is  my  fault  or  Dr. 
Hayne's  fault,  but  that  it  is  the  fault  of  one  or  the  other 
I  am  sure.  But  the  statistics  that  Dr.  Tucker  has  showed 
you  with  reference  to  the  other  Southern  States  will  apply 
in  just  about  the  same  ratio.  1  think  Dr.  Hayne  will  bear 
me  out  in  that  statement.  That  appears  to  be  getting 
away  from  the  theory  of  some  disturbance  of  nutrition — ■ 
when  you  have  more  pellagra  in  your  fat  years  than  you 
have  in  your  lean  years.  Yet  it  is  not  conclusive;  and, 
in  view  of  our  present  knowledge  of  nutritional  diseases, 
or  diseases  brought  about  by  nutritional  disturbances,  there 
are  many  points  that  make  us  still  claim  that  pellagra  can 
not  be  divorced  from  the  question  of  nutrition.  The  dis- 
tribution that  he  mentioned  throughout  the  country  is  a 
very  interesting  thing  and  has  always  been  since  the  dis- 
covery of  pellagra  among  us  about  1908.  A  statistical 
study  was  made  of  the  United  States  at  that  time;  and, 
with  the  little  knowledge  we  had  of  pellagra,  its  extension 
throughout  the  country  unearthed  cases  in  nearly  every 
state  of  the  Union;  and  I  am  satisfied  that  today,  even 
with  the  greater  knowledge  of  this  disease,  there  are  morj 
cases  of  pellagra  in  the  so-called  nonpellagra  states  than 
we  have  here.  The  reason  I  say  that  is  that  a  nurse  who 
was  trained  in  this  section  of  the  country  went  into  a 
Northern  institution,  by  reason  of  marrying  an  attendant 
in  that  institution  whom  she  met  at  camp  here.  A  few 
years  later  a  doctor  from  here  visited  her.  He  asked  if 
there  were  any  pellagra  in  that  institution.  She  replied: 
the  Carolina.?   and   Virginia,    nieetinf;  at   Columbia,    South   Caro- 


2S4 


PELLAGRA— Tucker 


May,  1936 


"Plenty  of  it,  Doctor,  but  we  don't  call  it  that."  I  think 
we  can  predict  the  type  of  patient  who  will  develop  pel- 
lagra. Now,  I  believe  that  pellagra  is  due  to  the  withhold- 
ing of  food.  Goldberger  has  proved  that  starvation  will, 
in  a  normal  person  over  a  long  period  of  time,  produce 
pellagra.  I  know  that  pellagra  is  frequently  found  in 
individuals  with  certain  physical  disorders  which  interfere 
with  metabolism.  I  know  also  that  in  certain  agitated 
cases  of  mental  disturbance  we  can  predict  with  certainty 
that  such  a  person  will  develop  pellagra. 

It  is  fair  to  say  this — an  individual  who  is  so  sick  phy- 
sically that  he  can  not  properly  handle  food,  to  get  the 
necessary  elements  from  it  for  the  support  of  his  body, 
may  develop  pellagra.  There  may  be  other  factors  that 
we  do  not  know.  We  know  also  that  in  certain  other 
cases  we  can  put  the  proper  amount  of  food  into  the 
stomach  with  a  stomach  tube,  properly  balanced  and 
ever\-thing,  and  the  patient  can  not  adequately  use  that 
food,  and  that  patient  will  develop  pellagra.  All  of  us 
know  what  is  going  on  in  the  nutritional  world  today  in 
various  diseases,  particularly  pernicious  anemia.  We  do 
not  yet  know  what  factors  are  necessary  for  a  normal, 
healthy  person.  So  I  do  not  know,  and,  with  Dr.  Tucker, 
I  shall  not  be  dogmatic.  Yet,  while  statistical  tables  show 
this,  it  is  a  fact  that  in  institutions  where  we  did,  over  a 
long  period  of  time,  have  many  cases  of  pellagra,  we 
never  saw  what  might  be  termed  infection  from  any  case. 
I  think  that  is  very  interesting.  A  great  deal  of  experi- 
mental work  has  been  done  to  show  whether  it  is  com- 
municable, and,  so  far  as  I  know,  this  has  not  been  suc- 
cessfully proved. 

Dr.  James  A.  Hayne,  Columbia: 

Mr.  President,  and  gentlemen  of  the  Tri-State  Associa- 
tion, it  is  a  great  pleasure  to  be  with  this  Association  again. 
I  think  the  first  public  speech  that  I  ever  made  in  my  life 
was  made  to  this  Association  in  Danville,  Virginia,  in 
1904.    That  is  a  long,  long  time  ago. 

Anyone  practicing  in  South  Carolina  knows  that  we  have 
had  no  fat  years  and  no  lean  years.  When  the  collapse 
came  in  1920  we  had  no  stocks  and  bonds,  so  we  met  it  as 
we  did  a  crisis  in  a  foreign  country.  It  had  nothing  to  do 
with  conditions  in  South  Carolina.  South  Carolina  was 
eighty-five  per  cent,  agricultural;  it  was  eighty-five  per 
cent,  in  debt  and  a  hundred  and  twenty-five  per  cent, 
unable  to  pay  its  debts. 

Dr.  Tucker  is  absolutely  correct  as  to  the  occurrence  of 
pellagra  in  the  fat  years  and  the  lean  years.  In  South 
Carolina  in  1929  we  had  9SS  deaths  from  pellagra.  I  went 
to  the  State  Board  of  Health  at  its  meeting  and  told  them 
that  we  had  the  highest  number  of  deaths  from  pellagra 
since  1915,  when  we  had  1300  such  deaths.  They  said: 
"Doctor,  can  you  do  anything  about  it?"  I  said:  "I 
can  put  in  the  hands  of  the  general  practitioners  and  the 
people  suffering  from  pellagra  a  substance  which  contains 
more  of  the  specific  vitamin  than  any  other  substance. 
This  vitamin  is  contained  in  brewers'  yeast."  Brewers' 
yeast  was  selling  at  that  time  in  South  Carolina  for  $2.00 
a  pound,  or  whatever  the  druggist  could  get  out  of  it.  I 
found  out  that  I  could  procure  brewers'  yeast  for  IS  cts. 
a  pound.  Some  1300  tons  was  sent  out  from  my  office — 
not  pounds,  but  tons.  The  county  health  officers,  the 
physicians,  and  everybody  else  proceeded  to  give  brewers' 
yeast  to  those  suffering  from  pellagra.  This  was  done  not 
only  in  South  Carolina  but  in  Georgia  and  other  Southern 
States.  It  was  given  to  all  who  would  take  it.  That  is 
why,  I  think,  we  have  had  the  decline  in  the  lean  years 
and  why  we  had  the  prevalence  in  the  fat  years,  because 
up  until  1929  brewers'  yeast  was  not  distributed  gener- 
ally. 


Now,  I  never  have  believed  that  food  deficiency  is  the 
sole  cause  of  pellagra.  I  believe  there  must  be  some  pre- 
disposition and  that  when  a  person  with  the  predisposition 
comes  in  contact  with  food  deficiency  he  develops  pellagra. 
It  may  be  a  virus.  Dr.  Tucker;  I  don't  know  what  it  is; 
nobody  knows  anything  about  it ;  nobody  can  prove  any- 
thing. Any  study  that  will  help  us  in  this  situation  is 
worth  while,  and  I  am  perfectly  free  to  say  that  I  should 
like  to  see  the  whole  subject  opened  up.  I  have  never  been 
convinced  that  food  deficiency  is  the  whole  factor.  I  know 
that  food  will  cure  it.  A  lot  of  people  will  tell  you  to 
give  milk  and  tell  you  to  give  eggs.  Now,  milk  contains 
less  vitamin  BoG  than  any  other  food  I  know  of.  It  will 
distend  the  stomach  and  prevent  you  from  giving  other 
food.    Eggs  contain  ver>'  httle  of  that  vitamin. 

I  went  over  this  State  and  consulted  1000  pellagrins  as 
to  what  they  ate  and  what  they  did.  I  went  with  Dr. 
Akins,  of  the  United  States  Public  Health  Service,  and 
discussed  with  1000  pellagrins  what  they  ate,  what  they 
did.  We  found  certain  very  definite  things.  If  we  found 
any  individuals  who  had  eaten  meat  over  a  long  period  of 
time,  they  did  not  have  pellagra.  We  also  discovered  that 
if  we  found  an  individual  with  pellagra  this  person  ex- 
pressed a  dislike  for  rare  meat.  Now,  if  you  are  going  to 
treat  tuberculosis  you  start  with  milk,  eggs,  etc.  But  to 
treat  pellagra  you  turn  the  diet  upside  down  and  start 
with  meat,  tomatoes,  vegetables — with  milk  and  eggs  last. 

It  might  be  said  that  there  is  a  virus  which  causes  th^ 
tubercle  bacillus  to  flourish  in  human  tissue,  that  it  breaks 
down  the  soil,  prepares  the  soil.  All  I  know  about  viruses 
is  that  they  will  pass  through  a  porcelain  filter. 

I  know  I  have  been  talking  entirely  too  long,  but  I  am 
extremely  interested  in  the  paper  and  in    the  subject. 

Dr.  W.  H.  Seerell,  U.  S.  Public  Health  Service,  Washing- 
ton: 

I  am  very  much  interested  in  this  paper  and  in  the  dis- 
cussion. Dr.  Tucker  has  made  a  very  nice  study  of  the 
central-nervous-system  lesions  in  pellagra,  and  his  findings 
in  the  central  nervous  system  are  in  agreement  with  those 
of  other  workers  in  the  field.  In  his  discussion  of  the 
etiology  in  pellagra,  however,  I  do  not  believe  he  has  given 
sufficient  attention  to  some  other  contributions  to  the  liter- 
ature of  pellagra,  and  I  do  not  believe  that  his  conclusions 
are  sufficient  to  justify  the  assumption  that  pellagra  is  .a 
virus  disease.  That  pellagra  is  produced  by  inadequate  diet, 
that  it  can  be  prevented  by  adequate  diet  and  can  be  cured 
by  adequate  diet,  I  do  not  know  what  other  evidence  you 
need. 

I  was  much  surprised  to  hear  Dr.  Tucker  bring  up  that 
old  report  of  the  pellagra  monkey,  which  was  brought  out 
in  1913.  As  I  remember.  Dr.  Harris  published  that  report 
in  1913  as  a  preliminary  report.  Dr.  Harris  has  never 
published  the  complete  report,  and  no  one  has  been  able 
to  duplicate  his  results.  The  only  work  which  has  held  up 
is  this  food-deficiency  work. 

Dr.  Tucker  brought  out  some  statistics  from  Puerto  Rico 
and  China  and  Cuba.  He  mentioned  that  in  Puerto  Rico 
one  of  the  chief  articles  of  diet  is  salt  cod.  We  know  that 
fish  and  meat  are  preventives  of  pellagra.  In  Cuba  h> 
mentioned  beef,  which  is  also  a  preventive  of  pellagra.  In 
China  we  know  the  statistics  are  notoriously  inaccurate. 

Dr.  Wheeler  and  I  pointed  out  some  years  ago  that  poor 
economic  conditions  might  be  expected  to  cause  an  increase 
in  pellagra  incidence  only  when  they  adversely  affect  the 
food  supply.  Now,  there  have  been  a  number  of  factors 
which  have  operated  in  recent  years.  First,  there  has  been 
a  decrease  in  cotton  acreage,  with  a  corresponding  increase 
in  the  acreage  devoted  to  gardens,  etc.  Second,  there  has 
been  an  inpouring  of  relief  funds.     Third,  there  has  been 


May,   1936 


PELLAGRA— Tucker 


2SS 


widespread  educational  effort.  When  economic  conditions 
become  so  bad  that  cotton  raising  will  not  pay,  some  of 
the  land  goes  into  the  production  of  food  and  forage  crops, 
so  there  is  improvement  in  the  food  supply  even  though  no 
cash  is  available. 

Dr.  Tucker  dismissed  the  work  of  Goldberger  and  his 
associates  in  a  ver\-  few  words.  But  these  long-continued 
studies  are  too  important  to  be  dismissed  so  lightly.  We 
all  know  that  pellagra  was  produced  not  once  but  many 
times  by  means  of  a  restricted  diet.  Attempts  to  produce 
pellagra  by  injection  of  the  secretions  and  excretions,  even 
by  scales  from  the  skin  lesions,  failed  to  produce  it  in  any 
case.  Next,  there  was  no  extension  of  pellagra  in  institu- 
tions where  those  in  contact  with  it  had  an  adequate  diet. 
Next,  it  was  eliminated,  by  the  use  of  an  adequate  diet, 
from  institutions  where  it  had  been  rampant  for  years. 

Several  workers  have  told  of  the  excellent  results  that 
can  be  obtained  by  the  therapeutic  use  of  liver  extract.  If 
you  will  investigate  your  pellagra  cases  thoroughly  you 
will  find  they  have  all  been  on  a  restricted  diet.  If  you 
will  give  them  large  doses  of  brewers'  yeast  and  see  that 
they  get  lots  of  lean  meat,  vegetables,  and  fruits — and  also 
milk  and  eggs  (Dr.  Hayne  is  right  in  putting  them  last, 
but  they  are  such  valuable  foods  that  we  also  use  them  in 
pellagra),  you  can  cure  them.  If  you  want  to  keep  down 
pellagra  in  the  South,  do  all  you  can  to  encourage  home 
gardens,  livestock  raising,  and  the  use  of  milk. 

Dr.  J.  M.  RuFFiN,  Duke  University,  Durham: 

I  have  been  very  much  impressed  by  Dr.  Tucker's  re- 
marks. His  paper  shows  careful  preparation  and  grave 
thought,  and  one  can  not  help  but  be  impressed  by  the 
data  he  presents.  In  pellagra,  as  in  any  other  interesting 
and  unsolved  problem  in  medicine,  one  finds  very  many 
conflicting  views.  While  I  agree  with  some  of  the  things 
Dr.  Tucker  says,  there  are  certain  points  to  which  I  must 
take  exception.  One  point  which  I  want  to  discuss  is  the 
significance  he  attaches  to  the  low  mortality  since  1930, 
compared  with  the  high  mortality  prior  to  that  time.  Dr. 
Hayne  has  stolen  my  thunder  very  effectively.  I  want  to 
corroborate  what  he  says.  I  wish  to  supplement  what  he 
said  by  saying  that  when  I  came  to  North  Carolina  in 
1930  it  was  the  exception  to  see,  in  passing  through  the 
country,  chickens,  vegetable  gardens  and  cows.  All  the 
people  were  raising  at  that  time  was  cotton,  tobacco,  pine 
trees  and  children.  Now  one  sees  many  more  gardens. 
There  is  no  question  that  in  rural  North  Carolina  the 
dietary  is  much  superior  to  what  it  was  prior  to  1930. 

Dr.  Tucker  has  mentioned  the  dermatitis  that  occurs  in 
pellagra  on  exposure  to  sunlight.  In  130  consecutive  cases 
of  pellagra  which  have  been  seen  at  Duke  Hospital  I  found 
that,  when  specifically  questioned,  the  patient  almost  in- 
variable stated  that  the  dermatitis  appeared  after  he  had 
been  working  out  in  the  sunshine.  The  usual  story  was 
that  the  patient  had  subsisted  on  a  deficient  diet  throughout 
the  winter  months;  then  that  he  went  out  and  he  plowed 
new  ground  or  he  plowed  for  corn;  and  a  day  or  two 
later  his  hand  began  to  burn  or  he  noticed  little  blisters 
on  it,  and  then  the  typical  rash  of  pellagra  appeared. 
Almost  invariably,  with  this,  is  the  history  of  sore  tongue 
and  then,  later,  a  diarrhea.  We  found  that  history  so 
persistently  that  we  could  not  help  but  feel  that  there  must 
be  some  connection  between  the  appearance  of  the  lesions 
and  the  exposure  of  the  susceptible  individual  to  the  strong 
rays  of  the  sun.  In  15  of  these  patients  we  were  able  to 
produce  a  dermatitis  by  the  simple  process  of  exposing  the 
right  hand  and  arm  to  sunlight  for  twenty  to  thirty  min- 
utes daily.  That  dermatitis  varied  from  erythema  with 
folliculation  to  the  very  severe  lesions.  Some  became  sore, 
or  much  sorer  than  they  had  been;  the  patient  was  about 


to  die,  really,  and  the  acute  stage  of  pellagra  occurred. 
We  changed  the  diet  and  gave  them,  as  Dr.  Hayne  says, 
not  milk,  not  eggs,  but  a  general,  well  balanced  diet  and 
made  them  eat  it.  We  also  gave  them  liver  extract  and 
made  them  take  yeast,  and  these  patients  promptly  recov- 
ered after  a  period  of  10  days  or  two  weeks.  Then  we 
exposed  them  again  to  the  sun,  and  nothing  happened.  I 
do  not  see  how  anybody  can  draw  any  other  conclusion 
but  that  the  diet  had  protected  those  patients. 

Dr.  Tucker  has  pointed  to  the  seasonal  variations  of 
pellagra  as  being  indicative  of  an  infectious  disease,  but 
we  know  also  that  it  is  indicative  of  a  dietary  deficiency 
disease. 

(Dr.  Ruffin  then  showed  some  slides.) 

This  slide  is  an  extremely  interesting  one  and  is  full  of 
food  for  thought  for  us  all.  The  curved  line  is  the  peak 
of  intensity  of  the  sun's  rays.  The  straight  line  is  the 
opposite  of  the  preceding  charts.  My  interpretation  is  this: 
As  the  sun's  rays  increase  in  intensity,  which  occurs  fairly 
rapidly,  we  see  a  sharp  and  sudden  rise  in  the  incidence 
of  pellagra.  By  that  I  mean  a  sharp  increase  in  symptoms 
in  persons  who  had  had  it  all  the  time.  Then  we  have  an 
almost  equally  sharp  fall  in  symptoms  and  not  in  the 
intensity  of  the  sun's  rays.  That  is  something  I  think  you 
will  have  to  explain  away. 

Dr.  Tucker  has  spoken  of  pellagra  as  a  disease  which 
has  its  effects  chiefly  on  the  nervous  system,  which  is  true; 
but  I  wish  to  say  that  pellagra  which  manifests  itself  in 
the  nervous  system  is  the  late  stage  of  the  disease.  We 
all  know  that  pellagra  involves  the  nervous  system,  but  it 
could  not  very  well  be  a  primary  disease  of  the  nervous 
system  when  four  out  of  five  patients  show  no  changes  of 
the  nervous  system  at  autopsy. 

I  can  not  disprove  Dr.  Tucker's  theory,  and  he  can  not 
prove  it.  He  can  not  say  it  is,  and  you  can  not  say  it 
ain't.  But  you  have  not  got  sufficient  evidence  to  prove, 
or  even  state,  that  pellagra  is  a  disease  caused  by  a  virus. 
I  wish  to  point  out  another  fact — that  the  changes  which 
occur  in  pernicious  anemia  are  identical  with  certain 
changes  that  occur  in  pellagra.  And  I  am  sure  that  per- 
nicious anemia  is  not  a  virus  disease. 

I  am  sure  that  pellagra  is  a  disease  arising  from  dietary 
deficiency  plus  another  factor,  and  that  factor  is  probably 
what  we  might  call  individual  susceptibility.  By  that  I 
mean  that  some  patients  will  subsist  upon  a  certain  diet 
and  not  develop  pellagra,  and  other  patients  will  subsist 
upon  it  and  will  develop  it.  I  hope  Dr.  Tucker  will  par- 
don me;  this  is  no  reflection  on  his  work  at  all,  but  I  do 
not  believe  that  pellagra  is  a  primary  disease  of  the  nervous 
system,  and  I  do  not  believe  it  is  due  to  a  virus. 

Dr.  C.  B.  Epps,  Sumter: 

I  practiced  general  and  "ungenera!"  medicine  for  about 
eighteen  years,  and  since  then  I  have  been  interested  in 
other  things — surgery  mostly.  I  have  handled  a  great  many 
cases  of  pellagra,  and  I  can  not  at  this  time  remember  a 
single  case  of  pellagra  among  any  of  my  patients  except 
those  who  were  among  the  poor.  It  seems  to  be  pre- 
eminently and  predominantly  a  disease  of  those  who  have 
not  enough  to  eat,  and  I  think  that  that  fact  of  itself 
should  help  us  in  arguing  that  it  is  a  nutritional  disease. 
Now,  as  an  operator,  in  surgical  work  I  find  that  the  per- 
son who  has  pellagra  has  a  decreased  vitality  everywhere, 
you  might  say ;  and  as  a  surgeon  I  am  fearful  of  the 
patient  who,  at  the  time  he  entcrsd  the  hospital  for  some- 
thing that  needs  operation,  or  previously,  has  a  history  of 
pellagra.  I  refuse  usually  to  operate  on  such  a  patient 
unless  it  is  something  very  acute,  for  the  simple  reason 
that,  when  you  have  operated  on  your  patient,  you  go 
home  and  you  think  about  it  and  you  are  afraid  that  some- 


256 


PELLAGRA— Tucker 


May,  1936 


thing  else  will  happen,  you  are  afraid  that  something  will 
show  up — an  ileus,  a  peritonitis,  a  pneumonia  or  something 
else.  You  are  always  afraid  of  the  patient  who  either  at 
the  time  has  pellagra  or  gives  a  history  of  pellagra,  and  I 
am  sure  that  pellagra  occurs  in  those  whose  resistance  is 
lower  than  the  average  person's.  Whether  there  is  anything 
else  there,  or  not,  I  do  not  know;  but  I  feel  positive  that 
the  main  Cause  of  pellagra  is  nutritional  disturbance.  Now 
if  the  proper  food  will  not  only  prevent  pellagra  but  cure 
pellagra,  what  is  all  the  argument  about?  You  have  your 
preventive  and  you  have  your  cure,  the  two  main  thing< 
that  the  physician  and  the  surgeon  aim  at.  We  could 
argue  here  until  we  are  blue  in  the  face  and  even  grayer 
than  we  are  now,  and  we  would  not  get  anywhere.  It  is 
very  interesting  to  see  what  we  can  find  out.  i  think  we 
Democrats  in  the  South  should  preach  it  and  put  it  on  our 
program  this  year  that  the  New  Deal,  the  distribution  of 
brewers'  yeast  and  the  distribution  of  meat  have  had  a 
great  deal  to  do  with  the  reduction  of  pellagra;  and  I 
believe  we  should  preach  it  and  paint  it  everywhere — 
"More  Hoover,  more  pellagra." 

Dr.  George  R.  Wilkixson,  Greenville: 

For  the  last  seven  years  I  have  had  the  opportunity  to 
attend  to  the  dietary  Oi  340  children  who  did  not  have 
anything  to  eat  except  at  the  source  we  had  control  of. 
namely,  inside  an  orphanage.  Seven  years  ago  I  think 
that  there  was  not  a  child  in  that  institution  that  did  not 
have  some  signs  of  pellagra — some  outspoken  signs.  None 
were  so  advanced  they  would  show  on  the  skin,  but  it  was 
unmistakable  pellagra.  We  started  out  by  giving  brewers' 
yeast.  On  the  second  examination  the  gravity  of  the 
disease  had  decreased  considerably,  but  we  could  stiil  see 
that  the  children  had  pellagra.  They  had  persistent  sore- 
ness of  the  tongue.  During  the  second  year  we  added  a 
quart  of  milk  for  each  child  a  day.  That  did  not  lessen 
the  skin  manifestations  at  all.  All  the  time  we  gave  the 
yeast.  Then  we  added  to  the  meat  ration,  added  one  and 
a  half  ounces  of  meat,  and  saw  that  they  ate  it.  But  i. 
was  only  when  we  cut  down  the  starch  ration  that  wc 
got  anywhere.  We  took  away  the  molasses  and  cut  down 
the  amount  of  bread  and  made  them  eat  more  meat  and 
vegetables.  I  think  it  would  be  hard  now  for  anyone  to 
go  through  that  institution  and  find  a  child  who  has  any 
signs  of  pellagra.  Before  the  last  two  years  a  child  might 
come  in  with  a  nice  oily,  elastic  skin,  with  no  lines,  and 
it  would  not  be  in  there  six  months  until  it  would  show 
dryness  of  the  skin,  etc.  In  the  last  two  years,  since  we 
have  cut  out  the  molasses  entirely  and  cut  down  the 
amount  of  bread,  the  children's  skins  have  improved  mar- 
velously.  We  do  not  see  the  brown,  rough  skins.  It 
seems  to  me  that  that  means  a  good  deal,  that  the  condi- 
tioning factor  might  be  too  much  starch.  As  long  as  the 
children  were  allowed  to  eat  as  much  molasses  as  they 
wanted,  and  as  much  bread  as  they  wanted,  even  though 
they  ate  the  other  things  they  developed  the  skin  symp- 
toms. But  when  we  cut  down  the  starch,  then  they  got 
better. 

I  have  been  struck  with  this  fact,  that  lots  of  pellagrins 
would  have  a  considerably  reduced  metabolism,  and  it 
might  appear  that  they  might  have  myxedema,  or  a 
moderate  grade  of  my.xedema.  By  feeding  these  patients 
on  a  more  general  diet  and  feeding  them  brewers'  yeast, 
we  have  been  able  to  bring  them  back  to  normal  without 
the  use  of  thyroid  extract.  Of  course,  we  call  this  State 
the  Iodine  State,  but  we  see  patients  with  low  thyroid 
activity.  These  people  can  be  improved  by  the  same  sort 
of  diet  as  is  used  for  the  control  of  pellagra.  Ordinarily, 
physicians  see  the  disease  only  in  its  advanced  stage,  with 
black  hands,  etc.    It  must  be  very  prevalent,  but  in  milder 


form.  People  make  up  their  diet  of  foodstuffs  which  can 
be  kept  all  through  the  year  and  which  are  cheap,  rather 
than  provide  themselves  with  more  perishable  foods  which 
have  to  be  replenished  from  day  to  day  and  cost  more. 
If  we  get  our  people  to  cut  down  on  starches  and  substitute 
these  other  things,  I  think  we  shall  not  have  so  much  pel- 
lagra. 

I  think  it  has  been  proved  that  pellagra  is  a  deficiency 
disease,  but  it  is  a  fine  thing  to  open  wide  the  door  and 
not  exclude  the  consideration  of  other  possible  factors. 

Dr.  Clyde  Gilmore,  Greensboro: 

There  are  some  questions  that  have  not  been  answered, 
and  I  can  not  pass  by  this  opportunity  of  speaking  on  a 
subject  so  close  to  me  and  so  interesting  to  me.  It  hap- 
pened that  I  was  born  and  reared  in  Chatham  County, 
where  we  had  an  epidemic  of  pellagra  in  1913.  Now,  we 
had  our  cows,  had  chickens  and  eggs,  and  had  vegetable 
gardens.  Yet  we  had  an  epidemic  of  pellagra.  At  that 
time  it  was  supposed  to  be  due  to  eating  corn  bread,  and 
they  cut  out  eating  so  much  com  bread.  The  people  im- 
proved. I  made  a  study  involving  forty  individuals  who 
had  pellagra  in  1915.  We  also  had  a  recurrence  in  about 
28  per  cent,  of  their  number  in  1929.  It  could  not  be  estab- 
lished on  the  basis  that  they  were  poor  whites;  they  were 
not;  they  were  good  farmers.  I  could  not  e.xplain  those 
families  and  their  experience  on  that  basis. 

I  will  tell  you  about  some  common  factors.  First  of 
all,  there  was  almost  one  hundred  per  cent,  deficiency  in 
hydrochloric  acid  in  the  members  of  the  four  families. 
They  were  apparently  congenitally  subject  to  deficiency  of 
hydrochloric  acid,  and  those  who  had  a  total  absence  of 
acid  apparently  had  worse  cases  of  pellagra  than  those 
who  had  only  moderate  deficiency.  They  were  subject  to 
food  phobias,  it  is  true.  They  had  nervous  indigestion 
and  had  eliminated  from  their  diet  a  whole  long  series  of 
things,  which  possibly  had  something  to  do  with  it.  A 
few  of  them  were  on  strict  diets  because  of  high  blood 
pressure,  such  diets  as  we  used  to  prescribe. 

It  seems  to  me  that  we  have  gotten  off  to  a  wrong  start 
in  the  consideration  of  this  disease.  You  remember  the 
story  of  the  three  blind  men  who  went  off  to  investigate 
the  elephant  and  who  made  three  widely  conflicting  reports 
because  of  the  difference  in  their  points  of  investigation. 
A  number  of  us  believe  with  Dr.  Tucker  that  Goldberger 
wrote  a  very  important  chapter  but  not  the  final  chapter. 
I  believe  that  the  final  word  is  yet  to  come.  We  feel  that 
the  answer  will  come  from  solving  this  algebraic  problem — 
that  the  cause  is  an  unknown  factor,  plus  a  hereditan,- 
factor,  plus  a  climatic  factor.  Why  do  not  the  poor  white 
folks  up  in  New  England  have  pellagra.  Doctor?  I  believe 
the  cause  is  those  factors,  plus  a  dietary  deficiency,  plus 
absence  or  decrease  of  hydrochloric  acid. 

Now,  I  should  like  to  tell  you  briefly  about  the  members 
of  a  family  I  spoke  about.  Down  there  in  the  valley,  about 
50  years  ago,  twin  boys  were  born.  These  boys  became 
orphans  at  the  age  of  two.  One  child  was  adopted  by  a 
neighboring  family  and  reared  in  their  cabin,  with  the 
environmental  circumstances  of  the  backwoods.  The  other 
child  was  adopted  by  a  family  in  better  circumstances, 
went  to  college,  and  eventually  became  professor  of  math- 
ematics in  a  college.  The  other  boy  stayed  on  the  land 
and  eventually  became  a  badcwoods  country  storekeeper. 
Now,  at  the  age  of  48  both  these  men,  the  college  pro- 
fessor on  the  campus  and  the  country  storekeeper,  devel- 
oped pellagra.  Both  had  skin  manifestations,  both  had 
food  phobias,  both  died  in  the  Western  State  Hospital 
some  years  later. 

Two  sisters  were  reared  in  this  neighborhood.  One  mar- 
ried a  textile  worker  and  lived  in  a   cotton-mill   district. 


May,   1936 


PELLA  GRA—Tiicker 


2S7 


with  the  attendant  dietary  circumstances.  The  other  mar- 
ried a  truck  and  dairy  farmer.  They  had  plenty  of  milk 
and  eggs  and  meat  and  vegetables,  of  which,  apparently, 
she  took  her  share.  Both  sisters  developed  pellagra,  both 
had  depression,  both  had  almost  complete  absence  of  hydro- 
chloric acid,  both  died  of  the  disease.  There  is  much  to 
be  learned. 

Now,  in  Greensboro  in  1932  there  were  some  experiments 
made  on  dogs  with  black  tongue.  We  have  carried  the 
experiments  through  four  generations  of  dogs.  Yeast  and 
meat  will  prevent  the  disease  in  Walker  hounds;  yeast 
and  meat  will  cure  it.  But  in  the  same  kennels  are  the 
black-bone  hounds,  which  have  never  taken  the  disease. 

There  are  lots  of  questions  to  be  answered.  I  should 
like  to  close  with  one  plea  about  this  diagnosis  of  pellagra. 
One  of  the  reasons  why  those  in  institutional  work  are  so 
sure  that  it  is,  as  has  been  expressed  here  today,  a  disease 
of  poor  white  folks  is  that  at  the  very  beginning  your 
diagnosis  made  it  a  disease  which  could  not  be  ascribed  to 
polite  society.  Those  of  us  who  work  in  all  classes  of 
society  do  not  believe  and  can  not  believe  that  the  economic 
status  of  the  patient  has  much  to  do  with  pellagra.  Diet 
may  have,  because  of  the  various  phobias  which  people 
have,  but  I  hope  we  can  get  away  from  the  idea  that  it  is 
due  to  the  economic  condition  of  the  patient. 

Dr.  D.  W.  Ruffin,  Ahoskie,  N.  C: 

There  has  been  much  said  about  pellagra.  As  a  general 
practitioner  in  North  Carolina  I  have  a  lot  of  pellagra,  as 
naturally  I  would.  When  I  was  in  medical  school,  pellagra 
was  hardly  mentioned  unless  North  Carolina  was,  too.  I 
did  not  like  that,  because  plenty  of  other  States  have  it. 
It  was  always  emphasized  that  it  occurred  among  the 
lower  class  of  people.  That  is  quite  true,  but  in  my  own 
practice  and  in  other  physicians'  practice  I  have  seen  that 
occasionally  there  are  cases  in  wealthy  persons — persons 
able  to  buy  food.  But  those  persons  who  are  able  to  buy 
any  kind  of  food  often  have  a  fancy  for  a  certain  type  of 
diet. 

Dismissing  that  for  the  moment,  I  should  like  to  ask 
Dr.  Ruffin,  of  Duke  Hospital,  and  Dr.  Tucker  what  place 
drug  therapy  has  in  pellagra.  I  give  my  patients  drug 
therapy,  and  I  do  so  because  I  believe  it  really  does  good. 
I  also  give  them  the  dietary  regimen,  the  vitamins  that 
they  should  have  in  the  diet,  with  the  yeast,  etc.,  meat  and 
milk  and  green  vegetables.  In  addition  to  that,  I  give 
them  cacodylate  of  soda.  Th2  reason  I  do  that  is  that  my 
father,  who  was  a  physician  for  35  years,  had  a  lot  of 
experience  with  pellagra,  and  I  do  know  that  when  patients 
could  not  get  the  diet  they  should  have  he  used  pheno- 
bismuth  of  soda,  and  in  one  week  the  sore  tongue  would 
be  much  better.  The  watery  stools  would  clear  up,  too. 
(I  believe  one  doctor  mentioned  the  sore  tongue  that  would 
not  clear  up.) 

If  you  tell  the  average  patient  that  comes  to  you  that 
he  does  not  eat  properly,  he  does  not  take  that  very  se- 
riously. You  have  to  do  something  for  him  other  than 
that.  If  you  do  not  give  him  some  medicine  and  do  not 
do  something  for  him,  he  will  think  you  are  not  doing 
anything  and  he  will  pay  little  attention  to  your  directions. 

Dr.  Jas.  M.  Northincton,  Charlotte: 

With  reference  to  the  statement  that  more  poor  folks' 
having  pellagra,  I  call  attention  to  the  obvious  fact  that 
more  poor  folks  have  children:  there  are  more  of  us. 
The  widow  of  a  doctor  who  set  the  best  table  in  his  city 
died  of  pellagra,  and  there  is  no  doubt  that  she  partook  of 
the  food. 

The  word  "agnostic"  is  a  very  valuable  word.  It  means 
"not  knowing."     There  is  no  doubt  that  proper  eating  is 


an  important  factor.  Proper  assimilation  is  also  a  factor. 
But  it  is  not  the  sole  factor.  .\s  Dr.  Tucker  says,  there 
is  something  else.  Some  of  those  participating  in  the  dis- 
cussion have  said  that  Dr.  Tucker's  ideas  have  been  dis- 
carded. The  fact  that  a  theory  has  been  discarded  does 
not  prove  that  it  is  not  true.  The  theory  of  heredity  in 
cancer  was  discarded  50  years  ago,  but  now  it  is  accepted 
by  practically  everyone  who  studies  the  evidence.  Dr. 
Speas,  of  the  University  of  Cincinnati,  has  done  much 
work  on  pellagra,  and  he  tells  me  he  is  not  at  all  con- 
vinced that  food  deficiency  is  the  main  factor. 

Consider  the  people  in  the  coal-mining  State  of  West 
Virginia.  In  the  depression  following  the  war,  those  peo- 
ple were  very  hard  hit,  probably  harder  than  those  in  any 
other  industry.  When  we  in  North  Carolina  had  a  rela- 
tievly  fat  year,  for  us  (when  we  made,  second  to  Texas, 
the  biggest  crop  of  cotton  of  any  State  in  the  whole  Union 
and  sold  it  at  a  fancy  price,  because  the  boll  weevil  had 
destroyed  a  lot  of  cotton  in  other  States),  in  that  year, 
when  we  thought  we  were  well  off,  we  had  about  one 
hundred  cases  of  pellagra  to  one,  as  compared  to  West 
Virginia,  where  unemployed  miners,  a  great  part  of  the 
population,  were  living  on  corn  bread,  some  wheat  bread, 
molasses,  and  beans — which,  as  I  understand  it,  is  the  very 
diet  which  is  supposed  to  produce  this  poor  man's  disease, 
pellagra. 

Marion  Sims  is  supposed  to  have  had  pellagra,  and  there 
are  some  indications  in  his  autobiography  that  he  had, 
although  he  had  probably  an  excellent  diet.  The  most 
malignant  case  of  pellagra  I  ever  saw  was  the  case  of  a 
locomotive  engineer,  who  made  a  good  salary  and  spent 
most  of  it  on  his  table.  He  ate  probably  more  beefsteaks 
than  anybody  else  in  town. 

I  am  thoroughly  convinced  that  alcohol  has  something 
to  do  with  pellagra,  because  all  these  wealthy  people  I 
have  spoken  of,  who  had  pellagra,  along  with  their  good 
food  had  plenty  of  alcohol.  All  I  can  say  in  this  connec- 
tion is  in  this  uncertain  world  you  have  to  take  a  reason- 
able number  of  chances. 

Dr.  James  K.  Hall,  Richmond: 

I  recall  the  interrogatory  from  Job:  "Who  is  this  that 
darkeneth  counsel  by  words  without  knowledge?"  I  do 
want  to  ask  this,  if  the  disease  is  assumed  to  be  a  virus 
disease,  why  is  it  delimited  practically  to  the  South,  unless 
the  North  and  the  West  be  blessed  by  God?  If  the  disease, 
on  the  other  hand,  is  a  disease  that  must  be  due  to  a 
dietary  trouble,  why  is  it  delimited  to  the  South,  unless 
we  admit  that  the  physicians  in  those  regions  have  not 
learned  to  diagnosticate  it?  But  we  have  physicians  here 
today  from  the  region  of  the  Delaware  and  the  Schuylkill 
and  the  Potomac.  I  just  can  not  believe  and  never  have 
been  able  to  believe  that  all  the  starvation  indicative  of 
pellagra  exists  in  the  South.  I  do  believe  that  Dr.  Marion 
Sims  had  pellagra.  I  do  know  that  it  was  his  i)oor  health, 
whatever  the  cause  of  it,  that  took  him  from  Montgomery, 
Alabama,  to  New  York.  It  may  be  that  Dr.  Sims'  body 
was  poorly  nourished  because  he  had  chronic  malaria. 

Dr.  Tucker,  closing: 

I  certainly  appreciate  this  discussion.  I  think  a  great 
deal  of  my  answer  has  been  eliminated  by  the  various  dis- 
cussers disagreeing.  That  is  all  I  wanted  to  do;  I  wanted 
to  get  all  of  you  to  disagree  on  this  subject.  The  discus- 
sion has  gone  so  far  wide  I  can  not  answer  it;  we  have 
discussed  everything  from  dog  with  black  tongue  to  two 
Presidents,  one  with  a  raw  deal  and  the  other  with  a  New 
Neal. 

Now,  I  am  old  enough  to  have  gone  to  medical  college 
when  the  professors  said   that  typhoid   fever  was  not  due 


258 


FELLA  GRA—Tticker 


May,   1936 


to  a  germ.  The  day  when  these  problems  of  medicine  are 
settled  is  the  day  I  want  to  retire  and  the  day  I  am  going 
to  retire.  We  can  all  remember  when  malaria  was  consid- 
ered due  to  miasms,  and  it  was  with  a  great  deal  of  diffi- 
culty that  the  medical  profession  accepted  the  mosquito 
bite  as  the  cause,  and  there  is  going  to  be  a  good  deal  of 
difficulty  in  opening  up  this  subject.  Of  course,  virus  is  a 
good  subject  to  discuss,  because  nobody  can  prove  any- 
thing on  a  virus.  If  I  could  solve  the  virus  question  I 
might  just  sit  back  and  write  articles  for  a  thousand  maga- 
zines, and  tomorrow  morning  I  should  be  the  most  discussed 
doctor  in  the  world. 

There  is  a  basis  of  alcoholism  sometimes,  tuberculosis 
sometimes,  chronic  gastrointestinal  disturbance  sometimes, 
that  acts  as  a  basis  for  pellagra  in  susceptible  people. 

I  wish  to  say  to  Dr.  Hall  that  pellagra  is  not  confined 
to  the  South,  and  that,  if  it  is  not  a  virus  disease,  it  acts 
like  a  virus  disease. 

Alluding  to  Dr.  Hayne's  remark  as  to  the  lean  years, 
I  am  very  glad  to  know  that  there  were  no  lean  years  in 
South  Carolina.  If  I  had  known  it  four  years  ago  I  would 
have  moved  down  here. 

Of  course,  the  great  argument  is  that  a  certain  diet 
causes  pellagra  and  that  a  certain  other  diet  cures  pellagra. 
We  used  to  think  the  same  thing  about  tuberculosis.  Diet 
has  a  great  deal  to  do  with  tuberculosis.  Take  a  person 
with  tuberculosis,  even  if  the  disease  is  advanced,  and  put 
that  patient  in  a  sanatorium,  fatten  him  up,  and  the  lesions 
begin  to  heal.  Someone  said,  Dr.  Sebrell,  I  believe,  that 
fish  is  a  preventive  of  pellagra;  of  course:  fish  is  a  pretty 
widely  distributed  food.  I  do  not  know  how  much  vitamin 
there  is  in  salt  fish.  People  in  Puerto  Rico  eat  a  lot  o; 
fish ;  but  certainly  fish  constitute  a  small  part  of  the  diet 
in  the  interior  of  India.  Now,  it  may  have  been  true  that 
when  the  price  of  cotton  went  down  people  began  raising 
lots  of  good  foods;  but  in  Virginia  and  in  Florida  pellagra 
exists,  cotton  is  not  raised  and  the  gardens  are  good.  Some, 
of  course,  say  milk  is  no  good,  and  some  advise  milk. 

As  to  the  skin  lesions  being  due  to  the  sun  I  think  the 
sun  makes  them  worse.  The  fact  that  the  skin  lesions  did 
not  develop  under  the  straps  of  the  shoes  tends  to  make  us 
think  of  sunburn  in  the  picture  shown.  But  I  believe  the 
heat  has  more  to  do  with  pellagra  lesions  than  the  sun.  I 
have  seen  the  lesions  develop  in  February,  when  the  patient 
was  warming  himself  by  a  fire  and  was  not  exposed  to  the 
sun  at  all. 

If  the  dietary  deficiency  is  the  cause  of  the  pellagra, 
then  it  seems  to  me  that  in  the  country,  even  as  in  the 
city,  we  should  have  more  pellagra  in  the  winter  rather 
than  in  the  summer.  Of  course,  the  idea  as  to  the  cause 
is  rather  fixed  and  a  fixed  idea  is  very  hard  to  dislodge. 
I  do  not  want  to  convince  anybody,  but  I  want  to  dislodge 
these  fixed  ideas.  I  am  in  much  the  position  Kipling  was 
when  he  went  to  Quebec  and  criticised  the  very  cold 
weather  and  was  heartily  censured  by  a  newspaper.  He 
wrote  this  to  the  editor,  and  the  editor  was  sportsman 
enough  to  publish  it: 

"The  weather  up  here  in  Quebec 
Freezes  me  up  to  my  neck. 

They  ask  how  it  goes; 

I  say  I  am  froze. 
But  they  say  that's  not  cold  in  Quebec." 


practitioner,  of  effective  medical  service  for  each  of  his 
families,  will  divert  this  lay  educational  project  from  the 
path  of  free  clinic  and  state  medicine.  Programs  for  periodic 
examinations  adjustable  to  the  needs  of  each  locality  will 
create  unusual  opportunities  for  co-operation  among  gen- 
eral practitioners  and  specialists. 


Recurrent  Cerebellar  Abscess  of  Nine  Years  Duration 


A  39-year-old  housewife  in  the  Spring  of  1925  had  a 
discharge  from  the  r.  ear.  In  a  few  days  headache,  fever, 
nausea,  vomiting,  double  vision  and  confusion,  stiffness  of 
the  neck,  narrowed  r.  palpebral  fissure,  choked  discs,  nys- 
tagmus in  both  directions  and  localized  tenderness  over  the 
r.  cerebellar  region.  The  c.-s.  fluid  contained  100  cells,  the 
majority  lymphocytes.  Operation  revealed  a  small  abscess 
in  the  right  cerebellar  lobe  adherent  to  the  dura.  Cultures 
of  the  pus  showed  Staph,  aureus.  The  abscess  was  drained, 
and  the  patient  recovered  and  went  home  apparently  well. 

Three  years  later  came  a  sudden  return  of  headaches, 
nausea  and  vomiting,  tenderness  over  the  occipital  region, 
slight  haziness  of  the  optic  nerve  heads  and  slight  ataxia 
of  the  r.  arm  and  leg.  The  c.-s.  fluid  contained  400  cells. 
Explored  and  a  recurrent  abscess  found.  This  was  opened 
and  drained  and  culture  of  the  pus  showed  Staph,  albus. 

For  6  years  she  remained  well  except  for  the  frequent 
mild  headaches,  especially  in  the  presence  of  head  colds.' 
Then  sudden  severe  headache,  fever,  nausea,  vomiting. 
Patient  was  conscious,  oriented  and  co-operative;  com- 
plained of  severe  headache,  tender,  bulging  craniotomy 
defect.  A  few  palpable  tender  posterior  cervical  lymph 
nodes,  left  showed  slight  reddening  and  fullness  of  the 
drum,  a  stiff  neck,  bilateral  Kernig  and  Babinski  sign, 
intact  motor  power,  bilateral  secondary  optic  atrophy, 
c.-s.  fluid  under  250  mm.  of  water  pressure,  contained  2600 
cells,  82%  polys.  No  organisms  were  present  on  smear  or 
culture. 

On  the  second  day  incision  was  made  into  the  cerebellar 
scar  and  on  aspiration  4  c.c.  pus  obtained  at  a  depth  of  S 
cm.  In  the  attempt  to  get  a  better  exposure,  the  needle 
*as  dislodged  and  the  abscess  could  not  be  found  again. 
The  abscess  was  small  and  was  probably  emptied  by  the 
initial  aspiration.  Culture  of  the  pus  yielded  Staph,  albus. 
The  wound  was  sutured  loosely. 

For  a  while  the  patient  ran  a  low-grade  febrile  course. 
The  meningeal  signs  and  Babinski  sign  disappeared.  The 
purulent  discharge  slowly  subsided.  The  wound  healed, 
and  the  patient  was  discharged  on  the  23rd  day. 

When  seen  7  mos.  later  the  patient  was  free  of  com- 
plaints and  she  was  doing  her  housework.  She  noticed 
only  an  occasional  slight  discharge  from  a  small  sinus  at 
the  operative  site. 


Physicians  should  record  complete  physical  exam- 
inations (I.  J.  Murphy,  Mpls.,  in  Rad.  Review,  Mch.) 
for  an  ever-inceasing  number  of  apparently  well  people. 
During  the  numerous  home  visits  they  will  learn  how  each 
member  is,  and  as  indicated,  make  appointments  for  fur- 
ther examinations.     The   institution,   on   the  part  of   each 


Medical  Treatment  of  Appendicitis 
(Benjamin   Jablons,  New  Tork,   in   Med.    Rec,  April  15th) 

The  medical  treatment  of  appendicitis  concerns  itself 
chiefly  with  what  should  not  be  done: 

The  patient  should  not  be  given  a  cathartic  or  an  opiate. 

Do  not  (if  you  can  help  it)  put  on  ice  bags  or  heat. 
This  has  a  tendency  to  delay  surgical  intervention. 

Do  not  delay  operation. 

There  is  no  knovvn  method  of  treating  an  acute  suppura- 
tive inflammation  of  the  appendix  other  than  by  surgery. 
There  may  be  occasional  cases  where  rest  and  abstinence 
from  food  have  apparently  overcome  an  acute  inflammation 
of  the  appendix,  but  this  therapeutic  road  is  strewn  with 
the  corpses  of  those  who  through  surgery  might  have  been 
saved. 


May,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


A  Review  of  500   Cases  of  Sterility  in  Women   From   the 
Functional,  the  Endocrinal  and  the  Organic  \aewpoint* 

Robert  Thrift  Ferguson,  M.A.,  M.D.,  F.A.C.S.,  Charlotte,  North  Carolina 


THIS  SUBJECT  I  shall  discuss  as  briefly  as 
possible,  leaving  out  all  unessentials.  Ster- 
ility has  always  been  an  important  subject 
and  its  importance  seems  to  be  increasing. 

The  former  methods  of  treatment — dilating  the 
cervix,  curetting  the  uterus  and  various  cutting 
operations  about  the  cervix  without  first  deter- 
mining the  patency  of  the  fallopian  tubes — have 
been  definitely  discarded.  One  must  know  whether 
the  tubes  are  patent  before  rational  treatment  can 
be  outhned.  A  complete  history  and  careful  physi- 
cal examination  are  indispensable. 

To  present  the  subject  in  a  concise  manner  I  shall 
speak  to  you  from  two  slides  giving  in  detail  the 
examination  as  carried  out  in  my  office. 


.Average  age 

Average  menstrual  age  ^ 
Average  no.  yrs.  married 

Previous  operations 

D.  &  C 

Headaches 

Backaches 

Leukorrhea    

Tonsils  removed    ._ 

Painful  coitus 

Dysmenorrhea 

Hemorrhoids  

White  count  above  10  m. 
Red  count  below  4  mil._     8 

Pessaries  5 

Clots  at  periods  62 

Cystic  ovaries  20 

.Abscess  Bartholin's  giand     1 

Sterile  husbands 1 

Polyps 1 

.Appendectomies   37 


i4  SERIES 

28  Syphilis    1 

13      Fistula  in  ano 0 

7  Fissure  in  ano  _ „     7 

38      Gonorrhea  (proved)   4 

29  Heart  lesions  _ _____ _     7 

61  Tuberculosis    .__     2 

65      Fibroids  11 

34      Constipation 62 

60      One  or  more  pregnancies  30 
21      Malposition  of  uterus 47 

62  Miscarriages    ._ ._ 20 

1      Ectopic   (prior  to  test)..     1 

10       Cervicitis-endocervicitis      26 

8  Patent  tubes  (7S%)  _  20 

Non-patent  tubes  ..-_ 80 

Operations   by   me 20 

Pregnancy  following  test  IS 
.Average   b'ood   pres.    110  6 1 

.Albumin  in  urine  1 

Sugar  in  urine  1 

Enlarged   thyroid  7 

Ko.  patency  tests  239 


AVERAGE  FOR  500  CASES 

Average  age 28 

Average  menstrual  age ...  13 
.Average  no.  yrs.  married     6 

Previous  operations  39 

D.  &  C.  28 

Headaches  62 

Backaches    69 

Leukorrhea   44 

Tonsil;  removed 47 

Painful  coitus . 18 

Dysmenorrhea    60 

Hemorrhoids  3 

White  count  above  10  m.  20 
Red  count  below  4  mil.  23 


(1927-28-29-32-34  SERIES) 

Syphilis    ____  1.6 

Fistula  in  ano  __ 1 

Fissure  in  ano    1.8 

Gonorrhea  (proved)  6.4 

Heart  lesions  ,._  3.4 

Tuberculd:-"-  .     2 

Fibroids  _  ..     6 

Constipation    S2 

One  or  more  pregnancies  34 
Malposition  of  uterus ..._  41 

Miscarriages    _ 20 

Ectopic  (prior  to  test)....  1 
Cervicitis-endocervicitis  36 
Patent  tubes  (21.8%)   ....  46 


Pessaries _ 

Clots  at  periods 

Cystic  ovaries  

.Abscess  Bartholin's  gbnd 

Sterile  husbands 

Polyps    

Appendectomies  (Sth 
100)     


Non-patent  tubes  54 

Operations  by  me 20 

Pregnancy  following  test  10 
.Avcr.;ge   blood   prcs.   110/72 

.Albumin  in  urine   2 

Sugar  in  urine  .5 

Enlarged  thyroid   (Sth 

100)    ...___." 7 

No.  patency  tests 216 

The  age  of  the  patient,  average  28  years,  brings 
to  mind  the  average  menstrual  age  of  13,  which 
is  normal.  The  number  of  years  married  has  sig- 
nificance: some  of  my  patients  have  become  preg- 
nant after  having  been  married  14  years  and  with 
no  treatment  other  than  the  tubal  patency  test. 

Previous  operations  has  an  important  bearing 
because  many  are  rendered  sterile  from  adhesions 
subsequent  to  operations. 

Dilatations  and  curettages  have  apparently  been 
detrimental  in  a  number  of  cases  and  it  is  possible 
that  undue  scraping  around  the  tubal  ostium  may 
cause  the  formation  of  cicatricial  tissue  with  ob- 
struction. 

Headaches  and  backaches  are  frequent  accom- 
paniments of  menstruation  and  pelvic  disease  and 
it  is  not  surprising  that  62  per  cent,  of  the  patients 
so  suffered.  Both  of  these  conditions  when  origi- 
nating from  pelvic  disease  are  usually  relieved  by 
proper  treatment. 

In  leukorrhea  the  only  scientific  method  of  diag- 
nosis is  to  make  cultures  and  smears  in  every  case 
and  know  what  character  of  infection  you  are  deal- 
ing with.  A  white  discharge  is  rarely  infectious, 
while  all  yellow  discharges  contain  either  gonococ- 
cus,  streptococcus,  staphylococcus  or  the  colon  ba- 
cillus. In  one  case  I  found  a  pure  growth  of  gono- 
coccus  present  although  there  was  no  inflammation 
or  leukorrhea  and  the  cervical  mucus  was  a  clear 
white.  The  reason  for  taking  cultures  and  smears 
on  this  patient  was  that  she  had  a  suspicious  arth- 
ritis in  the  wrist  joint.  In  my  experience  from  75 
to  90  per  cent,  of  the  cases  of  sterility  appear  as 
a  sequel  to  gonorrheal  infection. 

In  47  per  cent,  of  my  cases  tonsillectomy  had 
been  done.  Focal  infection  does  not  always  lie  in 
the  tonsil  but  often  it  is  located  in  an  infected 
tube. 

Painful  coitus  has  occurred  in  18  per  cent,  of  the 
cases  and  occasionally  this  accounts  for  the  ster- 
ility. The  cause  of  this  condition  should  be  studied 
and  relieved  where  possible. 


•Presented   to   the  Medical   Society  of   the   State  of  North  Carolina,  meeting  at  Asheville.  Ma 


STERILITY— Ferguson 


May,  1936 


Dysmenorrhea  occurred  in  60  per  cent,  of  the 
cases  and  is  a  common  complaint  in  menstruating 
women  who  have  not  borne  children.  I  encounter 
many  in  this  particular  work  whose  tubes  are  defi- 
nitely closed  and  who  have  never  suffered  from 
dysmenorrhea  and  it  is  my  experience  that  ob- 
struction of  the  tubes  per  se  is  not  an  etiological 
factor  in  dysmenorrhea.  This  is  definitely  contrary 
to  the  belief  of  the  menstruating  woman. 

Hemorrhoids  are  common  during  and  following 
pregnancy  but  in  women  who  have  not  conceived 
I  have  discovered  only  3  per  cent. 

The  blood  counts  are  informative  but  I  have 
only  listed  here  white  counts  above  10,000  and 
red  counts  below  4,000,000.  A  white  count  of 
10,000  or  above  should  make  you  search  for  the 
cause,  and  a  red  count  below  4,000,000  usually 
indicates  mild  or  severe  anemia  and  requires  treat- 
ment. For  anemia  in  this  type  of  case  I  have 
found  nothing  so  satisfactory  as  iron  in  weekly  5- 
c.c.  doses  intravenously.  It  is  without  doubt  the 
best  regulator  known  for  use  in  cases  of  amenor- 
rhea. 

Fessanes  deserve  special  mention;  7  per  cent,  of 
those  in  this  group  have  worn  some  form  of  pes- 
sary prior  to  consulting  me.  Pessaries  are  valuable 
particularly  in  cases  of  descensus  of  the  uterus, 
and  especially  in  the  aged.  They  give  marked 
relief  when  properly  inserted  and  cared  for,  and 
permit  many  old  women  to  pass  their  remaining 
years  in  comfort.  The  next  most  important  indi- 
cation for  a  pessary  is  in  cases  of  retroversion, 
especially  in  women  who  have  not  borne  children; 
and  many  of  these  will  conceive  if  the  uterus  is 
properly  supported,  and  with  no  other  medication. 
For  a  majority  of  women  who  have  borne  children 
the  use  of  a  pessary  is  only  a  temporary  measure 
and  the  uterus  falls  back  into  its  original  position 
when  the  pessary  is  removed.  This  type  of  case 
requires  operative  interference.  Stem  pessaries, 
except  in  anteflexion  cases,  are  an  abomination. 
and  are  without  doubt  the  cause  of  many  cases  of 
sterility. 

Clots  at  the  periods  are  of  no  special  significance 
except  when  large  enough  to  produce  dysmenor- 
rhea. Since  the  clots  are  passed  at  the  periods  in 
49  per  cent,  of  the  cases,  and  pain  is  felt  in  only 
a  few,  I  feel  that  I  am  justified  in  making  this 
statement. 

Cystic  ovaries  have  been  found  in  2i  per  cent, 
of  my  cases  and  are  frequently  the  cause  of  ster- 
ility, this  fact  having  been  satisfactorily  demon- 
strated where  the  cyst  has  been  removed  and  con- 
ception has  followed  without  other  treatment. 

Abscess  in  Bartholin's  gland  is  exceedingly  com- 
mon in  acute  gonorrheal  infection.  Smears  and 
cultures  made  from  these    abscesses    has    proved 


them  to  be  due  to  the  gonococcus  in  100  per  cent, 
of  my  cases. 

I  have  been  surprised  at  reports  in  the  literature 
that  in  sterile  husbands  lay  the  cause  of  25  per 
cent,  of  non-fertile  marriages.  I  have  found  pri- 
mary sterility  in  the  male  in  only  1  per  cent,  of 
my  cases. 

Cervical  polyps  are  exceedingly  common  and  are 
occasionally  the  cause  of  sterility.  A  patient  from 
whom  I  removed  a  cervical  polyp  one  year  ago 
came  into  my  office  last  week  to  show  me  her 
baby.  She  was  34  years  of  age  and  said  that  she 
liad  been  treated  by  a  number  of  physicians  and 
told  that  she  would  never  conceive.  The  only  treat- 
ment I  gave  her  was  removal  of  the  polyp  in  the 
office  with  cautery  and  testing  the  patency  of  the 
fallopian  tubes,  which  I  found  normal. 

I  do  not  have  a  Wassermann  done  as  a  routine 
but  only  in  those  cases  in  which  the  history  sug- 
gests syphilitic  infection,  therefore  only  1.6  per 
cent,  were  positive. 

I  have  been  struck  with  the  fact  that  we  find 
many  unsuspected  conditions  when  they  are  search- 
ed for:  I  have  found  fistulae  and  fissures  in  ano 
in  1  and  1.8  per  cent.,  respectively. 

In  all  of  the  cases  presenting  leukorrhea  cultures 
and  smears  are  made,  and  6.4  per  cent,  of  the  cases 
have  shown  a  pure  growth  of  the  gonococcus. 
Cases  of  this  character  with  yellow  discharge  which 
does  not  show  the  gonococcus  invariably  show 
staphylococcus,  streptococcus  or  both.  It  has  never 
been  my  good  fortune  to  find  the  gonococcus  in 
any  case  of  infection  lasting  for  one  year.  The 
majority  of  cases  of  leukorrhea  can  be  cured  by 
local  applications;  some  require  the  use  of  the 
cautery;  while  a  small  number  need  coning-out  or 
amputation.  Douches  are  absolutely  useless  as  a 
cure  but  are  useful  as  a  cleansing  agent  during  the 
acute  stage. 

One  would  not  expect  to  find  heart  lesions  com- 
mon at  this  age  period  and  only  3.4  per  cent,  have 
shown  them. 

Tuberculosis  must  be  kept  in  mind  always  and 
where  there  is  the  slightest  suspicion  of  such  in- 
volvement sputum  and  x-ray  examinations  are 
made.  I  have  found  2  per  cent,  of  this  series  tu- 
berculous. One  of  these  cases  was  diagnosed  as  a 
tuberculous  salpingitis,  operated  on  and  cured. 

Fibroids  are  among  the  most  frequent  conditions 
found  during  pelvic  examinations  and  are  a  com- 
mon cause  of  sterility,  especially  where  the  tumor 
encroaches  on  that  part  of  the  tubal  canal  which 
is  included  in  the  walls  of  the  uterus.  Many  cases 
of  primary  sterility  lasting  10  years  or  more  have 
been  found  to  have  uterine  fibroids. 

Constipation  is  such  a  common  complaint — 52 
per  cent,  of  these  cases — that  it  is  hardly  worth 


STERILITY— Ferguson 


mentioning  in  a  paper  of  this  character:  I  believe 
a  large  majority  of  these  are  of  the  habit  type 
which  is  so  common  from  neglect. 

Secondary  sterility  is  very  common;  34  per  cent, 
of  my  cases  have  been  of  this  type.  Among  the 
causes  I  mention  post-partum  infections,  abortions, 
miscarriages,  lacerations,  tumors  and  malpositions. 
Abortions  are  the  cause  in  a  great  number  of  cases 
of  sterility.  Kakuschkin  in  an  observation  of  1921 
women  found  that  50  per  cent,  of  them  became 
sterile  for  more  than  two  years  following  artificial 
abortion.  He  found  the  average  number  of  abor- 
tions per  woman  in  this  series  was  2.34  per  cent, 
while  the  average  normal  delivery  was  only  1.87 
per  cent. 

Malposition  of  the  uterus  is  a  major  cause  of 
sterility  in  nulliparae,  especially  retroversion  and 
anteflexion,  the  latter  being  among  the  hardest  con- 
ditions to  relieve  by  any  method  known.  Preg- 
nancy follows  in  a  majority  of  the  cases  of  retro- 
version in  nulliparae  after  proper  insertion  of  the 
proper  pessary.  The  place  occupied  by  malposi- 
tions is  well  demonstrated  by  the  fact  that  41  per 
cent,  of  my  cases  have  suffered  from  this  condition. 
Miscarriages  and  abortions  alone  have  apparently 
accounted  for  20  per  cent,  of  my  cases. 

Ectopic  pregnancy  is  a  fairly  frequent  occurrence 
but  in  a  series  of  this  type  I  have  found  only  1  per 
cent,  followed  by  sterility. 

Cervicitis  and  endocervicitis  are  very  common 
causes  of  sterility  and  36  pjer  cent,  of  my  cases 
fall  under  this  heading.  Many  women  will  conceive 
when  inflammatory  conditions  have  been  relieved 
and  the  treatment  outlined  under  leukorrhea  is  ap- 
plicable here. 

My  findings  in  regard  to  the  patency  of  the  fal- 
lopian tubes  compare  favorably  with  those  of  other 
gynecologists  and  show  46  per  cent,  in  this  series. 
Of  the  500  cases  21.8  per  cent,  of  those  in  whom  I 
was  able  to  pass  air  through  the  tubes  have  been 
known  to  become  pregnant.  I  have  not  sent  out 
letters  to  these  patients  to  find  out  the  exact  num- 
ber who  have  conceived  but  am  giving  you  figures 
on  those  cases  in  which  I  happen  to  know  preg- 
nancy has  ensued.  As  you  know,  it  is  almost  im- 
possible to  get  replies  from  patients  even  though 
you  send  them  a  self-addressed  and  stamped  en- 
velope. In  54  per  cent,  of  these  cases  the  tubes 
were  permanently  closed.  I  have  operated  in  20 
per  cent,  of  these  latter  cases  and  have  found  the 
diagnosis  correct  in  every  instance.  Plastic  opera- 
tions on  the  tubes  are  rarely  followed  by  conception 
in  more  than  8  per  cent,  of  the  cases,  and  I  do  not 
advise  this  operation  unless  the  patient  has  ample 
means  and  does  not  object  to  a  2-weeks  confine- 
ment in  the  hospital,  and  then  only  after  advising 
her  of  the  small  percentage  of  successes. 


Pregnancy  following  insufflation  occurred  in  75 
per  cent,  of  my  last  series  of  11  cases  in  which  I 
\vas  able  to  get  air  through  the  tubes.  This  high 
percentage  of  successes  has  been  very  gratifying. 

The  blood  pressure  has  been  taken  on  all  the 
women  whom  I  have  examined  for  many  years. 
The  average  is  110/72,  and  this  appears  to  be 
normal  for  women  of  this  age  period. 

Albumin  in  the  urine  is  not  common  in  young 
women  and  I  have  found  only  2  per  cent,  in  this 
series.  All  specimens  are  obtained  by  catheter  where 
there  is  any  leukorrhea  and  this  rules  out  all  chance 
of  contamination  when  specimens  are  obtained  per 
vias  naturales. 

Sugar  also  is  rare  in  the  urine  of  women  of  this 
age  and  I  have  found  only  .5  per  cent,  in  this  series 
so  affected.  I  have  learned  to  suspect  its  presence 
in  young  obese  women  especially  where  there  is  a 
vulval  or  vaginal  irritation. 

It  is  a  well  known  fact  that  the  thyroid,  among 
other  ductless  glands,  is  a  frequent  contributor  to 
sterility,  and  7  per  cent,  of  my  cases  have  had 
demonstrable  disease  in  this  field.  In  my  experi- 
ence hypothyroidism  accounts  for  the  larger  num- 
ber of  cases. 

The  number  of  patency  tests  performed  on  any 
individual  is  determined  by  the  circumstances  in 
that  particular  case.  The  majority  of  patients  are 
subjected  to  only  one  test,  this  being  sufficient  to 
make  a  positive  diagnosis;  many  others  require 
repeated  tests.  For  a  patient  who  does  not  conceive 
following  a  first  test  which  shows  the  tubes  patent, 
and  after  the  husband  has  been  proved  fertile,  the 
test  is  repeated  seven  days  after  the  menstrual 
period  for  two  or  three  months. 

The  average  number  of  tests  which  I  have  per- 
formed in  each  series  of  100  cases  is  216. 

It  gives  me  a  great  deal  of  satisfaction  to  be 
able  to  state  that  there  have  been  no  harmful  se- 
quelae in  any  of  my  cases.  Practically  all  of  these 
tests  have  been  done  in  my  office  without  anesthe- 
sia. There  is  an  occasional  case  in  which  it  is 
desirable  to  perform  the  test  under  an  anesthetic 
and  these  tests  are  invariably  done  in  the  hospital. 
The  majority  of  my  tests  have  been  made  with  a 
simplified  apparatus  devised  by  myself  some  13 
years  ago  and  which  has  proved  eminently  satis- 
factory. 

Encouraged  by  many  requests  for  reprints  on 
articles  of  mine  on  this  subject  I  have  gone  some- 
what into  detail  regarding  the  findings  in  this  large 
series  of  cases  and  I  shall  conclude  with  some  gen- 
eral remarks  on  the  subject. 

Since  I  endeavor  to  do  only  the  necessary  and 
common-sense  things,  and  to  not  subject  my  pa- 
tients to  any  unnecessary  expense,  a  basal  metab- 


STERILIT  Y— Ferguson 


May,   1936 


olism  test  is  done  only  in  the  presence  of  definite 
indications. 

I  am  frequently  asked  if  I  inject  the  tubes  with 
lipiodol  and  use  the  x-ray  to  locate  the  seat  of 
obstruction.  This  I  do  not  do  for  what  appears  to 
me  a  very  good  reason;  that  is,  the  air  test  proves 
beyond  the  shadow  of  a  doubt  that  the  tubes  are 
obstructed  and  nothing  short  of  an  abdominal  sec- 
tion would  reveal  what  would  be  necessary  to  re- 
lieve the  obstruction,  therefore,  I  consider  this  an 
unwarranted  expense.  Most  patients  do  not  object 
to  the  simple  office  test  but  the  large  majority  balk 
at  hospitals  and  anesthetics.  There  are  many  con- 
ditions that  cause  sterility.  Among  the  local  causes 
are  intact  hymen,  dyspareunia,  tumors,  cysts,  cerv- 
ical stenosis,  cervicitis  and  endocervicitis,  malposi- 
tions of  the  uterus,  infections,  adhesions,  lacera- 
tions, polyps,  and  tuberculosis.  Among  constitu- 
tional diseases  are  endocrine  disturbances,  vitamin 
deficiencies,  incompatibility  and  consanguinity. 
The  latter  is  said  to  have  accounted  for  about  30 
per  cent,  of  sterilities  in  European  royal  families. 
Probably  10  per  cent,  of  all  marriages  are  involun- 
tarily barren. 

Conception  sometimes  follows  the  simplest  form 
of  medication  or  change  of  methods  so  that  it  is 
impossible  to  always  state  definitely,  in  any  indi- 
vidual case,  conception  would  not  have  occurred 
without  treatment. 

Knaus  claims  that  women  who  have  the  regular 
menstrual  cycle  of  28  days  can  conceive  from  the 
nth  to  the  17th  day  of  the  cycle  only.  My  advice 
is  to  take  this  cum  grano  salis  if  pregnancy  is  not 


desired,  for  we  have  all  seen  cases  conceive  follow- 
ing a  single  intercourse  at  any  time  in  the  cycle. 

There  are  cases  in  which  the  tubal  patency  test 
is  done  as  a  therapeutic  measure  and  I  have  several 
dysmenorrhea  patients  who  have  been  remarkably 
benefited  by  this  simple  measure.  Why.  I  do  not 
know.  Ordinarily  this  test  should  not  be  per- 
formed on  unmarried  women  without  specific  indi- 
cations. I  shall  shortly  report  100  cases  of  this 
type  with  the  indications  and  the  results. 

The  contraindications  to  tubal  insufflation  are: 
serious  cardiac,  pulmonary  or  renal  disease;  cervi- 
cal or  vaginal  infections;  large  tumors  or  cysts, 
and  —  an  absolute  contraindication  —  menstrual 
bleeding  from  any  cause  whatsoever. 

Artificial  insemination  can  be  practiced  in  se- 
lected cases  with  a  small  percentage  of  successes. 

Post-coital  examination  of  the  semen  may  be 
done,  as  advocated  by  Huhner.  or  by  using  a  con- 
dom specimen. 

In  determining  the  patency  of  the  fallopian  tubes 
it  is  easy  to  have  your  assistant  place  the  stetho- 
scope over  the  distal  extremity  of  the  tube  and 
detect  gas  bubbling  through.  The  gas  used  in  tHe 
test  is  of  little  importance;  some  claim  that  the 
use  of  carbon  dioxide  is  preferable  on  account  of 
the  rapidity  of  absorption;  others  use  oxygen;  I 
use  nothing  but  free  air.  With  the  use  of  my  sim- 
plified apparatus,  with  the  bulb  between  your  fin- 
gers, it  is  easy  to  discern  the  sudden  relaxation  of 
pressure  when  the  air  escapes  through  the  tubes 
into  the  abdominal  cavity  and  at  the  same  time  you 
notice  the  mercury  drop  in  the  gauge.     Following 


n^lp^lJ'l^lllq}nnlmglln^ll^lpl^u^l]^rt^l■»j'i^ll'ijm^|lBj^^M,w^|m^[^'^Jlll^a^lUq^li^^ll^ll^j'^ 


THE  FERGUSON  APPARATUS  FOR  TESTING  THE  PATENCY  OF  THE  FALLOPIAN 

TUBES 

Manufactured  by  Eimer  &  Amend,   Third  Ave.,  18th  to  19th  Street,   New  York,   N.   Y. 


May,  1936 


STERILITY— Ferguson 


263 


this,  when  the  patient  assumes  the  sitting  posture, 
pain  in  the  right  shoulder  is  postive  evidence  that 
at  least  one  of  the  tubes  is  patent. 

The  use  of  the  Keyes-Ultzmann  metal  cannula 
with  a  rubber  acorn  fitted  over  the  tip  is  not  very 
satisfactory  in  my  hands,  since  after  being  used  a 
few  times  this  rubber  has  a  tendency  to  slide  up 
on  the  cannula  and  permit  the  tip  to  press  against 
the  fundus  of  the  uterus  with  the  possibility  of  punc- 
ture if  one  is  not  careful.  I  find  my  apparatus  very 
much  more  satisfactory  for  this  reason,  and  also 
on  account  of  its  simplicity,  since  the  glass  bulb 
makes  the  rubber  unnecessary. 

I  use  a  20  per  cent,  solution  of  argyrol  contain- 
ing 12  minims  of  adrenalin  to  the  ounce,  in  the 
place  of  iodine,  to  paint  the  cervix,  as  some  patients 
complain  of  a  burning  sensation  following  the  use 
of  iodine. 

In  the  functional  cases,  or  those  in  which  the 
symptoms  cannot  be  referred  to  any  appreciable 
lesion  or  change  of  structure,  a  number  of  things 
must  be  taken  into  consideration.  One  of  the 
most  interesting  of  these  is  the  study  of  the  endo- 
crine system.  Dr.  Havelock  Ellis  says:  "In  the 
body  lie  great  rivers  of  hormones  which  irrigate 
the  human  body  and  profoundly  affect  the  flower- 
ing of  personality."  I  might  add  that  hidden  in 
these  rivers  are  multiudinous  personalities  of  which 
we  know  nothing.  Dr.  Ale.xis  Carrell,  in  his  recent 
book  "Man,  The  Unknown,"  gives  us  abundant 
evidence  of  our  ignorance  of  the  fluids  which  cir- 
culate through  the  human  body. 

The  endocrine  glands,  particularly  the  ovaries, 
the  pituitary  and  the  thyroid,  seem  to  be  the  major 
offenders  in  this  group,  while  the  adrenals  and  oth- 
ers are  being  investigated  in  this  connection.  The 
use  of  corpus  luteum,  theelin,  prolan,  progynon, 
folliculin  and  antuitrin-S  may  be  of  value  in  the 
treatment,  but  in  the  majority  of  cases  they  do  not 
seem  to  turn  the  trick. 

We  have  not  yet  pricked  the  bubble  in  the 
stratosphere  of  endocrinal  influence. 

The  organic  cases  are  the  easiest  to  treat  for  the 
reason  that  their  etiology  is  definitely  known  and 
experience  has  taught  us  about  the  percentage  of 
cases  in  which  we  can  expect  definite  relief. 


The  Rhythm  of  Fertility 

(Jos.    Brown,    Dfrs    Moine.s.    in    Jl.    Iowa    State    Med.    Soc, 
March) 

The  human  ovum  lives,  at  most,  12  hours  after  its  ex- 
pulsion from  the  follicle,  unless  it  is  fertilized.  We  have, 
then,  as  a  basis  for  our  calculation  a  spermatozoon  that 
may  live  and  fertilize  for  a  period  of  3  days,  a  graafian 
follicle  that  may  rupture  at  any  time  within  a  S-day 
period,  and  an  ovum  that,  unfertilized,  lives  only  a  few 
hours. 

.\t  least  12  days  must  elapse  for  the  endometrium  to 
develop  to  be  a  proper  nidus  for  the  nourishment  of  the 
embno.     There   must   of   necessity,   then,   be   a   minimum 


lapse  of  12  days  between  the  rupture  of  the  follicle  and 
menstruation. 

It  follows  that  conception  can  take  place  any  time 
within  the  5-day  ovulation  period,  and  since  spermatozoa 
may  live  for  3  days  in  the  fallopian  tube,  we  have  a 
total  of  8  days  during  which  conception  is  possible;  the 
few  hours  of  life  of  the  ovum  need  not  be  considered.  The 
other  days  of  the  menstrual  cycle  are  naturally  sterile 
days,  since  there  can  be  no  union  of  the  spermatozoa  and 
ova. 

Granting  a  woman  has  a  28-day  cycle  and  12  days  are 
necessary  for  the  preparation  of  the  endometrium,  we  de- 
duct 12  days  from  the  expected  day  of  the  next  menstrua- 
tion and,  from  the  12th  day,  begin  to  count  back  S  days 
for  the  ovulation  period  and  3  days  for  the  life  of  the 
spermatozoon,  the  period  of  the  12th  to  the  19th  day  in- 
clusive before  the  next  menstruation  are  fertile,  the  re- 
mainder are  sterile.  It  is  much  easier  to  figure  it  this 
way,  hence  the  value  of  keeping  a  calendar  for  several 
months  in  order  to  ascertain  accurately  the  date  of  the 
next  1st  day  of  menstruation. 

However,  Nature  does  not  always  work  with  such  regu- 
larity. 

In  calculating  remember  to  include  the  1st  day  of  the 
menstruation.  Miller  has  recently  reported  the  cohabita- 
tion record  of  154  couples  over  a  period  of  several  months: 
"There  were  2,200  cohabitations  both  before  and  after  the 
calculated  fertile  period,  not  one  of  which  resulted  in 
pregnancy."  More  recently  Weinstock  reported  416  preg- 
nancies in  as  many  women  following  a  single  coitus.  These 
women  were  observed  for  a  period  of  3  months.  He  con- 
cluded that  conception  is  possible  on  any  day  of  the 
menstrual  cycle,  more  so  between  the  5th  and  10th  day 
of  the  cycle.  I  have  2  objections  to  his  conclusions:  first, 
that  from  the  5th  to  the  10th  day  of  the  menstrual  cycle 
not  only  are  some  women  still  menstruating,  but  the 
endometrium  is  not  developed  enough  to  become  a  suitable 
habitat  for  a  growing  embryo,  and  that  in  the  ovary,  the 
corpus  luteum  is  undergoing  recession  and  the  new  ovum 
is  not  yet  developed;  second,  any  man  who  is  able  to 
control  and  limit  416  couples  to  a  single  coitus  over  a 
period  varying  from  1  to  2  months,  may  possibly  be  able 
to  control  Mother  Nature  herself,  and  with  him  I  have 
no  quarrel. 


Method  of  Retatntng  a  Soft  Rubber  Catheter  in  the 

Urethra 
(E.    M.    Bevis,   Tonasket,   Wash.,   in   Nor'wes.    Med.,  Mar.) 

We  use  elastic  rubber  bandage  material  that  will  anneal 
when  2  pieces  are  held  firmly  together.  That  distributed  by 
Universal  Distributors  of  Chicago  is  called  Super  Bandage. 

A  piece  is  cut  /"-shaped,  the  cross  of  the  T  one  inch  wide 
and  long  enough  to  encircle  the  penis  just  back  of  the 
glans  with  enough  overlap  for  anneaUng.  When  annealed 
the  tension  should  be  just  great  enough  to  prevent  slipping 
over  the  glans  without  constricting  the  circulation.  The 
upright  of  the  T  is  cut  ><  in.  wide  by  lyi  in.  long  with 
wings  i/i  in.  by  ->-^  in.  on  either  side  of  the  base  of  the 
upright.  These  wings  arc  wrapped  about  the  catheter, 
after  it  has  been  introduced  into  the  bladder,  and  fixed  to 
it  by  firmly  holding  the  wings  and  catheter  between  the 
thumb  and  finger  for  a  short  time.  The  catheter  must  be 
clean  and  dry. 

A  second  piece  of  bandage  tissue  J/^  in.  wide  by  3J/2 
inches  long  is  annealed  to  the  tissue  that  encircles  the 
penis  and  to  the  wings  that  hold  the  catheter  at  a  point 
on  their  circumference  opposite  the  upright  of  the  T,  to 
equalize  the  pull  on  the  penis  and  catheter.  The  harness 
is  clean,  comfortable,  seldom  breaks,  and  is  easily  and 
quickly  repaired,  making  the  care  of  these  patients  a  sim- 
ple and  satisfying  experience. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,   1036 


Common-Sense  in  Cardio-Vascular  Diagnosis* 

E.  J.  G.  Beardsley,  M.D.,  Philadelphia 

Clinical  Professor  of  Medicine,  The  Jefferson  Medical  College 


THE  medical  profession  has  existed  through  his  own  ability  and  usefulness  is  bound  to  prove 
six  thousand  years  of  written  history,  and  an  evil  influence  in  medicine.  The  well-educated 
tu^  M,oro^tor   oi-;n    «>ff;^;or„-„  ,nH  Qiti-incm      and  properly  trained  general    practitioner    is    the 

most  generally  useful  agent  in  medicine  today.  In 
addition  to  discharging  the  duties  of  an  excellent 
physician,  he  has,  under  favorable  conditions, 
proved  himself  to  be  perfectly  capable  of  acquir- 
ing and  using  the  special  skill  of  the  specialist, 
without  acquiring  the  medical  myopia  that  is  all 
too  common  in  the  field  of  specialism.  The  best 
specialists  in  any  field  are  found  to  be  the  indi- 
viduals with  the  broadest  medical  interests  and 
those  having  had  the  best  training  in  general  med- 
icine. Henry  Christian  has  bluntly  but  helpfully 
pointed  out:  "Physicians  may  be  divided  into  two 
classes  and  two  classes  only:  those  who  are  learn- 
ing and  those  who  are  forgetting;  those  who  each 
year  know  more  and  those  who  each  year  know 
less;  there  is  no  third  class."  In  a  time  of  economic 
depression  there  are  many  and  excellent  reasons 
why  physicians  should  profitably  occupy  their 
minds  by  study  and  by  systematic  and  practical 
medical  investigations.  There  is  an  unfortunate 
tendency  .when  one  is  not  fully  and  usefully  occupied 
professionally,  to  suffer  periods  of  discouragement 
that  can  be  profitably  sublimated  by  increasing 
one's  fund  of  medical  knowledge  and  by  improving 
in  technical  skill  and  dexterity. 

One  of  the  distressing  psychological  aspects  of 
modern  medicine  has  been  the  acquisition  by  many 
excellent  physicians  of  an  entirely  unjustified  sense 
of  professional  inferiority.  In  the  writer's  experi- 
ence this  unhappy  psychological  state  has  been  par- 
ticularly noticeable  in  connection  with  doubts  of 
their  ability  to  worthily  serve  the  best  interests  of 
their  patients  who  are  the  victims  of  cardiovascular 
disorders.  Various  explanations  can  be  thought  of 
for  such  a  state  of  mind.  Uncertainty  regarding 
economic  security  is  as  psychologically  disturbing 
in  the  physician  as  in  his  patients.  A  changing 
economic  world  causes  anxiety  for  the  future  of  the 
family  and  this  leads  to  introspection,  worry  and, 
frequently,  to  a  sense  of  inadequacy.  Another  self- 
evident  reason  for  many  physicians  feeling  that 
scientific  medicine  has  advanced  beyond  their  prac- 
tical application  of  it  lies  in  the  character  of  many 
scientific  papers  read  before  societies  and  published 
in  the  journals.  All  too  frequently  these  articles 
are  written  by  scientists  for  fellow-scientists  and 

•Prepared  for  presentation  to  the  Tri-State  Medical  Association  meeting-  at  Columljia,  S.  C,  Feljruary  ITth  and  ISth. 


^HE  medical  profession  has  existed  through 
six  thousand  years  of  written  history,  and 
the  character,  skill,  efficiency  and  altruism 
of  its  members  have  well  and  honorably  justified 
their  group  continuance  by  proving,  in  the  main, 
to  be  considerate,  dependable  and  helpful  agents 
for  the  guidance  and  care  of  sick  humanity.  Ex- 
perience through  the  ages  has  revealed  that,  to  be 
most  useful  to  his  patients  and  to  the  community, 
a  physician  must  be  an  individual  of  character  who 
possesses  a  sound  medical  philosophy  and  who  con- 
tinues throughout  his  professional  life  to  increase 
his  fund  of  knowledge  and  to  profit  by  all  of  life's 
experiences. 

It  is  common  knowledge  that  the  medical  guild, 
as  is  true  of  other  professions,  has  been  handicap- 
ped and  still  remains  encumbered  by  the  presence 
in  its  membership  of  a  minority  of  practitioners 
whose  characters,  ideals  and  comprehensions  of 
their  opportunities,  responsibilities  and  professional 
duties  are  limited  and  sometimes,  alas,  based  upon 
selfish  interests.  The  high  principles  and  the  gen- 
erally helpful  characteristics  of  the  majority  of  the 
members  of  the  medical  profession,  however,  are 
such  as  to  justify  and  maintain  such  a  degree  of 
public  respect  that,  in  every  land  the  designation, 
ethical  physician,  is  one  of  high  honor. 

A  wise  medical  practitioner  concerns  himself 
with  every  phase  of  human  conduct  and  existence 
and  is,  at  his  professional  best,  as  interested  in 
health  and  its  variations  and  manifestations  and 
in  the  prevention  of  illness  as  he  is  in  the  treat- 
ment of  disease.  Throughout  his  professional  life 
the  physician  deals  with  his  people's  health  and, 
just  as  certainly,  with  something  even  more  im- 
portant— their  happiness.  The  physician  is  by 
philosophy,  training  and  experience,  and  by  the 
great  aid  of  medical  tradition,  in  a  favorable  posi- 
tion to  know  more  fully  about  human  beings,  sick 
and  well,  than  is  any  other  man. 

The  status  of  the  practice  of  medicine  in  a  com- 
munity, large  or  small,  has  been  truly  said  to  be 
best  estimated  by  the  qualifications  of  the  average 
general  practitioner.  Any  influence  that  tends  to 
help  and  inspire  the  average  doctor  exerts  far- 
reaching  beneficial  effects  upon  the  medical  profes- 
sion and  upon  the  public  weal;  while,  on  the  other 
hand,  any  factor  which  discourages  the  general 
physician  and  has  a  tendency  to  cause  him  to  doubt 


May,  1936 


CARDIOVASCULAR  DIAGNOSIS— Beardsley 


265 


with  but  little  thought  of  interpreting  the  findings 
for  the  general  physician.  The  practitioner  who 
is  bewildered  by  unfamiliar  terms  and  scientific 
phraseology  does  not,  as  a  rule,  stop  to  consider 
that,  frequently,  the  so-termed  scientific  physician 
would  find  the  arduous  and  helpful  life  of  a  general 
practitioner  a  wholesome  and,  in  all  probability,  a 
humiliating  experience.  The  art  of  medicine  is 
entirely  unfamiliar  to  many  of  our  advocates  and 
exponents  of  scientific  medicine.  Many  brilliant 
scientific  workers  would  prove  a  sorry  disappoint- 
ment to  themselves  and  to  their  patients  when  tried 
in  the  veritable  crucible  of  the  varied  duties  of  a 
conscientious  and  hard-working  doctor. 

Another  reason  why  many  physicians  have  ac- 
quired an  inferiority  complex  regarding  their  ability 
to  diagnose  correctly  cardio-vascular  disorders  and 
treat  them  skilfully  is  a  legacy,  like  many  other 
evils,  of  the  exigencies  of  the  World  War.  Cardio- 
vascular "specialists"  were  manufactured  by  inten- 
sive methods  of  attempted  instruction  for  brief 
periods  of  time.  If  the  professional  raw  material 
from  which  such  specialists  evolved  was  sound,  and 
if  the  individual  medical  officer  possessed  a  sense 
of  humor,  the  necessarily  superficial  training  re- 
ceived may  have  stimulated  him  to  continue  his 
special  medical  education,  and  no  great  harm  was 
done.  If,  on  the  other  hand,  the  terms,  "cardi- 
ology," or,  "cardio-vascular  expert"  gave  any  med- 
ical officer,  or  has  given  any  physician  in  peace 
time,  the  impression  that  one  can  ignore  a  consid- 
eration of  all  the  systems  of  the  body  save  one  and 
still  prove  to  be  a  wise  and  safe  guide  for  a  sick 
individual — then  he  has  been  grievously  deceived,  or 
has  grievously  deceived  himself.  In  no  special  field 
of  medicine  is  a  well-rounded  medical  experience 
so  essential  as  in  dealing  with  the  various  disorders 
of  the  vital  organs. 

Another  factor  that  has  led  to  confused  thinking 
concerning  cardio-vascular  diagnosis  is  the  much- 
acclaimed  use  of  the  electrocardiograph  in  diagno- 
sis. In  modern  medicine  one  might  easily  acquire 
the  impression  that  the  most  important  single  fac- 
tor in  diagnosing  and  treating  heart  or  vascular 
disorders  is  the  use  of  the  electrocardiograph.  This 
instrument  was,  indeed,  invaluable  in  determining 
the  exact  nature  of  the  various  arrhythmias  and 
irregularities  of  the  heart  action.  It  is  useful  in 
determining  accurately  the  degree  of  severity  of 
certain  tjqjes  of  myocardial  degenerations;  but  it 
should  be  remembered  that,  compared  with  the 
information  to  be  obtained  from  a  painstaking 
clinical  history,  a  careful  physical  examination  and 
a  study  of  the  symptoms,  its  value  to  the  patient 
is,  in  the  majority  of  instances,  negligible.  The 
information  obtained  through  the  use  of  the  in- 
strument is  more  easily  and,  often,  more  accurately 


determined  by  sound  clinical  methods.  Instrument 
makers,  whose  representations  are  not  entirely  dis- 
interested, have  exaggerated  the  importance  of 
electrocardiography;  and  practitioners  whose  inter- 
ests are,  largely,  in  the  special  field  have,  uncon- 
sciously, minimized  the  great  importance,  simplicity 
and  usefulness  of  clinical  studies  and,  perhaps,  too 
extravagantly  lauded  the  information  to  be  obtain- 
ed by  instrumental  methods. 

Whatever  the  cause  or  causes  it  is  true  that 
hundreds  of  superior  practitioners,  possessing  ex- 
cellent clinical  training,  hesitate  to  make  a  positive 
statement  regarding  cardio-vascular  disorders  with- 
out apologizing  for  not  submitting  cardiographic 
and  fluroscopic  reports  with  an  x-ray  film  to  sub- 
stantiate their  clinical  statements. 

I  wish  to  submit  the  view  that  this  tendency  to- 
ward making  every-day  medicine  appear  difficult, 
complicated  and  possible  of  accomplishment  by  the 
exceptional  few  only  is  neither  based  upon  truth 
nor  befitting  clinical  medicine  and  the  well  train- 
ed practitioner  of  medical  art.  If  the  trend  to- 
ward extreme  specialism  is  allowed  to  dominate 
the  medical  world  it  will,  it  seems  to  me,  go  on 
to  our  having  cardio-vascular,  lung,  kidney,  liver, 
gall-bladder,  colon  and  bladder  specialists;  and 
continued  to  its  ultimate  conclusion,  we  may  have, 
as  J.  Chalmers  Da  Costa  prophesied,  practitioners 
who  will  limit  their  professional  attention  and  in- 
terest to  one  eye  or  one  ear.  All  this  explanation 
has  been  preparatory  for  an  earnest  plea  that  the 
average  physician  interest  himself  in  clinical  cardio- 
vascular examinations. 

What  is  so  difficult  about  examining  a  heart 
and  a  vascular  system?  Are  we  less  expert  in 
practical  medicine  than  were  our  medical  ancestors? 
Is  not  the  average  practitioner  capable  of  eliciting 
and  recording  a  dependable  history  of  past  ill- 
nesses?; and  is  he  not  able  to  obtain  additional 
information  concerning  long- forgotten  illnesses 
from  older  members  of  the  family  group? 

We  all  know  that  it  requires  more  medical  art 
to  patiently  elicit  a  complete  history  of  past  illnesses 
than  it  does  to  make  a  thorough  physical  examina- 
tion and,  as  far  as  the  writer  has  information  upon 
the  subject,  there  is  but  one  way  to  acquire  this 
particular  facility — that  of  taking  a  comprehensive 
but  brief  past  history  of  every  patient  one  treats.  A 
history  may,  easily,  be  complete  without  being 
lengthy.  When  the  history  has  been  obtained  the 
greatest  remaining  difficulty  encountered  in  mak- 
ing a  complete  physical  survey  of  the  cardio-vascu- 
lar system  of  the  patient  lies  in  getting  the  patient 
properly  undressed.  It  is  not  a  good  advertisement 
for  the  methods  of  the  medical  profession  that  so 
great  a  number  of  patients  do  not  expect  to  be 
completely  examined.    Good  clinical  habits  may  be 


CARDIOVASCULAR  DIAGNOSIS— Beardsley 


May,   1936 


formed  at  any  age.  They  are  worth  while.  It  is, 
of  course,  much  easier  to  make  a  complete  exam- 
ination than  a  partial  and  unsatisfactory  one.  It 
really  takes  less  time.  To  have  the  patient  properly 
prepared  for  a  physical  examination,  i.e.,  bare  to 
the  waist  and  sitting  in  a  good  light,  makes  the 
examination  easy  to  perform  and  reduces  the  time 
necessary  in  its  performance.  A  shoulder  shawl  or 
similar  practical  covering  is  an  essential  for  a  pa- 
tient's comfort  of  mind,  but  such  covering  should 
be  so  easily  adjustable  as  to  prove  a  help  instead 
of  a  hindrance  to  the  examination.  One  of  the 
serious  omissions  of  practitioners  who  hurry  through 
an  examination  of  the  chest  is  the  failure  to  de- 
vote the  brief  but  necessary  time  to  making  an 
intensive  investigation  of  the  normal  heart  and 
vessels.  It  seems  difficult  for  many  physicians  to 
interest  themselves  in  normal  hearts  and  the  phy- 
siological variations  of  normal.  No  clinician  who 
has  not  systematically  studied  the  variations  of 
normal  hearts  can  possibly  understand  and  inter- 
pret the  variations  noted  in  hearts  influenced  by 
pathology. 

The  ability  to  detect  minor  or  major  abnormali- 
ties of  the  cardio-vascular  system  quickly  and  easily 
is  determined,  in  great  measure,  by  the  examiner's 
perfect  familiarity  with  the  normal  physical  and 
psychical  variations,  under  varying  conditions,  and 
upon  his  use  of  a  long-established  routine,  but 
brief  and  practical,  method  of  procedure.  Such 
examinations,  methodically  and  systematically  per- 
formed, very  soon  acquaint  an  examiner  with  the 
normal  organ  and  its  variations  and  make  detec- 
tions of  functional  and  pathological  variations  ex- 
tremely easy. 

Very  few  physicians  are  fortunate  enough,  early 
in  their  professional  lives,  to  be  able  to  examine 
enough  individuals  with  normal  hearts  to  keep 
clearly  in  mind  the  physiological  variations  in  heart 
sounds.  Fewer  of  those  who  still  have  this  unusual 
opportunity  have  a  like  chance  to  compare  the  nor- 
mal with  an  equal  number  that  reveal  varying  de- 
grees of  pathological  change. 

The  most  important  and  most  practically  helpful 
single  physical  sign  in  a  study  of  cardio-vascular 
disease  is  the  location  of  the  apex  beat  of  the  heart. 

This  usually  extremely  simple  and  easily  per- 
formed procedure  having  found  the  apex  beat  dis- 
placed, one  is  moved  to  ask  why  this  is  so?  Fa- 
miliarity with  hundreds  of  normal  individuals  of 
varying  types  of  bodily  structure  is  a  necessity  for 
determining  whether  or  not  the  apex  is  in  the  nor- 
mal position.  An  interested  examiner  examines 
many  patients.  There  are  no  books  on  physical 
diagnosis  that  equal  a  systematic  study  of  a  large 
number  of  normal  individuals  and  every  physician 
has,  in  his  own  patients,  an  extensive  clinical  ex- 


perience if  he  remembers  that  a  carefully  perform- 
ed, systematic  examination  is  an  asset  to  a  doctor 
as  well  as  a  psychic  and  physical  stimulus  to  better 
health  for  the  patient.  A  well  conducted  physical 
examination  is  an  unexcelled  therapeutic  measure. 
There  are  few  patients  in  whom  a  careful  survey 
will  not  reveal  the  position  of  the  apex  beat  if 
common  sense  and  care  are  exercised.  An  apex  beat 
to  the  left  of  the  mid-clavicular  line  calls  for  ex- 
planation. It  usually  signifies  enlargement  or  dis- 
placement. To  have  the  patient  lean  forward,  ex- 
hale and  fail  to  inhale  for  a  few  seconds  may  be 
necessary  in  obese,  heavily  muscled  or  emphysema- 
tous individuals;  but  it  is  interesting  to  note  that 
skill  in  locating  the  apex  beat  by  careful  palpation, 
and  in  outlining  the  left  and  even  the  right  border 
of  the  heart,  is  easily  acquired  by  any  interested 
practitioner.  It  is  necessary  only  to  make  such  an 
examination  a  routine  to  quickly  acquire  the  skill 
and,  equally  important,  the  confidence  that  results 
from  proving  tp  one's  self  how  simple  the  method 
and  how  accurate  and  satisfactory  the  findings. 

To  be  compelled  to  resort  to  the  x-ray  film  to 
locate  the  position  of  the  heart  in  the  usual  patient 
is  not,  in  my  opinion,  an  evidence  of  proper  train- 
ing in  physical  diagnosis;  particularly,  it  is  not  evi- 
dence of  the  proper  and  systematic  use  of  that 
training. 

We  were  all  taught  a  classical  routine  in  physical 
examination — inspection,  palpation,  percussion  and 
auscultation.  The  more  accurately  and  thoroughly 
we  perform  the  first  two  methods  the  less  we  will 
find  it  necessary  to  depend  upon  the  last  two.  In 
palpating  for  the  apex  beat  we,  frequently,  at  the 
same  time,  discover  and  time  in  the  cardiac  cycle 
the  cardiac  thrill  that  is  so  revealing  of  the  nature 
of  the  obstruction  to  the  flow  of  blood  through  the 
mitral  valves;  and  methodical  palpation  over  the 
cardiac  base  frequently  reveals  thrills.  Percussion 
may  be  lightly  performed  when  proper  palpation 
has  elicited  all  the  information  that  can  be  re- 
vealed by  this  method  of  investigation.  Ausculta- 
tion is  easily  performed  and,  when  one  seeks  the 
patient's  aid  by  requesting  that  he  exhale  and,  for 
a  few  seconds  not  inhale,  the  cardiac  sounds,  both 
normal  and  abnormal,  are  easily  heard  and  as  easily 
interpreted. 

The  physician  who  fails  to  take  advantage  of 
varying  postures  of  the  patient — sitting  erect,  lean- 
ing forward,  lying  down — and  following  exercise  is 
not  doing  himself  justice  in  acquiring  useful  knowl- 
edge. Alurmurs  that  are  heard  with  great  difficulty 
when  the  patient  is  erect  may  be  readily  heard 
when  the  patient  is  recumbent.  The  knee-chest 
position  is,  not  infrequently,  very  helpful  in  elicit- 
ing an  early  and  obscure  mitral  stenotic  murmur. 
Often  gentle  exercise  will  make  evident  a  latent 


CA RDIO-VASC ULA R  DIA GNOSIS— Beardsley 


murmur  at  both  the  mitral  and  aortic  orifice  that 
would  otherwise  escape  detection.  While  carrying 
out  these  procedures  there  is  opportunity  to  note 
such  revealing  evidence  as  cyanosed  lips,  cheeks 
or  ears;  or  pulsating  veins  and  arteries  of  the  neck. 
Pulsation  in  a  vein  is  never  palpable,  but  one  is 
frequently  deceived  into  thinking  the  vein  pulsates 
by  palpating  through  the  vein  upon  the  strongly 
pulsating  artery.  Strong  arterial  pulsation  indi- 
cates, as  a  rule,  hypertension,  aortitis  or  aortic  in- 
volvement; while  venous  pulsation  generally  means 
mitral  or  tricuspid  difficulty. 

An  examination  of  the  liver  is  absolutely  neces- 
sary in  all  noncompensating  circulatory  difficulties 
and  a  perfect  familiarity  with  hepatic  pulsation  and 
hypertrophy  is  essential.  To  examine  for  the  pres- 
ence of  fluid  within  the  pleural  and  abdominal  cav- 
ity is  a  routine  procedure  in  all  systematically  con- 
ducted cardio-vascular  examinations. 

What  are  the  frequently  encountered  heart  and 
vascular  conditions  in  every-day  general  practice? 
It  is  easy  to  list  them  and  a  glance  simplifies  the 
subject  by  ridding  one's  mind  of  any  mysteries 
concerning  the  common  or  garden  variety  of  cardio- 
vascular ills. 

1.  Atherosclerosis  (including  coronary  sclerosis 
and  thrombosis) 

2.  Hypertensive  cardio-vascular  disease  (includ- 
ing its  complications) 

3.  Rheumatic  heart  disease 

4.  Cardio-vascular  syphilis 

5.  Xeuro-circulatory  asthenia 

6.  Cardiac  thyrotoxicosis 

7.  Bacterial  endocarditis 

8.  Pulmonary    hypertension     (the    emphysema 
heart,  cor  pulmonale  (White) 

9.  The  heart  influenced  by  focal  infections 
10.     The  functional  heart  disorders. 

Does  not  a  glance  at  this  list  of  maladies  make 
clear  the  view  that  a  careful  history,  a  painstaking 
physical  examination  and — extremely  important — a 
continued  observation  of  the  patient,  with  addi- 
tional notes  of  progress  from  time  to  time,  is  within 
the  capabilities  of  every  interested  and  well-trained 
physician?  The  family  physician  is,  for  the  ma- 
jority of  patients,  the  safest  and  best  guide  in  such 
disorders  as  we  have  listed. 

It  is  natural  that  more  patients  are  seen  who 
are  suffering  from  the  effects  of  arteriosclerosis 
than  from  any  other  of  these  etiological  agencies, 
for  arteriosclerosis  of  varying  degrees  is  a  physi- 
ological process  as  a  patient  ages.  To  make  a 
careful  physical  examination  in  an  aged  person 
who  has  no  symptoms  is  an  educational  experience 
which  many  physicians  neglect.  An  arcus  senilis, 
tortuour,  temporal  vessels,  brachial  vessels  that  roll 


too  firmly  under  the  palpating  fingers  and  sclerotic 
femoral  vessels — these  are  some  of  the  revelations. 
Is  it  not  practical,  efficient  and  helpful  to  locate 
the  apex  beat  (usually  displaced  well  to  the  left), 
to  percuss  the  left  cardiac  border  and  to  note,  all 
too  frequently  in  cases  complicated  by  hyperten- 
sion, the  throbbing  subclavians  and  carotids.  A 
systolic  murmur  at  the  apex  in  such  patients  is  to 
be  expected,  when  there  is  a  hypertrophied,  and 
in  many  instances  a  dilated,  left  ventricle;  and  a 
systolic  murmur  over  the  aortic  cartilage  and  over 
the  right  carotid  is  a  commonplace.  The  oppor- 
tunity of  examining  elderly  patients'  cardio-vascu- 
lar systems  should  never  be  neglected,  and  this  is 
particularly  true  of  those  who  have  no  symptoms. 

The  frequency  of  hypertensive  cardio-vascular 
disease  in  all  classes  of  patients  has,  unfortunately, 
forced  itself  upon  our  consciousness.  For  our  pa- 
tient's comfort  of  mind  many  of  us  would  wish 
that  the  lay  public,  intelligent  or  otherwise,  had 
never  heard  of  a  sphygmomanometer.  Those  phy- 
sicians who  feel  that  their  professional  duty  is 
well  performed  when  the  patient's  blood  pressure 
is  estimated  and  its  varying  height  expressed  to  the 
patient,  even  to  the  patient's  detriment,  have  not 
lived  up  to  the  Golden  Rule.  To  determine  the 
blood  pressure  without  examining  the  heart  does 
not  give  one  the  information  that  is  necessary  for 
the  patient's  peace  of  mind.  It  is  sufficient  evil  to 
be  afflicted  with  hypertension  without  having  a 
physician's  pessimism  to  encounter  and  suffer  from. 

There  is,  in  the  opinion  of  the  writer,  no  cardiac 
disorder  concerning  which  so  much  misinformation 
is  acquired  by  patients  as  the  usual  functional 
heart  affections.  Misinterpretation  of  a  sinus 
arrhythmia,  perfectly  physiological  in  childhood 
and  youth  and  often  persisting  into  adult  life,  can 
prove  a  pseudo-tragic  affair  for  the  patient  and  his 
family.  When  dealing  with  functional  heart  con- 
ditions it  is  particularly  necessary  that  the  physi- 
cian's knowledge  of  human  nature  be  utilized.  Too 
much  book  information;  too  much  attention  to 
fleeting  and  changeable  symptoms;  too  little  fa- 
miliarity with  the  psychology  of  apprehensive  and 
self-centered  individuals — all  these  are  dangerous. 

The  usual  functional  heart  disorder  is  not  diffi- 
cult to  diagnose  correctly  if  one  insists  upon  a 
proper  routine.  A  well-taken  history,  a  routine  ex- 
amination, with  special  attention  to  the  size  of  the 
heart,  an  exercise  test  followed  by  another  careful 
physical  survey  will  provide  the  necessary  findings 
to  exclude  organic  disease.  In  searching  for  etiol- 
ogical factors  one  must  keep  ever  clearly  before 
him  the  effects  of  sexual  stimulations  of  various 
kinds:  this  applies  to  children,  to  adolescents,  to 
adults  and  occasionally  to  those  of  more  mature 
age.     Sexual  psychology  and  psychopathology  are 


CARDIO-VASCULAR  DIAGNOSIS— Beardsky 


May,  1936 


not  sufficiently  recognized,  even  in  1936,  as  a  fre- 
quent cause  for  bizarre  cardiac  manifestations.  The 
effect  of  tea,  coffee,  coco-cola  and  other  similar 
beverages  must  be  seriously  considered  in  suscep- 
tible individuals. 

The  writer  can  justify  the  type  of  paper  he  has 
presented  only  by  remembering  how  much  he  was 
helped,  early  in  his  medical  career,  by  the  kindly 
advise  of  Doctor  Osier  to  "study  the  patient  more 
and  the  text-book  less  and,  especially,  profit  by 
every  opportunity  that  presents  itself  for  studying, 
with  as  much  care  as  if  they  were  ill,  perfectly 
normal  individuals  who  present  no  symptoms." 
No  experienced  teacher  is  deluded  enough  to  ex- 
pect to  change  long-established  habits  in  the  ma- 
jority of  practitioners.  If,  however,  there  are  young 
men  who  have  no  fixed  clinical  habits,  perhaps  one 
or  two  will  experiment  with  the  plan  I  have  out- 
lined. 

The  writer  is  convinced  that  the  Art  of  medicine 
is  much  more  important  than  is  its  highly  extolled 
Science,  and  that  so  it  will  remain. 

Each  patient  is  unlike  any  patient  who  has  lived, 
is  living  or  will  live  in  the  future;  and  the  patient 
always  will  be  more  important  than  the  illness  he 
suffers  from. 

The  general  physician  is  second  to  no  man  in 
helpfulness  to  his  fellows;  indeed,  the  facts  would 
justify  a  much  stronger  statement.  Let  not  his 
helpfulness  be  diminished  by  unfounded  doubts  of 
his  own  ability  or  mistaken  estimates  of  the  supe- 
riority of  the  knowledge  of  others. 


Uses  and  Abuses  of  the  Electrocardiogram 
(C.    J.    Lundy,   Chicago,   in    III.    Med.    Jl.,   April) 

The  electrocardiogram  is  all  too  often  used  to  determine 
cardiac  functional  capacity,  which  should  be  determined 
by  other  more  important  tests  and  observations.  One  ex- 
ample is  that  in  coronary  thrombosis,  with  infarction  of 
the  thin  wall  of  the  cardiac  apex,  the  damage  impairs 
cardiac  function  more  seriously  than  does  a  similar  area 
of  infarction  in  the  thick  posterior  wall  of  the  left  ventricle, 
yet  r-wave  inversions  may  be  the  only  sign  in  both  in- 
stances. Marked  widening  and  notching  of  the  QRS  com- 
plex in  one  case  may  indicate  serious  widespread  myocardial 
damage,  in  another  case  only  localized  injury  to  a  branch 
of  the  ventricular  conduction  system  and  only  limited  in- 
terference with  cardiac  function.  These  situations  are 
differentiated  by  clinical  examination,  and  by  the  use  of 
other  laboratory  measures.  Cardiac  functional  capacity 
does  not  always  parallel  electrocardiographic  evidence  of 
damage. 

An  electrocardiogram  showed  evidence  of  acute  rheu- 
matic fever  and  the  doctor  said:  "I  hate  to  put  him  to 
bed  as  long  as  that  will  require."  I  should  have  considered 
it  more  helpful  to  the  patient  if  he  had  said  that  the 
electrocardiographic  information  did  or  did  not  fit  in 
with  a  clinical  picture  of  active  rheumatic  fever,  and 
whether  or  not  it  was  correlated  with  the  history  or  with 
the  physical  examination. 

An  electrocardiogram  was  diagnosed  coronary  thrombosis 
and  as  a   result  the  patient   was  refused  a  life  insurance 


policy.  This  electrocardiogram  had  been  taken  with  the 
arm-lead  electrodes  reversed,  and  the  excellent  cardiologist 
who  made  the  diagnosis  didn't  notice  the  error  and  based 
his  opinion  upon  inverted  T  waves  in  the  first  lead. 

The  electrocardiogram  is  useful  in  all  phases  of  the  man- 
agement of  heart  disease,  in  certain  types  of  arrhythmias, 
heart  block  and  dextrocardia.  Primarily,  it  is  of  value  in 
determining  the  presence  or  absence  of  heart  disease.  /(  is 
an  aid  to  clinical  diagnosis  and  not  a  court  of  last  resort. 
In  syphihtic  heart  disease,  in  hypertensive  heart  disease, 
and  in  thyroid  heart  disease  electrocardiographic  evidence 
is  not  characteristic. 

In  early  diagnosis  of  rheumatic  heart  disease  the  electro- 
cardiogram serves  one  of  its  most  important  and  most 
sadly  neglected  functions. 

It  is  of  great  value  in  the  diagnosis  of  arteriosclerotic 
heart  disease  and  of  coronary  disease,  to  follow  the  course 
of  healing  of  the  area  of  infarction,  and  detect  signs  of 
0  ver-digitalization . 

The  electrocardiographic  signs  found  in  many  types  of 
heart  disease  are  similar  to  each  other  and  are  differentiated 
by  the  use  of  clinical  judgment. 


Diuretics  in  the  Treatment  of  Cardiac  Edema 
(J.  E.  Vl^ood,  Jr.,  University,  Va.,  in  Nor'wes.   Med.,  Mar.) 

In  the  long-standing  heart  failure  case  full  protein  main- 
tenance is  doubly  necessary.  Rest  in  bed,  proper  digital!-* 
zation  and  restriction  of  fluid  intake  will  reduce  edema 
in  many  patients. 

We  have  been  less  inclined  lately  to  rigid  fluid  restriction 
except  in  long-standing  instances  of  edema  with  a  ver>' 
limited  output  of  urine.  During  the  period  of  marked 
diuresis  following  drug  administration  the  fluid  intake 
should  be  increased.  Rigidity  in  the  limitation  of  water 
is  unwise  in  this  respect.  Instances  of  temporary  psychosis 
following  rapid  dehydration  are  frequent  enough  to  claim 
attention.  Recently  the  apparent  association  of  pulmonary 
infarction  after  a  brilliant  diuretic  result  has  impressed  us 
in  several  cases. 

The  combination  of  a  mercurial  salt  similar  to  salyrgan 
with  theophyllin,  sold  in  this  country  as  mercupurine  is  a 
Uquid  drug  in  ampoules  and  may  be  injected  intramuscu- 
larly or  intravenously  in  1-  and  2-c.c.  doses  similarly  to 
salyrgan. 

Mercupurine  in  our  limited  experience  appears  efficient 
and  nontoxic.  In  a  few  patients  we  have  tried  both  the 
intramuscular  and  intravenous  administration  with  a  good 
diuretic  result  and  no  unfavorable  side  reactions. 

Patients  with  hypertensive  and  arteriosclerotic  heart  dis- 
ease respond  best  to  diuretic  drugs.  Should  rest,  fluid 
restriction,  diet  and  adequate  digitalization  fail  in  the 
treatment  of  cardiac  edema,  the  xanthine  and  mercurial 
diuretics  should  be  tried  in  the  order  mentioned.  Com- 
bination of  these  drugs  with  certain  salts  and  with  each 
other  may  promote  diuresis. 

Edema  may  increase  cardiac  work  and  impair  cardiac 
efficiency,  and  the  early  use  of  suitable  diuretic  drugs  may, 
therefore,  have  a  double  advantage. 


In  clean  c.\ses  of  appendicitis  (P.  J.  Friedman,  New 
York,  in  Med.  Rec,  April  15th)  I  believe  the  patients 
should  be  kept  in  bed  no  less  than  8  or  9  days;  in  cases  that 
are  drained  a  longer  time  is  needed.  Allowing  a  patient  to 
get  up  too  soon  may  favor  the  formation  of  an  embolus. 
The  important  complications  are:  Abscess,  single  or  multi- 
ple, in  the  pelvis,  in  any  part  of  the  abdomen,  even  under 
the  diaphragm;  pylephlebitis  with  infection  of  the  liver, 
general  peritonitis. 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Cartilaginous  Growths* 

A.  E.  Baker,  jr.,  ]\I.D.,  Charleston,  South  Carolina 


SIJMPLE  chondromata  may  arise  from  cartilage 
wherever  it  is  found  in  the  body.  They  are 
usually  lobulated,  often  multiple,  surrounded 
by  a  fibrous-tissue  capsule  in  which  is  the  blood 
supply.  Growth  is  slow  and  except  in  rare  in- 
stances the  tumor  is  benign.  If  limited  and  at- 
tached to  areas  where  cartilage  normally  occurs, 
Virchow  terms  it  an  ecchondroma;  if  a  progressive 
t3T>e  arising  from  cartilaginous  tissue  in  places 
where  normal  cartilage  is  not  found,  he  calls  it  an 
enchrondroma. 

The  ecchondromata  are  small,  smooth  and  nodu- 
lar. The  histological  picture  is  the  same  as  that 
of  the  cartilage  from  which  it  originates.  They  are 
found  most  frequently  about  the  epiphyses,  the 
pubic  symphysis,  the  trachea  and  the  larynx. 

Enchondrorna,  the  true  progressive  type  of  car- 
tilaginous tumor  arising  from  tissue  where  cartilage 
is  not  normally  found,  begins  in  early  life  and  is 
thought  to  be  due  to  a  disturbance  in  development. 
Rickets,  trauma  and  misplaced  islands  of  cartilage 
are  factors  in  its  development.  They  are  found 
most  frequently  on  the  phalanges,  in  or  about 
joints,  on  the  shaft  of  long  bones,  on  the  scapula 
and  the  pelvic  bones.  These  tumors  attached  to 
bone  are  derived  probably  from  fragments  of  car- 
tilaginous cells  left  from  the  formation  of  the  bone 
during  intrauterine  life.  These  tumors  are  often 
found  in  the  tonsils,  in  the  uterus  and  in  the  ear  and 
neck  region.  In  the  pelvic  region  they  rapidly 
grow  to  a  large  size  often  obstructing  pregnancy. 

Ecchondroma  and  enchondroma  both  show  a 
gross  structure  similar  to  normal  cartilage.  The 
cells  are  irregularly  arranged  and  there  is  a  certain 
amount  of  intercellular  connective  tissue  contain- 
ing a  blood  supply.  Softening  is  not  infrequent 
and  often  leads  to  formation  of  cysts.  Calcification, 
ossification  or  sarcoma  may  develop.  Very  few  of 
the  tumors  are  of  a  pure  cartilaginous  nature.  The 
mixed  cartilaginous  growths  of  the  pharynx,  sali- 
vary glands,  breast,  kidneys,  ovaries,  uterus  and 
testicles  contain  myxomatous  portions  and  areas 
of  connective  tissue. 

So  we  have  the  pure  or  almost  pure  cartilaginous 
growths,  the  ecchondroma  and  enchrondroma.  Then 
we  have  the  mixed  cartilaginous  growths,  as  the 
myxochondroma,  chondrosarcoma  and  osteochon- 
droma. 

The  most  common  of  the  mixed  cartilaginous 
growths  and   the   one   which   we   are   called   upon 


most  frequently  to  treat  is  the  osteochondroma  and 
for  this  reason  I  am  taking  it  as  a  basis  for  this 
discussion. 

This  is  not  an  unusual  condition  but  is  one 
which  most  of  us  seldom  see  and,  therefore,  of 
which  we  have  little  opportunity  to  make  a  com- 
plete study.  As  far  back  as  1881,  von  Speicher 
collected  28  cases,  but  having  no  way  of  making 
proper  pathological  studies  to  determine  the  struc- 
ture of  the  growth,  could  come  to  no  conclusion 
as  to  its  origin.  From  that  date  until  the  present, 
there  have  been  numerous  series  of  cases,  single 
and  multiple.  Much  thought  has  been  given 
to  whether  or  not  there  is  any  hereditary  tendency 
or  whether  trauma  or  infection  plays  a  part,  or  if 
the  growth  is  of  neoplastic  origin.  In  the  past 
few  years  the  points  of  predilection  have  been 
established  and  the  pathological  process  determined. 
Much  light  has  been  thrown  on  the  prognosis  and 
treatment.  With  these  considerations  in  mind,  it 
may  be  of  interest  to  cite  the  following  case — a 
large  osteochondroma  of  the  knee — using  it  as  a 
basis  for  a  brief  discussion  of  the  recent  conclusions 
and  opinions  with  special  reference  to  the  cause, 
pathology  and  treatment. 

A  young  unmarried  lady,  28  years  of  age,  was  admitted 
to  the  Baker  Sanatorium  one  year  ago,  complaining  of  a 
hard  rounded  mass  on  the  inner  side  of  the  left  lower 
extremity,  just  above  the  knee.  Examination,  including 
x-ray,  resulted  in  a  diagnosis  of  osteochondroma  on  the 
medial  aspect  of  the  distal  end  of  the  left  femur.  She  is 
the  only  child  of  healthy  parents.  No  history  of  any 
family  tendency  to  this  condition.  (We  know  httle  or 
nothing  about  the  influence  of  heredity  in  deformities  of 
this  kind;  however,  there  are  such  instances  on  record, 
foremost  of  which  is  one  reported  by  Trawvick  of  Ken- 
tucky of  multiple  osteochondromata  in  mother  and  son. 
Reference  to  the  Uterature  shows  that  in  at  least  S0%  of 
such  cases,  regardless  of  the  location,  there  is  a  distinct 
history  of  trauma,  and  so  it  was  in  this  case.)  A  fall, 
injuring  the  left  knee  was  recalled  at  10  years  of  age,  18 
years  before  admission,  at  which  time  the  tumor  made  its 
initial  appearance. 

From  its  onset  the  growth  became  progressively  larger 
and  her  walking  more  awkward  due  to  an  effort  to  prevent 
the  knees  from  striking  together,  thus  the  lower  extremities 
appeared  quite  bowed.  At  no  time  was  this  growth  painful 
except  when  she  would  fall.  One  of  these  falls  which 
caused  an  exacerbation  of  symptoms,  brought  her  to  me 
for  treatment. 

Except  for  the  growth,  physical  examination  and  lab- 
oratory workout  were  essentially  negative. 

X-ray  configuration  of  this  tumor  can  be  readily  ana- 
lyzed into  two  separate  parts,  a  fiat  base  or  so-called 
pedicle  of  normal  bone  (exostosis)  and  a  cartilaginous 
cap    undergoing   calcification.      Although    trauma    is   often 

meeting  at   Columbia,    South   Care- 


270 


CARTILAGINOUS  GROWTHS— Baker 


May,   1936 


recalled  in  connection  with  the  first  appearance  of  the 
growth,  the  actual  cause  is  supposed  to  be  a  congenital 
defect  or  opening  in  the  periosteum  at  a  point  intended  for 
the  attachment  of  some  approaching  tendon,  the  most 
frequent  sites  being  the  lower  femur,  upper  and  lower  tibia 
ends  ,os  calcis,  upper  humerus  and  parts  of  the  pelvic 
bones. 


pushed  away,  the  periosteum  should  be  split  and  turned 
outward  and  the  mass  removed  with  chisel,  then  carefully 
curetting  every  remaining  part  of  the  tumor  mass  from 
the  underlying  bone.  The  tumor  should  be  widely  excised 
and  care  taken  that  no  particles  are  left  in  surrounding 
tissue. 


Pw 

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^^Try.  \  ▼ 

mhI 

ft'- 

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'"'^" ""'.." 

Osteochondroma — Pedicle   of   normal   bone   cap   of   fibrous 

tissue,  fetal  and  adult  cartilaginous  cells  undergoing 

calcification. 

At  one  or  more  of  these  points,  nature  causes  new  bone 
to  bulge  through  the  periosteal  opening  for  the  attachment 
of  the  approaching  tendon,  which  likewise  is  forming  car- 
tilage for  the  purpose  of  uniting  with  the  bony  outgrowth. 
When  the  tendon  and  bone  do  not  exactly  appro.ximate, 
an  excessive  amount  of  normal  bone  protrudes  through 
the  periosteal  opening  and  forms  the  base  or  pedicle  of 
the  tumor.  Likewise,  an  excessive  amount  of  cartilaginous 
tissue  is  thrown  out  from  the  center  of  ossification  in  the 
tendon,  which  forms  the  cartilaginous  cap  of  the  tumor. 
The  histological  section  of  osteochondroma  conforms  ex- 
actly to  the  x-ray  findings  in  that  it  shows  the  normal 
fibrous  tissue  of  the  tendon,  a  thin  layer  of  embryonic 
connective  tissue  containing  fetal  cartilaginous  cells,  then 
the  adult  cartilaginous  cells  undergoing  calcification,  all  of 
which  go  to  form  the  cap  of  the  tumor.  Next  to  this  is 
seen  the  base  or  pedicle  of  the  tumor  composed  of  true 
bone  which  originated  from  the  periosteal  cap.  The  micro- 
scope and  x-ray  therefore  demonstrate  that  osteochondroma 
is  a  tumor  of  two  distinct  parts,  the  base  arising  from  the 
bone  and  the  cap  from  the  tendon.  A  chondroma  plus  an 
exostosis. 

One  can  readily  see  that  no  part  of  this  growth  is  from 
a  neoplastic  origin,  but  is  only  an  excessive  amount  of  new 
bone  and  cartilage,  arising  from  normal  bone  and  tendon. 

Although  these  cartilaginous  and  mixed  cartilaginous 
masses  are  definitely  benign  growths  and  the  prognosis  for 
a  permanent  cure  is  good,  we  must  not  overlook  the  fact 
that  a  certain  percentage  will  undergo  secondary  malignant 
changes  indicated  by  rapid  growth,  pain,  or  softening  of 
the  mass,  which  may  result  in  chondrosarcoma  or  chondro- 
myxosarcoma.  The  follow-ups  of  these  two  malignant 
growths  in  our  larger  clinics  show  less  than  10%  of  S-year 
cures.  The  only  treatment  is  surgical  removal  carried  out 
on  all  accessible  growths  because  of  possibility  of  malig- 
nancy.    The   skin   incised   and   the    muscles    and   tendons 


Osteochondroma — before   and   after   operation. 

Because  these  tumors  tend  to  recur,  it  is  advisable  to 
use  the  cautery  or  pure  carbolic  acid  followed  by  alcoho^ 
after  removing  the  growth.  Some  advocate  application 
of  solution  of  zinc  chloride  to  the  freshly  curretted  bone 
and  the  insertion  of  radium  if  any  portion  of  the  mass  is 
thought  to  be  left.  It  is  advisable  to  use  the  x-ray  on 
the  area  from  time  to  time  to  determine  whether  or  not 
there  is  any  tendency  to  return.  "In  spite  of  the  fact  that 
these  growths  have  the  histological  structure  of  normal 
cartilage  they  may  recur  and  cause  fatal  metastasis." 

Discussion 

Dr.  a.  T.  Moore,  Columbia: 

I  think  Dr.  Baker  has  very  splendidly  presented  an  ex- 
tremely interesting  subject,  especially  to  those  who  are 
particularly  interested  in  bone  surger>'. 

The  literature  is  replete  with  all  sorts  of  confusing  term- 
inology about  bone  tumors;  and  the  more  one  looks  it  up, 
the  more  confused  one  becomes.  I  was  glad  to  hear  Dr. 
Baker's  classification.  I  had  written  to  him  and  asked 
him  for  a  copy  of  his  paper,  which  he  did  not  send  me,  so 
I  am  not  prepared  to  carry  on  his  same  train  of  thought. 
I  took  his  main  subject  of  cartilaginous  growths  and  pre- 
pared my  discussion  along  that  line  rather  than  limiting 
my  remarks  entirely  to  osteochondromas. 

Heading  the  list  of  bony  and  cartilaginous  growths  are 
osteoma  and  osteochondroma. 

An  osteoma  is  purely  and  simply  a  bone  tumor.  .An 
exostosis  is  the  same  thing  and  means  an  outgrowth  of 
bone.  These  tumors  are  very  rare  and  are  always  benign 
in  character.  Osteochondromas  are  frequently,  but  incor- 
rectly, called  exostoses. 

Osteochondroma  may  be  either  sessile  or  pedunculated. 
The  base  is  composed  of  bone  and  the  cap  is  covered  with 
cartilage.  These  growths  may  be  single,  but  very  fre- 
quently are  multiple  and  may  undergo  malignant  changes. 
These  tumors  characteristically  occur  in  the  long  bones 
adjacent  to  the  epiphysis  and  grow  toward  the   diaphysis. 

We  had  a  case  recently  in  which  we  took  off  osteochon- 
dromas from  the  ankle,  from  below  the  knee,  the  lower 
end  of  the  femur  and  the  shoulder.  They  were  large  enough 
to  be  mechanically  interfering  with  function. 

Chondromas  are  tumors  composed  entirely  of  cartilage, 
and  usuallv  occur  later  in  life  than  do  the  o;teochondro- 


May,  1936 


CARTILAGINOUS  GROWTHS— Baker 


271 


mas.     Cartilage  tumors  very  rarely   become  malignant. 

There  are  other  classes  of  very  benign  cartilage  growths 
that  I  just  simply  mention.  Loose  bodies  in  the  knees; 
osteochondritis  desiccans;  a  growth  of  loose  cartilage  in 
the  joint  all  are  perfectly  benign  situations.  Osteochondro- 
sis, the  growth  of  loose  cartilage  in  the  joint  is  a  benign 
affection.  There  are  various  theories  regarding  its  origin, 
but  it  is  generally  considered  to  be  a  new  growth.  Some- 
times, even  if  the  whole  synovial  lining  of  a  joint  is  re- 
moved, these  growths  will  recur.  Another  condition  of 
small  cartilaginous  bodies  within  a  joint  is  know^n  as  "rice 
bodies."  .Mso,  there  are  cartilaginous  growths  that  result 
from  trauma.     .\11  of  these  are  purely  benign. 

I  must  mention  another  class  of  growth  that  in  a  certain 
te.xt  book  is  included  in  the  same  chapter  with  the  osteo- 
chondromas, because  I  have  a  slide  or  two  that  I  want  to 
show  you.  The  giant-cell  tumor.  Some  authors  include 
these  with  cartilaginous  growths,  but  the  characteristic  of 
giant-cell  tumor  is,  of  course,  the  giant-cell.  They  occur 
in  the  same  location  as  osteochondromas;  and  also  may 
undergo  malignant  degeneration. 

Cystic  adamantinomas  are  similar  tumors.  They  spring 
from  embryonic  enamel  cell  rests,  and  of  course  are  found 
in  the  jaws.  I  hope  that  you  will  pardon  me  for  including 
them  in  this  general  discussion,  but  I  have  several  very 
interesting  cases  in  the  group  of  slides  which  I  will  now 
show.     (Showed  and  discussed  slides.) 

I  have  been  impressed  by  seeing  a  number  of  cases  re- 
ferred to  with  the  remark  that  a  small  bony  tumor  had 
been  noticed,  "simply  an  exostosis."  The  "exostoses"  are 
usually  osteochondromas,  and  they  are  not  always  simple. 
That  is  a  practical  point  I  would  like  to  pass  on  to  you. 
A  certain  definite  number  of  these  growths  (perhaps  5%) 
become  malignant,  and  all  bone  tumors  should  be  consid- 
ered in  a  serious  way.  I  think  when  feasible  all  bone 
tumors  should  be  removed,  and,  if  possible,  widely  excised; 
in  that  way  playing  safe  for  your  patients. 

Dr.  Baker,  closing: 
I   want  to   thank  Dr.  Moore   for  his  excellent  discussion. 


Decompression-  of  the  Gastro-Intestinal  Tract 

(H.    H.    Loucks   &    H.   C.    Fang,   Peiping,   in   Chinese    Med. 

Jl.,  Feb.) 

Swallowed  air  is  largely  responsible  for  the  distention 
of  the  intestinal  tract  in  ileus.  Through  a  tube  inserted 
just  beyond  the  anal  canal,  in  the  presence  of  actual  dis- 
tention, repeated  filling  and  emptying  of  the  large  bowel 
with  warm  tap  water  is  much  more  effective  in  evacuating 
gas  and  fecal  material  from  this  portion  of  the  intestinal 
canal  than  is  the  usual  enema  which  the  patient  frequently 
expels  immediately  if  it  possesses  irritant  properties  or  oth- 
erwise retains  indefinitely  because  of  an  atonic  condition  of 
the  colon,  and  is  one  of  the  easiest  ways  in  which  general 
peristalsis  can  be  initiated  and  the  small  bowel  emptied  of 
at  least  a  portion  of  its  contents. 

We  insert  an  ordinary  rectal  tube  just  through  the  anal 
canal  and,  by  a  means  of  a  glass  Y  or  T  tube,  connect  it 
with  an  enema  can  elevated  elevated  a  foot  or  so.  A  large 
basin  or  bucket  placed  on  the  floor.  Clamps  are  placed 
on  tubes  from  both  arms.  Ordinary  warm  tap  water  is 
allowed  to  enter  slowly  until  the  patient  complains  of 
distention  or  has  a  desire  to  expel  the  fluid.  The  tube  to 
the  enema-can  is  then  clamped  promptly  and  that  to  the 
basin  opened  and  the  fluid  within  the  colon  allowed  to 
flow  out.  This  process  is  repeated  over  and  over  until 
sometimes  as  much  as  10  to  IS  litres  of  warm  water  have 
been  allowed  to  run  in  and  out. 

A  rectal  tube  usually  can  be  inserted  regardless  of  the 
patient's  position  and  the  patient  need  not  be  disturbed  in 
any  way  while  the  irrigation  is  being  carried  out. 


.■\nother  satisfactory  method  is  a  rectal  tube  inserted 
through  the  anal  canal  connected  by  means  of  large  calibre 
rubber  tubing  with  an  enema-can  partly  filled  with  warm 
water  4  in,  above  level  of  the  patient's  abdomen.  Water 
can  enter  the  colon  only  as  fast  as  it  is  absorbed,  and 
through  the  tube  gas  may  escape  and  bubble  out  from  the 
can.  Large  quantities  of  fluid  may  be  administered  by  this 
technique  and  large  quantities  of  gas  evacuated. 


The  Technique  of  the  Local  Injection  of  Saline 

Solution  for  the  Relief  of  Pruritus  Ani 

(Wm.   J.   Schatz   &   Vaughan    Sprenkel,   Allentown,    Penn.. 

in  Amer.  Jl.    Dig.   Dis.  &   Nutri.,   Mar.) 

A  10  c.c.  syringe  with  a  23-guage  needle,  %ths  in.  in 
length,  sterile  physiological  saline  and  a  good  light.  The 
patient  is  in  the  left  or  right  lateral  position  with  the 
lower  leg  drawn  somewhat  backward,  the  upper  hip  tilted 
away  from  the  operator. 

Cleanse  with  liquid  soap  and  water,  then  with  alcohol. 
The  greatest  pruritic  involvement  is  usually  posterior,  so 
select  the  posterior  quadrant  for  the  initial  injection.  In- 
ject along  the  edge  of  the  pigmented  area  1J4  in.  external 
to  the  edge  of  the  anus.  After  the  needle  has  punctured 
the  skin,  the  point  is  directed  toward  the  rectum  as  the 
spoke  of  a  wheel.  The  barrel  of  the  syringe  is  lowered  so 
that  the  shaft  of  the  needle  lies  in  the  subcutaneous  tissue, 
parallel  to  the  skin.  The  needle  is  inserted  until  its  point 
is  in  yi  in.  of  the  rectal  wall.  Three  to  5  c.c.  of  the 
solution  are  slowly  injected.  Only  a  slight  resistance  is 
felt  and  no  discomfort.  The  needle  is  withdrawn  and  the 
procedure  repeated  employing  a  somewhat  smaller  volume 
in  the  less  involved  quadrants  until  the  total  of  10  c.c. 
has  been  injected.  A  total  volume  of  IS  to  20  c.c.  of 
solution  may  be  required  for  cases  with  extensive  pruritis. 
Gently  massage  by  a  pledget  of  cotton  saturated  with 
alcohol  or  disinfectant. 

A  faint  sense  of  fulness  is  felt  about  the  injected  area. 
Except  for  the  slight  discomfort  caused  by  the  introduc- 
tion of  this  small-gauge  needle  there  is  no  pain. 

A  measure  of  relief  is  experienced  within  2  to  4  hours. 
Complete  alleviation  without  recurrence  is  obtained  in 
50%  of  all  cases.  In  a  few  instances  it  is  necessary  to 
repeat  the  procedure  within  a  week.  Of  the  remaining 
cases  about  one-half  have  complete  relief  with  a  recurrence 
of  the  symptoms  within  2  to  6  months.  These  usually 
suffer  no  recurrence  following  the  second  treatment.  The 
remaining  group  of  patients  experience  benefit  and,  al- 
though they  are  not  completely  relieved,  it  is  possible  to 
keep  them  comfortable  by  injections  administered  every 
1  to  3  months  as  required. 


Clinical  Manifestations  of  Anorectal  Disease 


Referred  symptoms  occurred  231  times  in  70  (31%)  of 
a  series  of  225  patients  with  anorectal  disease.  Of  the 
231  symptoms  found,  143  (62%)  were  cured,  65  (28%) 
were  improved  and  12  (S%)  were  unimproved  by  surgical 
or  nonsurgical  treatment  of  the  anorectal  lesions  encoun- 
tered. 

Neurologic,  gastrointestinal,  genitourinary  and  rheumatic 
symptoms  are  frequently  caused  by  anorectal  disease.  When 
such  symptoms  are  encountered  inquiries  concerning  the 
anus  and  rectum  should  be  included  in  the  clinical  history 
and  a  rectal  examination  should  be  made.  Digital  exam- 
ination alone  is  not  sufficient  as  many  of  the  lesions  are 
not  palpable.  Such  lesions  when  located  at  or  near  the 
anus  may  be  seen  with  an  anoscope.  This  instrument  is 
inexpensive  and  its  use  is  simple. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


Surgical   Observations 

A  Column  Conducted  by 

The  Staff  of  the  Davis  Hospital 
Statesville,  N.  C. 


Gynecological  Examinations 

Gynecological  examinations  should  always  be 
done  systematically  and  with  great  care  and  atten- 
tion to  details. 

In  the  office,  routine  examination  of  women  pa- 
tients who  are  suffering  from  some  pelvic  condition, 
it  is  often  necessary  to  finish  the  examination  in  a 
short  space  of  time,  and  if  there  are  any  obscure 
conditions  present  of  importance  these  can  be 
worked  out  in  the  hospital,  where  every  possible 
aid  is  at  hand.  Sometimes  considerable  time  and 
patience  are  necessary  for  getting  an  accurate  his- 
tory. 

The  clitoris  should  always  be  examined.  If  there 
are  any  adhesions  about  the  organ,  these  should  be 
freed  very  carefully.  Also  the  patient  should  be 
advised  just  what  after-treatment  to  give  the  af- 
fected areas. 

About  the  vulva  should  be  noted  any  new 
growths,  tumors  or  signs  of  inflammation.  The 
inguinal  glands  should  be  carefully  noted. 

A  vaginal  speculum  should  be  used  to  permit 
carefuly  inspection  of  the  cervix  by  a  good  light. 

A  pelvic  bimanual  examination  will  usually  indi- 
cate whether  or  not  there  is  a  pelvic  tear,  the  gross 
condition  of  the  cervix,  the  size,  position  and  shape 
of  the  uterus,  and  whether  or  not  there  are  any 
tumors  or  masses  in  the  pelvis. 

Cancer  should  be  looked  for,  also  tears,  erosions 
and  any  other  pathological  conditions  in  or  about 
the  cervix  or  the  vaginal  region  generally.  Skene's 
glands  should  be  carefully  "milked"  upward  in  or- 
der to  see  whether  or  not  there  is  any  infection 
present.  Sometimes  a  smear  from  these  glands  is 
advisable.  A  smear  from  the  cervix  should  be  ob- 
tained routinely,  and  examined  for  pathological 
organisms,  especially  the  gonococcus  and  the  trich- 
omonas vaginalis. 

Bartholin's  glands  are  often  infected,  and  this 
condition  may  be  overlooked  unless  an  abscess 
forms.  No  pelvic  examination  is  complete  without 
a  careful  palpation  of  Bartholin's  glands,  and  if 
any  enlargement  is  noted  this  should  be  recorded 
and  given  appropriate  care. 

There  is  no  doubt  but  that  the  Skene's  glands, 
when  once  infected  may  continue  to  be  a  source  of 
gonococcal  infection  for  a  long  time,  and,  unless 
treated  radically,  the  patient  may  have  a  repeated 
recurrence  of  the  old  infection  which,  otherwise, 
would  have  lasted  only  a  short  while.  Bartholin's 
glands  also  may  harbor  organisms  which  will  re- 
infect the  patient  from  time  to  time. 


It  is  always  important  to  note  whether  or  not 
there  is  a  cystocele.  This  may  often  be  overlooked. 
One  of  the  common  sjTnptoms  of  cystocele  is  in- 
ability to  void  without  great  effort.  By  having 
the  patient  strain  or  bear  down,  if  there  is  a  mark- 
ed cystocele,  it  is  readily  seen  that  the  urine  is 
directed  downward  into  the  pouch,  or  cystocele, 
rather  than  toward  the  internal  opening  of  the 
urethra. 

Relaxation  of  the  vesical  sphincter  is  not  an 
uncommon  finding  when  looked  for.  It  may  be 
noted  that  there  is  incontinence  which  varies  from 
an  occasional  escape  of  small  amount  to  frequent 
involuntary  passage  of  large  amounts,  especially 
when  straining  or  lifting.  This  condition  should, 
of  course,  be  treated  prop>erly,  and,  as  the  operation 
is  comparatively  simple,  it  should  always  be  done 
when  indicated.  Patients  often  fail  to  mention  this 
to  the  doctor,  thinking  it  perhaps  a  natural  thing. 
If  every  patient  is  asked  as  to  the  involuntary 
escape  of  urine,  it  is  surprising  the  number  who 
will  be  found  to  have  a  relaxed  vesical  sphincter. 
Repair  of  this  is  a  great  relief,  as  it  prevents  many, 
embarrassments  and  constant  fear  of  embarrass- 
ment, which  is  even  worse.  A  rectocele  is  a  com- 
mon cause  of  constipation.  Unless  this  is  carefully 
looked  for  it  may  be  overlooked.  Old  pelvic  tears 
are  always  troublesome  and  should  receive  careful 
consideration. 

In  the  examination  of  the  cervix  the  best  possi- 
ble light  should  be  used.  If  there  is  any  sign  or 
even  a  suggestion  of  malignancy,  a  small  cutting 
loop  operated  with  the  endotherm  current  will  make 
section  of  tissue  for  biopsy  without  any  difficulty. 

The  examination  of  the  perianal  region,  the  anal 
canal  and  the  rectum,  is  a  very  important  part  of 
the  examination.  Hemorrhoids  of  various  kinds 
may  be  found,  even  in  the  same  patient.  A  pilo- 
nidal sinus  or  sacrococcygeal  cyst  is  also  not  in- 
frequently a  cause  of  trouble.  Sometimes  an  ab- 
scess will  form  in  this  locality  and  cause  a  great 
deal  of  trouble.  Often  upper  abdominal  symptoms 
may  be  secondary  to  certain  types  of  hemorrhoids. 

Smears  or  hanging  drops  from  the  cervix  and 
the  vaginal  area  will  aid  in  locating  the  trichomo- 
nas. The  monilia  organisms  should  also  be  looked 
for. 

Pelvic  conditions  should  not  be  treated  lightly. 
Every  possible  trouble  should  be  kept  in  mind  and 
a  careful  search  made  for  each.  Repeated  exam- 
inations may  be  necessary.  Blood  counts  are  often 
a  great  help,  also  the  blood  sedimentation  rate,  espe- 
cially in  pelvic  infections.  Where  there  is  a  sus- 
pected pregnancy  or  possibly  tubal  pregnancy  with- 
out signs,  the  Aschheim-Zondek  test  or  some  simi- 
lar test  should  be  made. 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


273 


DEPARTMENTS 

HOSPITALS 

R.  B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  Editor,  Greensboro.N.  C. 


Hospital  Noises  and  Odors 

This  subject  was  brought  to  my  attention  by  a 
fellow-worker  who  has  noticed  objectionable  and 
disagreeable  noises  and  odors  as  he  visited  the  hos- 
pitals. He  requested  that  our  readers  have  their 
attention  called  to  the  fact  that  if  doctors  visiting 
the  hospitals  were  annoyed  the  visitors  and  pa- 
tients would  be  even  more  so. 

The  NOISES  in  a  hospital  for  the  most  part  come 
from  doors  slamming,  service  rooms,  diet  kitchens, 
delivery  rooms,  elevators,  hollow  tile  walls,  and  the 
noises  of  visitors,  doctors  and  nurses  who  forget 
that  they  are  in  a  home  for  the  sick.  None  of  these 
sources  are,  so  far,  beyond  redemption;  but  great 
improvement  can  be  made  with  a  small  expenditure 
coupled  with  a  little  common  sense. 

The  doors  of  a  hospital  should  all  have  some  form 
of  rubber  stop  or  other  efficient  apparatus  to  pre- 
vent slamming.  Either  of  these  can  be  had  within 
reason  and  within  reach  of  a  hospital's  pocketbook. 

The  noise  from  the  service  rooms  can  largely 
be  eliminated  by  the  architect  and  the  hospital 
personnel.  The  walls  should  be  lined  with  gypsum 
blocks  which  absorb  the  sounds  to  a  most  amazing 
extent. 

The  service  rooms  should,  as  far  as  possible,  have 
a  different  opening  from  the  regular  hall  for  the 
hospital,  and  in  all  cases  have  an  outside  window 
in  which  is  placed  an  exhaust  fan.  There  should 
be  a  bed  pan  sterilizer  in  every  service  room.  This 
room  should  be  placed  at  some  distance  from  the 
reception  room  or  the  business  office. 

Those  emptying  bed  pans,  enema  basins,  urinals 
and  dressing  trays  should  avoid  the  "rough  house," 
which  with  some  employees  seems  to  be  a  habit. 
There  is  no  need  for  knocking  and  slamming  these 
metal  utensils.  It  soon  wears  them  out,  and 
"sooner"  wears  out  the  nerves  of  the  patients.  The 
swinging  door  to  the  service  rooms  should  be  well 
fitted  and  be  kept  closed. 

What  has  been  said  of  the  service  room  holds 
good  also  for  the  diet  kitchen.  It  is  to  be  remem- 
bered that  this  is  a  great  place  for  the  interns  and 
nurses  to  gather  at  late  hours.  It  would  not  be 
a  miss  to  put  a  sign  on  the  wall  of  this  room  as 
follows:  "This  is  the  diet  kitchen  for  the  patients 
and  not  for  the  nurses  and  doctors." 

The  delivery  room  is  usually  well  planned  by  the 
architect,  and,  if  the  hospital  is  at  all  modern, 
noise  is  eliminated.  In  the  older  hospitals  a  great 
improvement  could  be  brought  about  by  using 
ceiling  and  wall  gypsum  block. 


The  elevators  can  be  made  less  noisy  by  having 
solid  doors,  and  by  being  kept  well  lubricated. 
The  engineer  can  do  the  latter.  Those  using 
elevators,  if  they  will,  can  close  the  doors  carefully 
and  almost  noiselessly. 

Whoever  allows  anyone  to  persuade  him  to  use 
hollow  tile  building  or  remodeling  a  hospital  will 
forever  after  regret  it.  The  slightest  noise  on  the 
first  floor  at  the  front  is  echoed  and  magnified 
until  it  is  larger  on  the  third  floor  back.  The  writer 
speaks  from  e.xperience  on  this  subject. 

It  should  not  even  be  necessary  for  any  persons 
to  have  to  be  called  down  about  speaking  too  loud 
in  a  hospital,  certainly  not  visitors  who  have  come 
to  see  sick  people,  or  doctors  and  nurses.  However, 
unnecessary  as  it  may  seem,  it  actually  happens 
even  though  well  regulated  hospitals  have  signs 
placed  in  conspicuous  places  calling  attention  to 
the  desire  for  "QUIET." 

The  ODORS  of  a  hospital  are  even  more  objec- 
tionable than  the  noises.  Many  of  them  could  be 
materially  lessened  if  hospital  operators  would  real- 
ize how  unpleasant  they  are.  I  am  persuaded  that 
those  who  work  in  hospitals  cease  to  have  the  acute 
sense  of  smell  they  did  have  before  going  to  work 
in  such  institutions.  Most  bad  odors  come  from 
bed  pans,  urinals,  toilets,  garbage  cans  or  trash 
cans,  wards,  linen  chutes,  operating  rooms,  and 
even  some  times  from  the  general  kitchen. 

If  bed  pans  and  urinals  were  thoroughly  sterilized 
each  time  they  are  used  they  would  not  have  a 
bad  odor.  If  possible  to  prevent  it,  these  utensils 
should  never  be  circulated  up  and  down  the  main 
halls  of  hospitals.  When  they  are  being  carried 
to  the  emptying  places  they  should  be  tightly  cover- 
ed. 

Toilets  should  be  well  located  for  convenience 
and  ventilation.  An  exhaust  fan  shuld  be  placed 
in  all  of  them.  Some  type  of  deodorant  should  be 
kept  in  the  urinal  sink  and  the  commode.  These 
two  ine.xpensive  arrangements  would  make  all  the 
difference  in  the  smell  of  this  room. 

Garbage  and  trash  cans  are  often  neglected  too 
long.  We  must  have  them  but  nothing  with  a 
bad  odor  should  be  put  in  them.  These  should  be 
put  immediately  into  the  incinerator.  The  cans 
should  be  emptied  by  the  day  orderly  when  he  goes 
off  duty,  and  by  the  night  orderly  when  he  goes  off 
duty. 

Wards  seldom  smell  disagreeable  if  dressings  are 
changed  often  enough,  and  if  deodorant  solutions 
that,  themselves,  have  no  objectionable  odor 
are  placed  in  bed  pans  when  they  are  placed  under 
the  patients.  It  is  also  to  be  remembered  that  a 
ward  needs  more  ventilation  than  a  private  room. 

The  soiled  linen  sheets  would  not  give  out  a  bad 
odor  if  linen  that  is  badly  soiled  is  first  rinsed  out 
in  the  hopper. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


Certain  foods  when  they  are  being  cooked  give 
off  a  disagreeable  odor.  Even  if  it  is  not  a  bad 
odor  it  would  take  the  appetite  of  the  patients  for 
that  certain  food.  Exhaust  fans  here  and  closed 
doors  of  the  kitchen  would  greatly  help  prevent 
this. 

Last  but  not  least,  we  will  consider  the  odor  from 
the  operating  room.  While  this  is  seldom  objec- 
tionable or  even  noticed  by  hospital  employees, 
it  is  always  noticed  by  patients  who  have  recently 
been  operated  on.  The  worst  of  these  odors  is 
that  of  ether.  This  is  especially  true  if  the  patient 
has  recently  had  an  ether  anesthesia.  It  is  down- 
right pitijul  to  hear  small  children  complain  of  this 
odor  even  months,  and  sometimes  years,  after  they 
have  taken  ether  for  a  tonsillectomy. 

A  hint  to  the  wise  is  sufficient;  a  suggestion  to 
the  intelligent  is  helpful.  Let  us  endeavor  to  make 
less  noise  and  smell  less  bad. 


GENERAL  PRACTICE 

WiNGATE  M.  Johnson,  M.D.,  Editor,  Winston-Salem,  N.  C 


Open  Season  foe  Hospitals 
As  this  is  written — the  last  ofApril — the  news- 
papers and  various  speciaHsts  in  other  people's 
duties  seem  to  have  declared  an  open  season  on 
hospitals.  The  story  of  the  child  who,  in  news- 
paper English,  "allegedly"  died  because  the  City 
Memorial  Hospital  of  Winston-Salem  refused  her 
admission  has  been  heralded  by  the  Associated  Press 
throughout  the  nation,  and  columns  have  been 
filled  with  abuse  of  the  authorities.  More  recently 
the  James  Walker  Memorial  Hospital  of  Wilming- 
ton has  come  in  for  its  share  because  an  old  man 
died  two  days  after  being  refused  admission  there — 
presumably  of  a  terminal  pneumonia  superimposed 
upon  a  cardio-renal  condition. 

I  do  not  know  the  facts  in  the  Wilmington  case, 
but  it  is  hard  to  believe  that  hospitalization  could 
have  postponed  the  end  appreciably.  In  Winston- 
Salem,  the  physicial  who  sent  the  child  to  the 
hospital  admitted  that  she  was  in  a  dying  con- 
dition when  she  left  home.  Instead  of  calling  the 
hospital  over  the  telephone,  however,  as  is  the 
custom,  he  gave  the  father  a  note  asking  that  the 
child  be  admitted  as  an  emergency  case  for  an  x-ray 
picture  of  her  chest,  to  know  how  much  fluid  to 
withdraw.  The  admitting  clerk  failed  to  note  the 
word  "emergency"  in  the  note,  and,  since  the 
father  did  not  have  enough  money  to  pay  the  requir- 
ed amount,  declined  to  admit.  The  newspapers 
made  much  ado  about  the  incident,  blaming  the 
little  girl's  death  on  the  hospital.  As  a  matter  of 
fact,  she  had  been  sick  three  weeks,  and  the  pre- 
sumption is  that  she  died  of  empyema.  Empyema 
does   not   develop   overnight.     The   probability   is 


that  had  it  been  recognized  and  relieved  by  surgery 
a  week  or  ten  days  earlier,  the  child  might  now 
be  alive:  but  let  that  pass.  Granting  that  a  mis- 
take was  made  by  the  hospital  authorities,  v/hy 
should  this  mistake  be  aired  so  conspicuously,  and 
the  fact  overlooked  that  this  same  hospital  last 
year  admitted  more  than  1500  emergency  cases 
without  question?  Surely  one  error  in  1500  is  not 
bad  for  any  human  system.  Furthermore,  the 
public  should  know  that  this  hospital  treated  127 
automobile  accident  cases  alone,  representing  a  cost 
of  $6,517  of  which  only  $1829  was  paid.  Out  of 
40,131  patient-days,  21,783  kere  charity — consider- 
able more  than  half. 

It  is  really  too  flattering  to  a  hospital  to  impute 
to  it  the  power  to  save  the  life  of  a  dying  child  by 
an  x-ray  picture,  or  to  prolong  the  life  of  an  old 
man  in  the  final  stages  of  myocarditis;  but  it  is  not 
fair  to  the  hospital  to  give  the  public  only  a  small 
part  of  the  facts.  Such  a  presentation  is  of  the 
nature  of  Harriet  Beecher  Stowe's  Uncle  Tom's 
Cabin,  which  was  as  grossly  unfair  to  the  people  of 
the  South  as  are  the  newspaper  stories  and  edi- 
torials now  under  discussion.  While  the  freedom 
of  the  press  may  be  a  good  thing,  like  other  things 
which  are  good  in  moderation,  it  can  be  greatly 
abused. 

A  misguided  specialist  in  other  people's  duties 
wrote  our  hospital  superintendent  that  he  could 
not  understand  how  the  Lord  would  send  tornadoes 
on  Greensboro  and  Gainesville,  and  overlook  Win- 
ston-Salem, after  such  a  happening.  To  which  Dr. 
Whittington  aptly  replied,  "the  Lord  knew  the 
facts  in  the  case  better  than  you  and  the  press." 

The  Eighth  District  Meeting 
It  is  with  some  shame  that  I  admit  publicly — 
and  only  to  give  my  soul  the  benefit  of  an  honest 
confession — that  when  the  program  of  the  meeting 
of  the  Eighth  District  Meeting  that  was  to  be  held 
April  ISth  at  Mount  Airy  fell  into  my  hands,  it 
did  not  seem  particularly  appetizing.  Indeed,  if 
any  excuse  for  staying  at  home  had  offered,  I 
would  have  been  rather  glad.  My  guardian  angel 
must  have  been  on  the  job,  however,  and  saw  that 
all  my  work  was  cleaned  up  in  time  to  go,  and  even 
provided  transportation  in  Dr.  Paul  Johnson's  Olds- 
mobile. 

Before  the  first  paper  was  half-finished,  I  was 
glad  I  had  come,  and  by  the  time  the  last  one  was 
read,  I  was  thoroughly  ashamed  of  having  even 
thought  of  playing  slacker.  It  is  doubtful  if  any 
doctor  who  will  pay  any  sort  of  attention  can 
attend  any  medical  meeting  without  learning  some- 
thing: but  this  meeting  was  unusually  packed  with 
worth-while  suggestions.  Of  peculiar  interest  to 
me  were  Dr.  Ravenel's  remarks  on  ."Xdvances  in  the 


SOUTHERN  MEDICINE  AND  SURGERY 


Prevention  and  Treatment  of  Contagious  Diseases. 
It  was  timely,  clear-cut;  and  the  fact  that  it  was 
spoken  rather  than  read  added  greatly  to  the  in- 
terest. Dr.  Ravenel  made  the  following  interesting 
points,  among  others:  A  life-saving  procedure  in 
the  desperately  toxemic  cases  of  diphtheria  is  the 
use  of  glucose.  The  prophylactic  value  of  Sauer's 
whooping-cough  vaccine  is  established  beyond  per- 
adventure,  but  it  is  not  necessary  to  give  each  in- 
oculation in  two  doses,  as  the  tissues  of  even  an 
infant  will  tolerate  the  2-  or  3-c.c.  amounts  given. 
Also,  the  24-c.c.  vials  can  be  purchased  much 
cheaper  than  the  8-c.c.  vials  for  each  patient.  The 
use  of  the  scarlet  fever  vaccine  is  not  advisable 
for  two  reasons:  the  reaction  is  often  severe,  and 
the  immunity  is  short-lived.  Parenthetically,  I 
have  never  been  able  to  understand  why  scarlet 
fever  vaccine  gives  only  temporary  immunity, 
though  the  disease  itself  confers  (usually)  perman- 
ent protection;  whereas  diphtheria  to.xoid  gives 
permanent  immunity,  though  the  actual  disease 
does  not. 

The  use  of  human  whole  blood  or  serum  from 
patients  who  have  had  measles,  or  the  placental 
extract  now  available,  in  the  prevention  or  modi- 
fication of  measles,  was  discussed.  The  practical 
objection  to  using  any  of  these  methods  is  the 
difficulty  of  determining  the  date  of  exposure  in 
most  cases. 

The  most  interesting  observation  made  was  the 
use  of  immuno-transfusion  in  patients  desperately 
ill  with  scarlet  fever,  typhoid  fever,  or  septicemia. 
The  donor  was  given  typhoid  vaccine  intravenous- 
ly seven  hours  before  the  transfusion.  Dr.  Ravenel 
showed  several  fever  charts  of  patients  who  respond- 
ed in  a  most  dramatic  manner  to  this  treatment. 

Dr.  C.  O.  DeLaney  read  a  practical  paper  on 
The  Treatment  of  .Acquired  Renal  Dystrophia,  giv- 
ing the  symptoms,  diagnosis,  indications  for  opera- 
tion, and  end-results  in  this  type  of  case.  He  il- 
lustrated it  by  lantern  slides  of  x-ray  films. 

Dr.  Carl  T3mer  read  an  excellent  paper  on  Leu- 
corrhea,  giving  the  two  main  causes:  endocervicitis, 
from  puerperal  lacerations,  and  infection  with  the 
trichomona  vaginalis.  The  former  he  treated  by 
cauterization.  In  the  latter  he  found  that  the  use 
of  a  25  per  cent,  sodium  chloride  solution  douche- 
one  glassful  to  enough  water  to  make  a  quart — used 
daily  or  twice  a  day  gave  excellent  results,  but 
shoul  be  continued  for  some  weeks  after  an  ap- 
parent cure. 

Dr.  J.  H.  McNeill  gave  a  good  discussion  of  sub- 
arachnoid hemorrhage,  with  a  case  report. 

Dr.  Wortham  Wyatt  presented  a  splendid  study 
of  his  personal  experience  in  The  Relationship  of 
Focal  Infections  to  Dermatology,  showing  how 
very  frequently  infected  tonsils  or  teeth,  and  oc- 


casionally other  foci,  were  responsible  for  stubborn 
skin  lesions. 

After  the  dinner  at  the  Blue  Ridge  Hotel,  Dr. 
Finley  Gayle,  of  Richmond,  gave  the  principal 
address,  on  a  most  timely  subject:  Selective  Human 
Sterilization.  He  showed  that,  like  so  many  other 
suggestions  for  human  uplift,  it  works  out  much 
better  in  theory  than  it  does  in  practice.  As  he 
spoke,  I  could  not  help  thinking  of  the  presidential 
address  of  my  good  friend  Thurman  Kitchen  in 
1929,  in  which  he  took  the  same  position,  was 
criticized  in  a  newspaper  article  by  Dr.  Crane  of 
the  University,  and  then  simply  annihilated  Dr. 
Crane  through  the  same  newspaper.  I  wish  Thurman 
could  have  heard  Dr.  Gayle's  address. 


PEDIATRICS 

G.  W.  KuTSCHER,  M.D.,  F.A..'\.P.,  Editor,  Asheville,  N.  C. 


Certified  Milk 

There  are  only  two  Certified  Milk  Dairies  in 
the  entire  state  of  North  Carolina,  one  in  Asheville 
and  the  other  at  Pinehurst.  The  Asheville  dairy, 
part  of  the  Vanderbilt  Estate,  is  known  as  Bilt- 
more  Farms  dairy.  A  herd  of  over  200  pedigreed 
Jersey  cows  produce  each  day  more  than  1,000 
quarts  of  what  is  to  become  Certified  milk,  much 
of  which  goes  on  daily  routes  to  surrounding  towns 
and  even  as  far  as  Charlotte.  To  be  certified  it 
must  come  up  to  certain  rigid  standards.  This  milk 
is  delivered  to  its  destination,  packed  in  ice.  In 
other  words  it  is  delivered  to  the  consumer  as 
Certified. 

It  is  the  only  safe  raw  milk  on  the  market.  In 
some  of  the  Northern  cities  it  is  being  pasteurized 
for  added  protection.  We  feel  that  pasteurization 
of  the  Asheville  product  is  unnecessary  because 
the  milk  never  comes  in  contact  with  the  air  or 
human  hands  from  the  cow  to  the  time  when  you 
remove  the  cap  from  the  bottle.  The  cows  are 
machine  milked  into  a  closed  system  of  stainless 
steel  pipes,  holding  tanks  and  finally  into  auto- 
matic bottle-filling  machines.  The  milk  has  al- 
ready been  cooled  before  it  is  bottled  and  is  kept 
at  a  temperature  below  50°  C.  until  it  is  delivered. 

Weekly  bacteria-  and  fat-content  estimations 
are  made  on  this  product.  An  upper  limit  of  10,000 
bacteria  per  c.c.  and  a  minimum  of  4  per  cent,  fat 
are  rigidly  observed  by  every  Certified  Milk  dairy. 
These  dairies  are  controlled  by  the  medical  pro- 
fession. Not  a  drop  of  this  milk  can  be  sold  without 
the  approval  of  the  local  medical  milk  commission. 

Some  of  the  "National  Methods  and  Standards" 
under  which  this  milk  is  produced  include,  the 
hygiene  of  the  dairy  buildings,  the  construction  of 
stables,  the  immaculate  equipment  of  milk  re- 
ceiving rooms,  the  scrupulous  care  of  utensils  and 


SOUTHERN  MEDICINE  AND  SURGERY 


May,   1936 


machines,  the  management  and  scientific  feeding 
and  inspection  of  the  herd,  the  special  veterinary 
supervision  and  testing  of  the  cows,  the  control  of 
tuberculosis  and  abortion  disease,  the  carefully 
maintained  record  of  each  cow  in  the  herd,  the 
exact  technique  to  be  followed  by  employees  in 
milking  and  handling  and  transporting  the  milk, 
the  frequent  and  thorough  medical  examinations  of 
employees  and  a  long  list  of  strict  standards  for 
the  milk  itself. 

For  several  years  the  Asheville  herd  has  been 
free  of  tuberculosis  and  abortion  disease.  It  is  now 
the  first  large  dairy  to  be  free  of  mastitis. 

There  must  be  approved  apparatus  for  the 
sterilization  of  bottles  and  utensils,  which  must  be 
free  from  bacteria  and  chemical  reagents.  Ther- 
mometers must  be  examined  at  least  once  a  week 
by  a  comparison  with  a  standard  tested  thermom- 
eter. In  the  milking  stlls,  kept  like  operating 
rooms,  each  cow  carefully  cleaned  before  milking, 
must  have  at  least  600  cubic  feet  of  air  space. 

Visitors  are  prohibited  from  entering  the  milking 
ps*te,.  but  may  see  the  procedure  through  plate- 
glass  windows. 

Visitors  to  Asheville  during  the  State  Medical 
Meeting  in  May  were  surprised  to  see  how  clean 
milk  can  really  be  when  they  saw  it  collected  at 
the  Biltmore  dairy.  This  treat  is  open  to  all  visit- 
ors to  Asheville  or  any  other  city  where  milk  is 
produced  under  Certified  standards. 

In  Virginia,  Certified  Milk  is  produced  at  Nor- 
folk, Portsmouth  and  Roanoke;  in  Georgia,  at 
Atlanta,  Augusta,  Brunswick,  Chamblee  and  De- 
catur. 

Certified  Milk  has  been  aptly  and  properly  char- 
acterized as  the  last  word  in  clean,  safe  and  nutri- 
tious milk  supply.  Milk  is  among  the  most  im- 
portant of  our  foods.  Of  all  milks,  Certified  is 
the  freshest,  the  cleanest,  the  safest,  the  most 
normal  in  vitimin  and  mineral  content,  the  most 
uniform  and  the  most  carefully  protected  from  con- 
tamination, the  most  sure  to  contain  all  the  possible 
nutritional  elements. 


RADIOLOGY 


Wright  Clarkson,  M.D.,  and  .\llen  Barker,  M.D., 
Editors,  Petersburg,  Va. 


Bronchiectasis:  Its  Diagnosis  and  Treatment 
A  discussion  of  this  disease  is  prompted  by  the 
excellent  manner  in  which  it  was  described  by 
Doctor  Arthur  C.  Christie^  in  his  Carman  Lecture 
delivered  before  the  Radiological  Society  of  North 
America  at  its  last  meeting.  Doctor  Christie  has 
clearly  brought  to  our  attention  the  present-day 
conception  of  the  etiology,  pathology,  diagnosis  and 
treatment  of  bronchiectasis,  and  the  following  par- 


agraphs are  written  to  emphasize  his  views  on 
this  subject  and  with  the  hope  of  further  stimulat- 
ing physicians  to  suspect  or  recognize  the  disease 
in  its  early  stages. 

The  frequency  with  which  bronchiectasis  occurs 
and  the  disability  and  mortality  accompanying  it 
have  been  recognized  only  during  the  past  few 
years.  Many  physicians  fail  to  diagnose  even  the 
advanced  cases  and  never  suspect  the  disease  in 
its  early  stages,  when  removal  of  the  etiological 
factor  might  restore  the  patient  to  complete  health. 
Frequently  cases  of  bronchiectasis  are  placed  in 
tuberculosis  sanatoria  because  of  a  history  of  hem- 
optysis, when  other  clinical  and  laboratory  data 
do  not  support  the  diagnosis  of  tuberculosis.  Bron- 
chiectasis is  the  most  common  pulmonary  disease 
and  hemoptysis  is  one  of  its  frequent  symptoms. 

In  1922  it  was  found  possible  to  visualize  the 
bronchial  tree  by  means  of  roentgenograms  made 
after  the  introduction  of  an  iodized  oil  into  the 
bronchi  (bronchography).  Since  that  time  many 
cases  of  the  disease  have  been  discovered.  Cases 
of  bronchiectasis  before  that  time  were  frequent-ly 
diagnosed  either  as  tuberculosis  or  as  chronic  bron- 
chitis. 

Even  though  it  is  possible  correctly  to  diagnose 
practically  every  case  of  bronchiectasis  by  means 
of  bronchography,  many  physicians  are  entirely  un- 
familiar with  the  procedure  or  doubt  its  efficacy. 
Symptoms  and  Signs 
Only  the  classical  signs  and  symptoms  of  the  late 
stages  of  the  disease  are  found  in  textbooks.  These 
consist  of  paroxysms  of  coughing  with  the  expec- 
toration of  various  amounts  of  foul  sputum,  loss 
of  weight,  recurring  attacks  of  fever,  and  in  the 
very  advanced  cases,  clubbing  of  the  fingers — pul- 
monary osteo-arthropathy.  While  such  symptoms 
do  justify  a  clinical  diagnosis  of  bronchiectasis, 
even  in  these  cases  bronchography  is  necessary  to 
exclude  lung  abscess,  or  other  suppurative  proc- 
esses. 

It  is  in  the  early  stages  of  the  disease  that  it  is 
so  important  to  make  a  correct  diagnosis,  because 
at  this  time  removal  of  the  etiological  factor  will 
frequently  restore  the  patient  to  normal.  Yet  these 
are  the  patients  who  present  no  definite  physical 
signs  or  symptoms  of  chest  pathology.  The  most 
frequent  early  symptom  is  an  annoying  cough  with 
or  without  the  expectoration  of  a  small  amount  of 
sputum.  In  many  instances  there  is  a  history  of 
blood-tinged  sputum  over  a  period  of  months  or 
years.  It  is  important  to  emphasize  hemoptysis  as 
a  frequent  symptom  of  bronchiectasis,  and  accord- 
ing to  some  authors  it  occurs  in  approximately  SO 
per  cent,  of  the  cases.  Therefore,  in  cases  suspect- 
ed of  having  tuberculosis,  other  definite  laboratory 
and  clinical  data  must  be  available  before  the  diag- 


SOUTHERN  MEDICINE  AND  SURGERY 


nosis  is  made.  Often  the  only  symptoms  present 
are  a  slight  cough,  and  some  loss  of  energy  which 
persists  and  causes  the  patient  to  be  branded  a 
neurotic.  It  should  be  emphasized  that  even  mild 
and  apparently  insignificant  symptoms  demand  a 
thorough  examination  of  the  chest,  which  must 
include  roentgen  study  of  the  bronchial  structures 
by  means  of  an  opaque  oil. 

Etiology 
It  is  now  recognized  that  the  majority  of  cases 
are  the  result  of  infections.  The  disease  often  fol- 
lows such  acute  inflammations  as  influenza,  whoop- 
ing cough  and  measles.  Sinus  disease  is  known  to 
be  frequently  associated  with  bronchiectasis  and 
many  believe  it  to  be  a  causative  factor.  Obstruc- 
tion of  a  bronchus  by  a  tumor,  foreign  body,  or 
pressure  is  often  followed  by  bronchiectasis  in  the 
portion  of  the  lung  supplied  by  the  obstructed 
bronchus.  Bronchiectatic  lung  areas  are  frequently 
seen  in  children  who  have  aspirated  foreign  bodies 
which  were  not  removed.  It  is  believed  by  some 
that  diseased  tonsils  are  an  important  etiological 
factor,  especially  in  those  cases  occurring  in  chil- 
dren. Any  suppurative  or  chronic  inflammatory  dis- 
ease which  tends  to  destroy  the  musculature  and 
elastic  tissue  of  the  bronchi  may  be  followed  by 
bronchiectatic  dilatations. 

Pathology 
Infection  is  always  present  in  bronchiectasis  and 
always  precedes  dilatation  of  the  bronchi.  The 
early  changes  consist  of  inflammation  of  the  mu- 
cous membranes,  which  become  hypertrophic.  As 
the  inflammation  e.xtends,  it  involves  the  entire 
bronchial  wall  and  finally  the  peribronchial  tissues. 
During  the  hypertrophic  stage  much  purulent  se- 
cretion occurs,  with  ulcerations  which  are  responsi- 
ble for  the  hemorrhage.  If  the  disease  is  allowed 
to  progress,  there  is  atrophy  of  the  mucous  mem- 
branes, the  musculature  and  the  elastic  tissue.  At 
this  stage  the  weakened  bronchial  walls  dilate,  and 
the  resulting  cavities  are  filled  with  a  purulent,  foul 
secretion.  Persistent  coughing,  by  increasing  the 
intrabronchial  pressure,  further  dilates  the  bronchi, 
and  a  vicious  cycle  is  established.  Peribronchial 
fibrosis  secondary  to  peribronchial  infection  exerts 
traction  on  the  atrophied  bronchial  walls,  which 
further  dilate,  and  these  still  larger  cavities  become 
filled  with  infected  secretions. 

Diagnosis 
In  the  far-advanced  stages  of  the  disease  a  roent- 
gen examination  may  not  be  necessary  for  a  diag- 
nosis; but  to  allow  the  condition  to  progress  to  this 
stage  is  to  sacrifice  the  opportunity  for  an  early 
diagnosis,  and  all  possibility  of  a  cure.  It  is  only 
in  the  early  stages  that  a  correct  diagnosis  and  re- 
moval of  the  cause  will  restore  the  health  of  the 


patient.  When  the  disease  is  once  suspected,  we 
have  at  our  disposal  a  method  by  which  this  diag- 
nosis can  be  made.  Plain  roentgenograms  of  the 
chest  are  sufficient  in  many  of  the  advanced  cases, 
but  in  the  early  stages  it  is  necessary  to  outline  the 
bronchial  tree  by  a  roentgen  examination  of  the 
chest  made  after  the  introduction  of  one  of  the 
iodized  oils.  Even  in  the  advanced  cases,  bron- 
chography serves  to  locate  the  lesions  and  permits  a 
difl'erential  diagnosis.  The  method  is  not  difficult 
and  causes  the  patient  little  discomfort.  Good  local 
anesthesia  is  necessary  to  abolish  the  cough  and 
swallowing  reflexes,  and  this  is  obtained  preferably 
by  use  of  a  2-per  cent,  spray  of  cocaine  repeated 
at  intervals  for  one-half  hour.  Following  anesthe- 
sia, the  oil,  which  has  been  previously  warmed,  is 
dropped  slowly  on  the  base  of  the  tongue  while  the 
patient  breathes  deeply,  with  the  tongue  drawn  for- 
ward. The  flow  of  oil  into  any  chosen  bronchus 
can  be  obtained  by  posture.  If  preferred,  the  oil 
may  be  introduced  directly  into  the  larynx  with  a 
curved  cannula  under  direct  vision  by  using  a  laryn- 
geal mirrow.  Stereoscopic  films,  and  if  thought 
necessary,  lateral  and  oblique  films,  are  made. 
Proper  diagnosis  depends  on  prof)er  interpretation 
of  the  roentgenograms,  which  necessarily  must  be 
done  by  one  familiar  with  chest  roentgenography. 
An  active  parenchymatous  tuberculosis  is  practi- 
cally the  only  contraindication  to  the  procedure. 
Contrary  to  the  opinions  of  many,  old  fibroid  tuber- 
culosis is  not  a  contraindication. 

Treatment 

While  the  treatment  of  bronchiectasis  is  not  yet 
satisfactory,  during  recent  years  physicians  have 
learned  enough  of  its  etiology  and  pathology  to  en- 
able them  to  institute  logical  therapy.  As  in  the 
treatment  of  other  diseases,  the  etiological  factors 
must  be  removed  when  possible. 

It  is  important  first  to  clear  up  disease  of  the 
paranasal  sinuses  and  tonsils.  Many  of  the  early 
cases  of  bronchiectasis  will  be  cured  by  removal  of 
these  foci  of  infection. 

Obviously,  if  a  foreign  body  or  bronchial  tumor 
is  responsible  this  must  be  removed  at  once. 

Certain  unilateral  cases  are  markedly  improved 
by  artificial  pneumothorax,  the  lung  being  main- 
tained in  a  state  of  collapse  for  a  sufficient  length 
of  time.  In  other  cases  better  results  are  obtained 
by  phrenicectomy. 

In  certain  other  unilateral  cases,  with  involve- 
ment of  only  one  lobe,  the  diseased  area  may  be 
completely  removed  by  pneumectomy  or  lobectomy. 
However,  radical  pulmonary  surgery  carries  with 
it  a  high  mortality  and  the  operation  must  be  re- 
served for  a  very  few  carefully  selected  cases. 

Postural  drainage  for  the  treatment  of  suppura- 
tive lung  diseases  is  a  simple  procedure,  and  this 


SOUTHERN  MEDICINE  AND  SURGERY 


Mav,  1936 


treatment  is  invaluable  in  the  care  of  those  patients 
who  expectorate  quantities  of  foul  sputum.  The 
patients  are  made  more  comfortable  and  the  spill- 
ing over  of  excess  secretions  to  normal  lung  is  pre- 
vented. The  most  favorable  posture  for  the  indi- 
vidual can  be  determined  only  after  the  disease  has 
been  definitely  localized  by  bronchography.  Bron- 
choscopic  drainage  is  extremely  valuable  in  many 
cases,  especially  when  postural  drainage  fails  to 
obtain  the  desired  results;  but  the  procedure  is  lim- 
ited to  those  skillfully  trained  in  the  use  of  the 
bronchoscope. 

One  of  the  most  valuable  of  all  therapeutic  pro- 
cedures is  the  introduction  of  one  of  the  opaque 
oils  into  the  diseased  area,  and  this  can  be  done 
easily  in  the  office  and  with  little  discomfort  to  the 
patient.  The  method  of  introduction  is  identical 
with  that  described  above  for  diagnostic  purposes. 
The  injections  may  be  given  every  two  to  four 
weeks,  depending  on  the  results  obtained  in  the  in- 
dividual case.  The  mode  of  action  of  the  oil  is  not 
yet  known.  The  improvement  so  frequently  noted 
may  be  the  result  of  the  liberation  of  free  iodine 
which  destroys  the  infecting  organisms,  or  of  me- 
chanical displacement  of  the  secretions  by  the  heav- 
ier oil. 

No  one  treatment  outline  can  be  given  to  suit 
every  case.  However,  it  is  certain  that  continued 
cooperation  between  radiologist  and  general  practi- 
tioner will  result  in  the  discovery  of  many  early 
cases  at  a  time  when  treatment  is  most  valuable. 
Thus,  much  of  the  invalidism  resulting  from  ad- 
vanced bronchiectasis  will  be  obviated,  and  many 
cases,  such  as  those  now  in  sanatoria  with  an  in- 
correct diagnosis  of  tuberculosis,  will  profit  by  the 
correct  diagnosis  of  bronchiectasis,  thereby  permit- 
ting proper  treatment  without  the  economic  loss  in- 
curred by  hospitalization. 


1.     Christie,  Arthur  C:     Bronchiectasis:   Its  Diagnosis 
and  Treatment.     Radiology,  Feb.,  1936,  26:138-145. 


CARDIOLOGY 

Clyde  M.  Gilmore,  A.B.,  M.D.,  Editor,  Greensboro,  N.  C. 


The  Hypothyroid  Heart 
It  has  long  been  generally  known  that  hyper- 
action  of  the  thyroid  gland  is  responsible  for  many 
cases  of  disturbance  of  cardiac  function,  and  en- 
largement of  the  gland  with  toxic  symptoms  are 
among  the  first  things  investigated  in  a  cardiac 
study.  It  is  not  so  generally  accepted,  however, 
that  hypofunction  of  the  gland  also  is  responsible 
for  many  vague  cardiac  symptoms  and  that  esti- 
mation of  the  thyroid  function  is  of  distinct  value 
in  placing  many  borderline  cases. 

It  is  true  that  the  heart  symptoms  of  advanced 
myxedema  have  been  recognized  for  a  long  time, 


but  the  classical  picture  of  myxedema  is  rarely 
seen.  We  have  been  greatly  impressed  in  the  past 
two  years  by  an  unusual  number  of  cases  with 
borderline  symptoms  of  dyspnea,  slight  cardiac 
enlargement,  weak  and  distant  tones,  sometimes 
systolic  murmurs,  easy  fatigue,  puffy  ankles  and 
sluggishness,  in  which  were  found  a  moderately  low 
metabolism  and  in  which  striking  benefit  was  de- 
rived from  thyroid  therapy.  So  frequently  has  this 
occurred  that  we  now  do  routine  metabolic  readings 
on  all  cardiac  patients  and  find  more  help  and  de- 
rive more  aid  from  those  who  show  low  than  from 
the  few  who  show  elevated  metabolic  readings. 

We  have  had  to  completely  revise  our  former 
conception  of  hypothyroidism — thick  lips,  puffy 
face,  large  tongue,  thick  dry  skin,  sluggishness, 
obesity  and  hypotension.  The  symptoms  of  this 
glandular  deficiency  may  be  entirely  confined  to 
the  circulatory  or  to  the  digestive  systems.  Obesity 
may  be  entirely  absent  with  a  marked  hypothy- 
roidism. 

The  estimation  of  thyroid  function  is  especially 
valuable  in  distinguishing  between  coronary  dis- 
ease or  myocardosis  in  the  young  and  middle-aged 
because  of  the  similarity  of  symptoms.  The  find- 
ings of  unstable  blood  pressure,  easy  fatigue,  dysp- 
nea on  e.xertion  accompanied  by  substernal  fullness, 
and  even  electrocardiographic  changes  in  the  T 
wave  are  common  findings  in  both  conditions.  The 
differentiation  is  further  confused  by  the  fact  that 
hypothyroid  patients  are  subject  to  neuritis  pains 
and  these  are  sometimes  localized  in  the  chest  and 
arms.  Fluoroscopic  examination  of  the  hypothy- 
roid heart  shows  weak,  flabby  contractions  with 
some  enlargement  and  not  infrequently  hilus  edema. 
In  the  electrocardiogram  there  is  frequently  low 
voltage  and  the  T  waves  may  be  flat  or  low  and, 
in  advanced  cases,  even  inverted.  In  late  stages 
of  myxedema  there  is  a  pericardial  exudate  which 
gives  the  impression  of  a  tremendous  cardiac  hyper- 
trophy but  which  magically  disappears  with  thyroid 
therapy.  Four  of  our  recent  such  patients  had 
thyroidectomy  six  to  ten  years  ago  with  not  enough 
of  the  gland  left  for  metabolic  needs. 

The  patient's  general  physical  condition  should 
receive  first  attention,  all  focal  infection  should  be 
removed  and  anemia  if  present  should  be  corrected. 
If  obesity  is  present  this  should  be  reduced  by  diet 
and  exercise  as  it  will  obviously  take  less  thyroid 
to  carry  on  the  metabolic  processes  of  a  patient 
weighing  150  pounds  than  one  who  weighs  200 
pounds.  Thyroid  therapy  is  specific  and  striking 
benefit  is  seen  within  two  weeks.  We  usually  give 
a  test  dose  of  1  grain  of  thyroid  extract  3  times  a 
day  for  20  days  and  then  adjust  the  dosage  by  the 
resulting  change  in  metabolic  readings.  It  is  well 
to  remember  that  there  is  a  great  variation  in  the 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


potency  of  the  extracts  now  on  the  market  and 
our  results  have  been  consistently  uniform  only 
since  we  have  confined  our  prescriptions  to  the 
standardized  enteric-coated  tablets. 


SURGERY 


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


Modern  Understanding  of  Shock 

We  know  the  causes  and  manifestations  of  surgi- 
cal shock  but  what  the  condition  really  is  we  do 
not  know.  Theories  about  it  are  of  academic  in- 
terest rather  than  of  practical  value.  Trauma  and 
hemorrhage  cause  shock  and  at  operation  should 
be  prevented  by  gentleness  in  handling  the  viscera, 
by  accurate  dissection  and  by  careful  hemostasis. 
That  psychic  trauma  may  augment  physical  trauma 
is  often  forgotten  by  physicians  who,  when  opera- 
tion is  accepted  by  the  patient,  should  reassure 
him  in  every  way  possible.  Body  warmth  must  be 
maintained  both  during  and  after  operation. 

It  is  of  interest  to  know  that  reaction  to  injury, 
to  hemorrhage,  to  operation,  to  the  causes  of  shock 
may  manifest  itself  in  two  very  different  ways.  In 
torpid  shock,  which  is  the  ordinary  kind,  the  pa- 
tient lies  almost  lethargic,  with  pallor,  weak  pulse, 
clammy  skin  and  subnormal  temperature.  When 
aroused  questions  are  answered  in  monosyllables. 
In  erethistic  shock,  on  the  other  hand,  although  the 
pulse  is  weak  and  the  skin  clammy,  the  patient  is 
restless  and  in  many  cases  so  wildly  delirious  that 
he  has  to  be  restrained.  Narcotic  drugs  have  but 
little  effect  in  controlling  this  restlessness,  which  is 
•from  involvement  of  the  higher  brain  centers  and 
often  terminates  in  exhaustion,  high  fever  and 
death. 

In  a  young  farmer  a  hard  cancerous  mass  in- 
volving the  splenic  flexure  and  descending  colon 
with  fixation  to  the  parietal  peritoneum  after  ex- 
tensive dissection  and  some  bleeding,  was  freed  with 
a  mass  of  attached  muscle  from  the  anterior  ab- 
dominal wall  and  exteriorized.  The  tumor  mass 
was  left  outside  the  abdomen  with  the  incision  int(j 
the  abdominal  wall  sutured  to  the  afferent  and  ef- 
ferent colon.  After  a  few  days  when  the  abdomi- 
nal wound  had  begun  to  heal  it  was  planned  to 
remove  the  growth  extraperitoneally  and  in  this 
way  prevent  infection  and  peritonitis,  the  usual 
cause  of  death  in  large  gut  resection.  The  fecal 
fistula  could  be  closed  later.  The  man  left  the 
table  in  fair  condition.  A  blood  transfusion  was 
given.  In  a  few  hours,  in  spite  of  maximum  doses 
of  morphine,  he  became  so  restless  that  he  had  to 
be  held  in  bed.  His  temperature  was  106°  before 
he  died  of  erethistic  shock  24  hours  after  opera- 
tion. 

It  is  easy  to  say  that  surgical  shock  should  be 


prevented  and  certainly  every  precaution  should  be 
taken  to  protect  the  surgical  patient  from  it;  but 
unless  the  surgeon  is  so  cold-footed  as  to  deny  his 
patient  the  chance  of  cure  which  operation  offers 
in  an  otherwise  hopeless  condition  shock  may  de- 
velop in  spite  of  every  care. 

In  the  treatment,  Frazier  (Journal  A.  M.  A., 
Nov.  30th,  193S)  after  stressing  prevention  of 
shock  and  recalling  that  lowering  the  head  of  the 
patient  and  the  application  of  external  heat  should 
be  done  as  a  routine  aptly  says  that,  regardless  of 
the  mechanism,  the  loss  of  blood  volume  is  a  defi- 
nite reaction  to  tissue  injury  and  must  be  consid- 
ered in  treatment.  "The  restoration  and  main- 
tenance of  blood  volume  may  be  accepted  then  as 
of  basic  importance  in  the  treatment  of  shock,  and 
the  problem  of  shock  is  inseparably  connected  with 
the  maintenance  of  blood  volume."  Glucose  in 
physiological  salt  solution  diffuses  so  rapidly  that 
it  is  of  temporary  benefit  only.  Whether  blood 
volume  loss  is  from  hemorrhage  or  from  other 
causes,  if  shock  depends  upon  blood  volume  loss  it 
is  an  evident  fact  that  blood  transfusion  by  restor- 
ing blood  volume  should  be  the  most  effective  treat- 
ment. 

Our  experience  in  every-day  surgical  practice  con- 
firms this.  The  favorable  response  to  transfusion 
is  immediate  and  the  effect  is  lasting.  This  is 
particularly  true  if  there  has  been  hemorrhage. 

Frazier  stresses  the  good  effect  of  the  slow  giving 
of  10%  ethyl  alcohol  in  10%  dextrose.  From  it 
patients  get  a  feeling  of  warmth  and  exhilaration. 
Both  the  glucose  and  the  alcohol  are  of  food 
value.  Two  liters  may  be  given  intravenously  in 
24  hours. 

We  have  used  this  in  several  cases  and  are  favor- 
ably impressed  with  it.  We  have  had  no  experi- 
ence with  the  intravenous  administration  of  acacia 
solution  to  maintain  adequate  circulation  till  trans- 
fusion can  be  done.  Acacia  solution  may  be  had 
in  sterile  ampoules  and  is  said  to  be  without  un- 
favorable reaction,  although  it  has  been  found  that 
acacia  stays  in  the  blood  for  months. 

In  conclusion,  the  prevention  of  shock  is  most 
important  but  the  recognition  and  prompt  treat- 
ment of  beginning  shock  is  essential.  Advanced 
shock  may  be  fatal  no  matter  what  treatment  is 
given. 


PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 
Pitt  County  Health  Officer 


The  Private  Physician  and  Syphilis  Control 
The  control  of  syphilis  is  one  of  the  most  press- 
ing public  health  problems  of  today. 

It   is   estimated   that    750,000   cases   of   syphilis 


SOUTHERN  MEDICINE  AND  SURGERY 


May,   1936 


are  clinically  recognized,  annually,  with  less  than 
one-half  of  these  obtaining  early  treatment,  the 
stage  when  the  possibility  of  cure  is  greatest.  It  is 
generally  agreed  that  no  great  advance  can  be 
made  in  the  control  of  syphilis  until  the  indigent 
syphilitic  can  get  treatment  without  cost  to  him 
and  that  we  should  have  some  law  making  treat- 
ment compulsory. 

The  Advisory  Committee  to  the  U.  S.  Public 
Health  Service  on  a  venereal  disease  control  pro- 
gram makes  certain  recommendations.* 

I  here  quote  some  of  the  more  important  recom- 
mendations: "The  free  distribution  of  anti-syph- 
ilitic drugs  by  the  State  to  all  sources  of  treatment 
is  rational  as  a  partial  subsidy." 

Doctor  Thomas  Parran,  Jr.,  now  Surgeon  Gen- 
eral, stated  last  year  while  Commissioner  of  Health 
for  the  State  of  New  York  that:  "For  a  number 
of  years  the  State  Department  of  Health  has  been 
distributing  without  charge  arsphenamines  and 
other  antisyphilitic  remedies  to  physicians  in  pri- 
vate practice  for  the  treatment  of  their  marginal 
patients,  as  well  as  for  the  treatment  of  patients 
in  the  clinics  and  institutions.  This  policy  is  being 
extended  to  embrace  the  free  distribution  of  such 
drugs  for  the  treatment  of  all  patients." 

Referring  further  to  the  Advisory  Committee's 
report,  I  quote:  "Suppression  of  quack  and  drug- 
store treatment."  "It  is  the  function  of  the  local 
health  department,  the  local  medical  society,  phar- 
maceutical society,  and  other  interested  agencies  to 
attempt  to  abolish  the  practice  of  the  quack  and 
the  druggist  in  prescribing  treatment  for  venereal 
diseases." 

As  the  writer  sees  it,  it  is  probable  that  the  phar- 
maceutical society  or  druggists'  association  should 
take  the  initial  step  in  suppressing  drug  store  treat- 
ment of  venereal  diseases.  The  pernicious  habit  of 
the  druggist  in  prescribing  "calomel"  for  a  chancre 
has  prevented  many  patients  from  securing  early, 
efficient  antisyphilitic  treatment. 

The  Advisory  Committee  further  recommended 
that  the  private  practitioner  and  the  health  officer 
use  the  dark-field  examination  of  chancre  secre- 
tions, calling  attention  to  the  fact  that  the  dark- 
field  method  will  make  a  diagnosis  long  before  the 
serologic  test  is  of  value. 

Another  committee  recommendation  is  that  all 
pregnant  women  be  examined  for  syphilis;  and  it  is 
stated  that  prenatal  transmission  of  syphilis  can 
be  prevented  in  the  vast  majority  of  cases  if  treat- 
ment is  instituted  before  the  fifth  month  of  preg- 
nancy. 


The  Advisory  Committee's  report  contains  many 
valuable  suggestions  and  it  should  be  read  by  all 
physicians  interested  in  the  control  of  venereal  dis- 
ease. 


HUMAN  BEHAVIOR 

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


♦Reprint  No.  S4  from  "Venereal  Disease  Information," 
January,  1936,  Superintendent  of  Documents,  Washington, 
D.  C.    Price,  Sc  per  copy. 


Mostly  in  Retrospection 
Here  I  am  in  St.  Louis  to  attend  the  annual 
meeting  of  the  American  Psychiatric  Association, 
one  of  the  oldest  medical  organizations  in  the 
United  States.  It  affords  me  the  only  opportunity 
to  hear  by  papers  and  discussions  what  has  taken 
place  in  psychiatric  thought  within  the  last  year, 
and  to  meet  in  intimate  association  the  leading 
psychiatrists  of  Canada  as  well  as  of  this  country. 
All  sorts  of  theories  and  opinions  are  enunciated 
and  the  discussion  is  usually  lively  and  always  can- 
did and  sometimes  devastating.  One  seldom  hears 
what  we  are  so  accustomed  to  hear  in  the  South — 
expressions  laudatory  of  the  essayist.  One  of  the 
readers,  who  is  especially  interested  in  suicide,  will 
contend  that  many  fatal  automobile  accidents  are 
not  accidents  at  all,  but  self-invoked  deaths — sui- 
cide. Many  of  the  casualty  companies  have  prob- 
ably long  entertained  the  same  notion.  Another 
essayist  will  speak  upon  projection — an  elaboration 
of  his  belief  that  we  physicians  deal  not  always 
with  disease  in  the  individual,  but  with  the  projec- 
tion into  the  patient  of  our  own  notions  about  the 
patient.  And  occasionally,  of  course,  and  some- 
times more  than  occasionally,  we  doctors  project 
our  misconceptions  into  the  patient,  and  talk  about 
and  medicate  that  misconception.  That  statement 
is  more  applicable  to  us  mental  doctors  perhaps 
than  to  those  physicians  who  deal  with  the  physical 
diseases.  And  another  paper,  the  reading  of  which 
I  shall  hear,  will  set  forth  the  author's  reasons  for 
believing  that  many  diseases  that  are  apparently 
of  physical  origin  are  instead  of  emotional  origin, 
and  are  unconsciously  transformed  into  physical 
conditions  simulative  of  structural  disease.  That 
possibility  must  be  borne  in  mind  always,  of  course, 
in  an  emotional  person.  Chronic  fear,  for  example, 
such  that  the  individual  may  be  unwilling  to  con- 
fess, may  cause  organic  changes  in  the  circulatory 
apparatus. 

But  I  intended  to  speak  of  the  past  rather  than 
of  the  present  or  of  the  future.  The  last  week 
was  both  qualitatively  and  quantitatively  unusual 
with  me.  On  Tuesday  night  I  presided  as  chair- 
man at  the  meeting  of  the  Section  on  the  History 
of  Medicine  of  the  Richmond  Academy  of  Medi- 
cine. Dr.  J.  McCaw  Tompkins  presented  to  the 
Academy  for  his  family  a  snuff  box  used  by  his 
ancestor,  Dr.  James  Drew  McCaw,  and  a  volume 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


by  Dr.  William  Harvey,  almost  two  hundred  years 
old.  And  Dr.  M.  Pierce  Rucker  presented  to  the 
Academy  a  portrait  of  Dr.  Philip  Syng  Physick, 
painted  probably  by  Tully.  The  address  of  the 
occasion  was  made  by  Dr.  David  Riesman,  of 
Philadelphia,  on  "Life  in  a  Mediaeval  University." 
The  meeting  was  inspiring  and  stimulative.  A 
study  of  the  history  of  medicine  teaches  us  how 
slowly,  and  with  what  pains  and  labours,  increases 
have  been  made  to  medical  knowledge.  Many 
medical  men  have  hated  new  ideas,  and  they  have 
joined  laymen  in  persecuting  the  doctor  who  has 
been  interested  in  trying  to  find  out  where  the  blue 
begins.  In  the  very  midst  of  a  week  already  made 
too  busy  I  was  subpoenaed  to  attend  in  the  United 
States  Court  the  trial  of  a  physician  for  having 
violated  the  Federal  Narcotic  Law.  On  Friday  I 
presented  to  the  Virginia  Academy  of  Science  at 
its  annual  meeting,  held  at  the  Virginia  Military 
Institute,  a  study  of  the  physique  and  personality 
of  Peter  Francisco.  He  was  a  giant,  who  had 
probably  been  kidnaped  from  his  home  in  Southern 
Europe  when  he  was  so  young  that  he  could  re- 
member the  tragedy  only  vaguely,  and  was  taken 
to  the  Colony  of  Virginia,  and  left  in  abandonment 
on  the  wharf  at  City  Point.  A  home  was  found 
for  him;  he  became  precociously  large  and  strong, 
and  on  account  of  his  superhuman  strength  and 
his  great  valour  displayed  in  battles  in  the  Rev- 
olutionary War  he  became  the  most  famous  private 
soldier  in  our  history.  In  driving  through  Buck- 
ingham County  on  the  way  to  Lexington  I  passed 
near  his  old  home,  Locust  Grove.  It  should  be 
preserved  as  a  historic  shrine.  I  interpreted  Peter 
Francisco  as  a  probable  exhibition  of  hyperpituitar- 
ism. 

I  was  unable  to  hear  through  to  the  finish  the 
paper  which  followed  mine  because  the  daily  drill 
of  the  cadets  of  the  V.  M.  I.  beguiled  me  out  of 
the  hall.  Warfare  makes  no  appeal  to  me,  but  the 
rhythmic  roll  of  a  military  band,  the  synchronized 
movements  of  the  drilling  soldiers,  the  ringing,  in- 
comprehensible orders,  and  the  awakening  of  his- 
toric recollections,  stir  my  emotions  in  spite  of 
myself,  and  for  the  moment  I  am  a  soldier,  too. 
After  the  captains  and  the  kings  had  departed  and 
the  spectators  had  gone,  I  stood  alone  in  front  of 
Stonewall  Jackson's  monument,  and  read  on  it  an 
excerpt  from  his  statement  on  the  morning  of  May 
3rd,  1864,  not  many  hours  before  he  received  his 
mortal  wounds:  The  Virginia  Institute  will  be 
heard  from  today.  In  giving  up  his  life  he  became 
one  of  the  world's  immortals.  Must  it  not  ever 
be  so?  Must  one  not  always  give  up  self  for  some- 
thing greater  and  better  than  self?  And  I  went 
to  the  chapel  of  Washington  and  Lee  University 
and  stood  before  the  recumbent  statue  of  General 


R.  E.  Lee.  And  I  felt,  as  always,  that  I  was 
looking  upon  a  god,  not  dead,  but  only  asleep. 
In  what  other  village  can  one  commune  with  a 
Lee  and  a  Jackson?  As  I  journeyed  northward  to 
Staunton  I  stopped  at  old  Timber  Ridge  Presby- 
terian Church  and  read  the  inscription  upon  the 
marker  placed  near  there  upon  the  spot  occupied 
by  the  cabin  in  which  Sam  Houston  was  born.  He 
was  one  of  the  most  remarkable  figures  in  Ameri- 
can history,  who  has  not  yet  been  properly  cred- 
ited with  what  he  did  for  his  country.  There 
would  seem  to  be  little  doubt  that  he  was  abnormal, 
and  that  many  of  his  achievements  were  made 
possible,  if  not  caused  by,  his  abnormality.  He 
spent  the  first  half  of  his  life  in  escaping  from 
civilization,  and  the  latter  portion  of  it  in  fabri- 
cating a  civilization  in  a  wilderness.  Had  it  not 
been  for  the  resourcefulness  and  the  courage  of 
Sam  Houston  at  least  a  third  of  the  present  area 
of  the  United  States  might  belong  to  some  foreign 
nation. 

Near  Houston's  birthplace  Ephraim  McDowell, 
the  pioneer  surgeon  of  the  wilderness,  was  born 
in  1771.  But  McDowell,  unlike  Sam  Houston, 
acquired  a  sound  education  both  in  the  colonies 
and  abroad.  A  monument  to  his  memory  stands 
in  Danville,  Kentucky.  I  think  Dr.  McDowell 
married  a  daughter  of  General  Isaac  Shelby,  one 
of  the  heroes  of  King's  Mountain.  Near  the  birth- 
place of  McDowell  is  the  old  McCormick  farm, 
where,  in  his  father's  blacksmith  shop,  Cyrus  H. 
McCormick  perfected  the  grain  reaper,  which  al- 
most immediately  revolutionized  agricultural  life. 
Only  a  few  miles  away  lived  Gibbs,  who  invented 
the  sewing  machine  that  made  the  chain  stitch 
possible.  And  that  mechanism  meant  as  much  to 
womankind  as  the  harvesting  machine  meant  to 
mankind.  At  Staunton,  late  in  the  day,  I  took 
my  two  travelling  companions  to  see  the  birth- 
place of  Woodrow  Wilson — the  manse  of  the  Pres- 
byterian Church.  When  the  west-bound  train  of 
the  Chesapeake  and  Ohio  took  me  aboard  I  found 
myself  on  a  train  named  for  George  Washington 
and  in  a  car  that  bore  the  name  of  William  Clark, 
who  was  second  in  command  of  the  Lewis  and 
Clark  expedition  which  explored  the  region  all  the 
way  from  Charlottesville  to  the  Pacific.  And  with- 
out Jefferson's  sagacity  and  their  adventure  the 
great  region  taken  over  by  them  might  have  been 
lost  to  the  United  States.  And  another  car  of  the 
train  bore  the  name  of  Dr.  James  Craik.  He  was 
the  neighbour  of  George  Washington,  his  personal 
physician,  his  most  intimate  friend,  and  he  closed 
the  eyes  of  Washington  in  death. 

At  breakfast  time  on  the  following  morning  I 
looked  out  upon  Maysville,  Kentucky.  There  was 
born  Dr.  Pelham,  a  graduate  of  Jefferson  Medicql 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


College,  who  established  himself  in  Person  County, 
North  Carolina,  married  a  Miss  McGehee,  moved 
to  Alabama  where  that  son  was  born  who  became 
Gen.  J.  E.  B.  Stuart's  great  artillerist,  the  gallant 
Pelham.  I  hope  North  Carolina  will  place  a  mark- 
er at  the  birthplace  of  his  mother. 

Here  in  St.  Louis  on  this  Sabbath  morning  I 
drove  in  a  taxicab  to  634  South  Broadway,  and 
looked  upon  the  house  in  which  Eugene  Field  was 
born  in  1850.  I  looked  out  of  the  window  that  I 
imagined  he  gazed  out  of  as  a  child,  and  I  walked 
down  the  steps  worn  somewhat  perhaps  by  his 
little  feet.  And  I  know  that  I  should  rather  be 
the  author  of  "Little  Boy  Blue"  than  to  have  rep- 
resented Missouri  in  the  United  States  Senate  for 
thirty  years,  as  that  great  North  Carolinian,  Thom- 
as Hart  Benton,  did.  And  then  my  travelling  com- 
panions. Dr.  H.  C.  Henry  and  Dr.  E.  H.  Alder- 
man, drove  with  me  out  of  the  city  eight  or  ten 
miles  to  the  farm  on  which  U.  S.  Grant  was  living 
when  he  volunteered  for  service  in  the  Civil  War. 
Near  the  hotel  in  which  we  are  lodged  stood  the 
old  market  to  which  Grant  used  to  haul  cord  wood. 
And,  as  I  thought  of  all  the  blood  that  had  to  be 
let  on  which  he  might  be  floated  into  the  White 
House  -  -  -  -  I  wondered  -  -  -  if  -  he  -  -  might  -  - 

not  -  -  have been  -  -  happier  -  -  -  had  he 

continued  -  -  to  sell  cord  wood.  And  in  contrast 
with  the  killings  and  the  slaughterings  done  in  his 
climb  upward  I  thought  of  the  contributions  of 
Ephraim  McDowell,  Cyrus  H.  McCormick,  and 
Eugene  Field.  But  peace  conferences  will  fail  again 
and  yet  again  because  mankind  looks  upon  warfare 
as  man's  supreme  achievement.  That  which  has 
been  is  that  which  shall  be — and  there  is  no  new 
thing. 


The  press  reports  the  illness  from  apople.xy  of 
Dr.  James  Tate  Mason,  president-elect  of  the 
American  Medical  Association,  at  his  home  at  Se- 
attle. Dr.  Mason  is  a  native  of  Orange  County, 
Virginia;  and  a  graduate  in  medicine  of  the  Uni- 
versity of  Virginia  in  the  class  of  1905.  He  served 
an  interneship  at  the  Polyclinic  Hospital  in  Phila- 
delphia, soon  after  the  interneship  there  of  Dr. 
J.  S.  McLester,  his  predecessor  in  the  presidency 
of  the  American  Medical  Association.  Dr.  Mason 
and  Dr.  Ivan  P.  Battle,  of  Rocky  Mount,  North 
Carolina,  were  fellow  high-school  students  in  the 
old  school  at  Locust  Dale,  Madison  County,  Vir- 
ginia. Dr.  Mason  has  made  a  distinguished  name 
for  himself  in  the  great  Northwest.  He  is  a  hand- 
some, genial,  winsome  man,  who  loves  his  fellow- 
man.  He  has  the  hearty  sympathy  of  his  multitude 
of  friends  in  his  invalidism. 


What  a  Task  or  How  to  Clean  the  Cellar 

NOTE. — This  came  along-  with  Dr.  Hall's  MS,  presumably 
having  been  placed  in  the  envelope  surreptitiously  by  a 
patient  who  had  recently  had  a  remarkable  experience 
which  he  was  anxious  to  share  with  his  fellow-men. — 
Edr. 

I  had  twelve  bottles  of  whiskey  in  my  cellar  and 
my  wife  made  me  empty  the  contents  of  each  and 
every  bottle  down  the  sink.  So  I  did  as  my  wife 
desired,  withdrew  the  cork  from  the  first  bottle  and 
poured  the  contents  down  the  sink,  with  the  excep- 
tion of  one  glass  which  I  drank. 

I  then  withdrew  the  cork  from  the  second  bottle 
and  did  likewise,  with  the  exception  of  one  glass 
which  I  drank.  I  then  extracted  the  cork  from  the 
third  bottle,  emptied  the  good  old  booze  down  the 
bottle  except  the  glass,  which  I  devoured.  I  pulled 
the  cork  from  the  fourth  sink  and  poured  the  bottle 
down  the  glass  when  I  drank  some.  I  pulled  the 
bottle  from  the  cork  of  the  next,  drank  one  sink 
out  of  it,  then  threw  the  rest  down  myself.  I  pulled 
the  sink  out  of  the  next  cork  and  poured  the  bottle 
down  my  throat.  I  pulled  the  next  bottle  out  of 
my  throat  and  poured  the  cork  down  the  sink.  All 
but  the  one  sink,  which  I  drank.  I  pulled  the  next 
cork  down  the  bottle  and  drank  the  cork. 

Well,  I  had  them  all  empty  and  I  steadied  the 
house  with  one  hand,  and  counted  the  bottles  with 
the  other,  which  were  twenty-four.  I  also  counted 
them  again  when  they  came  around  and  I  had  sev- 
enty-four, and  as  the  house  came  around  and  I 
counted  them  again.  Finally  I  had  all  the  houses 
and  bottles  counted  and  I  proceeded  to  wash  the 
houses  but  I  couldn't  get  the  bottle  into  the  brushes 
so  I  turned  the  bottles  inside  out  and  washed  and 
wiped  them  and  went  upstairs  and  told  my  other 
half  all  about  what  I  had  done,  and  OH  BOY 
!!!!!!  !)—(&%//***&&  MM!  I've  got 
the  wisest  little  nice  in  the  world. 


SEEING  THINGS 
By  BILL  CHILES 

The  other  night  upon  the  stair, 
I  saw  a  man  that  wasn't  there; 

He  wasn't  there  again  today; 
I  wish  that  he  could  go  away. 


Alcohol  is  a  useful  and  justifiable  analgesic  in 
DYSMENORRHEA  (O.  R.  Grimes,  Gadsden,  in  Jl.  Md.  Assn. 
Ala.,  April).  Its  use  is  frowned  upon  by  many  gynecolo- 
gists, and  there  is  some  slight  danger  of  habit  formation. 
However,  not  many  of  our  patients  are  so  poorly  balanced 
that  they  will  become  habitual  tipplers  if  we  advise  them  to 
take  a  toddy  2  or  3  times  daily  for  2  days  a  months. 


Mortality  from  cesarean  sections  (E.  G.  Langrock,  in 
N.  Y.  Slate  Med.  JL,  Mch.)  in  the  U.  S.  is  frightfully  high 
— at  least  6  to  10%  and  probably  higher  as  many  such 
deaths  are  never  reported. 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


BEYOND  THE  VEIL 
By  CROESBECK  WALSB 


While  I  sit  and  meditate 
Details  of  my  height  and  weight 
Notes  on  my  presumptive  age 
Group  themselves  upon  the  page. 
A  capricious  appetite 
Muddles  up  my  dreams  at  night, 
Such  a  tingling  of  the  skin 
Must  betoken  ill  within. 
There's  a  hurt  that  seems  to  rise 
From  the  bones  behind  my  eyes 
And  a  roaring  in  my  ears 
That  has  nettled  me  for  years. 
Now  that  I  am  in  full  swing 
Let  me  tell  you  everything. 
Lightning  pains  that  ebb  and  flow 
Antedate  my  vertigo. 
From  my  forehead  to  my  feet 
Sleeping  waking  on  the  street 
With  a  tumult  and  a  cry 
All  my  life  has  gone  awry. 

Shall  I  take  the  thyroid  test? 
That's  the  one  I  like  the  best. 
Bid  them  count  my  blood  once  more 
I  went  through  it  all  before. 
What  a  curious  game  to  play, 
How  I  wish  that  I  might  say, 


"Doctor,  doctor,  are  you  blind 
To  the  aegis  of  my  mind? 
Tests  that  prove  me  free  from  sin 
Mark  the  hour  your  chores  begin. 
Shun  the  skeptic's  point  of  view." 
Why  there's  nothing  wrong  with  you 
Only  sets  my  teeth  on  edge 
And  is  why  I  often  pledge 
Loyalty  to  other  schools 
Euphemistic  in  their  rules. 

Count  my  blood,  omit  no  test 

See  that  care  and  truth  invest 

Your  supply  of  midnight  oil 

In  the  effort  to  assoil. 

When  the  drudgery  is  done 

And  of  every  test  not  one 

But  proclaims  to  all  the  block 

I  am  healthy  as  a  clock 

Learn  the  roots  of  my  disease 

Spring  from  episodes  like  these. 

Are  you  searching  for  a  cause? 

Visualize  my  dumb  in-laws. 

Let  them  raise  my  husband's  pay 

So  that  I  can  move  away 

To  another  better  street 

Where  I  never  have  to  meet 

Those  who  watched  the  sqtialid  strife 

Of  my  early  married  life. 

Lend  me  beauty,  curl  my  hair 

Mold  me  so  that  men  will  stare 

And  the  neighbors  say  I  should 

Try  my  luck  at  Hollywood. 

Grant  me  more  than  words  to  bless 

Bread  that's  free  from  bitterness. 

Nuptial  life  that  knows  no  fear 

All  my  pains  will  disappear. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


Southern  Medicine  and  Surgery 

OrnciAi.  Okgan  ot 

Tri-State  Medical  Association  of  the 
Carolinas  and  Virginia 

Medical  Society  of  the  State  of 
North  Carolina 


James  M.  Norihington,  M.D.,  Editor 


-Richmond,  Va. 
-Charlotte,  N.  C 


Department  Editors 

Human   Behavior 
James  K.  Hall,  M.D,  

Dentistry 
W.  M.  RoBEY,  D.D.S 

Eyo,   Ear,  Note  and  Throat 
Eye,  Ear  and  Throat  Hospital  Group Charlotte,  N.  C. 

Orthopedic  Surgery 

O.  L.  Miller,  M.D j Charlotte,  N.  C. 

John  Stuart  Gaux,  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 


Obstetrics 
Henry  J.  Lancston,  M.D 

Gynecology 
Chas.  R.  Robins,  M.D - 

Pediatrics 
G.  W.  Kutscher,  jr.,  M.D. 


High  Point,  N.  C. 

Danville,  Va. 

Richmond,  Va. 

Asheville,  N.  C. 


General  Practice 
Wingate  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.  Gilmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 
N.  Thos.  Ennett,  M.D 


Radiology 


Allen  Barker,  M 
Wright  Clarkson 


- \ 

,  M.D. ) 


Greenville,  N.  C. 
..—Petersburg,  Va. 


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. 


A  Word  for  the  Practical  in  Medicine* 

The  great  Jewish  Prime  INIinister  of  Britain  said 
that  practical  men  are  men  who  practice  the  mis- 
takes of  their  ancestors;  but  the  politicians  do  not 
aim  at  consistency,  as  illustrated  by  Senator  L.  S. 
Overman  protesting  that  no  candidate  should  be 
held  accountable  for  what  he  says  in  a  political 
campaign — and  it  is  to  be  remembered  that  politi- 
cians are  campaigning  all  the  time.  We  frequently 
hear  it  absurdly  said  of  some  idea  that  theoreti- 
cally it  is  good,  but  it's  not  practical;  when  a  mo- 
ment's consideration  of  the  fact  that  practice  is 
theory  at  work  reveals  the  absurdity  of  any  such 
statement.  Any  theory  which  can  not  be  made  to 
work  is  a  bad  theory.  I  wish  to  bring  up  some 
points  in  medical  practice  which  appear  to  have 
practical  importance  and  to  be  based  on  a  sound 
theory.  The  theory  is  broad  and  comprehends  not 
only  the  medical,  but  I  believe  almost  every  other, 
aspect  of  life.  It  is  that  our  immediate  aim  in  any 
given  case  should  be  the  reasonably  satisjactory, 
rather  than  the  best.  • 

A  lot  of  frothy  stuff  is  spoken  and  written  about 
how  every  sick  person  is  entitled  to  the  best.  With- 
out going  into  the  intricacies  involved  in  the  ques- 
tion as  to  what  do  entitle  and  best  mean,  we  may  as 
well  face  the  fact  that  the  supply  of  the  best  of 
anything  is  too  limited  to  meet  the  demands  of 
more  than  a  very  small  number  of  persons.  Gen- 
erally, also — although  price  is  by  no  means  an  ac- 
curate criterion  of  value — the  scarcity  of  the  best 
places  it  beyond  the  reach  of  all  but  a  very  few 
purses. 

Most  of  us  accept  without  demur  and  are  con- 
tented with  reasonably  satisfactory  medical  care; 
and  when  circumstances  make  it  desirable  that  a 
case  be  taken  care  of  in  a  hospital,  reasonably  sat- 
isfactory equipment  and  attention  is,  in  the  vast 
majority  of  instances,  all  that  is  desired  and  all 
that  the  family  will  purchase;  but,  too  often,  not 
all  they  can  be  sold.  Sales-resistance  in  general  is 
weak  in  the  vast  majority:  resistance  to  "Of  course 
you  want  the  best"  for  a  sick  or  dead  person  is 
wellnigh  non-existent,  and  relatives  should  be  pro- 
tected and  fortified  against  such  insidious  attack. 

Anything  and  everything  bearing  on  his  patient's 
health  recovery  comes  within  the  scope  of  the  doc- 
tor's business;  therefore  keeping  down  every  item 
of  the  expense  of  illness  is  the  doctor's  concern,  for 
many  an  illness  is  prolonged  by  anxiety  about 
mounting  debt,  and  in  many  another  this  anxious 
worry  is  the  final  factor  that  brings  the  disease  to 
a  fatal  issue. 

We  live  in  an  age  of  slogans.     To  a  bromidic 


•Presented  to  the  Section  on  Practice  of  Medicine  of  the 
Medical  Society  of  the  State  of  N.  C,  meeting  at  Ashe- 
ville, May  6th. 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


quotation  of  "Man  can  not  live  by  bread  alone," 
a  bright  and  bored  gentleman  replied,  "No,  in 
North  Carolina  we  just  must  have  aphorisms." 
Most  of  these  aphorisms  are  more  false  than  true: 
many  are  silly,  e.  g.,  "The  customer  is  always 
right;"  but,  somehow,  the  vast  majority  of  us  ac- 
cept as  true  anything  we  hear  repeated  two  or 
three  times;  so  it  comes  about  that,  "You  get  what 
you  pay  for,"  "Health  is  the  greatest  thing  in  the 
world,"  and  "The  place  for  a  sick  man  is  in  a  hos- 
pital" pass  glibly  from  tongue  to  tongue,  with 
scarce  a  one  to  question.  On  serious  analysis, 
though,  how  much  of  fact  is  to  be  found  in  these 
statements?  As  the  miner  would  ask,  How  do  they 
assay?  No  one  of  these  statements  is  true.  Every- 
body knows  that  oftentimes  one  gets  less,  that  now 
and  then  he  gets  more,  and  that  its  very  seldom  he 
gets  just  what  he  pays  for. 

One  hears  education,  home,  electricity,  water, 
the  heat  of  the  sun,  Mother  Earth,  memory  and 
dozens  of  lesser  things — to  say  nothing  of  charity, 
character  and  mother-love — proclaimed  as  "the 
greatest  thing  in  the  world."  I  have  even  heard 
life-insurance  and  plumbing  so  proclaimed!  Super- 
latives— purple  adjectives — have  little  place  in 
language;  almost  none  in  a  doctor's  language;  and 
doctors  would  do  well  to  be  on  constant  guard 
against  being  beguiled  by  others'  use  of  them. 

Under  any  but  very  extraordinary  circumstances 
the  place  for  most  sick  men  who  have  beds  is  in 
their  own  beds. 

The  World  War  influenza  epidemic,  the  scarcity 
of  civilian  doctors  and  the  great  abundance  of 
money  made  circumstances  far  from  ordinary. 
Then  a  number  of  sick  greatly  in  excess  of  normal 
had  to  be  cared  for  by  a  number  of  doctors  far 
below  the  normal,  and  money  was  abundant.  Put- 
ting patients  into  hospitals  economized  on  the  item 
of  medical  care  which  was  scarcest.  Average  con- 
ditions are  rather  the  reverse:  present  conditions 
quite  the  reverse.  Now  there  is  no  more  than  the 
to-be-e.xpected  amount  of  sickness;  the  doctors  in 
government  employ  who  would  ordinarily  be  in 
private  practiie  are  occupied  mostly  with  those 
who  should  be  private  patients,  thus  reducing  con- 
siderably the  number  to  be  ministered  to  by  the 
private  practitioners:  ant  many  can  not  possibly 
pay  for  hospital  care,  while  the  number  who  can 
not  afford  to  pay  for  it  is  enormous.  But  expensive 
habits  are  heard  to  break  and  people  who  have 
been  taught,  under  these  extraordinary  circum- 
stances, by  their  doctors  that  "the  place  for  a  sick 
person  is  in  a  hospital,"  even  that  "it's  a  life  and 
death  matter,"  are  hard  to  unteach  when  circum- 
stances return  to  normal  and  below  normal.  Nice 
discrimination  is  among  the  highest  of  the  powers 
of  the  mind.     A  good  many  doctors,  apparently. 


take  no  note  of  the  changed  conditions  when  ad- 
vising their  patients.  A  few  months  ago  a  man 
who  had  never  been  a  patient  of  mine,  but  for 
whom  I  had  had  a  chance  to  do  a  favor,  came  to 
me  in  distress.  He  had  an  anal  fissure  and  an 
excellent  gentleman  and  surgeon  had  told  him  to 
"go  on  over  to  the  hospital;  I'll  'phone  and  give 
the  necessary  orders,  and  I'll  come  over  in  the 
morning  and  fix  you  up."  And,  almost  in  tears, 
this  father  of  a  large  family  on  small  wages  said 
to  me,  "Doctor,  I  can  not  possibly  spare  more 
than  $10.00  for  the  whole  job,"  and  I  knew  he 
couldn't  spare  that.  I  told  him  to  go  and  tell  the 
surgeon  what  he  had  told  me;  and  if  he  did  not 
arrange  to  do  the  work  in  his  office  and  dress  his 
wound  as  long  as  necessary  for  the  sum  he  named, 
to  come  back  and  I  would  see  that  it  was  taken 
care  of  by  someone  else.  Everything  went  off 
smoothly. 

This  surgeon  is  a  good  surgeon,  and  he  is  one 
of  the  best  and  kindest  men  I  know:  he  just  fol- 
lowed the  habit  that  he  got  into  during  the  fat 
years,  when  there  were  more  demands  on  his  time 
than  could  be  met  and  when  everybody's  pockets 
were  bulging. 

The  foreign  medical  journals,  particularly  the 
British,  carry  many  articles  which  show  solicitude 
about  the  expense  of  sickness.  It  is  no  uncommon 
thing  to  find  a  statement  that  a  certain  article  is 
usually  employed,  but  a  certain  other  article  is 
just  as  good  and  costs  less.  With  the  exception 
of  information  that  certain  drugs  may  be  had  more 
cheaply  under  their  chemical  names  than  under 
names  that  are  copyrighted,  if  such  statements 
appear  in  our  own  journals  they  escape  my  notice — 
and  I  am  on  the  lookout  for  them. 

We  are  too  prone  to  prescribe  well-touted  drugs 
of  unproved  value  and  of  which  everything  is  un- 
certain except  their  exorbitant  price.  This  is  poor 
practice  among  the  wealthy:  it  is  a  serious  wrong 
in  cases  in  which  the  cost  of  a  day's  supply  of  the 
drug  consumes  a  large  part  of  the  daily  wage  of 
the  family. 

In  many  instances  what  is,  on  its  face,  the  second 
or  third  best  is  really  the  best;  for  to  many  a 
sick  man  the  distress  of  accumulating  debts  which 
he  can  see  no  way  of  paying,  even  by  depriving  his 
family  of  the  ordinary  necessities  of  life,  will  weigh 
more  against  his  recovery  than  the  more-or-less 
hypothetical  advantage  of  "the  best"  treatment  will 
weigh  in  favor  of  recovery. 

The  highly  trained  nurse  is  one  of  the  finest 
products  of  the  past  century.  Under  favorable 
circumstances  her  services  in  illness  are  invaluable. 
But  the  family  on  average  income  can  not  pay  for 
the  services  of  a  registered  nurse  through  an  illness 
of  any  considerable  length;  and  in  many,  perhaps 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


most,  homes  other  help  can  be  of  more  practical 
usefulness  in  sickness. 

Many  a  patient  and  many  a  friend  tells  about 
going  to  such  a  place  and  having  "a  complete  ex- 
amination." Some  doctors  allege  that  they  make  a 
complete  examination  at  every  first- visit.  I  wonder 
what  they  mean  by  complete.  If  one  of  you  has 
what  appears  to  be  an  ordinary  headache  it  is 
highly  improbable  that  you  will  do  more  than  take 
a  dose  of  aspirin  and,  if  you  have  the  opportunity, 
lie  down  for  a  while  in  a  dark  room.  If  your 
headache  is  persistent  or  recurs  frequently,  in  the 
absence  of  manifest  cause,  you  will  go  to  a  doctor 
expecting  him  to  examine  into  your  case  suffciently 
to  resonably  satisfy  himself  that  the  cause  is  found; 
not  that  you  will  be  given  a  routine  or  complete 
examination,  or  be  "put  through  the  naill."  No  one 
in  his  senses  will  deny  that,  if  every  person  who 
consults  a  doctor  were  subjected  to  a  minutely 
detailed  examination  supplemented  by  scopic 
investigations  through  all  the  external  orifices  and 
through  x-ray  and  electrocardiographic  investiga- 
tion; and  his  urine,  feces,  gastric  juice,  blood, 
sputum,  spinal  fluid  and  discharges  examined  chem- 
ically, microscopically  and  culturally,  some  disease 
would  be  discovered  that  now  remains  undiscov- 
ered: but  there  are  not  enough  doctors  in  the  world 
to  do  all  this;  there  is  not  enough  money  to  pay 
for  all  this;  and  patients  in  general  have  too  much 
sense  to  submit  to  it.  As  it  is,  a  lot  of  them  are 
being  driven  to  cultists  by  over-examination.  They 
are  made  uncomfortable  by  reasoning  that  some- 
thing very  serious  must  be  wrong  to  require  all  this 
investigation,  and  they  flee.  A  great  many  remain 
with  us  taking  their  examination-induced  phobias 
from  one  doctor  to  another.  There  is  a  tale  told 
in  Charlotte  which  has  a  bearing  on  some  of  this. 
A  patient  on  the  table  awaiting  operation  under 
spinal  anesthesia,  asked  where  his  surgeon  was, 
and  getting  the  reply,  "He  will  be  in  in  a  minute; 
he  always  says  a  word  of  prayer  before  he  oper- 
ates"; the  patient  sprang  from  the  table,  demanded 
his  clothes  and  announced  that  if  it  was  all  that 
serious  he  was  going  on  home — and  he  did. 

When  a  patient  tells  you  he  has  an  ague,  burn- 
ing fever  and  drenching  sweat  every  other  day  and 
feels  pretty  well  on  the  alternate  days,  how  much 
more  do  you  know  after  finding  the  malaria  organ- 
ism in  the  blood  than  you  knew  before?;  and  in 
what  way  is  your  treatment  influenced  by  whether 
or  not  the  organisms  are  found? 

Two  or  three  years  ago  a  radiologist  friend  gave 
me  a  glowing  account  of  the  efficacy  of  the  x-rays 
in  treating  boils.  I  told  him  I  did  not  doubt  that 
it  was  the  best  treatment,  meaning  that  it  would 
effect  cure  most  promptly  and  least  painfully;  but 
I  added   the  opinion  that   if   a   doctor  practicing 


medicine  in  a  village  near  Charlotte  were  to  at- 
tempt to  refer  to  a  radiologist  every  patient  who 
came  to  him  because  of  boils  he  would  make  of 
himself  a  laughing-stock.  Naturally,  people  would 
ask,  If  he  can't  treat  boils,  what  can  he  treat; 
what's  he  good  for — and  in  just  a  little  while  he 
would  have  moved  on,  or  his  wife  would  be  taking 
in  boarders,  according  to  whether  he  could  learn 
how  broad  a  meaning  the  word  best  has.  For  the 
village  to  lose  the  care  that  can  be  given  by  no  one 
but  a  doctor  who  lives  right  there  is  too  high  a 
price  to  be  paid  for  getting  boils  well  in  a  few  days 
less  time. 

It  is  of  great  practical  importance  that  doctors 
exercise  political  influence  and  that  they  collect 
more  of  their  fees  than  they  are  now  collecting.  A 
communication  from  Dr.  W.  C.  Bostic,  of  Forest 
City,  recalls  and  emphasizes  an  idea  I  have  long 
had  bearing  on  both  political  action  and  collections. 
Through  Dr.  Bostic's  initiative  it  has  been: 

Resolved,  that  the  Rutherford  County  Medical 
Society  and  the  Rutherford  County  Club  favor  the 
present  schedule  of  license  fees  for  automobiles  for 
the  State  of  North  Carolina.  That  twenty-five  per 
cent,  of  the  fees  collected  for  automobile  license 
plates  be  used  to  furnish  insurance  to  cover  liabili- 
ties for  each  and  every  automobile  licensed  by  the 
State. 

The  amount  of  insurance  to  be  applied  on  per- 
sonal injuries,  medical  and  hospital  treatment  and 
to  the  repair  of  damage  to  automobiles  and  other 
vehicles  and  property. 

That  this  body  in  session  furnish  our  Represen- 
tative and  Senators  with  copies  of  the  resolution 
urging  them  to  see  that  same  is  enacted  into  law 
at  once. 

That  each  and  every  member  write  or  wire  their 
endorsement  of  this  measure  and  in  every'  way 
urge  the  passage  of  such  a  bill  in  the  present  Leg- 
islature  

The  State  may  purchase  this  insurance  to  be 
furnished  the  owners  of  automobiles  from  reliable 

insurance  companies at  a  very  low  rate; 

but  if  not  able  to  purchase  it  at  a  very  low  rate 
then  the  State  should  create  a  company  to  handle 
this  insurance  and  also  other  insurance  needed  to 
cover  other  State  controlled  institutions. 

At  first  glance  my  thought  was  that,  inasmuch 
as  the  adoption  of  the  plan  would  place  us  at  the 
mercy  of  the  insurance  companies,  it  would  be  nec- 
essary that  the  State  do  its  own  insuring;  on  read- 
ing further  it  was  seen  that  this  was  provided  in 
the  resolution.  Wisely  this  provision  is  extended 
to  all  insurance  purchased  by  the  State.  The  stock 
argument  of  the  insurance  agent  that  you  can  not 
afford  to  carry  your  own  risk,  but  his  company 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


287 


can  because  of  the  volume  of  business.  The  State 
has  the  volume  of  business. 

Going  back  to  the  automobile  liability  insurance, 
if  there  is  any  such  thing  as  cooperation  between 
different  groups  of  employees  of  the  State,  it  is 
reasonable  to  suppose  that  there  will  be  some  effort 
made  to  enforce  the  laws  against  dangerous  driving 
when  it  is  known  that  every  wreck  costs  everybody 
in  the  State  something. 

In  the  medical  journal  of  this  State  there  have 
been  carried  in  recent  years  two  excellent  articles 
by  Dr.  Alfred  Worcester,  of  Harvard,  on,  respect- 
ively, "The  Care  of  the  Dying"  and  "The  Care  of 
the  Dead."  The  demand  for  reprints  of  the  former 
article  has  been  greater  than  for  any  other  thing 
published  unner  the  present  management  of  the 
journal,  and  the  second  is  worthy  of  the  same 
popularity  and  of  adoption  as  a  rule  and  guide. 
There  Dr.  Worcester  speaks  convincingly  of  the 
unreasonableness  of  attempting  to  prevent  or  delay 
the  return  of  the  dead  human  body  to  its  original 
dust.  Pathetic,  futile,  expensive  attempts  to  ac- 
complish an  end  undesirable  to  society;  and,  did 
relatives  but  know  themselves,  undesired  by  them! 
It  is  well  within  the  scope  of  a  doctor's  duty  to 
inculcate  these  truths,  to  fortify  the  bereaved 
against  the  wiles  of  the  undertaker  and  against 
their  own  vanity,  and  to  exert  his  influence  against 
the  vulgarity  of  ostentation  in  disposing  of  the 
dead. 

The  fact  that  each  of  us  can  arrange  for  decent 
disposal  of  his  own  remains  by  cremation  at  a 
total  and  final  cost  of  no  more  than  $100.00  has 
already  interested  many  doctors  in  the  State.  My 
own  insurance  is  made  payable  to  my  family,  not 
to  an  undertaker. 

I  realize,  gentlemen,  that  to  advise  a  patient  is 
one  thing  and  to  get  him  to  accept  and  follow 
advice  is  quite  another;  that  although  you  may 
know  that  you  can  take  care  of  a  patient  at  low 
cost  and  reasonably  well,  he  may  elect  expensive 
examinations  and  consultations  and  refuse  to  be 
dissuaded;  that  some  will  demand  the  most  ex- 
pensive room  in  the  hospital  and  keep  it  filled  with 
hothouse  flowers,  when  a  ward  bed  and  yard  blos- 
soms would  be  much  more  in  order;  that  a  few 
revel  in  being  examined  by  the  hour,  in  telling 
how  thorough  the  doctor  was  and  in  lugging  around 
100-page  clinic  and  hospital  records  of  what  has 
been  found  out  about  and  done  to  them.  I  am 
asking  only  that  your  influence  be  exerted  on  the 
side  of  discrimination. 

I  realize  that  a  few  doctors  are  prone  to  examine 
their  patients  too  little,  to  ask  some  questions  and 
write  a  prescription.  All  of  us  see  patients  die— 
e.g.,  of  cancer  of  the  larynx  or  rectum — who  would 
have  lived  years  longer  if  they  had  been  examined 


when  they  first  made  complaint  to  their  doctors. 
But  you  are  being  constantly  warned  about  going 
to  this  extreme,  while  seldom  is  a  voice  raised 
against  going  to  the  other  extreme. 

Of  necessity  and  because  of  a  time  limit  imposed 
for  your  protection,  I  leave  much  unsaid.  I  trust 
I  have  not  thrown  away  the  child  and  saved  the 
afterbirth. 

Scores  of  practical  points  that  might  well  have 
been  included  will  occur  to  each  of  you.  I  trust 
many  will  be  brought  out  in  the  discussion. 

It  is  said  that  the  famous  Dutch  painter.  Van 
Dyck,  was  once  asked:  "How  do  you  mix  your 
paints?"  Van  Dyck,  as  I  have  recently  learned, 
was  married  to  the  daughter  of  the  Scottish  physi- 
cian, Dr.  Patrick  Ruthven.  I  like  to  regard  the 
possibility  that  the  doctor  influenced  the  artist  to 
reply  as  he  did:    "With  reason,  sir." 


The  Development  of  Roentgenology 
The  celebration  on  April  22  nd  by  Drs.  R.  H. 
Lafferty  and  C.  C.  Phillips,  of  the  fortieth  year  of 
the  x-ray  and  of  the  twentieth  year  of  their  use  in 
Charlotte,  suggested  that  this  would  be  a  fitting 
time  for  outlining  the  stages  in  the  utilization  of 
this  still-marvelous  agent. 

We  are  indebted  to  Dr.  Lafferty  for  the  outline 
which  follows: 

Any  one  who  has  been  observing  the  develop- 
ment of  roentgenology  for  the  last  forty  years  has 
seen  many  startling  and  interesting  developments. 

When  Wilhelm  Konrad  Rontgen,  working  in  his 
laboratory  at  Wiesbaden  in  the  last  few  days  of 
1895,  discovered  the  ray  which  was  first  called  the 
x-ray — x  being  a  long-accepted  symbol  for  the  un- 
known or  little-understood — he  was  using  an  excited 
Crookes  tube. 

The  developments  since  that  time  have  been  of 
profound  interest  to  all  educated  persons,  particu- 
larly to  the  physicist  and  the  physician.  In  most 
of  the  early  experiments  the  same  type  of  apparatus 
was  used.  Dr.  Henry  Louis  Smith  at  Davidson 
College  and  the  three  students  who,  on  January 
12th,  1896,  secretly  entered  the  physical  laboratory 
and  made  the  first  x-ray  pictures  in  America,  were 
using  the  same  type  of  apparatus  that  Rontgen 
used.  Dr.  Smith  used  this  apparatus  in  the  village 
of  Harrisburg,  in  Cabarrus  County,  with  a  battery 
of  storage  cells  to  generate  the  current,  for  localiz- 
ing the  first  foreign  body  ever  localized  in  the 
trachea.  Instead  of  making  a  plate,  however,  the 
fluoroscope  was  used,  and  so  no  permanent  photo- 
graphic record  was  made. 

Probably  the  next  step  in  the  physical  develop- 
ment of  the  x-ray  was  the  utilization  of  the  static 
machine  for  giving  a  high-voltage  current  with  cer- 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


tain  modifications  of  the  old  Crookes  tube.  In 
using  these  machines  many  difficulties  were  en- 
countered. Inside  the  cabinet  we  were  compelled 
to  use  either  calcium  chloride  or  sulphuric  acid  for 
absorbing  the  moisture.  The  penetrating  power  of 
the  tubes  had  to  be  tested  and  generally  the  early 
operators  used  the  small  hand-fluoroscope  and  test- 
ed on  their  own  hands  to  see  how  well  the  bones 
could  be  seen.  As  a  result  of  this  many  fingers 
and  hands  and  some  lives  were  lost  from  burns. 
The  exposures  were  made  on  photographic  plates 
and  it  took  too  long  a  time  to  be  practically  useful. 
After  reporting  the  long  exposures  that  were  nec- 
essary to  make  a  plate  of  a  hand  or  an  arm  for 
locating  a  bullet,  Dr.  Pupin  gives  Edison  the  credit 
for  suggesting  that  a  screen  covered  with  some 
fluorescent  substance  be  placed  against  the  emul- 
sion of  the  plate  which  would  add  an  additional 
glow  and  thus  lessen  the  length  of  the  exposure. 
The  wonderful  result  of  this  idea  has  been  devel- 
oped to  a  very  high  degree  in  the  modern  intensi- 
fying screen  and  the  making  of  plates  and  screens 
of  much  greater  speed.  The  change  from  the  old 
glass  plate  coated  on  one  side  to  the  film  which 
carries  a  double  coating  so  two  intensifying  screens 
may  be  used  with  the  film  between  has  enabled 
us  to  make  more  rapid  exposures  and  obviate  the 
dangers  and  the  inconveniences  incident  to  inevi- 
table breaking  of  some  of  these  plates. 

Next  a  motor  was  used  to  rectify  the  current 
and  a  transformer  to  step  up  the  voltage.  This 
type  of  machine  was  used  for  many  years.  The 
transformers  were  made  larger  and  still  larger  and 
stronger  until  today  there  are  a  few  that  will  in- 
crease the  voltage  to  something  like  a  million  volts. 
During  this  time  the  tube  passed  through  many 
stages  of  development,  various  gases  being  used  to 
give  "hardness"  or  "softness"  to  the  tubes — de- 
creasing the  amount  of  gas  in  the  tube  giving  a  high 
voltage  and  a  harder,  more  penetrating  ray. 

About  1913  Dr.  W.  D.  Coolidge,  of  General 
Electric  Company,  perfected  the  hot-cathode  tube 
which  permitted  the  current  to  cross  the  vacuum 
tube  on  heat  waves  and  by  varying  the  intensity 
of  this  it  could  easily  cause  a  variation  in  the  pene- 
tration of  the  ray.  This  tube  before  very  long 
almost  entirely  superseded  the  gas  tube. 

The  next  step  in  the  development  of  the  machine 
was  the  introduction  into  the  current  of  the  Kene- 
tron  type  of  tube  to  rectify  the  current.  There  is 
also  made  today  the  tube  that  dissipates  as  heat 
half  of  the  alternating  current  received  using  only 
one  side  of  the  wave.  This  does  away  with  the 
rectification  by  motor  or  by  the  Kenetron  tube. 

When  Rontgen  demonstrated  his  discovery  to 
the  Academy  of  Medicine  early  in  1896,  Dr.  Kolli- 
ker,  Professor  of  Anatomy  at  the  College,  upon 


seeing  a  plate  of  the  hand  and  also  fluoroscopic 
images  of  the  bones  of  the  hand,  immediately  an- 
nounced that  it  would  prove  of  great  value  in  the 
study  of  the  bones  of  the  body. 

For  some  time  after  this  the  x-rays  were  used 
mainly  for  observing  bones  and  opaque  foreign 
bodies;  then,  with  improved  apparatus  and  tech- 
nique, it  was  found  that  distinctiveness  could  be 
made  nice  enough  to  differentiate  diseased  from 
health  lung  tissue,  and  thus  pulmonary  diagnosis 
was  brought  into  the  x-ray  field;  later  the  intro- 
duction of  opaque  media  and  various  drugs  for 
rendering  the  kidneys  and  gallbladder  visible  great- 
ly further  enlarged  the  usefulness  of  these  rays. 

When  we  delve  into  the  field  of  radiotherapy  the 
constant  trend  is  to  increase  the  voltage  and  at  the 
same  time  increase  filtration  of  the  ray  that  reaches 
the  patient.  This  leaves  the  ray  of  very  short 
wave  length  approaching  quite  near  to  the  gamma 
ray  of  radium  to  be  applied  to  the  area  that  is 

being  treated.  

Beware 

In  the  past  month  messages  have  come  from  two 
good  doctors  in  our  State  suggesting  that  their  fel- 
low-doctors be  warned  against  paying  out  money 
to  strangers  without  looking  well  into  their  creden- 
tials. 

One  of  these  warnings  is  against  buying  any  sort 
of  insurance  policy  without  first  ascertaining  from 
our  State  Insurance  Department  that  the  company's 
character  is  acceptable  to  this  Department. 

The  other  warning  is  against  handing  over  in- 
struments and  money  to  strangers  who  come  around 
representing  themselves  as  being  in  the  instrument 
repairing  or  replating  business. 

Right  away  a  good  many  will  say,  "Another 
proof  of  the  well-known  gullibility  of  doctors.  You 
can't  teach  them  anything."  Doctors  are  no  more 
gullible  than  other  folks.  Gullibility  is  a  very 
general  characteristic;  and  doctors  can  be  taught  a 
great  deal.  So  the  readers  of  this  journal  are 
warned,  as  they  will  be  warned  again  and  again, 
of  the  folly  of  handing  money  or  anything  else  of 
value  to  any  stranger  until  he  submits  conclusive 
evidence  of  his  reliability. 

An  honest  man  does  not  mind  giving  surety;  a 
dishonest  man  should  certainly  be  required  to  fur- 
nish surety. 

In  this  connection  we  again  suggest  the  making 
of  our  invariable  rule  not  to  allow  any  one  to  sell 
you  anything  in  your  office,  and  to  buy  nothing 
involving  any  considerable  sum  without  sleeping  on 
it.    "Coolness  and  counsel  come  with  the  night." 


-,  of 


In  our  issue  for  March,  on  p.  140:     "Dr. 

Anderson,  S.  C,"  as  taken  from  Marion  Sims'  book,  on 
request  of  the  Surgeon  General's  Library,  is  found  to  have 
been  Dr.  Philip  A.  Wilhite. 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Tri-State  Medical  Association  of  the 
Carolinas  and  Virginia 

Thirty-Eighth  Annual  Meeting 

Columbia,  South  Carolina 

February  17th-18th,  1Q36 


The  Thirty-Eighth  Annual  Meeting  of  the  Tri- 
State  Medical  Association  of  the  Carolinas  and  Vir- 
ginia was  called  to  order  by  Dr.  Marion  H.  Wyman, 
Chairman  of  the  Committee  on  Arrangements,  in 
the  ballroom  of  the  Jefferson  Hotel,  Monday,  Feb- 
ruary 17th,  1936,  at  9:25  a.  m. 

Dr.  Wyman:  Dr.  DuBose,  President  of  the  Co- 
lumbia Medical  Society,  will  say  a  word  of  welcome. 
Dr.  Theodore  M.  DuBose,  jr. 

GREETING 

Theodore  M.  DuBose,  Jr.,  M.D. 
President,  Columbia  Medical  Society 
On  behalf  of  the  Columbia  Medical  Society,  it 
is  my  great  pleasure  to  welcome  you  gentlemen  to 
our  city.  We  consider  ourselves  greatly  honored  in 
the  presence  of  such  a  distinguished  gathering,  and 
we  trust  that  your  time  spent  here  will  be  not  only 
profitable  but  pleasant  enough  to  have  you  come 
back  again  soon.      (Applause.) 

RESPONSE  TO  GREETING 
C.  C.  Orr,  M.D. 
President,  Tri-State  Medical  Association 
Mr.  Chairman,  our  Secretary  has  somewhat  an- 
ticipated the  warm  reception  accorded  us  here,  for 
in  his  preliminary  remarks  to  the  program  he  states: 
"Columbia,  the  capital  city  of  South  Carolina,  has 
entertained  the  Tri-State  Medical  Association  of 
the  Carolinas  and  Virginia  on  many  occasions,  and 
each  of  these  has  been  a  highly  successful  meeting. 
The  progressive  spirit  of  the  doctors  of  Columbia 
assures  enthusiastic  support  of  all  that  is  best 
in  medicine,  and  the  social  charm  of  South  Caro- 
linians constitutes  one  of  the  compelling  reasons 
for  attending  the  meeting."  Our  Secretary  has  al- 
ready responded  beautifully,  and  there  is  little  left 
for  me  to  say.  But  to  you,  Dr.  DuBose,  and  to 
the  members  of  the  Columbia  Medical  Society,  in 
behalf  of  myself,  the  members,  friends,  and  guests 
of  the  Tri-State  Medical  Association,  I  want  to 
say  we  thank  you  most  cordially  for  the  kind  re- 
ception into  your  midst  and  into  your  hearts.  We 
do  not  come  to  you  as  strangers;  neither  do  we 
feel  that  we  are  in  the  midst  of  strangers.  We  are 
closely  drawn  together  by  our  geographical  situa- 
tion, by  our  interwoven  history,  and  by  the  number 
of  distinguished  men  and  scientists  that  the  three 
states  have  given  to  the  profession. 


When  George  Washington  was  President  of  the 
United  States,  he  had  occasion  to  pay  a  visit  to 
his  aged  mother,  living  at  the  old  home  in  Virginia. 
As  he  neared  the  home  a  messenger  was  dispatched 
to  announce  his  arrival.  The  messenger  found  the 
mother  of  Washington  attending  to  her  house- 
hold duties  as  usual.  Addressing  her,  he  an- 
nounced: "His  Excellency,  the  President  o  fthe 
United  States,  is  approaching  to  pay  his  respects." 
She  replied:  "You  go  back  and  tell  George  to  come 
right  on;  I  shall  be  glad  to  see  him."  Dr.  DuBose, 
and  members  of  the  Columbia  Medical  Society,  we 
feel  that  your  message  to  us  is:  "Come  right  on; 
we  are  glad  to  see  you."      (Applause.) 

Medicine  is  not  static;  it  is  progressive.  We 
have  our  social,  economic  and  scientific  problems. 
It  has  been  said  that  medicine  is  at  the  cross- 
roads, not  knowing  exactly  which  way  to  go. 
Hence  it  behooves  us  to  keep  studying  and  reading 
and  writing  papers  and  holding  such  meetings  as 
we  have  here  today,  for  by  these  gatherings  we  are 
greatly  benefited  both  socially  and  scientifically. 

We  appreciate,  Mr.  Chairman,  the  opportunity 
accorded  us  for  holding  these  gatherings.  I  know 
you  are  delighted  to  have  us  with  you,  and  we  are 
pleased  to  be  here.  Again,  in  behalf  of  the  mem- 
bers of  the  Tri-State  Medical  Association,  I  want  to 
thank  you  very  heartily  for  your  cordial  and 
friendly  welcome.      (Applause.) 

RECOMMENDATION   OF  PRESIDENT   ORR,   FROM 
PRESIDENTIAL  ADDRESS 

Exercising  the  privilege  of  my  office  I  desire  to 
present  a  few  suggestions  for  the  consideration  of 
the  Council  and  members  of  the  Association. 

First:  Last  year  we  had  an  encouraging  in- 
crease in  membership  and  we  think  this  year  will  be 
as  good  or  better;  but  there  are  still  a  number  of 
good  physicians  in  each  of  our  three  States  whose 
addition  to  our  ranks  would  be  helpful  to  them  and 
helpful  to  us.  I  suggest  the  appointment  of  a 
membership  committee  in  each  State  to  invite  them 
to  become  members. 

Second:  I  suggest  that  honorary  membership  be 
granted  to  those  members  of  this  Association  who 
have  been  members  and  paid  dues  regularly  for 
twenty-five  years,  and  that  honorary  members  be 
entitled  to  all  privileges  of  the  Association  without 
payment  of  dues. 

Third:  I  suggest  that  the  three  Councillors 
elected  each  year  be  chosen  by  the  body  of  the 
Association  instead  of  by  the  Council. 

Fourth:  I  suggest  that  the  President  be  elected 
one  year  in  advance  of  the  beginning  of  his  term 
of  office  and  that  the  President-Elect  be  chosen 
from  the  State  in  which  the  next  year's  meeting 
will  be  held. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


I  desire  that  a  committee  be  appointed  to  con- 
sider these  suggestions  and  if  the  committee  ap- 
proves them  to  put  them  in  proper  form  for  presen- 
tation to  the  Council  and  possible  later  adoption 
or  rejection  by  the  Association. 


MEMORIAL  SERVICE 


Dr.  Kirby  G.  Averitt 

By  J.  F.  HiGHSMiTH,  SR.,  M.D.,  Fayetteville 

Kirby  Gladstone  Averitt  was  born  March 
10th,  1870,  at  Stedman,  Cumberland  County,  N.  C. 
After  graduating  with  honors  from  the  Clement 
High  School  in  1887,  he  entered  the  University  of 
Maryland  in  1890  and  graduated  from  that  Institu- 
tion in  1893.  He  was  licensed  by  the  Board  of 
Medical  Examiners  of  N.  C,  May  13th,  1893. 

On  September  ISth,  1935,  Dr.  Averitt,  while  at 
his  post  of  duty  in  attending  a  very  difficult  obstet- 
rical case,  was  suddenly  stricken  with  an  attack  of 
cerebral  hemorrhage  and  three  days  later  he  died 
in  Highsmith  Hospital.  He  had  been  about  his 
regular  duties  and  was  hard  at  work  until  the 
summons  came.  His  son,  who  was  with  him  while 
attending  this  last  case,  requested  that  he  go  home, 
but  he  insisted  upon  staying  with  his  case  until 
he  had  himself,  under  most  sterile  precautions, 
catheterized  the  patient  preparatory  to  delivery. 

Dr.  Averitt  was  the  old  time  type  general  prac- 
titioner and  will  be  greatly  missed.  He  worked 
hard  and  played  little.  He  attended  postgraduate 
courses  and  lectures  on  pediatrics  and  internal 
medicine  at  various  times.  He  served  his  coun- 
try in  the  Volunteer  Medical  Service  Corps  at  Fort 
Bragg,  N.  C.  He  was  a  past-President  and  Hon- 
orary Member  of  the  Cumberland  County  Medical 
Society,  and  an  Honorary  Fellow  of  the  Medical 
Society  of  North  Carolina  of  which  Society  he  was 
Vice-President  in  1925.  Dr.  Averitt  was  a  member 
of  the  Cumberland  County  Board  of  Health  for 
many  years.  At  the  time  of  his  death  he  was  a 
member  of  the  State  Board  of  Medical  Examiners, 
and  he  had  served  as  President  of  that  body.  He 
was  a  Fellow  of  this  Association  and  of  the  Amer- 
ican Medical  Association.  Dr.  Averitt  was  well 
informed  on  all  medical  subjects,  and  had  one  of 
the  best  libraries  of  any  general  practicing  physician 
in  the  State. 

Dr.  Averitt  will  be  greatly  missed  in  the  pro- 
fession. His  counsel  was  extensively  sought,  and 
his  influence  will  be  handed  down  for  years  to 
come. 

Leaves  have  their  time  to  fall 
And  flowers  to  wither  at  the  North  wind's  breath, 
And  stars  to  set;  but  thou  has  all  Seasons 
For  thine  own — O  Death! 


Dr.  Alexander  McNiel  Blair 

By  C.  H.  Cocke,  M.D.,  Asheville,  N.  C. 

Governor   for   North   Carolina,    American   College   of 
Physicians 

Alexander  McNiel  Blair  was  born  in  Buffalo, 
N.  Y.,  July  30th,  1873,  and  died  at  his  home  in 
Southern  Pines,  N.  C,  November  27th,  1935. 

Receiving  his  early  education  in  the  public 
schools  of  Buffalo  and  Niagara  University,  he  was 
graduated  from  the  Medical  Department  of  the 
University  of  Niagara  in  1897.  Dr.  Blair  settled 
in  Southern  Pines,  in  1903,  where  he  was  actively 
engaged  in  practice  save  for  the  summer  months, 
which  he  spent  in  Bethlehem,  N.  H.,  also  in  active 
work.  His  postgraduate  work  was  done  at  Har- 
vard University,  Polyclinic  Postgraduate  Hospital 
in  Philadelphia,  Children's  Hospital  in  Boston,  and 
the  Royal  Victoria  Hospital  in  Montreal.  He  was 
a  member  of  the  Volunteer  Medical  Service  of  the 
staff  of  the  Lee  County  Hospital,  Sanford,  N.  C. 
He  became  a  Fellow  of  the  American  College  of 
Physicians  in  1925,  and  in  addition  held  member- 
ship in  the  Moore  County  Medical  Society  of  which 
he  was  President;  the  N.  C.  State  Medical  Society; 
the  Tri-State  Medical  Association;  the  Southern 
Medical  Association,  and  the  American  Medical 
Association,  as  well  as  being  a  Fellow  of  the  Amer- 
ican College  of  Radiology. 

Dr.  Blair  was  actively  interested  in  social  and 
civic  matters  in  his  community,  was  a  director 
in  the  Citizens  Bank  &  Trust  Co.,  and  a  member 
of  the  Presbyterian  Church.  His  chief  medical 
interests  were  diseases  of  the  chest  and  stomach, 
though  his  work  was  not  entirely  limited  to  those 
phases  of  internal  medicine.  At  the  time  of  his 
death,  he  was  the  oldest  practitioner  in  service  in 
Southern  Pines. 


Dr.  Samuel  Harmon 

By  J.  H.  McIntosh,  M.D.,  Columbia 

"A  King  once  said  of  a  Prince  struck  down, 
Taller  he  seems  in  death." 

And  in  the  nigh  on  to  seventy  years  that  I  have 
compassed  I  have  known  no  one  to  whom  these 
words  more  aptly  apply  than  to  Dr.  Harmon. 

Those  of  us  who  knew  him  intimately  were  so 
accustomed  to  his  uprightness,  his  steadfastness, 
his  forthrightness  and  his  real  worth  that  it  has 
taken  his  death  to  make  us  realize  what  a  man 
among  men  he  was. 

Samuel  E.  Harmon  was  born  in  Lexington 
County,  South  Carolina,  on  August  24th,  1871,  and 
his  birthplace  is  now  deep  under  the  waters  of  Lake 
Murray.  His  mother  died  when  he  was  only  two 
years  old  and  he  was  reared  until  he  was  seventeen 
by  his  maternal  grandmother.  He  came  from  that 
stratum  that  is  the  real  backbone  of  any  country — 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


the  great  middle  class.  I  have  often  heard  him  say 
that  when  his  father,  a  young  Confederate  soldier, 
came  home  after  the  surrender  of  Lee's  army,  he 
found  everything  in  ruins;  and  that  he  started  life 
with  one  blind  mule  on  a  rented  tract  of  land.  The 
father  was  an  energetic  and  successful  farmer  who 
at  the  time  of  his  death  had  accumulated  a  very 
considerable  estate. 

Dr.  Harmon  was  educated  in  the  public  schools 
of  Lexington  County  and  in  the  Columbia  City 
Schools;  and  then  spent  one  year  at  Newberry 
College.  He  then  began  the  study  of  medicine  at 
the  University  of  Tennessee  at  Memphis,  and  was 
graduated  from  this  institution  with  the  degree  of 
Doctor  of  Medicine  in  1899.  He  then  went  to 
New  York  City  and  entered  the  Post  Graduate 
Medical  School  for  another  year  of  study. 

He  returned  to  Columbia  in  the  spring  of  1900 
and  began  his  life  work  in  the  general  practice 
of  medicine  and  surgery.  After  continuing  for 
twelve  years  in  general  practice,  in  1912  he 
limited  his  practice  to  surgery.  And  in  this  field 
he  has  been  most  eminently  successful. 

He  was  for  thirty-five  years  an  active  and  useful 
member  of  The  Columbia  Medical  Society:  of  The 
Second  District  Medical  Association;  The  South 
Carolina  State  Medical  Association;  The  Tri-State 
Medical  Association;  The  Southern  Medical  Asso- 
ciation; and  The  American  Medical  Association. 
He  was  also  a  member  of  The  Association  of  Sur- 
geons of  the  Seaboard  Airline  Railroad  Company, 
and  a  Fellow  of  The  American  College  of  Surgeons. 

He  has  served  as  President  of  The  Columbia 
Medical  Society;  President  of  The  Second  District 
Medical  Association;  and  at  the  time  of  his  death 
was  the  active  and  useful  President  of  The  South 
Carolina  State  Medical  Association.  For  sixteen 
years  he  was  on  the  Board  of  Councillors  of  the 
State  Medical  Association  and  for  twelve  years 
was  the  Chairman  of  that  body.  And  each  of  these 
positions  he  has  filled  with  marked  earnestness, 
fidelity  and  usefulness. 

In  every  noteworthy  life  there  are  always  dis- 
tinguishing traits.  In  the  life  of  Dr.  Harmon  to 
me  the  distinguishing  trait  was  his  courage.  This, 
I  think,  is  best  illustrated  by  an  incident  early  in 
his  career,  but  ever  afterwards  his  life  revealed 
this  same  high  courage.  When  Dr.  Harmon  began 
the  study  of  medicine  the  preceptorship  was  still 
in  vogue.  Dr.  Harmon  chose  for  his  preceptor  a 
physician  who  to  all  appearances  was  the  most 
active,  most  up-to-date  and  most  successful  doctor 
in  the  community.  His  offices  were  fhe  most  com- 
plete, he  drove  the  finest  of  horses,  and  he  had  a 
large  number  of  people  fooled.  But  at  the  same 
time  this  man  was  everything  a  real  doctor  should 
not  be.     Dr.  Harmon  entered  this  office  and  for 


some  months  worked  there.  At  last  he  found  out 
for  himself  just  what  his  preceptor  was  doing.  And 
then  he  told  him — "I  am  leaving.  I  have  no  desire 
to  be  associated  in  any  way  with  an  unprincipled 
scoundrel  and  a  murder  of  unborn  babies."  And 
with  that  he  took  his  hat  and  left  the  office  and 
never  again  put  his  foot  inside  the  door.  That, 
gentlemen,  took  real  courage — for  a  green,  un- 
tutored country  youth  to  stand  up  face  to  face 
and  say  to  an  apparently  highly  successful  man 
such  words  as  those  —  that  was  courage  of  the 
highest  degree.  And  never  after  during  his  life 
when  there  was  any  need  for  it  did  Dr.  Harmon 
ever  show  any  lack  of  courage.  Dr.  Harmon  never 
in  any  way  alluded  to  this  incident,  never  dis- 
cussed it.  My  knowledge  of  it  is  derived  from 
others,  who  did  know  of  this  occurrence  of  some 
forty  years  ago. 

Next  to  his  courage  were  his  earnestness  and 
steadfastness.  To  Dr.  Harmon  life  was  not  a 
gay  adventure;  each  day  had  its  problems  which 
must  be  solved,  and  to  the  solving  of  these  he 
applied  himself  assiduously.  It  was  this  that  in 
his  latter  years  led  him  to  the  study  of  that  per- 
plexing problem  now  known  as  Organized  Med- 
icine. He  devoted  much  time  and  thought  to  this 
question,  and  the  profession  have  often  listened 
to  his  sound,  logical  views  on  this  subject.  I  can 
not  say  that  I  was  always  in  accord  with  him  in 
this  matter,  but  I  can  always  respect  his  sanity 
and  clarity  and  the  forcefulness  of  his  presentation. 

His  death  was  really  a  benediction  to  a  man  of 
Dr.  Harmon's  temperament.  He  was  at  his  work 
almost  up  to  his  last  minute.  On  the  afternoon 
of  December  26th,  1935,  he  had  just  finished  a 
small  office  operation  and  the  patient  had  left.  Dr. 
Harmon  appeared  very  weary.  He  sat  in  a  chair 
and  the  nurse  who  was  assisting  him  in  the  office 
says  he  looked  very  tired  and  white.  In  a  few 
minutes  he  made  his  way  to  a  lounge  in  one  of 
the  rear  rooms  and  lay  down.  By  this  time  his 
breathing  was  very  labored  and  great'  drops  of 
sweat  were  running  down  his  face.  The  nurse  in 
alarm  telephoned  both  the  hospitals  and  the  Medi- 
cal Building  and  asked  that  a  doctor  be  hurried  to 
Dr.  Harmon's  office  as  he  appeared  very  ill.  She 
then  rushed  next  door  to  his  residence  to  call  his 
wife  and  son.  On  returning  to  the  office  the  nurse 
found  that  he  had  already  passed  away — less  than 
half  an  hour  after  his  patient  had  left  the  office. 
And  those  of  us  who  knew  Sam  Harmon  know 
that  even  though  he  was  alone  he  faced  this  crisis 
just  as  calmly  and  courageously  as  he  had  met  every 
other  crisis  in  his  life. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


Dr.  Frederick  L.  Potts 

By  DeWitt  Kluttz,  M.D.,  Washington,  N.  C. 

The  history  of  the  medical  profession  of  Craven 
County  teems  with  the  names  of  men  of  science, 
self-sacrificing  and  efficient,  whose  lives  were  de- 
voted to  the  healing  of  the  sick  and  the  improve- 
ment of  sanitary  conditions.  Among  them  is  that 
of  Dr.  Frederick  Latham  Potts. 

Frederick  Potts  was  born  at  Washington,  Beau- 
fort County,  North  Carolina,  December  10th,  1873, 
a  son  of  William  A  .and  Josephine  Latham  Potts. 
He  attended  private  schools  at  Washington,  N.  C, 
and  Scranton,  Pa.  Later  he  studied  at  the  Uni- 
versity of  Georgia  and  the  Medico-Chirurgical  Col- 
lege of  Philadelphia;  the  latter  having  since  been 
consolidated  with  the  University  of  Pennsylvania. 
He  was  graduated  therefrom  in  1899  with  the  de- 
gree of  Doctor  of  Medicine. 

Prior  to  his  graduation,  in  1898,  he  began  the 
practice  of  medicine  at  Vanceboro,  N.  C,  where  he 
remained  until  1900,  when  he  went  to  Spartanburg, 
S.  C,  where  he  operated  a  hospital  and  practiced 
siSFgery  exclusively  until  1916.  He  then  returned 
to  Vanceboro,  N.  C,  and  carried  on  a  general  prac- 
tice until  his  death,  March  23rd,  1935. 

Dr.  Potts  was  a  Presbyterian,  a  member  of  Mor- 
gan Lodge,  A.  F.  and  A.  M.,  of  Spartanburg;  New 
Bern  Chapter  No.  46,  R.  A.  M.;  Saint  John's  Com- 
mandery  No.  10,  K.  T.,  of  New  Bern;  and  Sudan 
Temple,  A.  A.  O.  N.  M.  S.,  of  New  Bern.  At  his 
death  he  was  a  member  of  the  Craven  County  Med- 
ical Society,  the  Medical  Society  of  the  State  of 
North  Carolina,  the  American,  and  the  Tri-State 
Medical  Associations. 

Dr.  Potts  is  survived  by  his  wife,  the  former  Miss 
Lucy  White,  one  daughter,  Mrs.  Charles  Lea,  jr., 
and  one  granddaughter.  Also  surviving  him  are  a 
brother,  Rev.  John  R.  Potts,  of  Greenville,  N.  C, 
and  a  sister,  Mrs.  Ida  Kugler,  of  Philadelphia,  Pa. 


Dr.  Luther  A.  Robertson 

By  H.  J.  Langston,  M.D.,  Danville 

Luther  A.  Robertson  was  born  in  Pittsyl- 
vania County,  Virginia,  December  21st,  1874. 

The  son  of  Dr.  William  S.  Robertson  and  Annie 
G.  Law  Robertson.  He  practiced  medicine  in 
Pittsylvania  for  a  long  period  of  time. 

Dr.  W.  S.  Robertson  practiced  in  the  country  and 
lived  on  a  farm;  hence  Dr.  L.  A.  was  called  "Dr. 
Luther,"  and  living  on  a  farm,  he  learned  a  good 
many  things  about  plain  life  and  living.  Dr.  Luther 
entered  Wake  Forest  College  in  1892,  and  there  he 
took  a  straight  literary  couse,  consisting  of  the 
Sciences,  Modern  Languages,  History,  and  so  on. 
He  was  very  popular  at  Wake  Forest — a  good  stu- 
dent, participating  in  all  the  various  activities  of 


student  life  and  a  member  of  the  Varsity  baseball 
team.  In  1896,  Wake  Forest  College  conferred 
upon  him  the  Bachelor  of  Arts  degree.  In  the  fall 
of  1896  Dr.  Robertson  entered  the  Medical  College 
of  Virginia  at  Richmond,  and  in  1900  won  his 
Doctor  of  Medicine  degree. 

From  1900  to  1903,  Dr.  Luther  was  assistant 
to  Dr.  Jos.  A.  White.  As  a  student  and  as  an 
associate,  Dr.  Luther  made  many  friends  among 
the  profession  in  the  City  of  Richmond.  In  1903, 
he  came  back  to  his  native  county  and  opened  an 
office  in  Danville,  his  practice  being  limited  to^ 
diseases  of  the  eye,  ear,  nose  and  throat,  and  from 
that  period  until  the  first  of  May,  1935,  he  had  an 
active  practice.  For  a  number  of  years  he  was 
the  only  person  in  this  section  who  limited  his 
practice  to  this  specialty.  He  worked  for  the  poor 
and  the  rich,  the  black  and  the  white,  the  learned 
and  the  unlearned,  giving  to  each  patient  kindly, 
careful  and  unhurried  consideration.  It  is  said 
that  he  never  became  angry  or  ugly  to  any  person, 
though  the  person  might  be  however  unreasonable 
and  impatient.  There  has  not  lived  in  the  first 
part  of  this  century  any  man  in  the  South  who  has 
been  more  useful  and  has  done  a  more  complete 
job  than  has  Dr.  Luther  A.  Robertson. 

Though  he  gave  completely  to  his  profession,  he 
had  time  himself  for  unhurried  conference  with  any 
member  of  the  profession  who  would  hail  him  on 
the  street  or  call  at  his  office.  He  always  had  time 
to  treat  any  member  of  the  profession's  family  care- 
fully and  accurately.  He  was  never  cruel  in  discuss- 
ing any  member  of  his  profession.  Apparently,  he 
had  learned  that  if  there  was  no  good  word  to  be 
said  an  ugly  criticism  was  out  of  order. 

Dr.  Robertson  enjoyed  cards;  enjoyed  mixing 
and  mingling  with  friends;  enjoyed  roaming  around 
in  the  fields:  he  got  abundance  of  pleasure  out  of 
hunting,  and  he  enjoyed  fishing  once,  twice  or 
three  times  a  year. 

It  was  the  latter  part  of  April,  1935,  that  he 
made  up  his  mind  that  he  would  have  a  hernia 
corrected  which  had  been  of  more  or  less  discom- 
fort to  him,  so  he  went  to  Richmond  where  this 
condition  was  corrected.  He  was  getting  along 
beautifully,  until  the  evening  of  May  15th,  he  told 
his  nurse  he  was  a  little  uncomfortable,  turned  on 
his  side — and  left  us. 

The  profession  has  lost  one  of  its  most  useful 
men,  and  the  people  have  lost  one  of  their  kindest 
and  ablest  servants. 

It  affords  me  no  little  pleasure  to  testify  to  the 
value  and  usefulness  of  Dr.  Luther  A.  Robertson. 
He  was  my  friend.  He  served  my  family  and 
he  served  me,  and  he  gave  his  best  efforts  to  try 
to  save  my  wife's  life.  All  of  us  would  do  well  to 
follow  in  his  footsteps  in  being  kind  and  generous 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


293 


.^ 


Eli  Lilly /\nd  Company 

FOUNDED     187  6 

!Makers  oj  ^Medicinal  Products 


"SECONDARY"    ANEMIAS 

In  anemias  of  the  microcytic  type,  the  response 
to  Lextron  (Liver-Stomach  Concentrate  with 
Iron  and  Vitamin  B,  Lilly)  is  rapid.  When  he  pre- 
scribes Lextron  the  physician  is  assured  that 
his  patient  will  receive  all  the  materials  essential 
to  blood  regeneration  in  anemias  of  this  class. 
Lextron  (Liver-Stomach  Concentrate  with 
Iron  and  Vitamin  B,  Lilly)  is  supplied  in  bottles 
of  84  and  500  pulvules. 


T'rompt  Attention  Qiven  to  Projessioml  Jncfuiries 

PRINCIPAL    OFFICES    AND    LABORATORIES,    INDIANAPOLIS,    INDIANA,    U.S.A. 


Please  Mention  THIS  JOURNAL  When  Writing  to  Advertisers 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


and  broad-minded  toward  our  fellows  in  general  and 
especially  toward  the  sick.  I  have  lost  a  friend,  and 
I  am  sure  all  of  you  feel  as  I  do. 


late  him  we  shall  do  credit  to  ourselves.  I  feel  that 
anything  we  might  say  about  him  would  fall  far 
short  of  describing  the  man  as  he  was. 


Dr.  J.  H.  Shuford,  Hickory,  N.  C. 

Jas.  M.  Northington,  M.D.,  Charlotte 

Mr.  President  and  Gentlemen:  Dr.  Shuford  was 
one  of  the  most  lovable  men  I  ever  knew.  I  knew 
him  in  civil  life,  and  I  knew  him  in  military  life, 
and  I  have  never  known  a  man  who  more  com- 
pletely measured  up  to  the  full  stature  of  a  man. 
He  was  a  lad  in  Hickory,  and  when  he  was  moved 
to  enter  upon  the  study  of  medicine  h  ewas  induced 
by  a  pharmacist  in  that  then  village  to  go  to  the 
far-away  University  of  Michigan.  There  he  came 
under  the  influence  of  Dr.  Victor  Vaughan  and  such 
other  masters  of  the  art  and  science  of  medicine, 
and  they  gave  his  professional  life  its  directing 
force.  When  the  War  came  on  he  closed  his  office 
and  his  hospital  and  he  went  out,  as  so  many  of  us 
did,  to  contribute  his  bit  toward  doing  what  was 
called  at  the  time — and  we  really  thought  it  was — 
fighting  to  make  the  world  a  safe  place  to  live  in. 
Now,  that  was  not  accomplished,  as  all  of  us  can 
realize,  but  that  does  not  detract  from  the  motive. 
He  came  back  from  the  War  broken  in  health  and 
much  broken  in  spirit,  and  just  a  few  weeks  ago  I 
stood  beside  his  grave  and  heard  and  saw  the  final 
salute  to  the  dead  and  this  good  man  and  this  ex- 
cellent doctor  returned  to  the  earth  from  which  he 
came. 

A.  C.  McCall,  M.D.,  .^sheville 

I  should  like  to  say  just  a  few  words  in  regard 
to  Dr.  Shuford.  I  met  Dr.  Shuford  in  the  Service. 
We  were  in  France  together  for  many  months,  and 
I  learned  to  know  him  very  well.  He  was  a  friend 
to  us  all,  and  we  all  learned  to  love  him.  He  re- 
turned to  this  country  before  some  of  us  did.  When 
all  of  us  came  back  we  made  it  a  point  to  look  up 
Dr.  Shuford,  and  I  kept  in  contact  with  him  in 
his  home  in  Hickory  after  the  War;  although  I  did 
not  see  him  very  often,  we  often  sent  each  other 
messages.  He  was  beloved  by  the  entire  battalion. 
The  personnel  looked  upon  him  as  their  friend;  the 
officers  of  the  organization  looked  upon  him  as  their 
friend.  .We  felt  that  we  could  talk  to  him  about 
anything,  personal  or  professional  and  receive  sym- 
pathetic hearing.  When  he  lost  his  health  and  came 
to  Asheville  seeking  relief  I  had  the  pleasure  of 
calling  upon  him  several  times.  Each  time  he  would 
smile  the  old  smile,  just  as  he  did  in  Army  days, 
and  say:  "I  shall  be  all  right";  and  he  never  gave 
up  until  the  last  few  days  of  his  life.  I  feel  that  in 
Dr.  Shuford's  death  not  only  have  I  lost  a  very  dear 
friend  but  the  medical  profession  of  North  Carolina 
has  lost  a  very  fine  member.    If  we  strive  to  emu- 


Dr.  Z.  G.  Smith,  Marion,  S.  C. 

Beverley  R,  Tucker,  M.D.,  Richmond 

I  should  like  to  say  just  a  word  about  Dr.  Smith. 
I  had  known  Dr.  Zach  Smith  for  thirty-odd  years. 
The  things  that  were  said  about  Dr.  Luther  Rob- 
ertson could  be  repeated  about  Dr.  Zach  Smith.  He 
was  a  true  friend  not  only  of  his  fellow  physicians 
but  of  every  human  being,  black  or  white,  that  came 
within  his  ministrations  in  South  Carolina.  In  his 
death  the  medical  profession  of  his  State  and  Sec- 
tion sustains  a  heavy  loss. 


Tuesday  Morning  Session 

The  Secretary's  report  was  received  with  com- 
mendation. 

On  motion  of  Dr.  Southgate  Leigh,  the  President 
was  authorized  to  appoint  a  committee,  of  three  or 
more  members,  on  cancer  control.  Seconded  by  Dr. 
M.  H.  Wyman  and  passed  unanimously. 

On  motion  of  Dr.  Leigh,  the  President  was  also 
authorized  to  appoint  a  committee,  of  three  or  more 
members,  to  consider  and  take  steps  to  instruct  the 
public  and  to  inform  the  members  of  the  Associa- 
tion in  regard  to  the  common  cold.  Seconded  by 
Dr.  Wyman  and  passed  unanimously. 


Tuesday   Afternoon   Session 
ELECTION  OF  OFFICERS 
President  Orr:    The  election  of  officers  is  now  in 
order.    Nominations  will  be  received  for  President, 
who  is  to  come  from  South  Carolina. 

Dr.  J.  H.  Mcintosh,  Columbia:  The  honor  of 
presenting  the  name  of  one  of  her  favorite  sons  for 
the  high  honor  of  President  of  this  Association  this 
year  falls  to  South  Carolina,  and  at  the  request  of 
one  of  his  many  friends  I  am  presenting  to  this  As- 
sociation the  name  of  Dr.  George  H.  Bunch,  of 
Columbia.  Dr.  Bunch  has  long  been  a  member  of 
the  departmental  staff  of  Southern  Medicine  &  Sur- 
gery, and  he  is  known  to  most  of  you.  I  am  sure 
you  would  find  him  a  satisfactory  officer  in  every 
way. 

Dr.  Bunch's  nomination  was  duly  seconded. 

Dr.  F.  M.  Roiith,  Columbia:  I  desire  to  place 
before  you  the  name  of  a  man  who  has  been  an  ac- 
tive member  of  this  Association  for  many  years, 
who  has  been  active  in  its  councils  and  who  is  a 
successful  young  surgeon  and  a  good  doctor — Dr. 
Douglas  Jennings,  of  Bennettsville. 

Dr.  Jennings'  nomination  was  duly  seconded. 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Dr.  J.  T.  Wolfe,  Washington,  D.  C:  This  is  my 
first  attendance  at  the  Tri-State,  but  I  have  cer- 
tainly been  compelled  to  observe  the  untiring  ef- 
forts and  the  fidelity  to  duty  of  the  Chairman  of 
the  Arrangements  Committee,  and  his  very  kindly 
attitude  towards  all  the  visitors,  and  his  desire  to 
make  us  all  feel  at  home,  and  I  wish  to  place  in 
nomination  the  name  of  Dr.  Marion  H.  Wyman. 

This  nomination  was  seconded.  Upon  the  vote 
being  taken.  Dr.  Douglas  Jennings  was  elected 
President. 

President  Orr  asked  Dr.  A.  E.  Baker  and  Dr. 
R.  B.  jNIcKnight  to  escort  the  newly-elected  Presi- 
dent to  the  platform.     (Applause.) 

Dr.  Douglas  Jennings:  Gentlemen,  I  fear  you 
have  made  a  mistake.  I  have  been  and  am  inter- 
ested in  the  Tri-State  Medical  Association.  I  thank 
you,  and  I  promise  you  my  best  efforts  in  behalf  of 
this  Association.     (Applause.) 

President  Orr:  I  turn  my  office  over  to  Dr.  Jen- 
nings.   I  know  it  is  going  into  good  hands. 

I  want  to  thank  Dr.  Wyman  and  his  Committee 
and  the  members  of  the  Columbia  INIedical  Society 
for  their  untiring  efforts  in  taking  care  of  us  and 
seeing  that  we  have  had  a  good  time,  and  I  also 
want  to  thank  Dr.  Northington  for  his  work  in  pre- 
paring such  an  excellent  program.  These  things 
have  all  entered  into  making  our  meeting  success- 
ful. 

Dr.  Jas.  M.  Northington:  Dr.  Orr's  unceasing 
interest  in  the  Association  and  his  untiring  efforts 
have  made  possible  this  excellent  meeting  which  we 
are  just  concluding. 

The  following  Vice-Presidents  were  elected: 
Virginia:  Dr.  0.  O.  Darden,  Richmond. 
North  Carolina:  Dr.  A.  C.  McCall,  Asheville. 
South  Carolina:  Dr.  James  S.  Fouche,  Colum- 
bia. 

Dr.  Jas.  M.  Northington  was  re-elected  Secre- 
tary-Treasurer. 

On  motion  of  Dr.  Northington,  the  following  res- 
olution was  adopted: 

Resolved,  that  the  Tri-State  Medical  Association 
of  the  Carolinas  and  Virginia  express  its  apprecia- 
tion of  the  courtesies  extended  by  the  local  doctors, 
the  Columbia  Medical  Society,  the  Committee  on 
.Arrangements,  the  Jefferson  Hotel,  and  the  press  of 
Columbia,  especially  to  the  members  of  the  Com- 
mittee on  Arrangements  for  their  very  courteous  and 
efficient  arrangements  for  the  meeting. 

There  being  no  further  business  to  come  up,  the 
Association  adjourned  sine  die. 


F-OR 


PAIN 


The  majority  of  the  phy- 
sicians in  the  Carolinas 
are  prescribing  our  new 


tablets 


A*'"'S 


751 


Analgesia  and  Sadatlve    \  '"rts     5  parts       I  part 
Aspirin  Phenacetin  Caffein 

We  will  mail  professional  samples  regularly 
with  our  compliments  if  you  desire  them. 
Carolina   Pharmaceutical   Co.,    Clinton,   S.   C. 


A    PRESCRIPTION    OF   KlNC    Turt    TIME    FOR    BALDNESS    (C. 

L.  Jefferies,  Bluefield,  in  W.  Va.  Med.  Jl.,  Apr.)  was  pre- 
pared by  mixing  the  fats  of  the  horse,  the  crocodile,  the 
hippopotamus,  the  snake  and  the  ibex;  it  was  to  be  applied 
freely  and,  I  imagine,  proved  to  be  just  about  as  effective 
as  our  modem  remedies. 


Burlington,  N.  C,  is  said  to  have  been  named  for  a 
Jersey  bull  imported  by  a  local  farmer  from  BurUngton, 
New  Jersey,  and  named  for  his  place  of  birth. 


ELIXIR 

BRO-SA-CA  COMP. 

Elixir  Bromide,  Salicylate  and  Caffeine 
Compound. 

Migraine-Sedative 

Recommended   for  use  in  the  treatment  of 
Nervous  Headache,  Colds  and  La  Grippe. 

Average  Dosage 
One  to  two  teaspoonfuls,   as   prescribed   by 
physician. 

How  Supplied 
In  Pints,  Five-Pints  and  Gallons  to  Physicians 
and  Druggists. 


Burwell  &  Dunn  Company 

Manufacturing    <^^^3   Pharmacists 


CHARLOTTE,  N.  C. 

Sample  sent  to  any  physician  in  the  U. 
request. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


NEWS  ITEMS 


Mecklenburg  County  (N.  C.)  Medical  Society,  even- 
ing April  7th,  Medical  Library,  Charlotte,  Dr.  HamUton 
VV.  McKay,  president. 

Dr.  Parks  M.  King  abstracted  an  article  from  Time  on 
the  attitude  of  Dr.  Parran  towards  socialized  medicine.  He 
also  read  a  letter  dated  1872  addressed  to  Dr.  McCombs 
on  the  use  of  virus  for  smallpox. 

Dr.  R.  B.  McKnight  stated  that  he  is  preparing  an  article 
on  the  local  library. 

Paper  on  Insulin  by  Dr.  E.  J.  Wannamaker,  discussed 
by  Dr.  J.  S.  Hunt;  Atresia  of  the  Vulva  by  Drs.  J.  R. 
Adams  and  Preston  Nowlin,  discussed  by  Dr.  H.  W.  Mc- 
Kay; Irradiation  Therapy  in  Uterine  Bleeding  from  Causes 
Other  than  Cancer  by  Dr.  C.  C.  PhiUips,  discussed  by  Drs. 
J.  R.  Shull,  Otho  Ross,  C.  D.  Lucas,  P.  M.  King  and  T.  D. 
Sparrow. 

Dr.  R.  B.  McKnight  called  attention  to  unpaid  obliga- 
tions due  the  Physician's  Credit  Exchange. 

The  following  resolutions  were  offered  by  a  committee 
composed  of  Dr.  Oren  Moore,  chairman;  Dr.  A.  M.  Whis- 
nant  and  Dr.  George  W.  Pressley,  passed  unanimously: 

"Be  it  resolved  that  the  Mecklenburg  County  Medical 
Society  go  on  record  as  expressing  its  sense  of  deep  loss  in 
the  passing  of  our  fellow-member,  Dr.  C.  H.  C.  Mills. 

"Further  be  it  resolved  that  his  long  years  of  practice 
of  his  specialty  in  this  locality  has  added  immeasurably  to 
the  knowledge  and  abihties  of  the  other  members  of  our 
profession,  and.  to  the  safety,  comfort  and  happiness  of  in- 
numerable expectant  mothers. 

"Further  be  it  resolved  that  his  simplicity  of  life,  hi- 
lack  of  pretention,  and  his  great  skill  should  be,  and  are, 
an  example  for  all  who  survive  him. 

"Further  be  it  resolved  that  a  copy  of  these  resolutions 
be  spread  on  the  Minute  Book  of  the  Mecklenburg  County 
Medical  Society  and  another  copy  he  presented  to  his  wife. 
and  that  she,  with  his  children,  be  assured  of  our  deep  sor- 
row in  their  bereavement." 

A  committee  to  supervise  hospital  insurance  acceptable 
to  the  hospitals  and  approved  by  the  Medical  Society, 
appointed  by  the  president,  is  composed  of  Dr.  Frank 
Smith,  chairman.  Dr.  Andrew  Blair,  Dr.  E.  R.  Hipp.  Dr. 
Thomas  D.  Sparrow,  and  Dr.  Vann  M.  Matthews.  The 
function  of  this  committee  is  to  arbitrate  and  ad\'ise  as  to 
fees  between  physicians  and  all  hospital  insurance  associa- 
tions whose  contracts  are  acceptable  to  the  hospitals  of 
Charlotte.  Three  members  of  the  committee  with  the 
chairman  have  authority  to  pass  on  any  matter  that  might 
come  before  the  whole  body  for  action. 

The  secretary  called  attention  to  communication  from 
Dr.  W.  C.  Bostic  of  Forest  City,  N.  C,  with  respect  to 
resolutions  of  the  Rutherford  County  Medical  Society  in 
regard  to  the  present  schedule  of  licenses  fees  for  automo- 
biles for  the  State  of  North  Carolina,  and  that  25%  of  the 
fees  collected  for  automobile  licenses  be  accepted  to  furnish 
insurance  to  cover  liability  for  each  and  every  automobile 
hcensed  by  the  State. 

S.  W.  Davis,  Sec. 


Drs.  Moore,  Whitehead,  Herbert,  C.  H.  Cocke  and  Parker. 

Dr.  G.  W.  Kutscher  of  the  Committee  on  Arrangements 
for  the  State  Meeting  reported  on  Scientific  Exhibit  for 
our  local  members. 

Dr.  Cocke  moved  the  next  meeting  he  dispensed  with 
on  account  of  conflicting  date  with  the  session  of  the  State 
Med.  Soc,  seconded  and  carried. 

A  letter  to  our  president  in  regard  to  Mrs.  Helen  Ger- 
trude Randle  of  the  Sun  and  Diet  Institute  of  Asheville 
from  the  Amer.  Med.  Assoc,  was  read.    No  action  taken. 

Dr.  Murphy  presented  a  letter  to  Dr.  Ringer  in  regard 
to  the  coming  course  in  Obstetrics  at  Asheville  June  22nd 
to  26th  for  the  physicians  of  the  10th  Dist.  Med.  Soc.  by 
the  U.  S.  Children's  Bureau  and  arranged  for  the  N.  C. 
State  Board  of  Health.  Dr.  Herbert  moved  the  society 
wire  acceptance  of  the  proposed  date  for  this  course,  act 
as  host  for  the  meeting  and  make  proper  arrangements 
for  meeting  place,  etc.     Sec.  and  carried. 

Adjournment. 


Buncombe  County  (N.  C.)  Medical  Society-,  Asheville, 
regular  meeting  the  evening  of  April  20th  at  the  City 
Hall  Building,  President  Parker  in  the  chair,  62  members 
and  2  visitors  present. 

The  chair  recognized  Dr.  Paul  H.  Ringer,  who  in  a  few 
fitting  words  introduced  Dr.  Tibor  de  Cholnoky  of  New 
York  City,  who  spoke  on  Cancer  and  Electro-Surgerj-. 
Cases  cited  were  advanced  cancer  of  the  head  and  face, 
cancer  of  the  breast  and  cervix.     Questions  were  asked  by 


The  annual  meeting  of  the  American  Assocl\tion  tor 
the  Study  of  Goiter  will  be  held  in  Chicago,  June  8th  to 
10th.  W.  Blair  Mosser,  M.D.,  Kane,  Penna.,  is  Corres- 
ponding Secretary. 


From  Dr.  A.  E.  Bakeb,  jr.,  Charleston 

The  convention  of  the  A.  C.  L.  Surgeons,  held  in  Charles- 
ton April  7th,  opened  with  a  meeting  in  the  Francis  Marion 
Hotel  ballroom.  Addresses  from  several  prominent  doctors 
featured  the  session. 

At  the  opening  session,  Dr.  R.  S.  Cathcart  welcomed  the 
delegates  to  Charleston.  Dr.  A.  T.  S.  Clay,  of  Savannah, 
responded  with  the  same  address  he  dehvered  in  Charleston 
34  years  ago  at  the  second  annual  convention  of  the  asso- 
ciation of  surgeons  of  the  Plant  System,  which  is  now- 
incorporated  with  the  A.  C.  L. 

Other  addresses  were  heard  from  Dr.  Stewart  R.  Rob- 
erts of  Atlanta;  Dr.  Frank  H.  Laney,  of  Boston;  Dr.  Her- 
man Watson,  of  Lakeland,  Fla.;  Dr.  Beverley  R.  Tucker, 
of  Richmond,  and  Dr.  F.  A.  Hoshal,  of  Charleston. 

Dr.  Douglas  Jennings,  of  Bennettsville,  spoke  before 
the  Medical  Society  of  South  Carolina  at  Roper  Hospital 
April  2Sth.  At  the  regular  meeting  of  the  society  April 
14th,  Dr.  J.  A.  Siegling,  Chicago,  spoke  on  Grow-th  Arrest 
of  Long  Bones  Incident  to  Epiphyseal  Injury  and  Disease, 
and  Dr.  C.  P.  Segard,  New  York,  on  Recent  Work  on 
Vimtamines. 

Dr.  and  Mrs.  Hugh  Tolen  Ball,  of  Greer,  announce  the 
engagement  of  their  daughter,  Helen  Cody,  to  Dr.  Thad- 
deus  Graham  McCullough,  of  Kingstree  and  Columbia. 
The  wedding  will  take  place  in  June. 

Mr.  and  Mrs.  William  Waugh  Turner,  of  VV'innsboro, 
announce  the  engagement  of  their  daughter,  Ruth  Yonge, 
to  Dr.  Joseph  .'Mien  Johnson  of  Florence  and  Walhalla. 
The  wedding  will  take  place  in  the  early  summer. 

The  death  of  Dr.  James  Monroe  Austin,  38,  after  a 
very  brief  illness  came  as  a  great  shock  to  his  many 
friends.  He  had  gone  about  his  regular  duties  at  the  State 
Hospital  up  until  a  few  days  before  and  his  condition  was 
not  regarded  as  serious.  Doctor  Austin  was  born  at  Coro- 
naco.  Greenwood  County,  the  son  of  the  late  Dr.  J.  D. 
.Austin.  He  was  graduated  from  Presbyterian  College  with 
honors,  after  having  serv-ed  his  countrv'  duing  the  World 
War.  For  several  years  he  was  connected  with  the  firm 
of  Dillard  and  Dillard  in  Clinton,  but  left  to  accept  the 
position  of  treasurer  of  the  Medical  College  of  S.  C.  He 
served  in  that  capacity  until  1930,  w-hen  he  was  graduated 
from  that  school.  .After  a  year's  interneship  at  the  South 
Carolina    State    Hospital,   he   joined    its   staff   as   assistant 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


physician.    He  was  a  member  of  tlie  American  Psychiatric 
Association. 


Dr.  Horace  Westlake  Frink,  53,  former  Professor  of 
Neurology  in  Cornell  Medical  School  and  president  of  the 
New  York  Psychoanalytic  Society,  died  April  ISth  of  heart 
failure  at  Pine  Bluff  Sanatorium,  near  Southern  Pines, 
where  he  had  gone  a  week  before  for  treatment.  Dr.  Frink 
was  an  assistant  to  the  late  Dr.  Charles  L.  Dana  in 
Cornell  and  later  a  pioneer  in  the  psychoanalytic  move- 
ment. He  spent  a  year  or  more  with  Dr.  Sigmund  Freud 
in  Vienna.  His  best  known  book,  "Morbid  Fears  and 
Compulsions,"  1916,  was  among  the  most  original  psycho- 
analytic books  written  in  America. 

Dr.  Frink  had  retired  several  years  ago  on  account  of 
his  health  but  had  lately  resumed  consultation  practice  in 
Chapel  Hill,  where  he  had  gone  for  the  education  of  his 
two  children.  He  also  had  lectured  at  the  Medical  School 
of  the  University  of  North  Carolina  since  his  coming 
South. 


Dr.  Thomas  F.  Wheeldox,  Richmond,  has  been  pre- 
sented a  hospital  on  wheels  by  George  A.  Richards  of 
Detroit  for  use  in  treating  crippled  children  and  adults. 
This  traveling  hospital  has  the  appearance  of  a  de  luxe 
coupe  but  removal  of  the  rear  seat  provides  space  for 
storing  16  aluminum  cases  of  various  sizes  to  hold  x-ray 
apparatus,  surgical  instruments,  operating  clothes,  fluoro- 
scope,  medicines,   bandages  and   other   medical   equipment. 

Mr.  Richards,  president  of  the  Detroit  Lions,  a  profes- 
sional football  team,  made  the  gift  because  h?  became 
interested  in  Dr.  Wheeldon's  work  among  crippled  chidren 
after  he  had  treated  Mr.  Richards'  sister,  victim  of  a 
motor  accident  in  Virginia. 


Drs.  Lafferty  (R.  H.)  and  Phillips  (C.  C),  of  Char- 
lotte, celebrated  the  fortieth  anniversary  of  x-ray  in  Char- 
lotte and  their  twentieth  anniversary  and  the  installation 
of  new  high  voltage  shockproof  therapy  equipment,  in 
their  offices  in  the  Charlotte  Sanatorium  on  the  evening 
of  April  22nd.  The  hosts  were  recipients  of  many  expres- 
sions of  high  praise  for  the  foresight  which  anticipated 
the  developments  in  the  usefulness  of  the  x-rays  in  Medi- 
cine and  for  the  admirable  manner  in  which  they  have 
kept  pace  with  these  developments. 


Dr.  Frederick  Pilcher,  jr.,  who  for  the  past  three  years 
has  been  a  fellow  at  the  Mayo  Clinic,  Rochester,  Minn., 
has  been  recently  appointed  first  assistant  to  Dr.  Hugh 
Cabot,  who  is  one  of  the  senior  consulting  surgeons  at 
the  Mayo  Clinic.  Before  going  to  Mayo  Clinic,  Dr.  Pil- 
cher spent  one  year  practicing  in  Richmond  and  has 
many  friends  in  that  city. 


Dr.  H.  Ward  R.andolph,  of  Richmond,  has  been  present- 
ed a  silver  platter  by  the  Board  of  Managers  of  the  Home 
for  Incurables  (terrible  name!)  as  a  token  of  appreciation 
of  twenty-five  years  of  medical  service  to  that  institution. 


Dr.  R.  S.  Herring,  a  member  of  the  attending  staff  of 
Grace  Hospital,  Richmond,  has  just  returned  from  a  year's 
study  at  the  University  of  Vienna;  Rotunda  Hospital,  Dub- 
lin, Ireland,  and  the  Chicago  Maternity  Center. 


Dr.  L.  a.  CROvreLL,  jr.,  Lincolnton,  has  announced  his 
candidacy  and  filed  for  Representative  for  Lincoln  County 
in  the  General  Assembly  of  N.  C. 


AS  AC 

ELIXIR    ASPIRIN    COMPOUND 


Contains  five  grains  of  Aspirin,  two  and  a  half 
grains  of  Sodium  Bromide  and  one-half  grain  Caf- 
feine Hydrobromide  to  the  teaspoonful  in  stable 
Elixir.  ASAC  is  used  for  relief  in  Rheumatism,  Neu- 
ralgia, Tonsillitis,  Headache  and  minor  pre-  and  post- 
operative cases,  especially  the  removal  of  Tonsils. 

Average  Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water  as  prescribed  by  the  physician. 

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


Burwell  &  Dunn  Company 

Manufacturing    ^=^^    Pharmacists 
Established    U^^     in    1887 

CHARLOTTE,  N.  C. 

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


Dr.  C.  M.  Byrnes,  Associate  Professor  of  Neurology  at 
Hopkins,  held  a  practical  neurological  clinic  as  a  special 
feature  of  the  meeting  of  the  Wayne  County  Medical 
Society  at  the  Goldsboro  Hospital  April  10th. 


Dr.  Kenneth  F.  Maxcy,  now  at  the  University  of  Vir- 
ginia, has  been  elected  Professor  and  Head  of  the  Depart- 
ment of  Preventive  Medicine  in  the  University  c;  Minne- 
sota Medical  School. 


NOTE. — At  the  meeting  of  the  Medical  Society 
of  the  State  oj  North  Carolina  held  in  this  month 
Dr.  Wingate  Johnson,  of  Winston-Salem,  wis  made 
president-elect.  More  extended  notice  of  the  meet- 
ing will  be  taken  in  our  issue  for  June. 


Dr.  Pdickney  Herbert,  of  Asheville,  spent  the   Easter 
season  in  Richmond. 


MULL-SOY 

VEGETABLE     |V1  I  L  K  SUBSTITUTE 


Clinically   Proven 


asily  prepared 
Send  for  fret  lamplc  an  J  lilcralurc 

THE  MULLER   LABORATORIES 

2935   FREDERICK  AVENUE 
BALTIMORE  -  MARYLAND 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


MARRIED 

Dr.  Delmar  J.  Weaver,  jr.,  of  Orange  County,  Virginia, 
and  Miss  Beulah  Borah  Tlirift,  of  Wasiiington,  D.  C, 
April  2nd.  Dr.  and  Mrs.  Weaver  will  reside  at  Rochester, 
Minnesota,  for  the  next  three  years. 


Deaths 

Dr.  T.  H.  Higgins,  62,  died  at  his  home  at  Trap  Hill, 
North  Carolina,  April  13th. 


Our  Medical  Schools 


University  of  Virginia 


On  April  Sth,  Dr.  John  Staige  Davis,  Associate  Professor 
of  Surgery  at  the  Johns  Hopkins  University,  spoke  before 
the  Albemarle  Medical  Society  at  their  meeting  at  the 
Medical  School  on  the  subject  of  Wounds  and  Scars. 

At  the  annual  initiation  meeting  of  Alpha  Omega  Alpha 
on  April  13th,  Dr.  T.  Duckett  Jones,  Director  of  Research 
at  the  Good  Samaritan  Hospital,  Boston,  Massachusetts, 
gave  the  Wilham  W.  Root  Memorial  Lecture,  speaking  on 
the  subject  of  the  Etiology  of  Rheumatic  Fever. 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  April  17th,  Dr.  J.  Arnold  Bargen,  of  the  Mayo 
Clinic,  spoke  on  the  subject  of  Functional  and  Anatomic 
Effects  of  Colitis  of  Long  Standing. 

On  the  morning  of  April  20th,  Dr.  W.  H.  Stoner,  Re- 
search Consultant  at  the  Experimental  Research  Laborato- 
ries of  Burroughs,  Wellcome  and  Company,  addressed  the 
Fourth- Year  Class  on  the  subject  of  Cancer  Research. 

Dr.  C.  S.  Lentz,  Superintendent  of  the  University  of  Vir- 
ginia Hospital,  spoke  before  the  joint  meeting  of  the  Tri- 
State  Hospital  Conference  and  the  Virginia  Dietetic  Asso- 
ciation, April  15th-18th,  on  the  subject  of  The  Hospital's 
Obligation  to  Its  House  Staff. 

Dean  J.  C.  Flippin  spoke  before  the  Ohio  Valley  Medical 
Society  at  their  meeting  in  Wheeling,  West  Virginia,  on 
April  17th  on  the  subject  of  .Aseptic  Meningitis. 

Dr.  Dudley  C.  Smith  attended  the  Annual  Conference  of 
Federal  and  State  Health  Officers  in  Washington  on  April 
13th.  He  read  a  paper  on  The  Epidemiology  of  Syphilis  as 
part  of  a  symposium  on  various  phases  of  the  Public  Health 
aspects  of  syphilis. 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  April  27th,  Dr.  Fred  M.  Hodges,  of  Richmond, 
spoke  on  the  subject  of  X-Ray  Therapy  of  Skin  Infections. 

Dr.  William  B.  Sharp,  Professor  of  Bacteriology  and  Pre- 
ventive Medicine  in  the  Medical  School  of  the  University 
of  Texas,  was  a  visitor  here  on  ."^pril  24th. 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  May  7th,  Dr.  Albert  M.  Snell,  of  the  Mayo 
Clinic,  spoke  on  the  subject  of  Pathologic  Physiology  of 
Common  Duct  Stone. 

Commencement  Exercises  for  the  Graduating  Class  of 
the  University  of  Virginia  Hospital  School  of  Nursing  were 
held  on  the  afternoon  of  May  7th.  Twenty-six  nurses 
from  the  University  Hospital,  ten  transfers  from  the  Shel- 
tering Arms  Hospital  in  Richmond,  four  one-year  affiliates 
from  Catawba  Sanatorium  and  four  from  Blue  Ridge  Sana- 
torium received  their  diplomas.  The  address  to  the  class 
was  made  by  Mrs.  A.  D.  Fraser,  former  president  of  the 
Charlottesville  Branch  of  the  American  Association  of  Uni- 
versity Women. 

At  the  annual  initiation  meeting  of  the  Society  of  Sigma 
Xi  on  April  30th,  Dr.  Carl  Caskey  Speidel  was  awarded 


the  President  and  Visitors'  Prize  of  $100.00  for  his  paper, 
Studies  on  Living  Nerves.  HI.  Phenomena  of  Nerve  Irri- 
tation and  Recovery,  Degeneration  and  Repair. 

The  following  members  of  the  Medical  FacuUy  attended 
the  annual  meeting  of  the  Virginia  -Academy  of  Science  at 
Lexington  from  May  1st  to  2nd  and  participated  in  the 
program  of  the  Medical  Section:  J.  E.  Kindred,  C.  C. 
Speidel,  S.  W.  Britton,  H.  Silvette,  W.  M.  Moir,  Alfred 
Chanutin,  M.  Ehrenstein,  Kenneth  Ma.xcy,  H.  E.  Jordan, 
E.  L.  Corey  and  A.  E.  Casey. 

Dr.  Alfred  Chanutin,  Professor  of  Biochemistry,  received 
the  annual  Virginia  Academy  of  Science  Research  Prize 
with  the  value  of  $50.00  and  the  Jefferson  Gold  Medal  for 
his  paper  on  The  Effect  of  Whole  Dried  Meat  Diets  on 
Renal  Insufficiency  Produced  by  Partial  Nephrectomy. 

The  seventeenth  Post-Graduate  Clinic  of  the  University 
of  Virginia  Hospital  was  held  on  Friday,  May  Sth,  with  the 
attendance  of  sLxty-one  physicians.  A  Neurological  Clinic 
was  conducted  by  Dr.  D.  C.  Wilson,  a  Dermatological 
Clinic  by  Dr.  D.  C.  Smith,  an  Oto-Laryngological  Clinic  by 
Dr.  F.  D.  Woodward,  an  Orthopedic  Clinic  by  Dr.  Robert 
V.  Funsten,  and  a  Surgical  CHnic  by  Dr.  C.  B.  Morton. 


Duke 

On  April  Qth,  Dr.  Emil  Novak,  Associate  Professor  of 
Obstetrics,  University  of  Maryland  School  of  Medicine, 
lectured  to  the  staff  and  students  on  "Amenorrhoea."      • 

On  April  9th  to  11th,  the  annual  meeting  of  the  Ameri- 
can Association  of  Anatomists  was  held  at  Duke  Univer- 
sity, with  325  teachers  of  anatomy  and  biology  in  the 
colleges  and  universities  of  the  United  States  and  Canada 
in  attendance.  Dr.  F.  H.  Swett,  Professor  of  Anatomy, 
Duke  University  School  of  Medicine,  was  in  charge  of  the 
local  arrangements. 


Medical  College  of  Virginia 


The  sixth  annual  Saint  Philip  Postgraduate  Clinic  for 
Negro  physicians  will  be  held  June  15th-27th.  The  clinic 
as  in  the  past  wiU  be  subsidized  by  the  General  Education 
Board  of  New  York. 

A  postgraduate  year  in  public  health  nursing  has  been 
added  in  the  Saint  Philip  Hospital  School  of  Nursing  for 
Negro  graduate  nurses.  The  course  opened  on  March  16th 
with  27  students  from  12  States  and  the  District  of  Co- 
lumbia. This  work  is  approved  by  the  United  States  Pub- 
lic Health  Service  for  the  reception  of  students  from  18 
co-operating  States  under  the  Social  Security  Act. 

Mr.  John  E.  Davis,  Instructor  in  Physiology,  has  been 
awarded  the  degree  of  Doctor  of  Philosophy  by  the  Univer- 
sity of  Chicago. 

Dr.  Carl  L.  A.  Schmidt,  Professor  of  Biochemistry,  Uni- 
versity of  California  Medical  School,  and  Dr.  W.  O.  Fenn, 
Professor  of  Physiology,  University  of  Rochester  Medical 
School,  were  recent  visitors  to  the  college,  lecturing  to  the 
students  while  here. 

The  first  annual  reunion  of  the  ex-internes  of  the  Hos- 
pital Division  of  the  college  was  held  March  20th.  Or- 
ganization was  completed,  officers  elected,  and  plans  made 
for  an  annual  meeting.  About  100  ex-internes  were  present 
for  the  meeting. 

Dr.  Edward  J.  Van  Liere,  Dean  of  the  School  of  Medi- 
cine, West  Virginia  University,  was  a  recent  college  visitor. 

Miss  Dorothy  J.  Carter,  Assistant  Director,  National 
Organization  for  Public  Health  Nursing,  visited  the  college 
this  month. 

Mr.  Thanning  Anderson  has  been  promoted  from  Asso- 
ciate to  Assistant  Professor  of  Anatomy. 

The  annual  Spring  Postgraduate  Clinics,  April  6th  and 


May,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


299 


7th,  were  unusually  well  attended  by  physicians  from  Vir- 
ginia, West  Virginia,  North  Carolina  and  South  Carolina. 
The  clinics  were  combined  again  this  year  with  the  Stuart 
McGuire  lectures,  Dr.  Edward  C.  Rosenow,  Head  of  the 
Department  of  Experimental  Bacteriology,  Mayo  Clinic, 
giving  the  McGuire  lectures — the  first  on  the  night  of  April 
6th  and  the  second  on  the  night  of  April  7th. 

Commencement  exercises  closing  the  ninety-eighth  ses- 
sion of  the  Medical  College  of  Virginia  will  be  held  at 
the  Mosque  Theatre,  Tuesday  evening,  June  2nd,  at  S 
o'clock.  Dr.  George  F.  Zook,  President  of  the  American 
Council  on  Education,  will  be  the  speaker. 

The  commencement  sermon  will  be  given  Sunday  evening, 
May  31st,  at  8  o'clock,  by  Dr.  Solon  B.  Cousins,  pastor  of 
the  Second  Baptist  Church. 

The  honorary  degree  of  Doctor  of  Science  will  be  con- 
ferred upon  Dr.  Lawrason  Brown,  Consulting  Physician, 
Trudeau  Sanatorium,  Saranac  Lake,  New  York. 

This  year  there  will  be  seventy-si.x  graduates  in  medicine, 
twenty-five  in  dentistry,  nine  in  pharmacy,  twenty-two  in 
nursing,  and  two  with  the  master  of  science  degree.  These 
represent  fourteen  States,  one  foreign  country,  and  thirty- 
four  of  the  one  hundred  counties  of  Virginia. 


BOOK  REVIEWS 


PARENTERAL  THERAPY;  A  Ready  Reference  Manual 
of  Extra-Oral  Medication  for  Physicians,  Dentists,  Phar- 
macists, Chemists,  Biologists,  Nurses,  Medical  Students  and 
Veterinarians,  by  Walton  Forest  Dutton,  M.D.,  Formerly 
Medical  Director,  Polyclinic  and  Medico-Chirurgical  Hos- 
pitals Graduate  School  of  Medicine,  University  of  Penn- 
sylvania ;  Visiting  Physician  to  the  Northwest  Texas  Hos- 
pital; Visiting  Physician  to  St.  Anthony's  Sanitarium;  Di- 
rector, Medical  Research  Laboratories,  Amarillo,  Texas; 
Colonel,  Medical  Officers'  Reserve  Corps,  U.  S.  A.,  and 
George  Burt  L.^ke,  M.D.,  Formerly  Special  Lecturer  in 
Hygiene,  Purdue  University ;  Editor,  Clinical  Medicine  and 
Surgery;  Associate,  American  College  of  Physicians;  Edu- 
cational Lecturer,  Illinois  State  Medical  Association;  Col- 
onel, Medical  Officers'  Reserve  Corps,  U.  S.  A.  Illustrated 
with  90  halftones  and  line  engravings.  Charles  C.  Thomas, 
Springfield,  111.,  and  Baltimore,  Md.  1936.  $7.50  postpaid. 
The  title  is  an  awkward  one,  but  no  handier 
word  than  parenteral  occurs  to  the  mind  when  we 
search  for  a  composite  term  to  designate  the  ad- 
ministration of  remedial  agents  by  routes  other 
than  the  mouth.  The  subject  is  one  of  great  and 
growing  importance.  Intradermal,  hypodermic, 
intramuscular,  intravenous,  intraperitoneal,  intra- 
cardiac, intraspinal,  intraneural,  intrapulmonary 
(inhalation) — all  these  methods  of  introducing 
agents  into  the  body  are  discussed;  also,  infusions 
of  salt  solution,  transfusion  of  blood,  making  col- 
lections of  blood  and  serum,  artificial  pneumotho- 
rax, cisternal  puncture,  infiltration  and  spinal  anes- 
thesia; injection  treatment  of  varicose  veins,  hem- 
orrhoids, hernia,  hydrocele,  bursae  and  nevi;  and 
ionic  medication.  There  is  a  valuable  inde.x  to 
manufacturers  and  distributors. 

Between  the  covers  of  this  book  is  a  vast  amount 
of  reliable  information  of  daily  usefulness,  conveni- 
ently arranged  for  rapid  reference. 


CLINICAL  HEART  DISEASE,  by  Samuel  A.  Levlne, 
M.D.,  F.A.C.P.,  Assistant  Professor  of  Medicine,  Harvard 
Medical  School ;  Senior  Associate  in  Medicine,  Peter  Bent 
Brigham  Hospital,  Boston;  Consultant  Cardiologist,  New- 
ton Hospital ;  Physician,  New  England  Baptist  Hospital, 
Boston.  445  pages  with  97  illustrations.  Philadelphia  and 
London:  W.  B.  Saunders  Company,  1936.    Cloth,  $5.50  net. 

Written  to  be  of  usefulness  to  bedside  doctors, 
this  book  shows  no  tendency  to  overestimate  the 
value  of  laboratory  investigations  and  it  is  conserv- 
ative in  recommending  them.  Without  dogmatism, 
but  with  proper  confidence,  the  author  states  his 
opinions,  which  have  been  gained  from  his  own  in- 
vestigations and  from  the  opinions  of  others,  and 
he  does  not  tire  the  reader  with  references.  This 
is  a  pleasing  discovery  in  any  book.  We  buy  Dr. 
Jones'  book  to  learn  what  Dr.  Jones  knows  and 
thinks,  not  to  be  confused  with  a  dozen  differing 
opinions.  It  is  comforting  to  find  paroxsmal  tachy- 
cardia added  to  the  list  of  heart  conditions  amen- 
able to  digitalis  treatment. 

We  are  told  that  electrocardiography  has  consid- 
erably improved  our  management  of  heart  disease, 
but  that  older  methods  of  examination  have  lost 
none  of  their  usefulness. 


SURGICAL  CLINICS  OF  NORTH  AMERICA,  issued 
serially,  one  number  every  other  month.  Vol.  16,  No.  1. 
Chicago  Number — February,  1936.  356  pages  with  78  il- 
lustrations. Per  Clinic  year  Februar>-  1936  to  December 
1936.  Paper  $12.00;  Cloth  $16.00  net.  Philadelphia  and 
London:  W.  B.  Saunders  Company,  1936. 

This,  the  initial,  number  of  the  new  volume  of 
these  clinics  opens  with  a  symposium  in  which  are 
presented  the  symptomatology,  diagnosis,  treat- 
ment, complications  of  surgical  eradication,  pre- 
operative treatment,  carcinoma  complicated  by 
pregnancy  and  ike  control  oj  pain  in  late  and  in- 
operable cases.  The  italicized  words  are  an  index 
of  the  practical  character  of  the  number.  Dr.  A. 
D.  Bevan  contributes  on  The  Present  Status  of  the 
Problem  of  Appendicitis — recognizing  that  it  is  still 
a  problem.  Closed  abdominal  wounds,  intermittent 
obstruction  of  the  ascending  colon,  manipulative 
surgery,  sprains,  torticollis,  postoperative  thrombo- 
sis, gangrene,  injection  in  hemorrhoids  and  minor 
surgery  about  the  eye — these  are  all  subjects  of 
great  importance  and  wide  interest. 


The  Queen  of  Sheba  (Neb.  Slate  Med.  Jl.,  Oct.)  was 
a  young  woman  with  a  defective  foot,  who  at  that  time 
ruled  on  both  sides  of  the  Red  Sea.  King  Solomon  was  a 
man  of  mature  years  and  among  his  other  talents,  he  was  a 
healer  of  great  renown. 


Vaccination  against  smallpox  in  the  second  year  re- 
duces to  a  minimu  mthe  chance  of  producing  encephalitis. 
Use  no  dressing  on  a  vaccination. 


Turnip  greens  are  more  healthful  than  spinach,  as  well 
as  far  more  acceptable  to  the  palate. 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  1936 


FELLOWS  OF  THE 
TRI-STATE  MEDICAL  ASSOCIATION 

OF  THE   CAROUINAS  AND  VIRGINIA 


Non-Resident 

Andes.  G.  C.  Milburn.  W.  Va. 

Barker,  L.  F.   (Hon.)  Baltimore,  Md. 

Cain,  Sylvester,  jr. Norcross,  Ga. 

Lyerly.  J.  G.  Jacksonville.  Fla. 

Metz,   R.   D.   Detroit.   Mich. 

Miles,  W.  G.   Milledgeville,   Ga. 

Elected  to   Fellowship   1936 

Endorsement  of  the  SEC.-TREAS. 

Northington,   Page  New  York  City 

South   Carolina 

Adcock,    D.    P.    Columbia 

Asbill,    D.    S.    Columbia 

Baker,   A.   E.,  jr.  Charleston 

Barksdale,   I.    S.   Greenville 

Bell,  F.  A.  Georgetown 

Black,    S.    O.    Spartanburg 

Bozard,   A.   Manning 

Brailstord,  A.  M.   Camden 

Brown,    R.    C.    L Lancaster 

Bunch,   G.   H.   Columbia 

Cannon,   Joseph  Henry  Charleston 

Carpenter.    E.   W.    (Hon.)    Greenville 

Carpenter,   W.   M.    Greenville 

Cathcart,  R.   S.    (Bx-Pres.)    Charleston 

Chamberlain.    OUn   B.    Charleston 

Corbett,    J.    W.    Camden 

Crawford,   R.   L.   Lancaster 

Davis,  T.   McC.  Greenville 

Dendy.    W.    S.    Pelzer 

Doughty,    R.   G.    Columbia 

Earle.   C.   B.    (Hon.)    Greenville 

Felder.    L.    S.    Columbia 

Fennell,  W.  W. Rock  Hill 

Finklea,    O.   T.    _   Florence 

Finney,    Roy  P.    Spartanburg 

Fouche,   James  S.   Columbia 

Gibbs,  W.   R.   _^_  Buffalo 

Gray.   E.   B.    Spartanburg 

Guerry,  LeGrand  (Bx-Pres.)   Columbia 

Hames,   H.    T.    Jonesville 

Hearin.   W.   C.   Greenville 

Heinitsh,  H.   E.,  jr.   Spartanburg 

Hines,    B.    A.    Seneca 

Horger.   E.   L.   Columbia 

Hoshall,  F.   A.    Charleston 

Jennings,    Douglas    Bennettsville 

Jervey,   J.   W..  jr.    Greenville 

Johnson,    F.    B.    (Bx-Pres.)    Charleston 

Jordan,    Fletcher    (Hon.)    Greenville 

Kelley,    E.    T.    Kingstree 

Kinney.    P.    M.    Bennettsville 

Littlejohn,   T.   R.    Sumter 

Lyles,    W.    B.    (Bx-Pres.)    Spartanburg 

McCants,   C.   S.    Winnsboro 

Mcintosh,  J.   H.    (Ex-Pres.) Columbia 

McLeod.     F.     H.     (Ex-Pres.) Florence 

McLeod.    James    _     Florence 

May,    Charles   R.    Bennettsville 

Miller,   C.  J.    ..Inman 

Mood.    G.    McF.   -_ Charleston 

Moore,  A.   T.  Columbia 

Norton,  J.  A.  Conway 

Pitts,  T.  A.    Columbia 

Powe,   W.   H Greenville 

Prioleau,   W.   H.    Charleston 

Ravenel,  James  J.  Charleston 

Rhame,    G.    S.    __.  Camden 

Rogers,   W.   C.   Hemingway 

Routh    Foster  M.    Columbia 

Smith,    D.   Herbert   Spartanburg 

Smith,    Hugh    Greenville 

Smith.   Josiah   E.    Charleston 

Stuart.   Garden  C.   Eastover 

Stuckey,   T.   M.   Bamberg 

Taft,    R.    B.    Charleston 

Taylor,  J.  H.   .Columbia 

Temples,    P.   M.    Spartanburg 

Thackston,   L.   P.   Orangeburg 

Thomas,  H    B.     Whitmire 

Timmerman.  W.    P.    (Hon.)    Batesburg 

Townsend,  E.  W.   Charleston 

Waddell.   R.   L.  Fort  Mill 

Wilkinson,    Geo.    R.    Greenville 

Wilson,    I.    R.,   jr.    Charleston 

Wilson,    Robert   (Ex-Pres.)    Charleston 

Wyatt,  C  .N.    Greenville 

Wyman.    M.    H.    Columbia 

Young.   J.   R.      Anderson 

Zimmerman,   W,    S.   Spartanburg 

Elected  to   Fellowship  1936 

Endorsement  of  O.   D.   BAXTER.     Sumter 

Brunson,    Sophia    (reinstated)    Sumter 


Mills     W.    B.    Sumter 

beibel,   R    A.         Sumter 

Snyder,    W.    J.,    jr.    Sumter 

Endorsement  of  E.  W.  CARPENTER,  Qreenville 

Carpenter,    W.   M.    Greenville 

Endorsement  of  DOUGLAS  JENNINGS,  Bennettsville 

Moore.  George  G.  McColl 

Endorsement  of  C.  R.  MAY.  Bennettsville 

Barnes,   L    P.    Bennettsville 

Evans,   Wm.    jr.    Bennettsville 

Graham.    C.    M.    qhq 

1:,IT^/-  w  ^ :::::::::::Fiorence 

Mead.    W    R     Florence 

Mobley,    M.    R.    Florence 

Endorsement  of  Ex-Pres.  McINTOSH,   Columbia 
McCutchen,    G.    T.    Columbia 

Endorsement  of  W.  P.  TIMMERMAN.  Batesburg 

King,    W.    W.    Batesburg 

Endorsement  of^  the  SEC.-TREAS 

Able.  K.   L.   Leesville 

Blake,    Herbert    Anderson 

in^t'o''^  ^  ^i ::-^v:::::::::::char1fslon 

Bristow,   W.  J.   __ Columbia 

DuBose,   T.  M..  jr.    Columbia 

Epps,    Carl   B.    (reinstated)    ""i:::::::::::      Sumter 

Gibbes,  J    Heyvvard  (reinstated)  Columbia 

Hayne,  Jas.  Adams  Columbia 

w^,.  ^'  ^\F-   TimmonsviUe 

Hope,    R-   M.     Charleston 

Kennedy,  G.  L.   _  Ninetv  Siv 

Mfu1f"T  ^T  ^J^""^" -"-:::::::::::__coiumbt^ 

M    ?"n  ^-  •^,%"'f'"?  Columbia 

Mosteller     Malcolm    _ Columbia- 
Nelson,    M.    L.     North 

Owens,  Frank  C. Columbia 

Z%^'r^'- 1.?-  ?■  K :-v:::_v:::::charye'?t^on 

Rodgers,    Floyd   D.    Columbia 

Tul-ilv  "^w  ^-   ?■    ('■^instated)    _-__:::::::"_:: Bennettsvilt 

w'  "f  't^t™-  ^-   Greenwood 

Ward,   J.   L.   Greenwood 

West.    Carl  A.   Camden 

^lii"^™!?'  S-  ^-  (reinstated) -V:::.:::::::  Columbia 

Zemp,   F.   Eugene   Columbia 

Virginia  and    District  of  Columbia 
Anderson,   John   C.    Chatham 

Barnett,    T.    NeiU    Richmond 

iear°*Wnh°"'""    <«°"-'    HIIIIIIIIIIII-RSchmond 

Bear.    Joseph   Rirhmnnrl 

Rl«n^'^'"w^-T,^ :::::::::::::Rlchm™d 

RW^n?;,  ^^i Richmond 

Bloedorn.    W.    A.    Wa^hino-tnn 

Brown.   Alex   G.    (Hon.)    III:: Richmond 

iu^ard  ^°''"B''  ^-  (Ex-Pres.) ::::::::::  R.'cSZnd 

1,'iv^o;  "^T-  ?•  .'^°"-? ::::::::;:r::::RichmoSd 

Buxton.  J.  T.   (Hon.)   Newport  News 

Chapman.  D.   G.  Riohmonrl 

Clarkson.  Wright I":::: Peie?sbur^ 

Co  X'l"^  S;  Sv  <«°"-> -:;:::.Richmond 

Courtney.   R.  H.   Richmond 

n»V-J.J^  ''n  ■  ^-    °-    Richmond 

Darden.   O.   B.    Riohmonrl 

Davis.    John   Wyatt   I" Lynchbure 

Davis.   J.    W.,   jr.   Lynchburl 

gSvil'  Ir ""r^^ :::::::::-'^^ichnS 

uavis.    W    T    .__ Washington 

FoW  "t     ivf     '  ^'"-   Nassawadox 

Fulfil    R     w    Washington 

duller.   R.   H.       South  Boston 

Gatewood.    B.    T.    Richmond 

kiiho..;,    w"^ Roanoke 

Had^?v  >    F^ Richmond 

HflU     r    ?■  Washington 

S^ I     ?•  ^-    7Sr~D— -> Washington 

MlLir.^j;  £^='/_^!!!:L:::::::::::: S'an^X?? 

gtrSu-D^. ^i-:::::::::::::::::::--"--^--"    IS 
^!s.fj  :::::::::::::::::::::::::E:E^^iB 

Henry,  H.  C.   PetersbutJ 

niaen.    J.   a.    _     Pungoteague 

Higgins.    Wm.    H.    Richmond 

Hill.    Emory  Richmond 

Hodges,   Fred  M.   Richmond 

Hodges.  J.  Allison  (Ex-Pres.) Richmond 

Horgan,    Edmund    Washington 


SOUTHERN  MEDICINE  AND  SURGERY 


Horslev.    J.    S.    Richmond 

Horsley,  J.    S.,   jr.   Richmond 

Hughes,  T.  B.  Richmond 

Hunter,  J.   W.,  jr.    Norfolk 

Hunter.   O.   B.    Washington 

Hutcheson,  J.  M.  Richmond 

Jacobson,    P.    Petersburg 

Johns,   F.   S.   Richmond 

Jones.    J.    B.    Petersburg 

Kane,  D.  P. Washington 

Kevser,  L.  D.   Roanolce 

Langston,  Henry  J.   Danville 

Leigh,    Southgate,    jr.    Nortolli 

Lvon.  J.  A.     Washington 

McGavock.    E.   P.   Richmond 

McGuire,    H.    H.   Richmond 

McGuire,    Stuart    (Ex-Pres.)    Richmond 

blasters.  Howard  R.   __   Richmond 

Jlichaux,    Stuart    (Hon.)    Richmond 

Jiiller,   C.    M.    (Hon.)    Richmond 

Mitchell,  J.  F. Washington 

llurrell.    T.    W.    Richmond 

Nicholson,  M.  M.   Washington 

Nuckols,    M.    E.    (Hon.)    Richmond 

Peabody,   J.    W.    __1 Washington 

Peple,  W.  L.   (Bx-Pres.) Richmond 

Pilcher.   J.   A.,   jr.   Roanoke 

Preston,   Robt.   S.   Richmond 

Protas,    Maurice   Washington 

Rawls.    J.    E.    (Hon.)    Suffolk 

Redwood,    F   .H.    Norfolk 

Renter,    F.    A.    Washington 

Righter,  Frank  P.  Richmond 

Rixey,   W^.   W.    Richmond 

Robins.   Charles  R.    (Hon.)   Richmond 

Rucker,    M.    P.    Richmond 

Shield,  J.  A.   Richmond 

Smith,    James    H.    Richmond 

Taller.  D.   D..   jr.    (Hon.)    Richmond 

Terrell.    E.    H.    (Hon.)    Richmond 

Titus,    E.    W.    Washington 

Todd,   M.   H.   Norfolk 

Tompkins.   J.  McC.   Richmond 

Torrence.   G.  A.  Hot  Springs 

Townsend.  M.  L.  Washington 

Tucker.   B.    R     (Ex-Pres.)    Richmond 

Turman,    A.    E.    (Hon.)    Richmond 

Unchurch,    R.    W.    Danville 

VanderHoof.    Douglas    (Hon.)    Richmond 

Vaughan,    Warren    T.    Richmond 

Wescott.   H.    H.    Roanoke 

Wheeldon.  T.  F.   Richmond 

White,  Chas.    S.    (Hon.)    Washington 

White,   Jos.   A.    (Ex-Pres.)    Richmond 

White,  Wm.  A.   (Hon.)  Washington 

Whitman,   W.    R.    Roanoke 

Wllfong,  C.  T. Richmond 

Williams,    Carrlngton    Richmond 

Williams,    J.    P.    Richmond 

Wilson,   D.   C.    University 

Wilson,   Franklin  D.   _,Norfolk 

Wolfe.  J.   T.  Washington 

Wrig-ht.  F.  J. Petersburg 

Elected  to   Fellowship  1936 
Endorsement  of  P.  H.  REDWOOD.  Norfolk 

Slaughter.    R.    F.    Norfolk 

Endorsement  of  Chas.  S.  WHITE.  Washington 

Hornaday,   F.   A.   Washington 

Endorsement  of  the  SEC.-TREAS. 

Camp.   Paul  D.   Richmond 

Bckles.   B.    F.    (reinstated)    Galax 

Graham,   A.    Stephens   Richmond 

Jeter.    N.    B.    Covington 

Jordan,    Wm.    R.    Richmond 

Law,    L.    A.    Alberta 

Leigh,   Southgate.   jr.   Norfolk 

North  Carolina 

Allan,    William   (HOn.)    Charlotte 

Allen,  Walter  O. Hendersonville 

AUgood,  R.  A.   Fayetteville 

Anders.   McTyeire  G.    (Hon.)    Gastonia 

Anderson,    R.    S.   Rocky   Mount 

Angel.    Edgar   Franklin 

Angel,    Furman    Franklin 

Apple.    B.    D.    Greensboro 

Ashby,   J.   W.    Raleigh 

Ashe,    J.    R.    Charlotte 

Ashworth,  W.  C.   Greensboro 

Barbee,    G.    S.    Zebulon 

Barret,   Harvey  P.   Charlotte 

Barron,    A.    A.    Charlotte 

Battle,   I.   P.   Rocky  Mount 

Baxter,   O.    D.   Charlotte 

Beam,  Hugh  M. Roxboro 

Black,    G.    W,    Charlotte 

Blackwelder,   V.   H.   Lenoir 

Blair,   Andrew,    jr,    Charlotte 

Eoice,  E.   S.   (Hon.)  Rocky  Mount 

Bolt,    C.    A.    Marshville 

Boney,    E.   R.    Kinston 

Bost,  Thomas  C.  Charlotte 

Bradford,  W.  Z. Charlotte 


Bray,   T.  L.   Plymouth 

Brenizer,    Addison   G.    (Hon.)    Charlotte 

B'ridges,  D.  T.   Lattimore 

Brinkley,  H.   M.   Durham 

Brooks,    R.    E.    Burlington 

Burrus.    J.    T.    (Hon.)    High   Point 

Burt,   S.   P.   Louisburg- 

Butler,   L.  J.   Winston-Salem 

Carpenter,   C.   C.   Wake  Forest 

Carnngton,  G,  L.  Burlington 

Carter,   T.   L.    Gatesville 

Cheves,    W.    G.    __B'unn 

Clark,    D.    D.    Clarkton 

Clark.    H.    S.    Asheville 

Cobb,  D.  B.  Goldsboro 

Colby,  C.  DeW. Asheville 

Coleman,    G.    S.    Raleigh 

Cooke,   G.  Carlyle Winston-Salem 

Coppridge,   Wm.   M.   Durham 

Cox.    Grover   S.    Tabor 

Crawford.  R.  H. Rutherfordton 

Crowell,  A.  J.  (Ex-Pres.) Charlotte 

Crowell,  L,   A.   Lincolnton 

Daniel,  N.   C.   Oxford 

Davis,   James  W.   Statesville 

Davis,    Richard   B,    Greensboro 

Davis,   S.  W.   Charlotte 

Davison,    W.    C.    Durham 

DeLaney,   C.   O.   Winston-Salem 

Dickinson,    E.    T. Wilson 

Dickson,  M.  S. Oakboro 

Dixon    G.    G.   Ayden 

Donnelly,    John    Huntersville 

Durham,    C.   W.    Greensboro 

Eason,  J.  A.  Williamston 

t-lhott,  Joseph  A.  Charlotte 

Elliott,  W.  P.  Lincolnton 

Ennett.   N.   Thos.    (Hon.)    Greenville 

Faison,    Elias    S^ Charlotte 

Fauntleroy,  J.  W.   Zirconia 

Ferguson,  R.  T. Charlotte 

Finch,  O.   B        Raleigh 

JormyDuval     T.    Whiteville 

Foster,  H.  H. Norlina 

Fox.  P    G    Raleigh 

Gage,   L.   G. Charlotte 

Gallant,   R.   M.   Charlotte 

Garren    R.  H.  Monroe 

Gaul,  J.    S.   _       Charlotte 

Gibbon,    Jas.    W.    Charlotte 

Gibbon,    R,^  L.   Charlotte 

Gilmore,    C.  M.   Greensboro 

Goudelock,   J.   J. Monroe 

Grantham,  W.  L. "Asheville 

Gn^n.  H.  W.  Hickory 

Griffin,  M.  A. Asheville 

Griffin.   W.   Ray  Asheville 

Guyton,  C.   L.,   jr.  Monroe 

Hardin,   R.  H.   Banner   Elk 

Harding,   B.   H.   Hamptonville 

Harrison,   E.   T.   High  Point 

Hart.  J    Deryl Durham 

Hart,   V    K    Charlotte 

Hathcock,    Thos.   A.    Norwood 

Haywood^  H.B.    Raleigh 

Hester,    W     S.    Reidsville 

Hicks,   C.    S.    Durham 

Highsmith,    J.    D.    Fayetteville 

Highsmith,   J.   F.    (Hon.)    Fayetteville 

Highsmith,    Seavy    (Hon.)    Fayetteville 

Hipp,    E.   R.    Charlotte 

Hodgin.  H.   H.    Red   Springs 

Ho  mes.    A.    B.    Fairmont 

Holt,    Wm.   P.   Erwin 

Holton,    T.   J.   Charlotte 

Houser    F^.   Cherryville 

Hovis.  L.  W. ,_  Charlotte 

Hutchinson,    S.   S Bladenboro 

Ivey,  H.  B    Goldsboro 

Jackson,  W.  L. High  Point 

Jarman,  F.  G. Roanoke  Rapids 

Johnson,  Floyd Whiteville 

Johnson,  Wiley  C, Canton 

Johnson,    W.    M.    Winston-Salem 

Johnston,   J.   G.    _     Charlotte 

Jones,   B.   N.    Winston-Salem 

Kelly,  Luther  W, Charlotte 

Kennedy     John    P.    Charlotte 

Kinlaw,  W.  B.  Rocky  Mount 

Kirksey,  J.  J. Morganton 

Kitchin,   T    p.   Wake   Forest 

Kluttz,  DeWitt Washington 

Knight,  H.  W. Bostic 

Koonce,    D    B    Wilmington 

Lacke.v,   W.   J.    Fallston 

Lassiter,  H.  G. Weldon 

Leak    W.  G.       Bast  Bend 

Lembach,  R^  F. Charlotte 

Lewis,   C.  W,   Beaufort 

Lewis,   J.   S.  Hickory 

Long,   I.   C.   Morehead   City 

Long,   V,   M.   Winston-Salem 

Love,    Bedford    (Hon,)    Roxboro 

Love,   W.   M.   Monroe 

Lucas,   C.   DeF.  Charlotte 


SOUTHERN  MEDICINE  AND  SURGERY 


May,  103 


MacNider.  Wm.  deB.   (Hon.) Chapel  Hill 

McBee.    P.    T.    Marion 

McBraver,  L.  B.  Southern  Pines 

McCampbell.   J.    Morganton 

McClelland,   J.   O.   Maxton 

McGowan.    C.    Plymouth 

McGregor.   G.  D.   Charlotte 

McKav.  Hamilton  W.   Charlotte 

McKav,    Robert   W.    Charlotte 

McKenzie.  B.  W.  Salisbury 

McKnight.   R.  B.   Charlotte 

.McLean,  E.  K.   Charlotte 

McMillan.  R.  D.  Red  Springs 

.McPheeters.    S.   B.    Charlotte 

McPherson.    S.   D.   Durham 

Maness,   A.   K.    Greensboro 

Martin.  J.  W. Roanoke  Rapids 

Martin,  M.  S. Mount  Airy 

Martin.    W.    F.    Charlotte 

Matheson,  J.  P. Charlotte 

Matthews,   B.  B.  Shelby 

Matthews,  V.  M. Charlotte 

.Miller,   O.   L.    Charlotte 

Miller.    R.    C.    Gastonia 

Mitchell.  R.  C.  Mount  Airy 

Moore,   A.   Wvlie  Charlottr 

Moore,    Oren    Charlotte 

Moore,  R.  A.  Charlotte 

Motlej'    F.    E.   Charlotte 

Mvers.    Alonzo    Charlotte 

Mvers,   J.    Q.    Charlotte 

Munroe,  H.  Stokes Charlotte 

Munroe.  J.  P.    (Ex-Pres.)   Charlotte 

Xalle,    Brodie   C.    Charlotte 

Xance.    Chas.   L.    Charlotte 

Xash.  J.  F.  Saint  Pauls 

Xeal,    Kemp   P.    Raleigh 

Xehlett.    H.    C.    Charlotte 

Newland,    C.    L.    Brevard 

Newton.   Howard  L,.   Charlotte 

Noblin.  R.  L.   Oxford 

Northington,  J.  M.  Charlotte 

Ogburn,   H.  H.      Green.sbo'-o 

Orr.   Chas.    C.    (Ex-Pres.)    Asheville 

Owen,    J.    F.    Raleigh 

Pace,   K.   B.    Greenville 

Page,  B.  "W.    Trenton 

Parsons.   W.   H.    EUerbe 

Peeler,  C.  N.   - Charlotte 

Pettewav,   G.   H.   Charlotte 

Phillips.    C.    C.    Charlotte 

Pittman,  R.  L.   FayetteviUe 

Procter.   Ivan   M.    Raleigh 

Pugh.  Chas.  H.  Gastonia 

Rankin,   W.    S.   Charlotte 

Rhodes.    J.    S.    TVilUamston 

Rhvne.  Robert  E. Gastonia 

Roberson,  Foy Durham 

Roberson.  R.   S. Hazelwood 

Roberts,  W.  M. Gastonia 

Robertson.  J.  N. FayetteviUe 

Ross,    R.    A.    Durham 

Rovster,   Hubert   (Ex-Pres.)    Raleigh 

Rovster,   T.   S.   Henderson 

Rudisill,   J.    D.    Lenoir 

Schenck.    S.   M.    Shelby 

Scruggs,  "W.  M.   Charlotte 

Shands,  A.  R.,  jr.  Durham 

Sharpe,   F.   A.   Greensboro 

Shelburne,  P.  A.    Greensboro 


Shull.    J.    Rush    Charlotte 

Sloan.  A.  B.  Mooresville 

Sloan,  Henry  L. Charlotte 

Sloan,  Wm.   H.    Garland 

Smith.  C.  T.  Rockv  Mount 

Smith.   D.    T.   Durhaivi 

Smith.   F.   C.   Charlott- 

Smith,  O.  F.  Scotland  Xe,k 

Smithwick.    J.   E.    Jamesvill.- 

Sparrow.   Thos.  D.    Charlotte 

Squires.   C.  B Charlotte 

Starr,  H.  F.   Greensboro 

Stevens,   M.  L.   Asheville 

Sumner.  E.  A. High  Point 

Symington,   J.   Carthage 

Tayloe,    J.    C.    Washington 

Tayloe.  Joshua,   2nd Washington 

Taylor,   E.   H.  E.   Morganton 

Taylor,    G.    W.    Mooresville 

Taylor.   Wm.   L.    (Hon.)    Oxford 

Thompson,    S.   Raymond  Charlotte 

Thorp.  A.   T.  Rockv  Mount 

Todd.   L.   C.    Charlotte 

Tucker,  John  HIU Charlotte 

^'ann,  J.  R.   Spring  Hope 

\'ernon.  J.   W.     Morganton 

Wannamaker,  E.  J.   Charlotte 

Warwick,    H.    C.    Greensboro 

Weathers,    Bahnson    Rosemary 

Weathers,   B.   G.    Stanley 

Weathers.    R.   R.    Knightdale 

Wheeler.  J.  H. Henderson 

Whitaker,  Paul  F.  Kinston 

AVhitaker,    R.    B.    Whiteville 

White.    T.    Preston    Charlotte 

Willis.  B.   C.    (Hon.)    Rocky  Mount 

■U^nkler,    H.    Charlotte 

Winstead,   J.   L.   Greenville 

Wishart,  W.  E. Charlotte 

\Vooten,  P.  P.   Kinston 

Elected  to  Fellowship  1936  • 

Endorsement  of  T.  C.  BOST,  Charlotte 

Franklin,    E.   W.    Charlotte 

Endorsement  of  J.   H.   HIGHSMITH.  Payette\'ille 

Albright,    C.    J.    Whiteville 

Endorsement  of  the  PRESIDENT 

Beall.  Louis  G.  (reinstated) Black  Mountain 

Hensley.    Chas.    A.    Asheville 

McCall,    A.    C.   Asheville 

Morgan,    B.    E.    Asheville 

Endorsement  of  J.  E.  SMITHWICK,  Jamesville 

Evans,   W.   F.    Williamston 

Pittman,  E.  E. Oak  City 

RufTin,    D.   W.    Ahoskie 

Endorsement  of  J.  T.   WOLFE,  Washington 

Gibson,   M.   R.   Raleigh 

Endorsement  of  the  SEC.-TREAS. 

Averitt,  H.  O.   FayetteviUe 

Choate.    Allyn    B.    Charlotte 

Gentry,    G.   W.    Roxboro 

James,  W.  D.    (reinstated)   Hamlet 

Kemp,   Malcolm  D.      Pinebluff 

Lvdav.    R.   O.    (reinstated)    Greensboro 

Massey,  C.   C.   Charlotte 

Peede,   A.  W.   Lillington 

Ray,    W.    Turner  Charlotte  , 

Ruffin,    Julian   M.    Durham  j 


^ 


■\V^MH^(^^^ 


^ 


Journal 

of 

SOUTHERN  MEDICINE   ^  SURGERY 


Vol.  XCVIII 


Charlotte,  X.  C,  June,   1936 


No.  6 


The   Physiology   and    Pathology   of    Uterine    Bleeding* 

Case  Reports 

IvAX  Procter,  M.D..  Raleigh,  Xorth  Carolina 
Department  of  Obstetrics  and  Gynecoiog>-,  Man.-  Elizabeth  Hospital 


IX  presenting  this  study  of  the  endometrium  as 
it  relates  to  the  physiology  and  patholog\-  of 
bleeding,  it  is  not  our  aim  to  offer  original 
data  but  to  show  results  in  certain  treatment  and 
to  present  in  a  simple,  clear  manner,  the  facts  which 
have  appeared  in  considerable  detail  in  literature 
but  often  in  a  way  confusing  to  the  general  practi- 
tioner of  medicine  and  surgery. 

In  the  study  of  this  subject  it  behooves  every 
clinician  to  familiarize  himself  with  at  least  the 
elements  of  the  anatomy,  physiology  and  pathology 
of  the  endometrium,  ovary  and  pituitary,  in  an 
attempt  to  make  more  accurate  diaanosis  and  ren- 
der more  rational  treatment. 

1.  ■"Histologically,  the  endometrium  is  made 
up  of  three  main  parts — the  lining  epithelium  which 
is  cf  the  columnar  type  but  low  and  almost  cuboidal 
in  the  resting  and  post-menstrual  phase.  Its 
growth,  however,  is  continuous  throughout  the 
c\'cle.  becoming  taller  and  taller  but  at  no  time 
secretory.  The  glands  are  of  the  straight  tubular 
tv'pe  (post-menstrual),  occasionally  branching. 
They  grow  large  and  tortuous  in  the  interval  stage. 
Their  low  lining  epithelial  cells  grow  taller  as  the 
menstrual  cycle  progresses.  The  stroma  is  made 
up  of  closely  packed  round  or  oval  cells,  visible 
only  as  nuclei,  the  cytoplasm  not  showing.  These 
cells  are  held  together  by  a  fine  mesh  work  of  em- 
bryonic connective  tissue.  They  take  on  a  rim  of 
cj'toplasm  at  menstruation  and  develop  during 
pregnancy  into  decidual  cells.  At  the  time  of 
menstruation,  there  is  an  increase  in  vascularity, 
the  gland  epithelium  opens  up  and  the  cytoplasm 
seems  to  run  out.  The  surface  epithelium  comes 
away  piecemeal.  The  stroma  contains  many  leu- 
kocytes and  wandering  cells,  especially  large 
mononuclears  with  dark-staining  nuclei."' 

The  endometrium  has  long  been  known  to  des- 
quamate at  regular  intervals  but  a  clear  e.xplanation 


of  this  striking  event  was  not  available  until  a  few 
years  ago  when  Smith  and  Engle  in  the  United 
States  and  Aschheim  and  Zondek  in  Germany, 
working  separately,  discovered  the  remarkable  ef- 
fect on  the  ovaries  and  testicles  of  animals  of  the 
transplantation  and  removing  of  the  anterior  pitui- 
tary body.  The  anterior  pituitary  has  been  right- 
fully called  the  general  headquarters  of  the  endo- 
crine system.  It  is  a  direct  stimulator  of  the  ovary. 
This  stimulation  is  produced  by  the  production  and 
liberation  from  the  anterior  lobe  of  a  substance 
(hormone)  called   (by  Zondek)  prolan. 

2.  This  substance  appears  in  two  forms,  prolan 
A  and  prolan  B  (or  rho  I  and  rho  II). 

Some  physiologists  believe  that  prolan  A  and  B 
are  one  and  the  same  substance  (hormone)  acting 
differently  under  varying  circumstances.  In  hu- 
mans prolan  A  is  continually  formed  but  prolan  B 
only  after  ovulation. 

Prolan  A  (the  se.x  stimulating  hormone)  acts 
directly  upon  the  ovary  to  stimulate  growth  and 
development  to  the  point  of  maturation  of  imma- 
ture (primoidal)  graafian  follicles.  As  these  folli- 
cles grow,  they  secrete  a  fluid  which  is  known  un- 
fortunately by  a  number  of  confusing  terms  ( female 
sex  hormone,  estrin,  folliculin.  follicle  fluid,  beta 
hormone,  beta  follicular  hormone,  ovarian  follicu- 
lar hormone,  feminin.  menformin),  but  I  shall  ask 
you  to  think  of  it  only  as  estrin  (related  to  estrus. 
the  heat,  se.xual  or  rutting  period  in  animals). 

Estrin  immediately  enters  the  blood  stream 
(about  the  seventh  day  of  the  menstrual  cycle, 
seven  days  after  beginning  of  menstruation)  and 
increases  up  to  ovulation  on  the  fourteenth  or  fif- 
teenth day  when  there  is  a  sharp  but  incomplete 
drop.  This  hormone  (estrin)  during  that  time  pro- 
duces congestion,  vascularization,  growth  and  hy- 
pertrophy of  the  basal  endometrium. 

Estrin  at  the  same  time  stimulates  the  uterine 

•Presented  to  the  Wake  County  Medical  Society.  September  12th.  1935,  and  to  the  Tri-State  Medical  Association  of 
the  Carolinas  and  Virginia  (by  title,  the  author  being  ill),  meeting  at  Columbia,  S.  C.,  February.  1936. 


UTERINE  BLEEDING— Procter 


June,  1936 


musculature  to  undergo  rythmical  contractions. 

After  rupture  of  the  graafian  follicle  on  or  about 
the  fifteenth  day  a  second  substance  (hormone) 
prolan  B  is  sent  out  from  the  anterior  pituitary. 
This  hormone  is  both  synergistic  and  antagonistic 
in  its  action  toward  the  former  prolan  A. 

Prolan  B  immediately  sets  out  to  perform  its 
most  important  function  of  changing  the  granulosa 
cells  of  the  graaffian  follicle  into  luteum  cells  and 
thereby  developing  the  corpus  luteum.  Now  pro- 
lan B  is  antagonistic  to  prolan  A  by  stopping  the 
growth  and  development  of  primordial  follicles  (so 
as  not  to  liberate  but  one  ovum) .  This  antagonistic 
action  stops  the  development  of  estrin  except  a 
small  quantity  which  is  produced  in  the  corpus 
luteum. 

As  a  result  of  the  growth  and  development  of  the 
corpus  luteum,  there  is  formed  a  second  ovarian 
hormone  called  progestin'*  (by  Corner),  meaning 
progestational  or  favoring  gestation.  This  luteniz- 
ing  hormone  (progestin,  corporin  or  lutin)  acts 
directly  on  the  endometrium  stopping  its  growth 
and  development  (thereby  antagonizing  estrin)  but 
sensitizes  the  endometrium  for  the  reception  of 
the  ovum.'*  As  pointed  out  by  Novak,  it  stimu- 
lates the  epithelium  of  the  endometrial  glands  to 
enter  the  secretory  phase  which  is  so  characteristic 
of  premenstruation  or  prenidation. 

Progestin  in  its  efforts  to  prepare  for  gestation 
stops  the  uterine  contractions  formerly  stimulated 
by  estrin. 

If  the  ovum  is  not  fertilized  it  disappears  in 
three  or  four  days,  the  corpus  luteum  undergoes 
retrogression  with  a  loss  of  progestin  (with  the 
original  appearance  of  prolan  B  and  progestin — 
estrin  has  been  stopped).  This  now  leaves  the 
endometrium  without  hormone  and  the  result  is 
degeneration  and  desquamation  with  hemorrhage 
that  we  term  menstruation.'"'  This  physiologic 
process  has  been  observed  under  the  eye  by  the 
transplantation  of  pieces  of  endometrium  into  the 
anterior  chamber  of  the  eye  of  animals.  "One 
could  observe  that  no  desquamation  took  place  the 
first  day  and  that  different  pieces  bled  at  different 
times."  This  may  explain  the  variation  in  time 
of  flow  of  different  women  and  the  long  approach 
or  cessation  with  spotting  seen  in  some  patients. 

In  this  type  of  study  of  the  pathology  of  men- 
struation, we  must  eliminate  benign  and  malignant 
tumors  and  inflammatory  processes  as  causes  of 
uterine  bleeding.  Then  we  have  etiologically  dis- 
turbances in  the  production  and  time  of  liberation 
of  anterior  pituitary  and  ovarion  hormones.  Our 
problem  is  the  recognition  of  the  dysfunction 
through  clinical  and  laboratory  investigation.  Not 
all  bleeding  from  the  uterus  is  menstruation,  for 
the  synergistic  and  antagonistic  action  of  the  hor- 


mones above  explained  is  necessary  for  true  men- 
struation. 

Women  may  bleed  from  the  uterus  at  almost  any 
time  during  life  but  let  us  consider  it  at  three  im- 
portant times — puberty,  maturity  and  menopause. 

We  have  not  uncommonly  seen  at  puberty  ex- 
cessive or  continuous  bleeding  which  is  probably 
due  to  failure  or  deficient  production  of  the  second 
ovarian  hormone  (progestin).  In  such  a  case,  if 
prolan  B  is  being  formed  its  antagonism  to  prolan 
A  is  not  sufficient  (alone  without  progestin)  to 
stop  growth  of  the  follicles  and  hence  the  produc- 
tion of  estrin.  This  allows  the  continued  growth 
of  the  endometrium  which  after  a  while  gets  so  old 
(comparatively)  that  it  degenerates  piecemeal, 
breaks  off  and  bleeding  occurs.  If  such  a  uterus 
is  curetted  and  the  entire  endometrium  is  removed 
(leaving  the  basal  layer),  then  by  the  time  prolan 
A  stimulates  more  follicles  and  thereby  estrin  the 
ovaries  may  be  mature  enough  for  prolan  B  to 
form  corpora  lutea  and  progestin  which  (with  the 
loss  of  estrin)  stops  endometrial  growth.  If  the 
ovaries  are  still  immature,  bleeding  may  return^* 
The  ideal  treatment  in  such  a  patient  would  be 
(while  bleeding)  the  injection  of  progestin  to  stop 
the  growth  of  the  endometrium  and  bring  about 
estrus  or  menstruation. 

Bleeding  in  mature  women  must  not  be  consid- 
ered functional  until  we  eliminate  pelvic  inflamma- 
tion, abnormalities,  benign  and  malignant  tumors. 
A  curettage  in  the  functional  cases  usually  delivers 
a  large  amount  of  pale  thick  endometrium  which 
histologically  shows  a  multiplicity  of  glands,  an 
increase  in  vascularity,  many  dilated  glands,  often 
presenting  the  appearance  described  by  No- 
vak. In  a  smaller  number  of  patients  we  find 
scanty  amount  of  endometrium  without  evidence  of 
hyperplasia.  This  may  be  due  to  the  curettage 
having  been  postponed  until  the  endometrium  has 
degenerated  and  come  away  following  a  previous 
hyperplasia.  But  other  patients  seem  to  show  the 
thin  endometrium  at  all  stages. 

In  many  patients  with  functional  bleeding  we 
have  found  chronic  endocervitis  with  the  pathologi- 
cal consequences  that  follow  upon  its  ascending  in- 
fection. Whether  this  infection  and  ascending  lym- 
phangitis is  a  factor  or  coincidence  is  to  be  seen. 

Bleeding  in  the  mature  as  well  as  the  adolescent 
cases  can  be  theoretically  controlled  by  the  use  of 
prolan  B  as  it  appears  in  antuitrin  S  or  follutein 
made  from  the  urine  of  pregnant  women.''  Injec- 
tion of  this  substance  into  mice  and  rats  caused 
lutenization  (progestin  production)  but  has  failed 
to  do  so  in  women.  However,  there  is  benefit  seen 
in  some  patients  probably  due  to  a  reciprocal  action 
between  the  anterior  lobe  and  the  ovaries. 

Zondek^   found   this  anterior  pituitary-like  sub- 


June,  1936 


UTERINE  BLEEDING— Procter 


Stance  in  the  urine  of  pregnant  women  and  based 
upon  this  is  the  explanation  of  the  Ascheim-Zondek, 
or  Friedman  test  for  pregnancy. 

We  have  been  using  for  the  past  year  in  the 
first  two  classes  of  patients  a  commercial  prepara- 
tion of  progestin  (proluton-Schering)  with  appar- 
ently favorable  results.  The  short  length  of  time 
necessitates  withholding  any  positive  statement. 

The  treatment  of  functional  uterine  bleeding  is 
not  ideal.  This  forces  us  at  times  to  use  other 
forms  of  therapy.  Although  the  thyroid  is  not  pri- 
marily one  of  the  sex  organs  it  apparently  affects 
the  action  of  all  endocrine  glands  and  seems  to 
augment  the  action  of  other  hormones.  We  use  it 
after  careful  study  of  the  basal  metabolic  rate. 

Haines  and  Mussey  at  Rochester  and  Litzenberg 
at  Minneapolis  report  68  to  73  per  cent,  good  re- 
sults in  some  500  cases  of  functional  bleeding  using 
five  to  eight  grains  of  thyroid  daily.  This  is  prob- 
ably an  excessive  dose  for  a  majority  of  our  pa- 
tients. 

Menopausal  bleeding  is  important  on  account  of 
the  possibility  of  malignancy.  No  treatment  should 
be  attempted  until  inspection  of  the  cervix  and 
thorough  curettage  of  the  endometrium  with  mic- 
roscopic study  has  eliminated  cancer.  This  type 
of  bleeding  is  but  little  affected  by  drugs,  for  cor- 
pora lutea  are  absent  or  unable  to  produce  suffi- 
cient progestin  to  counteract  the  estrin.  The  ideal 
treatment  after  eliminating  organic  disease  is  irra- 
diation with  x-ray  or  radium.  Radium  seems  to 
give  the  best  results  and  is  the  treatment  of  choice 
in  the  menopausal  group. 

.\dolescent  and  maturity  patients  should  be 
treated  conservatively  with  hormones  (progestin), 
th3Toid  or  curettage.  In  extreme  cases  radical 
measures  may  be  necessary  and  radium  is  a  valua- 
ble therapeutic  agent  if  used  judiciously.  It  must 
be  remembered  that  certain  patients  show  a  hyper- 
radio  sensitivity  and  even  small  doses  may  pro- 
duce sterility  or  menopause.  A  wise  selection  of 
cases  and  small  doses  of  radium,  however,  gives  a 
high  percentage  of  relief,  carries  no  mortality  (even 
in  extreme  cases)  and  is  preferable  to  hysterec- 
tomy, the  only  operative  procedure  that  is  to  be 
used  after  curettage  fails. 

A  Report  of  Thirty  Cases  of  Uterine  Bleeding 
The  adolescent  and  maturity  patients  were  of  the 
intractable  type  requiring  extraordinary  treatment 
and  the  menopausal  group  was  important  from  the 
diagnostic  standpoint  of  possible  malignancy. 

No.   patient?   requiring   surgical    or   irradiation   treat- 
ment   30 

No.  adolescent  under  21  _ 4 

(Two  of  the^e  radiated  under  18  years  of  age) 

No.  maturity  21-40  years  18 

No.  menopausal  40  or  above  8 


HEMOGLOBIN: 

35%  or  below 

35  to  50% 

50  to   75%  

70%  or  above 


(Eleven  of  the  thirteen  with  70%  were  in  the  ma- 
turity or  menopausal  groups  indicating  the  neces- 
sity for  early  action  (in  women  35  years  and 
above)   to  eliminate  malignancy.) 

HISTOLOGICAL   EXAMINATION   OF  ENDOME- 
TRIUM: 

Hyperplasia    27 

Atrophic  endometrium  , 2 

Normal    _ _ i 

NUMBER  OF  PATIENTS  TREATED  WITH  RADIUM: 
Ages:   20  years  or  under  2 

20   to   30  years  _. _ 10 

30  to  40  years  _ ____.     4 

40  years  and  above  -- 7 

AMOUNT  OF  IRRADIATION: 

16  patients  received    300  to  600  miligram  hours 
2         "  "  600  to  900 

6         "  "        1200  or  more        "  " 

(.\11   those   receiving   1200   miligram   hours   were   in   the 
menopausal  group) 

6  patients  had  only  D.  and  C. 

3         "        returned  after  D.  and  C. 

2         "  "        for  second  dose  of  irradiation. 

THERE  WAS  NO  MORTALITY: 

Bleeding  was  controlled  in  all  patients.  One  patient  had 
two  pregnancies  to  follow  irradiation.  One  pregnancy 
ended  in  abortion.  The  second  pregnancy  in  premature 
rupture  of  membrane,  intrauterine  infection,  contraction 
ring — operation  (Porro).     Recovery. 

SEVERE    PL1BERTY    BLEEDING 

CASE  REPORTS: 

Girl,  first  menstruation  started  six  months  before  ad- 
mission and  lasted  for  five  weeks,  soaking  6  or  more 
towels  daily.  Hemoglobin  i3%.  Treatment  direct  trans- 
fusion. Eight  months  later,  admitted.  Hemoglobin  33%. 
Bleeding  profuse.  Treatment  transfusion.  Readmitted 
again  that  year  and  also  the  following  year.  Hemoglobhi 
3S%-35%,  respectively.  Tran.=fusion  repeated.  Fifth  ad- 
mission (age  IS).  Referred  to  department  of  gynecology. 
Hemoglobin  35%.  Treatment  dilatation-curettage-intra- 
uterine  radium  50  miUigrams  for  12  hours.  Three  months 
later,  hemoglobin  46%.  Menstruation  recurring  26-day 
interval  lasting  four  days.  Six  months  after' irradiation, 
the  hemoglobin  was  76%. 

Radium  Not  Elective  But  Treatment  of  Necessity 
In  this  small  group  of  thirty  patients,  it  is  shown 
that  intrauterine  radium  is  an  effective  agent  in  the 
control  of  functional  bleeding.  The  writer  thinks, 
however,  that  although  irradiation  can  be  used  bene- 
ficially without  injury  to  health  or  producing  ster- 
ility, it  should  not  be  employed  until  more  conserv- 
ative forms  of  treatment  have  failed  to  produce  re- 
sults. There  are  exceptions,  as  in  the  case  of  Miss 
L.  H.,  who  was  referred  to  us  with  hemoglobin  of 
35%,  having  had  4  direct  transfusions  and  medi- 
cinal treatments.  This  patient's  physical  condition 
called  for  immediate  relief  and  radium  is  preferable 
to  abdominal  operation    from    the    standpoint    of 


UTERINE  BLEEDING— Procter  June,  1936 


1.  POST  MENSTRUAL   PHASE: 

The  endometrium  is  characteristically  thin. 
The  epithelium  is  of  the  low  cuboidal  type. 
The  glands  are  slit-like  with  narrow  lumen.      Tortuosity  is  absent,   and  the   epithelium 

often  shows  mitotic  figures. 
The  stroma  is  compact. 

2.  INTERVAL    phase: 

This  endometrium  was  removed  at  a  late  interval  stage.  Growth  and  hypertrophy  have 
taken  place.  The  epithelium  changes  to  the  columnar  type.  The  glands  grow  wide 
and  tortuous.     The  stroma  remains  closed. 

3.  PREMENSTRUAL  OR  SECRETORY  PHASE: 

The  surface  epithelium  is  high  columnar  type  (non-secretory).  The  glands  are  cork- 
screw type.  Their  euitliflium  is  irregular  and  frayed.  The  cytoplasm  of  the  epithelial 
cells  seems  to  pour  into  the  gland  lumen.  The  stroma  is  loose — the  cells  separated  by 
edema.  The  stroma  nuclei  have  taken  on  a  band  of  cytoplasm  and  some  may  resemble 
decidual  cells.  Vascularity  has  increased — the  capillaries  approaching  the  gland  lumen. 
The  stroma  is  infiltrated  with  leukocytes  and  wandering  cells,  particularly  large 
mononuclears  with  dark  nuclei.  Here  it  is  important  to  recognize  the  normal  endo- 
metrium and  not  confuse  this  stroma  with  that  due  to  inflammation. 

4.  MENSTRUATION  OR  BLEEDING   PHASE: 

This  shows  a  marked  dilatation  ot  blood  vessels.  There  is  a  breaking  away  of  the  surface 
endometrium  at  different  points.  The  basal  endometrium  remains  intact  and  from 
this  the  new  endometrium  is  formed.  Each  day  of  menstruation  the  endometrium 
presents  a  different  picture  for  the  entire  process  throughout  the  2,S-day  cycle  is  a 
gradual  hourly  and  daily  transition  from  one  phase  to  another. 

5.  ENDOMETRIUM  HYPERPLASIA: 

Curettings  from  a  case  of  functional  bleeding.  There  are  many  dilated  glands  irregular 
in  shape  and  size.  The  stroma  is  dark  and  closely  packed.  A  non-secretory  type  of 
endometrium  seen  in  the  absence  of  the  corpus  luteum  hormone. 

6.  ENDOMETRIAL  HYPERPLASIA: 

Curetting  from  a  case  of  functional  bleeding.  The  surface  epithelium  is  the  columnar 
of  the  interval  phase.  The  glands  are  both  small  and  large,  the  former  postmenstrual 
type — the  latter  cystic  in  appearance.  This  photograph  shows  a  cystic  gland  in  the 
center.  The  stroma  usually  shows  a  definite  increase.  It  is  compact,  stains  dark,  an 
indication  of   (non-secretory)    interval  endometrium  without  the    effect   of   progestin. 


June,  1936 


UTERINE  BLEEDING— Procter 


These  cuts  show  the  four  stages  of  norma!  menstruation  and  two  of  pathological  hyperplasia. 


UTERINE  BLEEDING— Procter 


June,  1936 


morbidity,  mortality  and  the  preservation  of  the 
reproductive  function. 

Hormones 
The  various  names  of  the  pituitary  and  ovarian 
hormones  have  been  listed  so  as  to  familiarize  our- 
selves with  them  and  to  prevent  confusion  in  study- 
ing the  literature  on  this  subject.  On  looking  over 
the  list  of  commercial  preparations  of  estrogenic 
substances,  one  sees  at  a  glance  the  necessity  of 
investigating  the  particular  brand  or  hormone  being 
used."  There  is  such  a  wide  variation  in  the  number 
of  units  contained  that  results  must  necessarily  be 
different. 

DIFFERENT    NAMES    FOR    ESTROGENIC    SUBSTANCES 

Estrin 

Follicle  fluid 

Female  sex  hormone 

Beta  hormone 

Beta  follicular  hormone 

Ovarian  follicular  hormone 


COMMERCIAL  PREPARATIONS,   estrogenic 
substances: 
Emminen 
Folliculin 
Menformon 
Theelin 
Theelol 
.^mniotin 
Progynon 

NAMES    FOR    CORPUS    LUTEUM    FLUID 

Progestin 
Corporin 

COMMERCIAL  PREPARATION:   corpus  luteum 

HORMONE 

Proluton   (Schering) 
Lutex  (Leo) 
Luteogan   (Henning) 

ANTERIOR  PITUITARY  HORMONE: 
Prolan  A. 
Prolan  B. 

ANTERIOR   PITUITARY-LIKE   HORMONE 

(Gonadotropic):   commerciai. 

.^ntuitrin  "S" 

Follutein 


strength  of  commercial  preparations 
R.  U.  means  rat  unit. 
I.  U.       "     international  unit. 
One  rat  unit  equals  approximately  five  international  units 


Antuitrin  "S" 
Follutein 

MOUTH:   (action  limited) 
Theelin  kapseal       each 
Amniotin  capsule       " 
Progynon  tablet         " 


VAGINAL: 

Theelin  suppository  " 
Amniotin  pessary       " 

HYPODERMIC:    {intramuscular) 
Theelin 
Theelin 
Theelin 
Amniotin 

Progynon 


1  ex.  hypodermic 
1  c.c.  " 


45  R.  U.  or 
200  R.  U.  or 
600  R.  U.  or 


1  c.c.  aqueous 

1  c.c.  in  oil  300  R.  U. 

1  c.c.  "     " 

1  c.c.  "     " 

1  c.c.  "     " 

1  c.c.  aqueous  25  R.  U.  or 

1  c.c.  in  oil      500  R.  U.  or 

1  c.c.  "     "      1000  R.  U.  " 

1  c.c.  "     "     2000  R.  U.  " 

1  c.c.  "     •'  10,000  R.  U.  " 


100  R.  U.— Parke  Davis 
12S  R.  U.— Squibb 

50  R.  U.— Parke  Davis 
1,000  I.    U.— Squibb 

225  I.    U.— Schering 
1,000  I.   U.—      " 
3,000  I.    U.—       " 

50  R.  U.— Parke  Davis 
2,000  I.   U.— Squibb 

50  R.  U.— Parke  Davis 

1,000  I.  U.—     "  " 

2,000  I.  U.—     " 

2,000  I.  U.— Squibb 

8,000  I.  U.—      " 

125  I.  U.— Schering 

2,500  I.  U.—      " 

5,000  I.  U.—      " 

10,000  I.  U.—      " 

50,000  I.  U.—       " 


CORPUS  LUTEUM 

HORMONE- 

— progestin 

Proluton 

Ic.c. 

1/25  I. 

U.— Sc 

1  c.c. 

1/5  I. 

U.— 

1  c.c. 

Vz  I. 

u.— 

" 

1  c.c. 

1  I. 

u.— 

" 

1  c.c. 

5  I. 

u.— 

Parke    Davis 

now 

offers    lipo- 

iitin    in    oi 

solut 

prog-estin:  1  c.c 

equals  1  R.  u. 

Proluton  is  the  crystaline  corpus  luteum  hormone 
(progesterone)  one  milligram  is  equal  to  one  inter- 
national unit  and  is  approximately  the  equivalent 
to  one  Corner- Allen  unit.     Due  to  the  suggestion 


of  the  League  of  Nations'  Standardization  Commit- 
tee (London,  1935)  proluton  is  now  declared  in 
international  units  and  the  practitioner  should  use 
this  standard  and  not  become  confused  with  the 
previous  European  rabbit  unit  or  Clauberg  unit. 

The  use  of  these  commercial  preparations  must 
be  carried  out  with  some  consideration  of  the  time 
of  administration — the  amount  of  hormone  used 
and  what  function  we  expect  them  to  perform.   For 


June.  1Q36 


UTERINE  BLEEDING— Procter 


Prown  0 


g.P-^.?.^pFi>u.C. 


TRIN+      OeSTPiN- 

Oestrin         \         PRo&c-sns  -      pRoc-EsriN 


imm 


A  diagraraatic  representation  of  the  liberation  of  Prolan  A  and  B  from  the  Anterior 
Pituitary  and  its  effect  upon  the  Follicles:  showing  also  the  transformation  of  the  ruptured 
Follicle  into  Corpus  Luteum  and  the  release  of  Estrin  (Oestrin)  from  the  Follicle  and  Progestin 
from  Corpus  Luteum  and  their  effect  upon  the   Endometrium. 


instance,  the  injection  of  estrin  (theelin,  amniotin 
or  progynon)  should  not  be  done  with  the  idea  that 
it  will  cause  the  ovary  to  form  more  estrin,  for  such 
treatment  is  only  substitutional  therapy  given  on 
account  of  delicient  or  absent  hormone.  In  order 
to  stimulate  the  ovary,  we  must  go  a  step  backward 
and  give  the  anterior  pituitary  hormone,  prolan  A. 
Theoretically,  this  should  be  used  at  the  end  of 
menstruation  and  for  a  few  days  following.  The 
estrogenic  substance  (theelin,  progynon  or  amni- 
otic) is  well  given  during  the  second  week  of  the 
menstrual  cycle.  Prolan  B  should  make  its  appear- 
ance in  the  cycle  after  ovulation  (14th  day)  has 
occurred,  for  it  is  the  agent  that  stimulates  the  for- 
mation of  the  corpus  luteum  and  its  hormone,  pro- 
gestin. The  clinical  use  of  progestin  (proluton) 
then  follows  in  sequence  the  17th  to  23rd  day  of 
the  cycle. 

I  wish  to  express  my  appreciation  to  Dr.  C.  C.  Carpenter, 
Waive  Forest  Medical  School,  for  his  hearty  co-operation 
and  assistance  in  the  pathological  studies  included  in  this 
report. 

References 

1.  Novak,  E.:      Obs.   &  Gyn.    Curtis   &   Collaborators — 
W.  B.  Sanders,  vol.  1,  p.  307. 

2.  Kane,  H.  F.:     Va.  Med.  Monthly,  col.  62,  no.  1,  Apr., 
1935,  p.  19. 

3.     Corner,  G.  W.:     //.  A.  M.  A.,  May  2Sth,  1935,  vol. 
104,  no.  21,  p.  1899. 
4.    Novak,  E.:     //.  A.  M.  A.,  May   18th,  1935,  vol.  104, 
no.  20,  p.  1815. 


5.  Allen,  E.:  //.  A.  M.  A.,  May  25th,  1Q3S,  vol.  21,  p. 
1901. 

6.  Kane,  H.  F.:  Va.  Med.  Monthly,  col.  62,  no.  1,  Apr., 
1935,  p.   19. 

7.  H.AAiBLEN,  E.  C:  Bui.  Assn.  for  the  Study  of  Internal 
Secretions,  vol.  19,  no.  2,  March  and  April,  1935,  pp. 
169-180. 

S.     Novak,  E.:     //.  A.  M.  A.,  March  23rd,  1935,  vol.  104, 

no.  21,  p.  999. 
9.     Pratt,    J.    P.:    Proceedings    of    Second    International 

Congress  for  Sex  Research,  1930,  p.  498-506. 

10.  Smith,  P.  E.:  Jl.  A.  M.  A.,  Feb.  6th,  1935,  vol.  104, 
no.  7,  p.  553. 

11.  Novak,  E.;     //.  .4.  M.  A.,  vol.  105,  no.  9,  p.  662. 

12.  BisKiND,  M.  S.:     Jl.  A.  M.  A.,  vol.  105,  no.  9,  p.  667. 


(E. 


Early   Diagnosis   in   .Abdomin.-u,   Surgery 

I.    Med.    Soc,    of    N. 


The  causes  of  "indigestion"  in  the  order  of  their  fre- 
quency: gallbladder  disease,  duodenal  ulcer,  carcinoma  of 
the  stomach,  gastric   ulcer,  appendicitis. 

Thirty  per  cent,  of  people  dying  after  45  years  of  age 
show  gallstones  at  autopsy;  20%  of  duodenal  ulcer  cases 
meet  with  some  catastrophe  sooner  or  later. 

Mortality  in  operating  upon  ulcer  cases  with  massive 
hemorrhage  is  higher  than  with  medical  treatment,  unless 
operation  is  performed  after  bleeding  has  stopped. 

Fifty-two  per  cent,  of  the  ca.ses  of  carcinoma  of  the 
stomach  reach  the  hospital  too  late;  yet  have  had  symp- 
toms referable  to  the  stomach  only  a  short  time.  When 
pain  in  the  belly  lasts  persistently  without  diarrhea  for  6 
hours,  a  surgeon  should  be  consulted;  50%  of  carcinomas 
of  large  bowel  are  within  reach  of  the  finger  by  rectal 
examination.  X-ray  will  rarely  show  cancer  at  the  recto- 
sigmoid junction,  but  the  finger  and  proctoscope  will  show 
it. 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


The   Psychotic   Disturbances   Incidental   to  Pregnancy, 
the  Puerperal  State  and  the  Menopause* 

R.  H.  Long,  M.D.,  Morganton,  North  Carolina 

State  Hospital 


BECAUSE  of  the  interest  of  the  profession 
and  the  laity,  a  brief  consideration  of  the 
causation  of  insanity  seems  in  order.  The 
causative  factors  in  mental  as  well  as  in  physical 
disease  fall  into  two  groups — predisposing  or  fun- 
damental and  exciting  or  precipitating.  The  excit- 
ing factor  in  the  production  of  mental  disease  is 
relatively  unimportant.  In  a  great  number  of  cases 
distressed  relatives  cite  instances  of  injury,  partic- 
ularly head  injury,  shock  and  disappointment,  bad 
health,  operations,  etc.,  and  feel  if  these  things 
were  corrected  the  patient  would  regain  his  mental 
health  immediately.  While  these  matters  should 
receive  proper  consideration,  it  is  essential  that  we 
not  lose  sight  of  the  fact  that  the  fundamental  or 
basic  cause  of  the  breakdown  lies  within  the  indi- 
vidual himself;  and,  it  will  be  the  aim  of  this  paper 
to  show  that  the  pregnant  and  puerperal  states  or 
the  menopause  should  be  regarded  only  as  the  ex- 
citing cause  of  the  breakdown  and  that  the  un- 
stable or  neuropathic  tendency  of  the  individual  is 
the  basic  or  fundamental  cause.  If  these  states  in 
themselves  were  actual  causes  of  insanity,  many 
more  women  who  bear  children  or  reach  the  meno- 
pause would  develop  a  psychosis,  but  happily  this 
occurs  only  in  those  with  an  unstable  make-up. 

The  pregnant  or  puerperal  state  is  made  possible 
because  the  individual  is  possessed  of  the  ability 
to  procreate;  whereas  at  the  time  of  the  menopause 
this  ability  is  lost  and  there  is  in  progress  a  gradual 
disarrangement  of  the  entire  endocrine  control  of 
various  mental  and  bodily  activities.  The  endo- 
crine glands  may  be  considered  as  links  in  a  chain, 
one  dependent  on  and  controlling  the  activation  of 
the  others.  These  interconnected  glands  exercise 
control  of  many  vital  functions  of  bodily  activity — 
sexual,  metabolic,  physical  development,  vasomotor, 
etc. — and  when  one  link  in  the  chain  is  weakened, 
whatever  the  cause  may  be,  the  entire  system  may 
be  thrown  out  of  gear  and  a  readjustment  be  made 
necessary.  Only  in  this  way  can  we  account  for 
the  multiplicity  of  physical  and  mental  symptoms 
during  the  period  of  involution  of  the  gonads. 

The  first  part  of  this  discussion  is  concerned  with 
psychotic  manifestations  occurring  when  there  has 
been  no  permanent  disturbance  in  the  ovarian  func- 
tion. However,  it  is  an  interesting  hypothesis  that, 
because  of  even  temporary  disturbance  in  the  nor- 


mal activity  of  the  ovary,  the  entire  endocrine  sys- 
tem may  be  thrown  out  of  balance  with  disturbance 
in  the  individual's  entire  physical  and  mental  life. 
With  this  explanation  we  can  understand  how  an 
individual  with  a  neuropathic  background  will  de- 
velop a  psychosis  during  or  after  pregnancy.  Few 
authorities  contend  that  there  is  a  distinct  clinical 
psychiatric  entity  occurring  during  pregnancy. 
There  is  often  observed  a  change  in  disposition, 
irritable  mood,  unnatural  appetite,  etc.,  which  is 
not  considered  definitely  abnormal.  This  is  usually 
only  temporary;  however,  definite  mental  symp- 
toms may  appear,  usually  those  of  a  dormant 
schizophrenia  or  a  manic  depressive  episode.  In 
these  cases  one  is  often  able  to  elicit  a  history  ■of 
insanity  in  the  ancestry  and,  in  individuals  with  a 
cyclothymic  personality,  a  history  of  previous  epi- 
sodes. In  the  puerperal  state,  also,  these  consid- 
erations hold  true,  except  that  there  is  always  the 
possibility  here  of  exhaustion  from  infection,  hem- 
orrhage, etc.  If  this  occurs,  the  clinical  picture  of 
the  mental  disturbance  is  that  of  an  exhaustion 
delirium. 

I  have  selected  five  cases  from  the  women's  de- 
partment of  the  State  Hospital  at  Morganton  and 
will  briefly  describe  the  conspicuous  symptoms. 
You  will  observe  in  the  majority  of  these  cases  the 
psychotic  symptoms  are  those  of  one  of  the  ordi- 
nary psychoses  which  has  been  lying  dormant  in 
the  individual  and  only  needed  some  undue  stress 
to  bring  it  to  light.  Some  of  these  developed  during 
the  early  months  of  pregnancy  while  others  devel- 
oped during  the  puerperium. 

Case  1. — Married  woman,  23,  mother  of  two  children, 
deserted  by  husband  two  years,  two  months  advanced  in 
illegitimate  pregnancy.  Onset  was  three  weeks  prior  to 
admission.  There  was  no  history  of  previous  mental  trou- 
ble, but  her  mother  was  insane.  At  first  she  lost  interest 
in  her  home  and  children,  and  became  seclusive,  depressed 
and  wrote  notes  expressing  her  intention  to  commit  suicide, 
giving  instructions  concerning  her  children  and  started  to 
river  but  was  apprehended.  On  admission  she  was  de- 
pressed and  expressed  delusion  of  unpardonable  sin  and 
apprehension  in  regard  to  her  soul's  welfare.  She  worried 
about  the  uncertainty  of  supporting  her  children  and  also 
over  being  pregnant  out  of  wedlock.  There  was  evident 
retardation  in  both  psychic  and  motor  fields.  Working 
diagnosis  recorded  as  manic  depressive,  depressed  phase. 
During  stay  in  hospital  she  continued  depressed  and  sui- 
cidal for  several  months.  Then  she  gradually  became  more 
cheerful  and  interested  and  about  seven  months  after  ad- 


•Presented    to   the    Post-Graduate    Asembly    ot    the    North   Carolina   Medical  Society  at   Banner  Elk,   N.   C.   August 
23rd,  1935. 


June,  1936 


PSYCHOTIC  DISTURBANCES— Long 


311 


mission  her  baby  was  born.  The  labor  was  not  difficult 
and  the  puerperium  was  uneventful.  She  was  discharged 
from  hospital  six  weeks  after  birth  of  baby  in  approxi- 
mately normal  mental  condition. 

Case  2. — Married  mother  of  two  children,  23,  admitted 
three  months  pregnant.  Mother,  father  and  maternal  aunt 
all  insane  and  had  been  committed  to  State  Hospital  at 
Morganton — diagnosis  in  each  case  manic  depressive  in- 
sanity. The  present  patient  had  been  admitted  three  years 
previously  with  history  of  attacks  prior  to  that  followed 
by  recovery.  She  seemed  to  make  a  good  recovery  after 
her  first  admission,  at  which  time  the  diagnosis  was  re- 
corded as  manic  depressive,  manic  phase.  At  time  of  last 
admission  she  was  overactive,  playful,  friendly  and  face- 
tious in  mood  with  moderate  elation ;  was  overtalkative, 
circumstantial  and  exhibited  flight  of  ideas.  Mild  paranoid 
trend  was  expressed.  Her  case  was  again  diagnosed  manic 
depressive,  manic  phase.  She  continued  excited  and  be- 
came violent  and  abusive  for  several  months.  Six  months 
after  admission  her  baby  was  born,  labor  and  puerperium 
normal.  The  patient  became  quieter,  but  was  still  critical 
and  exacting  when  released  on  parole  SJ2  months  after 
admission.  She  was  returned  a  month  later  in  a  depressed 
state  which  continued  for  several  months.  She  was  again 
paroled  nine  months  after  her  return  in  an  approximately 
normal  mental  state.  Seven  months  later  she  was  returned 
to  hospital  five  months  advanced  in  pregnancy  and  in  state 
of  manic  excitement.  The  baby  was  born  3;^  months 
later.  The  excitement  quickly  subsided  and  two  months 
later  she  left  the  hospital  in  an  apparently  clear  mental 
state.  Several  other  paroles  and  returns  have  occurred 
since  and  she  is  at  present  at  home.  From  experience  it  is 
about  time  for  her  to  come  back  and  in  all  probability 
she  will  be  pregnant. 

Case  3. — Married  woman,  28,  first  attack,  acute  onset 
one  week  after  childbirth.  At  first  she  was  exhilarated, 
conversation  irrelevant  and  flighty,  was  destructive  and 
had  the  delusion  her  food  was  poisoned,  took  no  interest 
in  baby.  On  admission,  l]/,  months  after  delivery,  she 
was  indifferent  and  silly,  at  times  mute  and  impulsive, 
said  the  Lord  talked  to  her  and  expressed  the  idea  she 
was  being  influenced  in  some  mysterious  manner.  Since 
admission  the  patient  has  been  entirely  mute  most  of  the 
time  and  often  refused  to  wear  clothes.  On  admission  she 
was  well  nourished  and  did  not  appear  acutely  ill,  exam- 
ination essentially  negative.  ,'\t  present,  one  month  after 
admission,  there  is  slight  indication  of  improvement — wears 
her  clothes,  eats  well  and  is  able  to  be  on  the  hall  part  of 
the  time — but  is  still  mute  and  silly.  Laughs  impulsively 
and  without  cause,  with  many  silly  gesticulations  and  man- 
nerisms.    Diagnosis  of  dementia  praecox  seems  justified. 

Case  4. — Married  woman,  20,  in  first  attack,  onset  one 
week  after  uncomplicated  childbirth,  when  she  suddenly 
jumped  out  of  bed  and  tried  to  run  away.  She  refused  to 
eat  when  the  family  was  looking,  was  resistive  and  as- 
saultive. On  admission  the  patient  was  well  nourished  and 
did  not  seem  acutely  ill.  Physical  examination  was  essen- 
tially negative.  During  routine  mental  examination  was 
lying  in  bed  with  covers  pulled  over  her  head,  resistive 
and  mute.  Cerea  flexibilitas  has  been  evident  much  of  the 
time  since  admission  and  she  has  been  fed  by  nasal  tube 
all  of  the  time.  At  present,  nine  months  after  the  onset, 
she  is  still  extremely  negativistic,  mute,  resistive  and  refuses 
food,  lies  in  bed  at  all  times  with  covers  over  her  head 
and  body  twisted  into  the  fetal  position.  Diagnosis  of 
dementia  praecox  seems  unquestionable. 

Case  5. — Widow,  36,  first  attack,  following  abortion  of 
five  months  illegitimate  pregnancy.    Onset  was  sudden  with 


agitation,  hallucinations  and  homicidal  and  destructive  ten- 
dencies. Had  severe  convulsion  followed  by  coma  and 
the  following  day  she  was  delivered  of  a  macerated  fetus. 
On  admission  to  State  Hospital  she  was  in  state  of  delirious 
and  confused  excitement  and  she  continued  in  this  state 
for  36  hours  with  complete  disorientation  and  apprehensive 
mood.  Feeding  was  by  nasal  tube.  On  third  day  after 
admission  her  mind  cleared  up  rather  suddenly,  she  became 
friendly  and  sociable,  talked  freely  and  coherently  and 
there  were  no  evident  psychotic  symptoms.  She  had  com- 
plete amnesia  for  the  events  of  this  episode.  On  admission 
and  for  several  days  after  her  mental  symptoms  disappear- 
ed she  exhibited  a  decided  impediment  of  speech  not  unlike 
the  slurring  speech  of  general  paralysis,  although  the  Was- 
sermann  reaction  was  negative.  This  speech  defect  grad- 
ually and  completely  disappeared.  Diagnosis  of  psychosis 
with  somatic  disease,  acute  delirium,  was  made. 

Comment 
These  few  cases  show  that  different  types  of 
mental  disturbances  develop  incidental  to  child- 
birth. Many  other  similar  cases  could  be  cited. 
In  the  first  two  cases  each  patient  undoubtedly  had 
a  cyclothymic  personality  which  e.xpressed  itself  in 
manic  depressive  episodes  in  the  early  months  of 
pregnancy.  Although  the  life  history  of  the  first 
patient  is  inadequate,  we  are  safe  in  assuming  a 
neuropathic  tendency  because  of  the  insanity  in 
her  mother  and  her  own  breakdown.  In  the  second 
case  this  tendency  is  well  known  from  personal  ex- 
perience. Because  of  the  frequency  of  her  attacks, 
even  before  pregnancy,  it  seems  that  pregnancy  is 
purely  incidental.  It  would  be  difficult  to  select  a 
nine-months  period  within  the  past  few  years  free 
of  episodes  of  depression  or  excitement.  The  two 
dementia-praecox  cases  developed  in  the  puerpe- 
rium about  one  week  after  delivery.  If  careful  life 
histories  were  obtainable  we  would  very  likely  dis- 
cover schizoid  traits.  It  is  inconceivable  that  such 
grave  disturbances  as  are  evident  here  would  de- 
velop in  one  with  a  sound  personality.  The  last 
case  is  typically  one  resulting  from  exhaustion,  and 
exhaustion  with  psychosis  may  result  from  any  se- 
vere physical  disease.  Some  authorities  contend 
that  these  cases  really  belong  in  the  dementia- 
praecox  group.  However,  the  picture  is  entirely 
different  from  the  usual  types  of  dementia  praecox 
and  seems  to  justify  a  separate  classification. 

The  second  part  of  this  discussion  is  devoted  to 
the  consideration  of  the  psychotic  disturbances  oc- 
curring in  women  at  the  time  of  the  menopause. 
The  question  whether  or  not  there  is  a  clinical 
psychiatric  entity  confined  to  the  involution  period 
of  life,  which  is  entitled  to  a  separate  classification, 
has  been  a  subject  of  discussion  for  many  years. 
Many  authorities  contend  the  psychoses  developing 
at  this  time  are  either  manic-depressive  episodes 
or  late  schizophrenias  and  are  brought  to  light  be- 
cause of  the  strain  of  readjustment  resulting  from 
the  endocrine  imbalance  incidental  to  the  disturb- 


PSYCHOTIC  DISTURBANCES— Long 


June,  1936 


ance  in  the  gonads.  It  is  their  contention  that 
when  a  careful  study  is  made  of  the  individuals 
life  history  one  will  find  either  a  schizoid  or  a  cy- 
clothymic trend.  If  the  individual's  personality 
has  been  of  a  seclusive,  shut-in  type,  introverted 
and  living  within  herself  and  at  involution  she  de- 
velops a  queer,  unnatural  and  bizarre  delusional 
trend  with  an  abundance  of  hallucinations  or  pro- 
nounced negativistic  behavior,  the  psychosis  should 
be  considered  as  a  late  developing  schizophrenia. 
On  the  other  hand,  if  careful  study  discloses  a 
cyclothymic  personality — an  extrovert,  interested  in 
outside  affairs,  at  times  buoyant,  enthusiastic  and 
happy,  but  at  other  times  gloomy,  subject  to  at- 
tacks of  the  blues  and  having  a  feeling  of  insuffi- 
ciency— the  psychosis  belongs  to  the  manic-depres- 
sive group. 

Another  group  of  investigators,  equally  as  illus- 
trious, do  not  deny  the  possibility  of  the  develop- 
ment of  these  cyclothymic  and  schizophrenic  psych- 
oses at  the  involution  period,  but  insist  there  is  a 
distinct  clinical  syndrome  observed  only  at  invo- 
lution and  call  it  involution  melancholia.  This 
classification,  involution  melancholia,  should  be  re- 
stricted to  those  cases  developing  for  the  first  time 
during  involution  with  no  previous  neuropathic  his- 
tory and  presenting  symptoms  of  an  agitated  de- 
pression with  marked  apprehension  and  fear  of 
impending  calamity  and  with  decided  suicidal  ten- 
dency. Suicide  is  more  common  in  this  than  in 
any  other  recognized  group.  Hallucinations  usually 
play  an  important  role,  but  the  terrifying  delusions 
are  usually  the  conspicuous  symptoms.  The  delu- 
sions are  many  and  varied.  They  may  be  of  a 
religious  nature — the  patient  has  sinned  against  the 
Holy  Ghost,  is  eternally  lost  and  doomed  to  Tor- 
ment; they  may  be  of  a  somatic  and  nihilistic  char- 
acter— the  brain  is  lead,  she  has  no  stomach,  no 
bowels;  or  they  may  be  of  a  persecutory  trend  and 
the  patient  explains  her  persecution  because  she 
has  been  so  wicked  and  sinful.  She  moans  and 
groans  and  is  in  constant  motion,  wringing  her 
hands,  pulling  her  hair,  and  she  may  refuse  food  be- 
cause of  her  delusional  ideas. 

In  these  cases  in  which  the  menopause  has  been 
artificially  produced  by  complete  removal  of  the 
gonads,  the  clinical  picture  is  somewhat  different. 
In  the  absence  of  neuropathic  tendency,  the  domi- 
nant symptoms  will  be  essentially  those  pointing 
to  endocrine  disturbances.  The  patient  complains 
of  severe  occipito-cervical  headache,  dizziness  and 
vertigo,  vasomotor  disturbances  and  there  may  be 
metabolic  dyscrasias,  unnatural  growth  of  hair,  etc. 
The  distressing  delusions  which  accompany  the 
other  type  are  usually  not  prominent. 

Statistics  show  that  approximately  ii  1-3%  of 
involution  melancholia  cases  go  on  to  recovery  and 


some  observers  claim  recovery  may  take  place  as 
long  as  four  or  five  years  after  the  onset.  The 
outcome  naturally  depends  to  a  great  extent  on 
the  degree  of  arteriosclerosis  present  and  also  is 
influenced  by  the  clinical  picture.  In  those  cases 
showing  a  strong  affective  reaction  or  with  a  his- 
tory of  such  a  personality,  the  prognosis  is  better 
than  in  those  of  a  schizoid  trend  showing  a  ridic- 
ulous, hypochondriacal  nature,  strong  perverse  sex- 
ual trends  with  negativistic  reactions.  In  other 
words,  if  schizoid  elements  dominate  the  picture  the 
outlook  is  not  so  good  as  in  those  cases  in  which 
the  disturbance  is  chietly  in  the  affective  field. 

The  following  cases  have  been  selected  to  dem- 
onstrate the  different  clinical  pictures  observed  in 
the  involution  period.  For  statistical  purposes  they 
are  all  classified  as  involution  melancholia. 

C.\SE  1. — Married  housekeeper,  4S,  in  first  attack,  three 
months  duration.  Her  father  wa.-;  insane.  Menses  irreg- 
ular for  some  time.  At  onset  she  became  seclusive,  thought 
people  were  against  her  and  refused  to  talk.  Prior  to  ad- 
mission she  had  the  delusion  they  were  planning  to  kill 
her  becaushe  she  was  such  a  great  sinner.  On  admission 
was  resistive,  seemed  afraid  and  refused  to  sit  down.  Later 
she  became  more  restless  and  agitated  and  would  not 
speak.  The  diagnosis  was  recorded  as  involution  melan- 
cholia with  schizoid  trend,  .'\fter  six  months  in  the  hos- 
pital she  had  improved  a  great  deal  and  was  paroled  fairly 
cheerful  and  industrious. 

Case  2. — Married  housewife,  49,  admitted  in  first  attack 
of  two-weeks  duration,  the  onset  being  sudden  with  ex- 
citement. A  sister  had  dementia  praecox ;  paternal  cousin 
also  insane.  Menses  were  irregular.  Prior  to  admission 
she  was  destructive  and  threatened  suicide,  thought  neigh- 
bors and  relatives  wanted  to  do  her  harm,  had  hallucina- 
tions of  sight  and  hearing.  Said  she  had  been  to  Heaven 
and  had  seen  and  talked  with  her  mother.  On  admission 
she  was  stilted  and  constrained  in  manner,  kept  eyes  closed 
and  refused  to  speak.  When  examined  was  not  so  confused 
and  talked,  but  was  irrational  and  impulsive.  She  ad- 
mitted auditory  and  visual  hallucinations  and  expressed  the 
idea  she  was  unworthy  and  her  soul  was  lost.  Diagnosed 
involution  melancholia. 

Comment 
These  two  cases  show  decided  schizoid  reactions. 
There  is  a  history  of  insanity  in  the  families  of 
both  indicating  probable  neuropathic  tendency. 
They  were  both  negativistic  and  at  times  violent. 
The  first  patient  showed  decided  improvement  and 
probation  was  granted;  however,  it  is  doubtful  if 
complete  recovery  will  take  place.  After  three 
months  hospitalization  the  second  patient  has  un- 
dergone no  essential  improvement.  She  is  at  pres- 
ent silly  and  childish  and  at  times  becomes  noisy 
and  violent. 

Case  3. — Single  woman,  43,  in  first  attack;  onset  six 
months  prior  to  admission.  No  insanity  in  family.  Menses 
irregular  for  some  time  with  complete  cessation  at  time 
of  development  of  her  psychosis.  Before  admission  she 
was  morose,  expressed  the  delusion  she  was  lost,  a  mob 
was  trying  to  kill  her  and  heard  threatening  voices,  was 


June,  1936 


PSYCHOTIC  DISTURBANCES— Long 


self-accusatory — had  not  lived  right  or  done  the  things 
she  should  have  done.  On  admission  she  was  depressed 
and  there  was  evident  retardation  in  both  psychic  and 
motor  fields.  Was  seclusive  and  asocial.  Admitted  audi- 
tory hallucinations.  The  Lord  used  to  talk  to  her,  but 
more  recently  the  Devil's  voice  had  been  telling  her  she 
was  lost.  She  was  self-accusatory,  had  been  a  terrible 
sinner  and  the  devil  had  her  in  his  power,  knew  a  mob 
was  after  her,  going  to  kill  her  for  she  could  hear  their 
threatening  voices.  After  a  few  weeks  in  the  hospital  she 
began  to  show  some  improvement,  but  two  months  after 
admission  she  developed  a  fulminating  pellagra,  from  which 
she  died  one  month  later. 

Case  4. — Woman,  56,  who  had  previous  attack  at  25 
followed  by  recovery.  At  46  both  ovaries  and  uterus  were 
removed,  alter  which  she  became  nervous  and  weakly  and 
has  never  felt  well  since.  Pronounced  psychotic  symptoms 
appeared  nine  months  prior  to  admission,  self-accusatory 
and  persecutory  delusions,  she  was  a  terrible  criminal,  was 
to  be  locked  in  a  dungeon  and  that  her  soul  was  lost, 
was  not  fit  to  live  and  her  husband  ought  to  be  electro- 
cuted for  keeping  her.  On  admission  she  was  depressed 
and  agitated,  picked  at  her  fingers  and  pulled  at  her 
clothes.  Remained  in  the  hospital  four  months  and  was 
allowed  probation.  Had  undergone  much  improvement, 
was  quiet  and  fairly  cheerful  and  had  apparently  given  up 
her  delusions. 

Comment 

These  two  cases  developed  in  individuals  appar- 
ently with  cyclothymic  personalities,  although  this 
is  not  definitely  established  in  the  first.  However, 
as  she  underwent  a  period  of  undue  elation  imme- 
diately preceding  the  onset  of  her  depression,  the 
assumption  is  that  she  was  of  this  temperament. 
She  made  definite  improvement  and,  had  it  not 
been  for  the  intercurrent  pellagra,  probably  would 
have  recovered.  In  the  second  case  the  cyclothymic 
trait  is  shown  more  satisfactorily.  There  is  a  defi- 
nite history  of  an  attack  30  years  previously,  from 
which  she  recovered.  After  four  months  hospitali- 
zation she  made  marked  improvement  and  if  gross 
arteriosclerotic  changes  have  not  occurred  should 
make  a  satisfactory  recovery.  The  queer  and 
bizarre  delusional  trend  indicating  schizoid  traits  is 
absent. 

Case  S. — A  woman,  36,  in  whose  family  there  was  no 
insanity,  admitted  in  first  attack.  The  onset  was  gradual 
and  first  noted  after  complete  removal  of  both  ovaries 
and  uterus,  when  she  became  nervous  and  irritable  and 
complained  of  vague  aches  and  burning  sensations  over 
entire  body ;  hot  flashes  annoyed  her  a  great  deal.  On 
admission  she  appeared  extremely  nervous  and  complained 
constantly  of  burning  sensation  in  top  of  head,  neck  and 
shoulders;  her  flesh  felt  queer  and  she  nearly  burned  up 
with  hot  flashes  at  times,  .^t  present  .eight  months  after 
admission,  no  essential  improvement  has  occurred,  although 
at  times  she  is  more  comfortable.  Much  glandular  therapy 
has  been  used.  She  was  allowed  probation  on  one  occasion 
and  stayed  at  home  two  months,  being  returned  in  practi- 
cally the  same  condition  as  when  she  left  the  hospital. 

Comment 
This  case  appears  to  be  the  direct  result  of  com- 
plete extirpation  of  both  ovaries.     The  symptoms 


are  essentially  physical  and  do  not  constitute  a 
psychosis  in  the  ordinary  sense  of  the  word.  She 
did  not  develop  a  frank  psychosis  because,  in  all 
probability,  she  had  a  sound  personality  free  of 
neuropathic  tendency. 

StJMMARY 

An  effort  has  been  made  in  this  discussion  to 
bring  out  the  following  points: 

1.  Pregnant  and  puerperal  states  do  not  pro- 
duce a  definite  psychiatric  entity. 

2.  The  psychoses  which  develop  at  this  time 
are  usually  either  manic  depressive  psychosis,  de- 
mentia praeco.x  or  exhaustion  psychosis. 

3.  The  type  which  develops  depends  on  the 
basic  personality  of  the  individual. 

4.  In  the  climacterium  many  cases  of  late 
schizophrenia  or  manic  depressive  insanity  are  un- 
earthed, this  depending  also  on  the  underlying  per- 
sonality of  the  individual. 

5.  In  artificial  menopause  the  physical  symp- 
toms usually  dominate  the  picture;  however,  if  the 
individual  is  neuropathic,  one  of  the  other  psychoses 
may  develop. 


The  Prevention  of  General  Paresis  and  Other  Late 

Manifestations  of  Neurosyhilis 

(C.    W.    Clarke,    New   York  City,    in    Med.    Times   <S.    L.    I. 
Med.  Jl.,  May) 

In  the  province  of  Alberta,  Canada,  an  effort  has  been 
made  to  apply  pyrexia  as  a  prophylactic  treatment  for 
the  prevention  of  general  paresis  in  all  cases  of  asympto- 
matic neurosyphilis  which  prove  resistant.  Beginning  in 
1931  in  the  Edmonton  Social  Hygiene  Clinic  every  case 
of  syphilis  showing  a  fully  positive  spinal  fluid  e.xamina- 
tion  after  at  least  9  months  of  treatment  with  arsphena- 
mine  and  heavy  metals  was  referred  to  the  Provincial 
Mental  Hospital  for  malaria  treatment. 

Of  the  58  cases  referred  from  the  Edmonton  clinic  31 
have  had  spinal  tests  at  least  one  year  after  completion 
of  the  malaria  treatment  and  of  these  14  (66  2/i%)  have 
become  absolutely  normal  to  all  four  tests.  While  the 
ultimate  results  in  this  group  cannot  be  stated,  consider- 
able experience  in  other  centers  in  Europe  and  America 
leads  one  to  expect  that  these  patients  will  not  develop 
dementia  paralytica  or  tabes  dorsalis. 

Since  good  results  in  a  high  percentage  of  cases  can  be 
obtained  by  the  prophylactic  methods  mentioned  above, 
is  it  not  practicable  to  apply  these  methods  generally  to  all 
cases  of  asymptomatic  neurosyphilis  which  are  resistant  to 
the  ordinary  methods  of  chemotherapy? 


With  modern  methods  of  treatment  (O.  S.  Ormsby, 
Chi.,  in  Jl.  A.  M.  A.,  Apr.  11th)  early  syphilis  can  be 
eradicated  in  the  majority  of  cases.  Continuous  treatment 
with  no  rest  periods  gives  the  best  results.  Alternate  courses 
of  arsphenamine  and  bismuth  are  recommended  covering  a 
period  of  at  least  eighteen  months  and  employing  a  mini- 
mum of  twenty  injections  of  old  arsphenamine  or  its  equiv- 
alent with  other  arsphenamines.  The  Wassermann  reaction 
is  usually  reversed  by  the  end  of  the  first  period  and  should 
remain  so  permanently.  The  early  reversal  of  this  reaction 
indicates  proper  progress  of  treatment,  but  by  no  means 
does  it  relieve  the  physician  of  carrying  out  the  outlined 
schedule. 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


Cardiovascular  Syphilis* 

An  Elementary  Study 
Thomas  Russell  Little john,  M.D.,  Sumter,  South  Carolina 


AN  elementary  study  of  this  subject  is  under- 
taken because  it  would  be  impossible  to 
discuss  it  fully  in  the  time  available. 

Cardiovascular  syphilis  includes  syphilis  of  the 
heart  and  aorta.  Other  than  aneurysm,  cardiovas- 
cular syphilis  has  been  discussed  very  little  by 
American  authors  until  recently.  This  study  will 
not  include  aneurysm. 

Cardiovascular  syphilis  disables  and  kills  those 
in  the  prime  of  life,  manifesting  itself  in  the  fourth 
and  fifth  decades.  There  are  about  20  per  cent,  of 
organic  heart  diseases  due  to  syphilis.  Negroes  and 
others  who  do  manual  labor  are  more  often  af- 
fected than  ones  who  live  sedentary  lives.  Males 
are  therefore  affected  more  often  than  females. 
Syphilis  of  the  aorta  is  a  forerunner  of  aortic  in- 
sufficiency, aneurysm,  and  occlusion. 

Syphilis  shows  thickening  of  the  walls  of  the 
vasa  vasora  which  impoverishes  the  blood  supply 
to  the  medial  muscle  coat;  producing  here  degen- 
eration, necrosis  and  reparative  fibrosis.  There  is 
some  intimal  degeneration  and  fibrosis,  too,  but 
the  important  event  is  in  the  media.  Therefore, 
the  damage  is  done  in  the  upper  part  of  the  aorta 
where  the  vasa  vasora  are  most  plentiful. 

The  aorta  is  elongated  and  tortuous.  The  vessel, 
although  thickened,  rarely  is  beaded  as  in  other 
sclerotic  conditions.  The  lining  of  the  aorta  looks 
scarred  and  nodular.  Syphilis  rarely  causes  de- 
struction of  the  valves  as  does  nonspecific  endo- 
carditis. The  valves  are  thickened,  shortened  and 
stiff;  or  they  may  be  pouch-like  and  adherent  to 
the  valve  walls.  There  is  a  widening  of  the  com- 
missure. The  syphilitic  heart  is  more  elongated 
than  the  hypertrophied  heart,  and  is  not  quite  as 
wide  laterally. 

Often  arteriosclerotic  changes  cause  dilatation 
of  the  aorta,  which  alone  seems  to  have  almost  no 
harmful  influence.  Syphilitic  aortitis  is  usually,  if 
not  always,  complicated  by  aortic  insufficiency. 
Syphilitic  aortic  insufficiency,  in  contrast  to  aortic 
stenosis,  usually  is  quite  rapid  in  its  progress,  the 
patients  dying  within  five  years. 

The  symptoms  appear  sometimes  before  the  signs. 
The  principal  symptoms  are  dyspnea  and  subster- 
nal pain.  Dyspnea  is  found  in  85  per  cent,  of  all 
cases  and  pain  in  60  per  cent.  It  is  the  earliest 
and  most  common  sign  of  a  decompensation  of 
luetic  origin.     Dyspnea  of  syphilitic  aortic  insuffi- 


ciency most  often  comes  on  at  the  moment  of 
awakening.  The  striking  feature  of  this  is  the 
fact  that  it  is  increased  in  a  reclining  position  and 
is  relieved  by  sitting  up.  The  tendency  is  for  the 
dyspnea  to  be  of  the  paroxysmal  type.  It  lasts 
IS  to  30  minutes,  passing  away  leaving  the  patient 
exhausted.  Profuse  cold  perspiration  may  occur, 
and  with  it  the  fear  of  death.  Cardiac  asthma  is 
a  very  serious  condition  and  if  of  luetic  origin  the 
patient  is  apt  to  die  within  a  year. 

The  substernal  pain  is  one  of  the  most  common 
symptoms.  It  is  very  often  passed  off  by  the  phy- 
sician as  rheumatic,  or  as  pain  caused  by  indiges- 
tion. The  site  of  the  pain  is  usually  the  precor- 
dium,  more  typically  at  the  base  of  the  heart.  Very 
often  it  is  associated  with  a  considerable  degree  of 
pain  on  pressure.  A  good  point  to  remember  in 
the  early  stages  of  the  disease  is  the  stationary 
character  showing  no  tendency  towards  radiation. 
The  pain  bears  little  or  no  relation  to  effort  or 
excitement,  having  no  association  with  dyspnea. 

Many  of  these  patients  die  suddenly,  without  a 
struggle.  Of  all  forms  of  heart  disease,  syphilis  is 
the  one  that  most  frequently  causes  sudden  death. 

There  is  very  often  faintiness,  vertigo,  or  nausea. 

Edema  is  not  a  prominent  sign,  it  usually  not 
being  present  as  in  rheumatic  heart  disease. 

The  main  sign  found  on  inspection  is  marked 
fullness  of  the  veins,  especially  of  the  neck,  veins 
of  the  upper  thorax  and  arms.  At  first  there  is  a 
visible  diffuse  pulsation  of  the  carotids  and  sub- 
clavians,  later  hopping  carotids.  The  subclavians, 
at  times,  seem  to  be  lifted  higher  by  the  dilatation 
and  they  are  sometimes  above  the  clavicles.  There 
may  be  swelling  or  a  pulsating  mass  in  the  epi- 
sternal  notch.  An  important  sign  is  pulsation  in  the 
second  right  and  left  interspaces  or  in  the  first  right 
or  left  spaces,  occurring  as  frequently  as  above 
mentioned.  These  are  easily  seen  if  you  have  the 
patient  on  a  table,  with  a  good  light  and  your  eyes 
on  a  level  with  the  body.  This  pulsation  may  be 
more  evident  when  the  patient  is  sitting  than  when 
lying.  It  is  more  readily  seen  than  felt  and  does 
not  give  the  feeling  of  being  more  forcible  than 
the  apex  as  you  find  in  aneurysm.  It  does  not 
lift  a  finger  as  does  an  aneurysm. 

In  a  number  of  cases  the  aorta  can  be  palpated 
in  the  episternal  notch  and  the  subclavian  arteries 
above  the  clavicles.     Occasionally  the  heaving  of 


•Presented  to  the  Tri-State  Medical  Association  of  the  Carolinas  and   Virginia,    meeting  at   Columbia,    South   Caro- 
lina. February  17th  and  18th. 


June,  1936 


CARDIOVASCULAR  SYPHILIS— Liltlejokn 


31S 


the  manubrium  can  be  felt;  but  it  is  better  seen 
than  felt,  and  you  may  feel  a  Corrigan  pulse,  never 
the  pulse  of  stenosis.  The  apex  beat  in  syphilitic 
aortic  valvular  insufficiency  is  not  as  diffuse  as  in 
endocardiac  aortic  insufficiency,  but  is  felt  only 
over  a  strictly  limited  area. 

Percussion  is  of  great  importance.  In  most  cases 
there  is  a  distinct  dullness  over  the  manubrium. 
The  dullness  extends  from  the  base  of  the  heart 
outside  the  edge  of  the  sternum  on  up  through  the 
first  interspaces.  As  a  rule,  the  dullness  is  more 
marked  to  the  right  than  to  the  left  and  this  is 
important. 

A  basal,  long,  blowing,  rather  soft  diastolic  mur- 
mur commencing  after  the  second  sound  is  heard 
best  over  the  midsternum  at  the  level  of  the  sec- 
ond interspace  and  left  sternal  margin  in  the  third 
and  fourth  interspaces.  The  second  sound  is  rarely 
displaced  by  the  murmur. 

The  systolic  blood  pressure  is  usually  high,  but 
not  so  high  as  in  primary  hypertensive  cases;  the 
diastolic  pressure  is  low.  The  greater  the  differ- 
ence, the  more  likely  we  are  dealing  with  cardio- 
vascular syphilis.  If  the  diastolic  pressure  is  noth- 
ing, this  is  almost  pathognomonic. 

Treat  the  decompensation  first  and  the  syphilis 
second.  I  mean  by  this  that  if  a  patient  has  con- 
gestive heart  failure  or  a  severe  pain  of  paroxysmal 
dyspnea,  he  is  placed  at  rest,  in  bed,  and  the  usual 
antisyphilitic  measures  are  instituted.  Some  au- 
thorities condemn  the  use  of  the  arsphenamines  in- 
travenously but  I  am  inclined  to  agree  with  those 
who  advocate  their  use,  judiciously  administered. 

Bibliography 

McCrae,  T,:  Aortitis.  Medical  Clinics  of  N.  A.,  Sept., 
1917. 

McCrae,  T.:  Dilatation  of  the  Aorta.  Jour,  of  the 
Med.  Sc,  Oct.,  1910. 

Herrick,  J.  B.:  Syphilis  of  the  Aorta.  Northwest  Med., 
Feb.,  1926. 

Moore,  J.  E.,  and  Danglade,  J.  H.:  The  Treatment  of 
Cardiovascular  Syphilis.    Am.  Heart  Jour.,  Oct.,   1930. 

Lewis,  T.:  Diseases  of  the  Heart.  MacMillian  and  Co., 
1933. 

Hirschfelder,  a.  D.:  Diseases  of  the  Heart  and  Aorta. 
/.  B.  Lippincott  Co.,  1913. 

Christie,-,  H.  A.:  Aortic  Lesions  in  Relation  to  Cardiac 
Function  and  Physical  Signs.  New  England  Jour,  of  Med., 
Nov.  5th,  1931. 

Lynch,  K.  M.:     Personal  communication. 

Discussion 

Dr.  William  Allan,  Charlotte: 

Dr.  Crowell  has  told  us  that,  for  instance,  in  Mecklen- 
burg County  we  have  only  4  per  cent,  of  syphilis  among 
white  people.  So  syphilitic  heart  disease  is  not  very  com- 
mon. Of  course,  we  see  syphilitic  heart  disease  in  the 
Negro.  I  must  say  I  think  we  rarely  see  it  in  time  to  do 
much  good,  particularly  in  the  Negro,  by  the  time  he 
comes  to  us.     I  have  seen  a  number  of  them  die.     I  can 


recall  only  one  patient  in  which  the  process  was  stopped 
entirely  and  he  was  a  white  man. 

Dr.  Littlejohn,  closing: 

I  wish  to  thank  Dr.  Allan  for  the  discussion  of  this  paper. 
I  believe  that  cardiovascular  syphilis  appears  in  more 
cases  in  white  persons  than  we  have  suspected,  in  North 
and  South  Carolina.  The  main  thing  in  examining  the 
heart  that  I  have  found  in  consultation  in  my  section  of 
the  State  is  that  all  doctors  pay  more  attention  to  the 
murmurs  than  all  the  other  symptoms  and  signs  we  have. 
Syphilis  almost  tells  you  what  it  is  by  the  pain — pain 
coming  on  at  the  same  time  at  night,  and  lasting  from  15 
to  30  minutes.  .\nd  the  diastolic  pressure  almost  tells  you ; 
if  you  see  a  patient  with  a  pressure  of  around  180  to  200, 
and  the  diastolic  pressure  is  SO,  you  ought  to  have  that 
patient  under  observation  for  syphilis  of  the  cardiovascular 
system. 


The  Concentration  Test  As  a  Practical  Means  of 

Determining  Kidney  Insltfficiency 

(J.  L  .Kestel,  Waterloo,  in  Jl.  Iowa  State  Med.  Soc,  Ma,y) 

The  best  and  simplest  test  to  determine  the  existence  or 
degree  of  kidney  destruction  is  the  concentration  test.  If 
the  sp.  gr.  rises  above  1.025  on  dehydration  for  18  to  24 
hours  the  kidney  function  is  considered  within  normal 
limits.  If  it  does  not  rise  above  1.016  or  1.018,  impair- 
ment is  marked,  and  suggests  renal  insufficiency.  There 
must  be  considerable  kidney  damage  before  flexibility  is 
greatly  impaired;  but  if  the  loss  of  function  is  no  greater 
than  that,  it  can  generally  be  disregarded  from  a  practical 
standpoint. 

Many  other  tests  of  kidney  function  that  are  in  general 
use  are  valuable,  but  none  of  them  is  as  easily  carried  out, 
and  few  if  any  are  as  accurate  or  comprehensive. 

The  patient  is  kept  on  a  dry  diet  for  a  day,  and  the 
sp.  gr.  of  successive  specimens  of  urine  is  taken.  If  large 
quantities  of  solids  are  present,  the  specimen  should  be 
centrifuged  or  allowed  to  settle  and  the  supernatant  fluid 
used  for  the  determination.  The  next  morning  the  speci- 
men should  show  a  specific  gravity  of  1.030  or  more,  nor- 
mally. For  routine  purposes  instruct  to  take  no  extra 
fluids  at  dinner  and  none  that  evening  or  on  the  following 
morning.  The  first  morning  specimen  is  discarded,  the 
second  is  saved  and  if  its  sp.  gr.  is  1.025  or  over,  the  kid- 
ney function  can  be  considered  normal.  If  the  sp.  gr.  of 
a  specimen  of  urine  or  routine  urinalysis  is  1.025  or  over, 
and  it  contains  neither  ulbumin  nor  sugar,  further  tests 
of  kidney  function  are  unnecessary'.  Albumin  or  sugar 
will  raise  the  sp.  gr.,  and  if  either  of  these  is  present  in 
more  than  traces,  the  direct  results  will  not  be  accurate. 
In  the  presence  of  sugar,  determine  the  percentage  and 
how  much  it  would  elevate  the  specific  gravity,  and  sub- 
tract this  from  the  reading.  One  per  cent,  of  protein 
elevated  the  specific  gravity  0.003.  A  stock  standard  solu- 
tion for  comparison  consists  of  50  c.c.  of  0.1  sodium 
hydroxide  and  8  gms.  of  copper  sulphate  with  water  up 
to  500  c.c.  Two  c.c.  of  this  freshly  diluted  with  2i  c.c. 
of  water,  has  a  similar  and  permanent  turbidity  as  1% 
albumin,  when  thiosalicylic  acid  is  used.  One  c.c.  of  urine 
is  placed  in  a  test  tube  and  24  c.c.  of  the  2%  thiosalicylic 
acid  is  added.  If  the  turbidity  is  the  same  as  the  stand- 
ard, the  urine  contains  0.1%  of  protein.  If  the  urine- 
thiosalicylic  acid  mixture  must  be  diluted  with  9  times 
the  amount,  a  ratio  of  1:10,  to  match  the  turbidity  of  the 
standard,  it  contains  1.0%.  With  such  a  result,  .003  would 
be  subtracted  from  the  observed  specific  gravity. 

If  marked  renal  insufficiency  is  suspected,  or  if  the 
individual  is  seriously  ill  from  any  cause,  dehydration  is 
inadvisable. 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


Spontaneous  Subarachnoid  Hemorrhage* 

James  H.  McNeill,  M.D.,  North  Wllkesboro,  North  Carolina 


HEMORRHAGE  into  the  subarachnoid 
space  may  occur  from  rupture  of  a  blood 
vessel  in  the  absence  of  violence.  It  is 
characterized  by  sudden  onset  with  severe  headache, 
nausea,  coma,  signs  of  meningeal  irritation  and 
blood  in  the  cerebro-spinal  fluid. 

Inciden'ce 
Ohler  and  Hurwitz^  report  24  cases  among  353 
cerebral  vascular  accidents.  They  found  it  to  be 
of  about  the  same  frequency  of  occurrence  as  sub- 
acute bacterial  endocarditis.  Dowling"  collected 
12  cases  from  the  admissions  in  the  Baltimore  City 
hospitals  in  three  years. 

Etiology 

By  far  the  most  frequent  causes  of  the  accidents 
are  arteriosclerosis,  hypertension  and  small  con- 
genital non-syphilitic  aneurisms  (berry  aneurisms). 
Dowling^  lists  the  following  causes: 

I.  Blood  dyscrasias:  II.  E.xtrinsic  disease  affect- 
ing the  subarachnoid  vessels:  1.  meningococcic 
meningitis,  2.  tuberculous  meningitis,  3.  meningo- 
vascular syphilis,  4.  embolism,  5.  heat  stroke;  III. 
Intrinsic  abnormalities  of  the  vessel  walls:  1. 
thrombrosis,  2.  degeneration  of  blood  vessel  walls 
from — a.  arteriosclerosis,  b.  hypertension,  c.  acute 
infections,  d.  poisoning,  3.  congenital  nevi,  4.  con- 
genital aneurisms. 

In  Ohler  and  Hurwitzs'^  series  the  age  limits  were 
17  and  70  with  an  average  age  of  SO.  Males  and 
females  are  about  equally  affected. 

Gayle  and  Easley"  report  the  occurrence  of  sub- 
arachnoid hemorrhage  after  lumbar  puncture  and 
they  attribute  the  event  to  the  sudden  lowering  of 
spinal  fluid  pressure.  Bramwell"  states  that  the 
attacks  are  often  started  by  exertion,  such  as  lift- 
ing, straining  at  stool,  coughing  or  sneezing. 

Birch*  cites  cases  due  to  coarctation  of  the  aorta 
and  to  polyarteritis  acuta  nodosa.  Syphilis  is  rarely 
a  cause.  In  patients  past  middle  life  arteriosclerosis 
or  hypertension  is  usually  the  cause,  while  in  the 
young  adult  the  congenital  aneurism  most  fre- 
quently causes  the  trouble. 

Symptoms  and  Physical  Signs 
Vague  prodromal  symptoms  may  occur,  but  the 
usual  hemorrhage  comes  on  absolutely  without 
warning.  The  first  symptom  to  appear  is  a  hard, 
severe,  bursting  headache  arising  in  the  occipital 
region  and  later  referred  to  the  vertex.  The  hem- 
orrhage may  be  instituted  by  some  physical  exer- 


tion or  by  an  emotional  upset  which  raises  the 
blood  pressure.  Vomiting  of  the  cerebral  type 
usually  follows.  Soon  the  patient  becomes  drowsy 
and  he  may  go  into  deep  coma.  Usually  he  can 
be  aroused  but  he  is  mentally  dull.  The  depth  of 
the  coma  depends  upon  the  extent  of  the  hemor- 
rhage. The  patient  may  stay  in  this  stuporous 
state  for  a  few  hours  or  a  few  days  and  spontane- 
ously recover.  On  the  other  hand,  coma  may  per- 
sist to  a  fatal  outcome.  Following  the  coma,  there 
is  frequently  mental  confusion.  Diplopia  and  epi- 
leptiform convulsions  may  ensue.  The  blood  pres- 
sure usually  falls  below  the  patient's  normal  level, 
the  pulse  is  slowed  and  respiration  is  embarrassed. 
On  account  of  the  meningeal  irritation,  the  neck 
may  be  stiff  and  Kernig's  sign  may  be  present.  As 
the  blood  in  the  spinal  fluid  acts  as  a  foreign  body, 
there  is  usually  a  slight  fever.  Retinal  hemorrhage 
and  papilledema  may  occur.  The  neurological  find- 
ings are  very  inconstant,  the  reflexes  being  either 
normal,  overactive,  or  underactive.  Herpes  zoster 
may  follow  hemorrhage,  due  to  irritation  of  the 
posterior  nerve  roots.  Hemiplegia  or  cerebral  nerve 
palsies  may  occur  from  clot  pressure  on  neighbor- 
ing structures.  The  spinal  fluid  is  under  increased 
pressure  and  is  bloody.  When  centrifuged,  the 
supernatant  fluid  is  distinctly  yellow  (xantho- 
chromic). The  bloody  spinal  fluid  may  be  differ- 
entiated from  a  bloody  tap  by  the  uniform  distri- 
bution of  blood  in  three  tubes,  by  the  yellow  color 
of  the  supernatant  fluid  and  by  the  absence  of 
clot. 

Laboratory  findings  are  inconclusive.  There 
may  be  a  moderate  leucocytosis.  Albuminuria  may 
be  present.  Glycosuria  and  acetonuria  occasionally 
occur. 

Prognosis 
The  ultimate  prognosis  is  bad.  There  is  a  good 
chance  for  recurrence  of  hemorrhage  even  in  a 
young  person  who  has  recovered  from  one  episode. 
Hall-  brings  out  the  fact  that  a  hemorrha'2;e  may 
recur  even  when  the  patient  is  at  rest  in  bed.  In 
Munk's^  series  of  9  cases,  all  resulted  fatally.  There 
was  a  50%  mortality  in  Ohler  and  Hurwitz^  series 
of  24.  Their  incidence  of  mortality  was  much 
higher  when  other  diseases  were  associated. 

Treatment 
The  best  means  of  treatment  is  a  moot  question. 
Each  writer  on  this  subject  has  his  own  ideas.    The 
main  point  of  difference  seems  to  be  whether  to 


•Presented  to  the  Eighth  District   (N.  C.)   Medical  Society,  meeting  at  Mount  Airy,  April  15th. 


June,  1936 


SUBARACHNOID  HEAfORRH AGE— McNeill 


317 


do  therapeutic  spinal  drainage  or  not.  No  one 
worker  has  had  a  sufficient  number  of  these  cases 
to  compare  the  results  obtained  by  draining  with 
results  in  cases  managed  without  draining.  Hall,- 
Dowling,"  and  Bramwell''  do  a  single  diagnostic 
puncture  and  do  not  repeat  it  unless  forced  to  do 
so  by  increasing  intracranial  pressure.  After  the 
first  week,  Dowling  favors  a  puncture  every  3  days 
until  symptoms  have  disappeared  and  the  spinal 
fluid  is  normal.  He  also  uses  concentrated  glucose 
solution  intravenously  and  magnesium  sulphate  by 
mouth  to  lower  the  intracranial  pressure.  Hall  con- 
siders venous  drainage  from  the  head  very  im- 
portant and  keeps  the  patient  propped  up.  Bram- 
well does  not  use  lumbar  puncture  unless  the  pres- 
sure signs  are  great,  because  the  patient  may  re- 
cover spontaneously  and  because  the  withdrawal 
may  cause  greater  hemorrhage.  Ohler  and  Hur- 
witz,^  Gayle  and  Easley''  and  Birch*  routinely  use 
daily  lumbar  punctures,  and  the  last-named  con- 
tributor to  the  literature  on  this  subject  believes 
that  there  is  little  danger  of  hemorrhage  induced 
by  puncture  because  the  puncture,  by  lowering 
intracranial  pressure,  lowers  the  arterial  blood  pres- 
sure. Gayle  and  Easley  favor  frequent  puncture 
to  prevent  adhesions  between  the  pia  and  arach- 
noid which  may  later  lead  to  epilepsy.  All  are 
agreed  that  absolute  rest  is  essential.  Bramwell 
uses  morphine  to  keep  his  patients  quiet,  but  Ohler 
and  Hurwitz  refrain  from  its  use  because  it  may 
depress  the  respiratory  center. 

With  my  limited  experience  with  these  cases  I 
would  not  dare  to  take  sides.  It  would  seem  that 
the  best  treatment  would  be  to  meet  each  symptom 
as  it  arises  while  making  every  effort  to  keep  the 
patient  absolutely  quiet.    I  cite  an  illustrative  case: 

Case   Report 

A  white  farmer,  68,  was  admitted  to  hospital  on  the 
morning  of  January  21st,  in  coma.  The  patient  did  not 
feel  as  well  as  usual  on  waking  that  morning,  ate  no 
breakfast  and  later  complained  of  a  severe  sick  headache. 
This  appeared  to  be  a  repetition  of  many  previous  attacks. 
After  the  onset  of  the  headache,  he  became  unconscious 
for  a  little  while  and  had  convulsive  movements.  Con- 
sciousness returned,  he  went  to  bed  and  apparently  to 
sleep.  He  could  be  roused  and  would  answer  questions 
but  was  mentally  slow. 

He  had  had  a  similar  attack  10  years  previously,  at 
which  time  he  felt  as  though  he  had  be«n  struck  on  the 
head.  He  was  nauseated  and  sleepy  for  three  days  after 
the  attack  which  gradually  cleared  up  after  bed  rest  at 
home.  This  attack  was  followed  by  sciatic  rheumatism. 
Since  the  initial  attack,  he  has  had  frequent  episodes  of 
sick  headache  lasting  for  about  three  days.  No  other  rele- 
vant facts  were  elicited  in  his  past  or  family  history. 

Examination:  The  patient  was  comatose  but  could  be 
partially  aroused.  His  blood  pressure  was  220/100,  tem- 
perature 97.6  axillary,  pulse  60,  respiration  14,  pupils  con- 
tracted but  reacted  to  Ught,  retinae  showed  no  hemorrhages 
nor  papilledema  but  there  was  moderate  sclerosis  of  the 
retinal  vessels.     The  radial  arteries  were  sclerosed.     Head 


and  neck,  thorax  and  abdomen  revealed  no  abnormalities. 
The  biceps,  patellar  and  ankle  jerks  were  within  normal 
limits,  but  sUghtly  more  active  on  the  left.  The  urine  was 
acid,  sp.  gr.  1.024,  no  albumin,  sugar,  casts  or  cells.  The 
cerebrospinal  fluid  was  found  to  be  under  a  pressure  of 
350  mm.  of  water  (normal  80-140)  ;  it  was  bloody  and  the 
supernatant  fluid  was  yellow  in  color. 

Course. — On  the  evening  of  the  day  of  admission,  the 
patient  had  a  generalized  tremor  which  looked  like  a 
chill.  The  body  was  not  cold.  He  answered  when  ques- 
tioned. His  pulse  became  more  rapid  and  Cheyne-Stokes 
respirations  developed.  There  was  marked  sweating  and  a 
little  fever.  His  temperature  ranged  from  97  to  101.6  in 
the  course  of  his  illness.  The  blood  pressure  dropped  to 
120/  56.  Stimulation  with  caffeine  sodiobenzoate  was  fol- 
lowed by  a  stronger  pulse  and  the  blood  pressure  rose  to 
140/70,  at  which  level  it  remained  during  his  stay  in  the 
hospital.  On  the  second  day  of  his  illness,  he  felt  fairly 
well  and  was  mentally  clear.  The  spinal  fluid  was  less 
bloody  than  on  the  first  day,  and  the  pressure  was  220  mm. 
of  water.  No  new  physical  signs  developed.  On  the  third 
day,  the  fluid  was  still  slightly  bloody  and  under  a  pres- 
sure of  SO  mm.  of  water,  and  he  was  somewhat  irrational 
at  times.  The  following  day,  he  had  a  very  slight  head- 
ache and  was  very  slightly  drowsy.  He  rested  well  the 
next  day.  On  the  sixth  day,  he  was  awakened  from  sleep 
by  a  severe  headache  at  five  in  the  morning.  His  respira- 
tions dropped  to  10  and  the  pulse  to  40.  The  spinal  fluid 
was  again  very  bloody  and  under  greatly  increased  pres- 
sure. He  was  drowsy  but  could  be  aroused.  After  the 
puncture,  he  complained  of  severe  headache,  his  blood 
pressure  rose  from  140/70  to  230/120.  On  the  seventh 
and  eighth  day,  he  had  recovered  from  this  reaction  and 
showed  no  increased  intracranial  pressure  symptoms.  An- 
other hemorrhage  occurred  on  the  ninth  day  and  from  this 
he  could  not  be  aroused  and  there  was  marked  rigid.ty  of 
the  neck.    Respirations  ceased  on  the  tenth  day. 

This  spontaneous  subarachnoid  hemorrhage  was 
evidently  arteriosclerotic  in  origin.  It  illustrates 
the  ultimate  poor  prognosis  in  all  these  cases.  After 
his  initial  attack  ten  years  before,  he  had  evidently 
had  many  small  leaks  causing  his  sick  headaches 
and  ultmately  leading  to  this  fatal  attack. 

Bibliography 

1.  Ohler,  W.  R.,  and  Hurwitz,  D.:  Spontaneous  Sub- 
arachnoid Hemorrhage.  Jl.  A.  M.  A.,  98:1856-1861, 
May  2Sth,  1932. 

2.  Hall,  A.  J.:  Spontaneous  Subarachnoid  Hemorrhage. 
Lancet,  222:1135-1139,  May  2Sth,  1932. 

3.  MuNK,  W.:  Subarachnoid  Hemorrhage  from  a  Medico- 
legal Point  of  View.  //.  of  Nervous  and  Mental  Dis., 
65:484-496,  May,  1927. 

4.  Birch,  J.  A.:  Spontaneous  Subarachnoid  Hemorrhage. 
Practitioner,  129:402-407,  Sept.,   1932. 

5.  Bramwell,  E.:  Spontaneous  Subarachnoid  Hemor- 
rhage.    British  Med.  Jl.,  3897:512,  Sept.  14th,  1935. 

0.  Gayle,  R.  F.,  jr.,  and  Easley,  R.  B.:  Spontaneous 
Subarachnoid  Hemorrhage.  Sou.  Med.  &  Sitrg.,  93: 
444-446,  June,   1931. 

7.  DowLLN-G,  H.  F.:  Spontaneous  Subarachnoid  Hemor- 
rhage.   Am.  Jl.  Med.  Scs.,  185:469,  April,  1933. 

8.  Walker,  A.  S.:  Spontaneous  Subarachnoid  Hemor- 
rhage. Med.  Jl.  of  Australia,  2:353-355,  Sept.  17th, 
193S. 


In  Silesia  an  apple  is  scraped  from  top  to  stalk  to  cure 
diarrhea,  and  upward  to  cure  costiveness. — Gould  &  Pyle. 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


Surgical   Observations 

A  Column  Conducted  by 

The  Staff  of  the  Davis  Hospital 
Statesville,  N.  C. 


Appendicitis   in   Infants   and   Small    Children 

Appendicitis  is  far  more  common  in  infants  and 
younger  children  than  is  ordinarily  supposed.  For 
many  years  doctors  have  hesitated  to  make  a  diag- 
nosis because  of  the  general  opinion  that  it  was 
uncommon  in  the  earlier  years.  Such,  however,  is 
not  the  case.  It  is  just  as  common,  or  even  more 
so,  among  children  as  among  adults.  It  is  true 
that  it  is  more  difficult  to  make  a  diagnosis  in  an 
infant  or  a  very  small  child,  as  they  cannot  tell 
us  just  how  the  pain  affects  them.  A  careful  study 
of  children,  however,  will  reveal  many  symptoms 
which  are  ordinarily  overlooked.  Frequent  attacks 
of  crying,  gastrointestinal  disturbances  of  various 
kinds  and  leucocytosis  are  common  symptoms:  in 
addition,  older  children  may  put  a  hand  to  the  side 
unconsciously. 

Pyelitis,  oi  course,  must  be  ruled  out  as  well  as 
other  things,  but  it  should  be  kept  in  mind  always 
that  appendicitis  is  very  frequent  during  the  earlier 
years  and  the  treatment  is  the  same  as  that  in 
adults. 

An  appendectomy  in  a  very  small  child  is  usually 
accomplished  without  any  great  difficulty.  General 
anesthesia  is  usually  necessary,  but  in  patients  a 
little  older  spinal  anesthesia  may  be  used  with  the 
greatest  satisfaction. 

It  is  quite  likely  that  many  children  have  gone 
through  infancy  and  childhood  suffering  much  from 
unrecognized  disease  of  the  appendix. 

Certainly  every  child  who  has  unexplained  symp- 
toms which  might  point  to  the  appendix  should 
have  a  careful  examination,  and  if  the  appendix  can 
be  convicted  prompt  removal  is  in  order. 

The  public  must  be  made  acquainted  with  the 
fact  that  appendicitis  is  very  frequent  in  infants 
and  small  children  and  must  be  treated  the  same 
way  as  in  adults.  Only  in  this  way  can  the  co- 
operation of  the  public  be  obtained. 

Abdominal  Drainage 

When  drainage  of  the  abdomen  is  necessary,  it 
is  better  to  drain  to  one  side  of  the  incision  in- 
stead of  through  the  incision — except  in  very  rare 
instances. 

Very  often  where  drainage  is  advisable  by  bring- 
ing the  drain  out  some  distance  away  from  the  in- 
cision it  is  possible  to  obtain  good  drainage  and  at 
the  same  time  avoid  having  a  weakened  incision 
with  extra  risk  of  development  of  an  incisional 
hernia. 


Gallbladder  drains  especially  may  be  brought 
out  to  the  extreme  right  through  the  abdominal 
wall.  In  this  way  much  better  drainage  is  ob- 
tained, and  when  the  need  for  drainage  has  passed 
the  drainage  opening  will  usually  close  up  rapidly. 

The  type  of  drains,  the  size  and  the  number 
should  all  be  carefully  considered,  and  when  drain- 
age is  instituted  it  should  be  done  with  the  idea  of 
obtaining  the  maximum  benefit  with  the  minimum 
of  abdominal  disturbances. 

Firm  rubber  tubing  is  rarely  ever  used,  as  it 
causes  much  distress  and  may  cause  serious  injury 
to  the  abdominal  viscera  if  left  in  any  length  of 
time.  Soft-rubber-tissue  tubular  drains  do  not 
cause  pressure  and  necrosis  or  give  the  patient  the 
least  discomfort;  they  provide  good  drainage  and 
may  be  left  in  longer  than  firm  tubes  could  be. 

Cigarette  drains  are  not  used  very  much  in  the 
rbdomen.  If  gauze  is  allowed  to  lie  in  contact  with 
the  abdominal  viscera,  especially  the  intestines,  for 
even  a  short  while,  the  intestines  become  closely 
adherent  to  the  gauze  and  removal  is  accomplished 
only  with  great  difficulty  and  possibly  danger  to 
the  intestines  and  other  structures.  Cigarette  gauze 
wicks  should  never  be  used  where  the  gauze  comes 
in  contact  with  the  intestines. 

Pelvic  drainage  also  presents  many  problems  but 
the  use  of  soft-rubber-tissue  tubular  drains  elimi- 
nates many  of  these  hazards  incident  to  drainage. 

Drainage  problems  should  always  be  considered 
carefully  and  drains  should  be  used  only  when  there 
is  definite  indication. 

X-ray  Examination  of  tlie  Spine 

In  x-ray  examinations  of  the  spine  there  are 
many  conditions  that  might  be  misinterpreted  by 
one  who  is  not  a  real  expert  in  this  work. 

Among  the  conditions  that  are  most  likely  to  be 
misinterpreted  are: 

1.  Anomalous  articulations  of  the  transverse 
processes  of  the  lumbar  vertebrae,  especially  those 
of  the  first  lumbar.  These  are  usually  unilateral 
and  are  often  mistaken  for  fractures,  especially 
where  there  has  been  trauma. 

2.  Early  arthritic  changes  in  articulations  are 
often  overlooked,  especially  when  careful  stereo- 
L^copic  studies  are  not  made, 

3.  Congenital  and  developmental  defects  of  the 
laminae  and  pedicles  are  brought  out  only  by  care- 
ful stereoscopic  x-ray  examination. 

Whenever  an  abdominal  x-ray  picture  is  made, 
the  patient  should  receive  careful  preparation  to 
minimize  the  gas  and  fecal  shadows.  The  patient 
should  be  thoroughly  immobilized;  as  the  slightest 
movement  may  confuse.  Only  tubes  of  very  fine 
focal  spot  should  be  used;  these  bring  out  the  de- 
tails necessary  for  accurate  diagnosis.  Stereoscopic 
antero-posterior  and  single  lateral  films  should  be 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


routine  procedures  in  obscure  conditions  of  the 
spine. 

The  type  of  films  used,  the  tube  and  the  method 
of  developing  all  are  important  factors  in  obtaining 
the  finest  films  and  only  by  the  most  meticulous 
care  and  accuracy  in  making  x-ray  films  of  the 
spine  can  we  hope  to  have  an  accurate  determina- 
tion of  the  condition  present. 

A  recheck  of  an  examination  should  always  be 
made  when  there  is  any  doubt  about  the  diagnosis. 

Differential    Diagnoses    Between   Ovarian    Cyst, 
Uterine    Fibroid    and    Pregnancy 

Ordinarily  a  pelvic  examination,  with  the  pa- 
tient relaxed,  will  clear  up  the  diagnosis,  but  in  the 
case  of  tightly  distended  thick-walled  cyst,  pressed 
down  firmly  against  the  uterus  differentiation  is  not 
so  easy. 

If  the  cyst  lies  in  the  midline  it  looks  just  like 
a  pregnant  uterus,  and  unfortunately  many  cysts 
grow  almost  as  rapidly  as  a  uterus  will  enlarge 
and  this  adds  to  the  difficulty  of  making  a  definite 
and  accurate  diagnosis. 

The  blood  sedimentation  rate  test  and  the 
-Ascheim-Zondek  test,  of  course,  will  aid  greatly  in 
clearing  up  the  diagnosis. 

In  removing  an  abdominal  cyst  of  any  kind, 
very  often  a  small  incision  will  suffice  if  the  con- 
tents are  evacuated.  It  has  been  argued  that  there 
is  danger  of  a  hemorrhage  of  the  cyst  if  the  pres- 
sure is  suddenly  removed.  Over  a  long  period  of 
years  and  a  large  number  of  cases,  I  have  never 
seen  a  hemorrhage  occur. 

Multiple  Operations 

Multiple  operations  are  often  not  only  possible 
but  very  desirable.  Whenever  a  number  of  opera- 
tions are  needed  and  can  be  done  under  one  anes- 
thesia and  without  jeopardizing  the  patient's  chance 
of  recovery  in  any  way,  it  is  advisable  to  give  the 
patient  the  maximum  benefit  with  the  minimum 
loss  of  time  and  the  minimum  expense. 

Among  the  multiple  operations  that  are  often  de- 
sirable are:  Perineal  repairs  with  uterine  reposi- 
tioning, appendectomy  or  proper  surgery  on  cystic 
ovaries,  under  tht  sajne  anesthesia  hemorrhoids  may 
be  removed  without  any  great  difficulty.  In  many 
instances  a  hemorrhoidectomy  will  give  as  much 
relief  as  the  pelvic  operation. 

During  the  stay  in  the  hospital,  the  removal  of 
moles  or  papillomatous  growths,  especially  about 
the  face  and  neck,  will  mean  much  to  the  patient. 
Eye,  ear  and  throat  conditions  that  can  be  treated 
while  the  patient  is  recovering  from  a  major  surgi- 
cal operation  should  have  attention  wherever  prac- 
ticable. Removal  of  tonsils  may  be  advisable  and 
may  be  done  a  few  days  before  the  patient  returns 
home. 


Sometimes  dental  work,  especially  removal  of 
grossly  abscessed  teeth,  may  be  properly  done  while 
the  patient  is  in  the  hospital. 

A  careful  consideration  of  patients  complaints 
and  treatment  of  as  many  of  them  as  can  consist- 
ently be  done  while  in  the  hospital  is  advisable. 

Examination   of   Spinal    Fluid    in    Surgical    Patients 

The  examination  of  spinal  fluid  in  surgical  pa- 
tients who  have  a  history  of  lues  is  always  advis- 
able. 

.■\t  the  time  the  spinal  anesthetic  is  administered, 
it  is  very  easy  to  collect  a  few  c.c  of  the  fluid  which 
will  be  sufficient  for  a  cell  count,  globulin  test  and 
Wassermann  and  if  necessary  a  mastic  test. 

If  there  is  evidence  of  cerebrospinal  syphilis  treat- 
ment is  to  be  instituted;  if  there  is  no  evidence  of 
trouble  it  will  be  a  satisfaction  to  the  doctor  and  a 
relief  to  the  patient  to  know  this. 


Protamine  Insulin  for  Dubetes 


"Protamine  insulinate"  is  being  produced  for  clinical 
trial  in  the  United  States  by  Eli  Lilly  and  Company,  and 
is  named  by  them  "protamine  insulin";  it  is  prepared  by 
tlie  addition  to  insulin  of  a  protamine  isolated  by  Hage- 
dorn  from  the  sperm  of  trout  (species  Salmo  iridus) 
which  forms  a  compound,  slowly  soluble  in  body  serum. 
This  compound  is  broken  down  and  insulin  is  liberated 
slowly  into  the  blood  stream.  This  new  preparation  for 
clinical  trial  consists  of  a  small  vial  of  protamine  to  be 
added  to  5  c.c.  of  U-50  insulin.  The  resultant  mixture 
corresponds  to  the  unit  strength  of  U-40  insulin.  The 
protamine  buffered  solution  must  be  added  from  a  cold 
sterile  syringe.  It  should  be  added  slowly  and  mixed 
gently  to  avoid  frothing.  Before  each  injection  the  mix- 
ture should  be  shaken  in  order  to  get  the  aliquot  propor- 
tion of  insulin  and  protamine  at  each  dose.  After  adding 
the  protamine  to  the  insulin  the  solution  appears  turbid. 
It  is  advisable  to  allow  it  to  stand  for  24  hours  before 
using.  Protamine  insulin  is  administered  subcutaneously 
in  the  same  manner  as  regular  insulin,  and  cannot  be  used 
intravenously.  From  the  depot  of  injection  absorption 
takes  place  slowly  into  the  circulation.  The  same  pre- 
cautions should  be  observed  to  change  the  site  of  injections 
as  with  regular  insulin. 

Protamine  insulin  should  not  be  used  in  coma  or  pre- 
coma states  where  quick  action  is  demanded.  When  a 
reaction  does  occur  from  protamine  insulin,  it  takes  place 
more  slowly  and  gives  additional  time  for  the  patient  to 
obtain  the  necessary  carbohydrates.  No  reactions  occurred 
at  night  during  sleep,  and  I  am  anxious  to  know  the  ex- 
perience of  others  with  regard  to  reactions  at  night. 

Protamine  insulin  in  conjunction  with  regular  insulin 
may  be  used  to  advantage  in  the  case  of  severe  diabetes 
where  the  blood  sugar  content  is  usually  high  in  the  early 
morning  hours. 

A  careful  selection  of  patients  is  necessary  in  order  to 
give  the  greatest  benefit  from  protamine  insulin. 

The  time  to  give  it  in  relation  to  meals  and  the  proper 
diet  ratio  of  carbohydrate,  protein  and  fat  requires  fur- 
ther investigation. 

Before  protamine  insulin  is  generally  used,  many  more 
clinical  experiences  with  its  use  in  all  types  of  diabetes 
should  be  made. 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


DEPARTMENTS 

GYNECOLOGY 

Chas.  R.  Robins,  M.D.,  Editor,  Richmond,  Va. 


Leukorrhea 

Leukorrhea  is  the  name  commonly  applied  to 
any  abnormal  discharge  from  the  female  genitalia 
that  occurs  independently  of  the  menses.  For  the 
purposes  of  this  paper,  our  discussion  will  refer 
primarily  to  leukorrhea  in  adults. 

The  discharge  originates  in  those  parts  which 
drain  through  the  lower  genital  tract,  and  comprise 
the  cervix,  vagina  and  vulva. 

The  normal  cervix  dips  into  the  posterior  fornix 
of  the  vagina.  That  part  that  is  exposed  in  the 
vagina  is  covered  with  squamous  epithelium.  At 
the  external  os  the  epithelium  becomes  columnar. 
The  cervical  canal  extends  from  the  vagina  to  the 
cavity  of  the  uterus.  Opening  into  it  are  innumer- 
able glands  of  the  racemose  variety  which  normally 
secrete  a  clear  viscid  alkaline  mucus,  which  is  dis- 
charged through  tubular  ducts  with  numerous 
branches  of  irregular  caliber  deeply  imbedded  in  the 
wall  of  the  cervix. 

The  vagina  is  lined  with  stratified  squamous 
epithelia  and  has  no  glands. 

The  vulva  is  composed  principally  of  the  labia 
minora  and  majora,  their  surfaces  in  close  contact 
and  covered  with  squamous  epithelia.  Between 
the  labia  minora  and  majora  are  deep  creases  which 
extend  upward  around  the  clitoris.  The  prepuce 
of  the  clitoris,  formed  from  the  labia  minora,  fre- 
quently harbors  smegma.  The  mucous  membrane 
contains  sebaceous  and  sudoriferous  glands.  On 
the  inner  aspect  of  each  labium  ma  jus  at  the  center 
of  the  vaginal  orifice,  external  to  the  hymen,  is 
the  opening  of  the  duct  of  the  corresponding  Bar- 
tholin's gland:  the  gland  embedded  in  the  sub- 
stance of  the  labium  majus.  These  two  glands  se- 
crete a  clear  somewhat  viscid  mucus  which  acts  as 
a  lubricant.  In  the  floor  of  the  urethra  are  two 
tubules  known  as  Skene's  glands  which  open  near 
the  external  urinary  meatus. 

The  cervix  and  vulva  have  a  normal  secretion 
from  the  various  glands  mentioned.  The  vagina 
has  no  glandular  secretion  but  there  is  normally 
present  a  slight  milky  fluid,  acid  from  the  action 
of  the  Doederlin  bacillus  on  the  glycogen  contained 
in  the  vaginal  wall.  It  also  contains  desquamated 
epithelia  and  various  bacteria  referred  to  as  the 
vaginal  flora.  On  the  vulva  and  perineum  are 
found  various  bacteria  derived  from  the  alimentary 
tract  which  easily  gain  access  to  the  genital  tract. 

The  Vulva's  exposed  position  makes  it  particu- 
larly liable  to  inflammation,  which  inflammation  is 
accompanied  by  leukorrhea. 


Smegma  causes  irritation  and  discharge  in  the 
uncleanly.  Pin  worms  which  have  their  normal 
habitat  in  the  lower  bowel  frequently  migrate  to 
the  vulva  causing  irritation  and  discharge.  The 
bacteria  about  the  anus  may  likewise  invade  the 
vulva  and  vagina. 

Gonorrhea,  as  a  rule,  has  its  first  manifestation 
in  the  vulva  most  frequently  as  a  urethritis.  In- 
fections confined  to  the  vulva  lend  themselves  to 
treatment  on  account  of  the  exposed  position,  but 
infection  is  frequently  harbored  in  Skene's  and 
Bartholin's  glands.  Gonorrhea  may  be  latent  there 
for  years. 

The  cervix  is  resistant  to  the  common  methods 
of  treatment  of  a  vaginal  discharge.  The  glands 
situated  in  the  deep  tissues  of  the  cervix  and  open- 
ing by  ducts  into  the  cervical  canal  are  inaccessi- 
ble. They  are  protected  by  the  normal  os  and  vis- 
cid mucous  secretion,  but  when  the  cervix  is  lacer- 
ated the  canal  is  exposed  to  the  vaginal  flora  which 
are  often  pathogenic.  Bacteria  of  various  sorts  in- 
vade these  glands  through  the  ducts.  This  is  par- 
ticularly true  of  gonorrheal  invasion,  which  has 
under  any  circumstances  a  definite  tendency  to 
ascend  the  genital  tract. 

T/ic  vagina  has  no  glands  but  may  become  in- 
fected from  the  below  or  from  above.  It  has,  how- 
ever, a  mechanism  of  defense  peculiar  to  itself. 
The  bacillus  of  Doederlein  by  its  action  on  the 
glycogen  in  the  squamous  epithelia,  maintains  the 
normal  acidity  of  the  vaginal  secretion  which  is 
antagonistic  to  foreign  bacteria.  When  the  vaginal 
secretion  becomes  alkaline,  there  is  a  profuse  leu- 
korrhea, because  the  foreign  bacteria  may  then  en- 
ter and  multiply  unopposed. 

Bartholin's  glands  and  the  cervical  glands  have 
a  normal  secretion  which  in  p>eriods  of  rest  is  only 
sufficient  to  keep  the  parts  moist  and  pliable.  When, 
however,  the  congestion  of  menstruation  supervenes, 
they  exhibit  increased  activity  so  that  preceding 
menstruation  and  frequently  following  it  there  is  a 
definite  mucous  discharge.  This  normal  condition 
in  many  women  is  regarded  as  a  leukorrhea.  There 
is  also  the  definite  secretion  of  these  glands  which 
marks  the  libido.  Neither  of  these  conditions  calls 
for  local  treatment. 

While  this  paper  refers  only  to  local  conditions 
in  the  lower  genital  tract,  it  must  be  remembered 
that  there  is  no  pelvic  disease  that  may  not  cause 
a  leukorrhea,  and  there  are  many  general  conditions 
that  have  such  expression.  Of  these  latter  diabetes 
is  a  striking  example,  and  it  should  always  be  taken 
into  consideration. 

It  is,  therefore,  necessary  that  before  undertaking 
the  treatment  of  leukorrhea,  a  careful  local  and 
general  examination  be  made.  It  is  quite  a  mis- 
take to  take  the  patient's  statement  as  a  basis  for 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


treatment.  Before  making  an  examination  there 
should  be  no  cleaning  of  the  parts  for  the  previous 
24  hours,  and,  if  possible,  the  bladder  should  not 
be  emptied  for  6  hours.  In  making  the  e.xamina- 
tion  the  vulva  should  be  inspected  minutely,  then 
the  vagina  and  cervix  should  be  inspected  through 
a  satisfactory  speculum  and,  finally,  a  careful  bi- 
manual examination  should  be  made.  Particular 
attention  should  be  directed  to  the  possibility  of 
gonorrhea  and  trichomoniasis. 

It  is  unnecessary  to  obtain  a  history  of  a  sus- 
picious intercourse,  as  the  objective  findings  will  be 
sufficient  to  establish  the  diagnosis  of  gonorrhea. 
In  a  fresh  case  the  microscopic  examination  of  a 
smear  is  of  great  value.  The  specimen  should  be 
taken  from  the  urethra  and  if  this  is  negative  and 
the  cervix  is  invaded  it  should  be  taken  from  the 
OS.  To  get  a  satisfactory  specimen  from  the  ure- 
thra, the  vulva  should  be  wiped  off  gently  and  the 
pus  expressed  from  the  urethra  by  milking.  How- 
ever, this  is  not  always  necessary.  When  we  are 
dealing  with  a  vulvitis  the  fact  that  the  urethra, 
and  frequently  Bartholin's  duct,  is  involved,  is  very 
strong  presumptive  evidence  of  gonorrhea. 

When  the  gonorrhea  is  chronic,  it  is  due  to  foci 
in  Skene's  or  Bartholin's  glands  or  in  the  cervix. 
Chronic  infection  of  Skene's  and  Bartholin's  glands 
is  pathognomonic  of  gonorrhea. 

The  trichomonas  is  a  flagellate  protozoon,  found 
rather  widely  distributed  in  the  body,  particularly 
in  the  mouth,  lungs,  intestinal  canal  and  vagina 
and  in  prostatic  secretions.  It  was  the  first  type 
of  organism  found  in  the  vagina,  and  was  thought 
to  be  non-pathogenic.  It  is  now  generally  regard- 
ed as  the  cause  of  a  profuse  irritating  leukorrhea, 
difficult  to  cure  and  with  marked  tendency  to  recur, 
particularly  after  menstruation.  In  untreated  cases 
there  is  marked  inflammation  of  the  vulva,  redden- 
ing of  the  vagina  with  discrete  bright  red  papules, 
particularly  over  the  surface  of  the  cervix  and  in 
the  fornices  of  the  vagina.  The  discharge  is  gener- 
ally thin,  yellowish  and  bubbly,  often  with  an 
odor.  It  has  been  said  that  it  never  invades  or 
involves  the  cervical  canal,  but  this  statement  has 
recently  been  questioned.  The  frothy  appearance 
of  the  discharge  is  of  diagnostic  value  as  is  also  it; 
profuseness  and  the  characteristic  changes  in  th3 
vagina.  However,  the  trichomonas  is  always  pres- 
ent and  numerous,  so  that  the  examination  of  a 
hanging-drop  under  the  microscope  will  always  es- 
tablish the  diagnosis. 

The  object  of  this  paper  is  to  emphasize  the 
necessity  of  a  systematic  and  thorough  examina- 
tion. It  would  be  beyond  its  scope  to  attempt  to 
outline  a  complete  treatment  nf  the  conditions  that 
may  be  found. 


The  following  general  principles  are  offered  as 
suggestions. 

If  inspection  reveals  collections  of  smegma  and 
uncleanliness,  removal  of  smegma  and  directions 
for  bathing  may  be  all  that  is  necessary. 

If  pin-worms  are  found,  they  should  be  extermi- 
nated by  the  standard  treatment  for  this  condition. 

If  the  secretions  of  the  vagina  are  alkaline,  a 
lactic-acid  douche,  .S-per  cent.,  is  indicated. 

If  leukorrhea  follows  parturition  and  examina- 
tion shows  traumatism  and  inflammation  of  the 
cervix,  the  use  of  ichthyol-and-glycerine  tampons 
combined  with  hot  antiseptic  douches  will  often 
yield  proinpt  and  satisfactory  results. 

If  congenital  erosion  is  present,  the  cervix  must 
be  fashioned  to  restore  a  normal  os.  The  possibil- 
ity of  diabetes  must  be  borne  in  mind  and  the  urine 
and  blood  examination  for  evidence  of  sugar. 

If  the  patient  is  pregnant,  the  trichomonas  must 
be  looked  for  and  destroyed  if  found. 

Other  causes  for  the  leukorrhea  will  be  found  if 
present  and  adequate  examinations  are  made.  A 
good  deal  has  been  written  recently  about  certain 
conditions  of  the  vagina  being  due  to  insufficient 
hormone.    This  is  still  in  the  experimental  stage. 

In  every  case  of  leukorrhea  especial  care  must 
be  taken  to  determine  the  presence  or  absence  of 
gonorrhea  or  trichomoniasis,  as  both  of  these  con- 
ditions have  a  tendency  to  run  a  tedious  course, 
and  are  often  difficult  to  cure. 

In  gonorrhea  it  is  important  to  know  what  to  do 
and  what  not  to  do.  In  the  acute  stage  much  harm 
is  done  by  doing  too  much  at  first.  The  patient 
should  be  put  to  bed  during  the  acute  stage,  the 
urine  alkalinized  with  sodium  citrate  and  a  bland 
diet  instituted.  Cleanliness  of  the  affected  parts 
can  be  maintained  by  pitcher  douches  every  3 
hours  of  a  1:5000  bichloride  or  a  1:4000  perman- 
ganate of  potash  solution.  The  labia  should  be 
kept  separarated  by  a  pedget  of  cotton,  renewed  as 
often  as  it  becomes  saturated.  The  vulva  should 
be  painted  once  or  twice  daily  with  a  2 S-per  cent, 
solution  of  argyrol.  In  this  stage  neither  the  ex- 
amining finger  nor  any  instrument  should  be  car- 
ried beyond  the  site  of  the  hymen  for  fear  of  caus- 
ing extension.  If  the  disease  has  already  invaded 
the  vagina,  mildly  antiseptic  douches  should  be 
given  twice  daily.  This  treatment  should  be  main- 
tained until  the  acute  stage  has  passed.  If  the 
disease  lingers  it  will  be  found  in  Skene's  or  Bartho- 
lin's glands  or  in  the  cervix.  If  it  persists  in 
Skene's  or  Bartholin's  glands  they  should  be  ex- 
terminated, as  there  is  little  prospect  of  curing  the 
case  otherwise.  When  the  cervix  is  involved,  the 
only  effective  treatment  is  heat.  This  may  be 
applied  by  electric  cautery,  diathermy  or  the  El- 
liott treatment.    All  of  these  act  by  raising  the  heat 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


in  the  cervix  to  a  point  sufficient  to  kill  the  gono- 
cocci. 

In  the  treatment  of  trichomoniasis  many  reme- 
dies have  been  advocated,  most  of  which  I  have 
tried.  I  began  with  Bland's  scrubbing  treatment 
and  continued  with  stovarsol  powder  and  picric 
acid  suppositories;  but  I  have  found  most  effective 
the  method  advocated  by  Rosenthal,  Schwartz  and 
Kaldor  in  the  Journal  oj  the  A.  M.  A.,  July  13th, 
1935.  This  consists  of  the  simple  douching  of  the 
vagina  with  a  25-per  cent,  salt  solution  twice  daily. 
One  teacupful  of  table  salt  in  four  of  water  makes 
the  desired  solution.  It  acts  by  dehydrating  the 
trichomonas.  It  is  used  at  home,  with  inspections 
and  tests  at  the  office  once  or  twice  weekly.  I  have 
supplemented  this  treatment  by  painting  the  vagina 
with  merthiolate  once  or  twice  a  week.  While  this 
burns,  it  soon  cools  off  and  is  very  effective.  The 
salt  douches  should  be  continued  for  two  months 
after  the  trichomonas  has  disappeared  from  the 
vagina. 

I  would  conclude  with  the  statement  that  leu- 
korrhea,  in  order  to  be  properly  treated,  must  have 
its  cause  diagnosed,  and  this  can  only  be  done  by 
careful  and  adequate  examinations.  When  the 
cause  and  site  of  the  discharge  are  located,  the 
proper  treatment  will  usually  effect  a  cure. 


A  New  and  Effecti\'e  Treatment  for  Trichomonas 
Vaginitis 


Treatment.  Give  the  patient  (1)  7  vaginal  suppositories 
of  1%  oxyquinoline  sulphate,  1%  picric  acid,  54%  menthol, 
made  up  in  cocoa-butter  base;  (2)  lactic  acid  solution, 
U.  S.  P. 

Procedure.  (1)  The  urine  is  examined  for  sugar  to  ex- 
clude diabetes.  (2)  Vaginal  spreads  are  examined  for 
gram-negative  intracellular  diplococci  to  exclude  gonorrheal 
infection.  (3)  The  cervix,  if  eroded,  is  treated  before 
starting  treatment.  (4)  All  patients  are  instructed  in 
personal  hygiene  after  defecation  (to  wipe  themselves  away 
from  and  not  towards  the  vagina).  (S)  The  patient  is 
told  to  insert  one  suppository  in  the  vagina  even.'  night 
before  going  to  sleep  and  to  keep  the  knees  elevated  for 
IS  min.,  then  to  lie  face  down  for  15  min.  The  following 
morning  the  patient  takes  a  douche  of  1  teaspoonful  of 
lactic  acid  to  1  qt.  of  warm  water.  This  procedure  is 
followed  for  7  days.  At  the  end  of  that  time  the  patient 
continues  to  douche  with  the  lactic  acid  for  3  more  days. 
Then,  for  4  days  the  patient  stops  all  treatment  and 
returns  2  weeks  from  the  time  of  the  beginning  of  the 
treatment  for  another  vaginal  spread.  If  still  positive  for 
trichomonas,  the  treatment  is  repeated  for  another  2  weeks; 
if  found  to  be  negative,  the  bladder  is  irrigated  with 
potassium  permanganate  solution  1 :  SOOO,  to  prevent  re- 
infection from  the  bladder.  (6)  The  patient  is  instructed 
to  take  an  enema  with  potassium  permanganate  solution 
1:5000,  to  prevent  reinfection  from  the  rectum.  (7)  The 
patient  is  asked  to  return  for  3  months  after  each  men- 
strual period  for  a  final  check-up. 

Results.  One  hundred  cases,  75%  were  in  married  wo- 
men, 11%  in  single  women,  8%  in  separated  women,  and 


6%  in  widows;  the  ages  IS  to  60  years;  duration  of  the 
disease  one  week  to  12  years.  All  were  relieved  of  itching 
and  burning  with  the  first  set  of  suppositories  and  lactic 
acid  douching,  and  there  was  a  marked  decrease  in  the 
vaginal  discharge.  In  70%  the  vaginal  spreads  were 
found  negative  for  trichomonas  with  one  set  of  supposi- 
tory treatment;  25%  required  a  2nd  set  of  suppositories 
and  lactic  acid  douches  before  the  spreads  were  negative 
for  trichomonas;  5%,  although  relieved  of  practically  all 
their  symptoms,  still  had  an  occasional  trichomonas  pres- 
ent in  the  vaginal  spread.  This  treatment  may  be  used 
with  safety  in  pregnant  women  suffering  with  trichomonas 
vaginitis. 


Milk  in  the  Treatment  or  Gonoblennorrhea 
(T.   H.   Luo,  Peiping.  in  Chinese    Med.  Jl.,  Jan.) 

Fifteen  patients  from  an  endemic  of  gonococcus  ophthal- 
mia were  studied  as  to  the  effect  of  parenteral  milk  injec- 
tions. 

Patients  treated  with  milk  and  local  measures  require  a 
shorter  period  for  recovery  than  those  receiving  local  treat- 
ment alone. 

The  therapeutic  effect  of  milk  is  attributed  to  the  action 
on  the  gonococcus  of  the  enzymes  or  antibodies  produced 
through  a  general  stimulation  of  the  various  tissues  of  the 
body,  the  fever  being  a  part  and  an  indicator  of  this  gen- 
eral reaction.  • 

Milk  injections  combined  with  lavage  are  thought  to  be 
sufficient  to  cure  gonococcus  ophthalmia. 

Milk  is  considered  the  most  efficacious  and  practical  for- 
eign protein  in  the  treatment  of  gonoblennorrhea. 


UROLOGY 

For  this  issue,  P.  Emery  Huth,  M.D,,  Sumter,  S.  C. 


A  Discussion  of  Foreign  Bodies  in  the  Urinary 
Bladder  With  An  Unusual  Calculus 
Resulting  Therefrom: 
Foreign  bodies  in  the  urinary  bladder  are  the 
result  of  curiosity  in  the  greater  number  of  cases, 
though  many  of  those  bodies  reach  the  bladder  by 
other  means.  For  instance,  some  result  from  mate- 
rial sloughing  into  the  bladder  from  the  perivesical 
spaces.  Prominent  among  this  type  of  foreign  body 
is  the  bony  spicule  resulting  from  traumatism,  frac- 
ture of  the  pelvic  girdle,  or  a  sequestrum  of  an 
osteomyelitis  of  the  pelvic  girdle.  Others  which 
gain  entrance  from  the  perivesical  spaces  are  for- 
ceps, ligatures,  sponges,  or  other  small  objects 
which  have  been  left  in  the  abdomen  accidentally. 
Still  others  may  increase  in  size  due  to  the  forma- 
tion of  calculi  on  those  already  in  it.  These  bodies 
may  have  been  left  in  the  bladder  intentionally, 
such  as  the  end  of  a  Pezzar  catheter  at  the  time 
of  suprapublic  cystotomy;  or  it  may  have  been 
broken  off  during  some  intraurethral  manipulation, 
as  for  instance,  a  piece  of  filiform  which  has  broken 
at  the  junction  of  the  silk  woven  portion  with  the 
metal  shank.  Of  foreign  bodies  introduced  for 
erotic  stimulation  we  need  only  say  that  their  num- 
ber is  limited  only  by  their  size  and  the  amount 
of  pain  which  the  individual  will  suffer  for  ero- 
ticism.    Some  of  the  unusual  ones  which  I  have 


June,  1036 


SOUTHERN  MEDICINE  AND  SURGERY 


seen  deserve  mention.  I  had  the  opportunity  to 
know  of  one  perfume  bottle  similar  to  the  medicine 
vial  of  the  homeopathic  practitioner,  having  been 
introduced  by  a  woman  for  erotic  stimulation:  A 
man  introduced  paraffin  into  the  urethra  and  thence 
into  the  bladder  for  the  same  purposes;  and  last 
is  the  case  in  which  a  male  patient,  in  catheterizing 
himself,  left  about  two  inches  of  a  No.  14-16  F. 
soft  rubber  catheter  in  his  bladder  and  was  unaware 
of  its  presence  until  told  of  it  by  me. 

Smooth  objects  or  soft  ones  give  symptoms  after 
variable  lengths  of  time.  If  the  object  is  rough  the 
symptoms  will  begin  very  quickly  after  introduc- 
tion. Sharp  objects  usually  begin  to  cause  symp- 
toms as  soon  as  the  bladder  contracts  upon  them. 
The  initial  changes  are  due  to  irritation  and  usually 
are  simply  urgency  and  frequency  of  urination. 
When  this  has  lasted  a  variable  time  infection, 
usually  of  an  alkaline  type,  always  develops.  Then 
the  initial  demands  for  calculous  deposits  have  been 
met.  Thompson-Walker  is  of  the  opinion  that  the 
usual  calculous  formation  in  this  instance  is  phos- 
phatic.  In  acid  urine  he  believes  that  uratic  calculi 
will  form.  The  calculus  may  form  on  a  portion 
of  the  foreign  body,  or  on  either  or  both  ends;  or 
it  may  completely  envelop  it.  Pieces  of  pliable 
foreign  bodies  may  break  off  and  be  expelled  in 
the  urine.  Young  and  Thompson-Walker  believe 
that  wax  is  the  least  likely  foreign  body  to  cause 
calculous  deposit  to  form  upon  it.  This  is  because 
the  surface  tension  of  wax  is  the  same  or  very 
close  to  that  of  urine.  However,  this  likelihood 
increases  directly  with  the  increase  in  the  amount 
of  debris  in  the  wax,  so  that  one  may  find  a  piece 
of  wax  acting  as  a  nucleus  of  a  large  calculus  in 
the  bladder. 

The  incidence  of  foreign  body  in  the  urinary 
bladder  is  higher  in  females  than  in  males,  due  to 
the  greater  ease  of  introduction.  The  age  of  this 
type  of  patient  is  usually  in  the  second  or  third 
decade  and  the  majority  are  unmarried. 

There  are  no  symptoms  which  are  definitely  in- 
dicative of  a  foreign  body  in  the  bladder.  The 
earliest  symptoms  are  those  of  cystitis — urgency, 
frequency  and  dysuria.  When  the  inflammatory 
reaction  begins  and  infections  start  later,  there  is 
P3airia  of  varying  and  increasing  severity.  The 
symptoms  of  cystitis  increase  in  severity  as  the 
process  continues.  Vesical  tenesmus  and  hematuria 
frequently  are  found  to  exist.  The  patient  often 
complains  of  a  peculiar  heavy  bearing-down  pain 
in  the  perineum,  especially  when  in  the  erect  posi- 
tion. This  pain  radiates  into  the  penis  and  scrotum 
of  the  male  and  the  vulva  of  the  female.  Some 
writers  accord  the  intermittent  urinary  stream,  due 
to  the  ball-valve  action  of  the  calculus,  high  im- 
portance.    When  a  calculus  forms  on  the  foreign 


body  all  the  symptoms  are  aggravated. 

The  diagnosis  should  present  no  difficulty  to  the 
modern  urologist.  It  is  sometimes  difficult,  how- 
ever, to  get  a  concise  history  of  his  case,  and  the 
less  likely  factors  of  previous  intravesical  manipu- 
lations and  operations,  so  one  may  proceed  to  ex- 
amine the  patient  with  the  thought  of  cystitis  only 
in  mind,  and  be  greatly  surprised  to  find  a  foreign 
body.  The  physician  may  try  to  reduce  his  patient 
expense  by  omitting  radiography  in  what  seems  to 
be  a  simple  case  of  cystitis  and  thereby  miss  the 
cause.  Or  again,  in  his  haste  to  minimize  the  dis- 
comfort to  his  patient,  he  may  perform  a  cursory 
examination  and  hurry  on  to  catheterize  the  ureters 
to  obtain  information  of  the  upper  urinary  tract. 

Since  the  modern  cystoscope  is  so  easy  to  use, 
we  rely  almost  entirely  upon  it  for  this  diagnosis. 
Cystoscopy  is  not  always  possible  in  these  patients, 
however,  because  of  reduced  bladder  capacity  or 
the  inflammation.  In  this  type  of  case  x-ray  ex- 
amination demonstrates  its  value;  but  all  such 
offending  bodies  are  not  opaque  to  x-ray.  In  such 
an  instance  we  must  treat  the  bladder  until  cys- 
toscopy is  possible. 

The  treatment  of  foreign  bodies  in  the  urinary 
bladder  permits  of  an  almost  limitless  display  of 
dexterity  and  ingenuity.  When  the  foreign  body 
is  small  enough  to  be  extracted  through  the  urethra 
we  may  use  Young's  cystoscopic  rongeur,  pro- 
vided the  bladder  is  large  enough  to  accommodate 
it.  When  all  prerequisites  are  obtained  the  opera- 
tor may  perform  a  brilliant  feat  of  transurethral 
surgery  in  removing  some  of  these  bodies.  This 
instrument  is  strong  enough  to  lend  itself  very  well 
to  this  type  of  manipulation  for  it  is  able  to  main- 
tain its  grip  on  an  object  once  it  is  obtained,  and, 
too,  it  is  operated  under  direct  vision.  With  this 
instrument  long  objects  can  be  manipulated  into 
position  to  be  extracted  through  the  urethra. 
When  infection  has  been  present  for  a  long  time 
the  bladder  will  not  permit  any  manipulations  in 
it,  and  we  must  then  prepare  it  by  proper  treat- 
ment, and  for  a  sufficient  length  of  time,  before 
attempting  to  operate  for  removal  or  manipulate 
by  any  transurethral  method.  By  means  of  the 
indwelling  urethral  catheter  the  bladder  can  be  irri- 
gated at  frequent  intervals,  its  capacity  determin- 
ed, and  far  more  important,  the  symptoms  usually 
cease  as  soon  as  the  catheter  functions  properly. 
After  the  bladder  has  been  prepared  by  controlling 
the  infection  and  dilating  it  enough,  a  suprapubic 
cystotomy  may  be  performed  and  the  foreign  body 
extracted;  or  if  it  is  small  enough  it  may  be  re- 
moved transurethrally.  The  postoperative  treat- 
ment is  entirely  dependent  upon  conditions  as  they 
arise.  A  suprapubic  drainage  tube  is  left  in  place 
until   the  infection   in  the  bladder  has  been  con- 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


trolled  and  then  it  may  be  removed  and  transureth- 
ral drainage  substituted  for  it. 

Foreign  bodies  composed  of  waxy  material  pre- 
sent a  different  problem.  They  are  lighter  than 
urine  and  float  in  the  dilating  medium  and  so  are 
highly  mobile,  which  factors  make  them  extremely 
difficult  to  grasp  with  an  instrument.  The  best 
method  of  attack  is  to  dissolve  this  type  of  foreign 
body  with  gasoline,  benzine  or  xylol,  but  I  feel  that 
these  solvents  would  be  irritating  to  the  bladder 
mucosa. 

A  man  came  to  me  just  after  I  began  doing 
urology  in  1928,  admitted  that  he  had  placed  some 
paraffine  in  his  urethra  and  complained  of  having 
had  urgency,  frequency  and  dysuria  ever  since  that 
time.  He  expressed  a  fear  that  a  piece  of  paraffine 
had  broken  off  in  his  bladder.  Cystoscopic  exam- 
ination disclosed  two  pieces  of  paraffine  floating  in 
the  dome  of  his  bladder,  each  a  half-inch  long  and 
as  thick  as  a  small  lead  pencil.  I  advised  him  to 
go  home  and  return  next  day  for  further  treatment. 
At  this  time  my  practice  was  in  a  big  oil  refining 
district  and  I  consulted  with  one  of  the  leading 
petroleum  chemists  to  find  out  what  would  dissolve 
paraffine.  He  told  me  xylol,  benzine  and  gasoline. 
I  expressed  my  fear  that  these  would  be  irritating 
and  he  agreed,  and  then  suggested  mineral  oil  such 
as  is  refined  from  Pennsylvania  crude  oil.  The 
patient  worked  at  one  of  the  oil  refineries  and  he 
easily  procured  a  gallon  of  mineral  oil,  and  I  in- 
structed him  to  boil  it  and  after  cooling  instil  two 
ounces  into  his  bladder  each  night  for  a  week,  re- 
taining it  all  night  if  possible,  and  then  return  for 
examination.  When  he  returned  in  a  week  the 
paraffine  was  gone  and  he  was  s\Tnptom-free. 

A  farmer,  aged  52,  married,  came  to  me  because 
of  involuntary  urination  and  painful  sensations  in 
the  bladder  and  urethra.  His  past  history  was  neg- 
ative except  for  attacks  of  acute  alcoholism  which 
last  for  several  days.  No  history  of  venereal  dis- 
ease. About  nine  years  ago  the  patient  had  an 
attack  of  acute  retention  of  urine,  was  relieved  by 
various  home  remedies,  and  then  he  passed  "gravel" 
for  about  five  years  at  varying  intervals.  An  acute 
alcoholic  debauch  preceded  this  attack.  Each  time 
he  passed  "gravel"  he  experienced  some  dift'iculty 
in  voiding  and  extreme  pain  in  his  bladder  and 
urethra.  Four  years  ago  the  symptoms  drove  him 
to  a  urologist  for  relief.  At  this  time  he  was 
advised  that  his  "glands"  needed  to  be  removed  by 
surgery.  He  was  treated  for  several  days  and 
there  was  great  improvement  in  his  symptoms.  This 
improvement  was  maintained  for  a  year  when  all 
the  bladder  symptoms  returned.  No  s-ray  exam- 
ination had  been  made  up  to  this  time.  For  the 
past  three  years  he  has  been  experiencing  urgency, 
frequency,  dysuria,  pyuria,  and  at  times,  hematuria 


and  acute  retention  of  urine.  When  he  had  an  at- 
tack of  acute  retention  he  w^ould  catheterize  him- 
self. 

On  presenting  himself  to  me  for  examination  he 
was  unable  to  control  his  urine,  voiding  every  five 
to  15  minutes,  and  e.xperiencing  acute  pain.  Fre- 
quently there  would  be  an  intermittent  passage  of 
urine  and  extreme  vesical  tenesmus.  He  has  passed 
many  calculi  ranging  in  size  from  that  of  a  match 
head  to  that  of  a  cherry. 

The  patient  looked  fifty  years  of  age,  was  well 
developed,  appeared  to  be  in  great  discomfort.  His 
clothes  were  wet  from  incontinence.  The  general 
examination  w-as  negative  for  any  gross  abnormali- 
ties. There  was  marked  tenderness  over  the  blad- 
der area. 

The  urethra  was  filled  with  a  solution  of  nuper- 
caine,  1  to  1000.  This  was  retained  for  ten  minutes. 
A  No.  24  F.  cystoscope  was  easily  introduced  into 
the  bladder.  The  patient  complained  bitterly  when 
the  instrument  passed  the  deep  urethra.  As  the 
instrument  entered  the  bladder  a  distinct  crepfta- 
tion  was  felt.  Ihe  bladder  capacity  was  found  to 
be  one  ounce.  This  did  not  permit  a  cystoscopic  J 
examination  to  be  made.  However,  a  large  round 
yellow  object  was  seen  which  suggested  a  calculus. 
By  permitting  the  water  from  the  irrigating  jar 
to  run  through  the  cystoscope  continuously  the 
prostate  was  seen  to  be  very  slightly  enlarged.  The ' 
cystoscopy  was  withdrawn  and  a  plain  x-ray  film 
was  made,  which  revealed  a  round  opaque  body 
1  yi  inches  in  diameter.  Through  this  shadow  could 
be  seen  a  denser  spiral  suggesting  a  piece  of  cathe- 
ter. The  radiological  diagnosis  was  a  foreign  body, 
probably  a  piece  of  catheter,  surrounded  by  a  cal- 
culus. The  patient  was  admitted  to  the  hospital 
and  an  indwelling  catheter  was  placed  in  his  urethra. 
From  that  time  on  he  experienced  no  more  pain. 
The  fluid  intake  and  output  were  measured  and 
found  to  be  satisfactory.  The  temperature  on  ad- 
mission was  101  and  rose  the  second  day  to  103. 
.■V  blood  smear  examination  at  this  time  demon- 
strated tertian  malarial  parasites.  The  malaria  was 
treated  successfully.  The  bladder  infection  was 
treated  by  lavage  with  warm  1 :  5000  potassium  per- 
manganate solution  three  times  daily.  An  attempt 
was  made  to  increase  the  bladder  capacity  by  in- 
creasing the  amount  of  this  solution  at  each  lavage. 
After  10  days  on  this  treatment  the  patient's  con- 
dition had  improved  so  greatly  that  it  w^as  decided 
to  operate  to  remove  the  calculus.  Under  ether 
anesthesia,  a  midline  suprapubic  incision  was  made. 
Due  to  its  small  capacity  inflation  was  impossible. 
On  incising  the  bladder  the  capacity  was  found  to 
be  much  greater  than  anticipated  and  the  apparent 
small  capacity  was  probably  due  to  the  intense 
inflammation.     When   a   finger   was    inserted   into 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


the  bladder  it  met  an  elongated  stone,  the  long  axis 
antero-posterior.  The  stone  was  extracted,  the 
bladder  drained  with  a  Pezzar  catheter,  drainage 
was  placed  in  the  space  of  Retzius  and  the  over- 
lying muscles  and  fascia  closed  in  anatomical  lay- 
ers. 

The  postoperative  course  was  uneventful  except 
for  profuse  drainage  from  the  space  of  Retzius. 
The  patient's  temperature,  pulse  and  respiration 
were  normal  after  the  third  postoperative  day. 

The  calculus  proved  to  be  made  up  of  two 
masses,  one  on  each  end  of  a  piece  of  soft  rubber 
urethral  catheter.  Each  mass  was  five-eighths  of 
an  inch  in  diameter  and  nearly  globular  except  for 
flattening  where  they  were  approximated.  The 
catheter  ran  a  true  spiral  through  the  two  masses. 

Comment:  This  case  is  presented  because  of 
the  unusual  calculous  formation  and  because  the 
patient  was  unaware  that  he  had  broken  a  catheter 
and  left  a  piece  in  his  bladder. 


CLINICAL  CHEMISTRY  &  MICROSCOPY 

For  this  issue,  Joseph  J.  Co.mes,  M.D.,  Raleigh,  N.  C. 


Tre.mtment  of  the  Overflow  Inxontinence  of 

XErROGE^^c  Vesical  Dysfunxtion 
(C.   D.   Creevy,  Minneapolis,   in   Minn.   Med.,    Maj') 

Methods  of  improving  or  restoring  the  expulsive  force 
include  the  use  of  drugs  which  stimulate  the  contraction 
of  smooth  muscle  (eserine,  pilocarpine,  acetyl  choline  and 
especially  its  more  stable  derivatives)  ;  rest  of  the  bladder 
by  intermittent  or  continuous  catheterization  or  by  cys- 
tostomy;  and  the  performance  of  presacral  neurectomy. 

Education  consists  in  training  the  patient  to  micturate 
at  regular  intervals  by  the  clock  even  in  the  absence  of 
any  conscious  desire  to  do  so;  to  assist  micturition  by 
assuming  that  position  (often  sitting)  in  which  he  himself 
finds  it  easiest  to  accomplish,  and  by  massaging  the  blad- 
der firmly  and  persistently  during  the  act ;  and  by  refusing 
to  allow  him  to  urinate  hastily.  Their  employment  abso- 
lutely requires  an  intelligent,  co-operative  patient. 

The  use  of  drugs  and  the  catheter,  coupled  with  train- 
ing, may  succeed  in  the  early  stages  when  retention  alone 
is  present,  but  when  the  stage  of  overflow  is  reached,  more 
effective  measures  are  usually  required.  An  essential  pre- 
liminar>'  to  therapy  in  these  cases  is  to  exclude  the  posii- 
bihty  of  a  complicating  mechanical  obstruction,  remem- 
bering that  a  prostatic  fibrosis  or  hypertrophy  so  slight  in 
degree  as  to  cause  no  symptoms  below  a  normal  bladder, 
may  lead  to  retention  or  overflow  if  even  mild  neurogenic 
vesical  dysfunction  exists. 

Early  in  their  course  partial  retention  develops,  and 
can  often  be  relieved  by  bladder  rest  with  the  inlying 
catheter  supplemented  by  drugs  to  increase  the  expulsive 
force,  provided  that  the  patient  is  then  trained  to  urinat  • 
at  regular  intervals  by  the  clock. 

In  selected  cases,  6  to  12  weeks  rest  of  the  bladder  by 
cystostomy,  followed  by  careful  training,  may  give  relief. 
The  habit  of  "urination  by  the  clock''  must  be  maintained 
permanently  if  recurrence  is  to  be  avoided. 

With  more  severe  damage  to  the  detrusor,  cystostomy 
is  best  supplemented  by  presacral  neurectomy,  which  should 
be  regarded  only  as  one  means  of  increasing  expulsive 
force. 

If  the  lesion  of  the  nervous  system  is  advanced  enough 
to  produce  fecal  incontinence,  the  prospect  of  cure  by 
these  methods  is  poor. 


Sedimentation  of  Red  Blood  Cells  in  Routine 
Physical  Examination* 

It  behooves  all  of  us  to  ever  strive  to  improve 
our  diagnostic  ability.  Tests  which  will  serve  this 
purpose  should  be  adopted  and  be  incorporated  in 
the  routine  studies  of  our  patients.  If  these  tests 
are  simple,  inexpensive,  easily  done  and  at  the 
same  time  reliable  and  valuable,  all  the  better. 
The  writer  wishes  to  bring  to  your  consideration 
the  sedimentation  rate  of  red  blood  cells  as  such  a 
test.  It  is  not  indicative  of  any  particular  disease 
but  when  there  is  an  increased  rate  there  is  a  de- 
struction of  tissue  and  no  physiological  conditions 
increase  this  rate  save  pregnancy  and  menses. 

The  procedure  of  this  test  is  not  standardized 
but  the  principle  underlying  all  of  them  is  the 
same.  The  method  used  by  the  writer  is  a  modified 
Cutler  technique.  In  a  tube  graduated  in  mm. 
marks  up  to  SO  and  of  S-c.c.  capacity,  O.S  c.c.  of 
5  %  sodium  citrate  is  placed  and  venous  blood  add- 
ed to  the  given  mark;  the  blood  and  citrate  are 
thoroughly  mixed  and  the  tube  placed  in  a  vertical 
position  with  readings  of  the  drop  of  the  red  cells 
taken  at  stated  intervals  of  5  to  IS  minutes  for  the 
first  hour.  The  final  reading  is  given  as  the  sedi- 
mentation rate,  a  correction  being  made  when  the 
red  cell  count  is  below  4,500,000  by  the  following 
formula: 

X 

—  — l=:amount  of  plasma  to  be  added  to  (or  re- 

Y  moved  from)  1  c.c.  of  blood. 

X=number  of  million  cells  per  c.  mm. 
Y=desired  number  of  million  cells  per  c.  mm. 

The  normal  sedimentation  rate  is  about  7  mm. 
for  the  first  hour,  the  rapidity  and  the  amount 
indicative  of  the  extent  and  activity  of  the  disease 
process. 

In  evaluating  this  procedure  we  must  understand 
that  a  normal  sedimentation  rate  does  not  rule  out 
disease.  It  does  indicate  the  absence  of  tissue  de- 
struction or  activity  of  infection.  The  test  is  not 
infallible  and  instances  have  been  reported  of  clini- 
cally active  disease  in  face  of  normal  sedimentation 
rate,  but  Cutler  observed  only  five  such  instances 
in  S,000  observations.  Schattenberg  reports  the 
observation  of  six  increased  sedimentation  rates  out 
of  1,100  examinations  with  nothing  abnormal  found 
in  routine  examination.  On  further  and  more  thor- 
ough clinical  study  of  these  six,  one  case  was  found 
to  be  myeloid  leukemia,  one  pellagra,  one  incipient 
pulmonary  tuberculosis,  two  subacute  salpingitis 
and  one  pityriasis  rosea.    He  states  these  conditions 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


were  found  only  after  the  increased  sedimentation 
rate  had  focused  further  attention  on  these  pa- 
tients. 

This  test  is  of  value  in: 

1)  Differentiating    between    inflammatory    and 
non-inflammatory  processes : 

Viz. — a.  in  the  chest 
b.  in  arthritis 
c.  in  the  genitourinary  system. 

2 )  Indicating  the  course  and  value  of  treatment 
in  chronic  infectious  processes: 

Viz. — a.  in  tuberculosis 

b.  in  peptic  ulcers 

c.  in  rheumatic  arthritis. 

3)  Differentiating  between   benign   and   malig- 
nant lesions. 

4)  Indicating  pregnancy  in  the  absence  of  in- 
fection or  malignancy. 

It  has  long  been  used  to  differentiate  between 
salpingitis  and  appendicitis.  It  is  of  value  if  the 
time  factor  be  taken  into  consideration.  The  sedi- 
mentation rate  is  low  in  appendicitis  if  taken  within 
48  hours  of  the  onset  but  high  in  salpingitis.  The 
reason  for  this  is  not  attributed  to  the  difference  in 
typ>e  of  infection,  but  to  the  difference  of  the  two 
organs  as  regards  function  and  nerve  supply.  The 
appendix  is  innervated  by  fibers  from  both  the  sym- 
pathetic and  parasympathetic  nervous  system,  the 
tube  by  the  sympathetic  only.  The  tube  can  be 
distended  considerably  without  giving  rise  to 
symptoms  while  the  slightest  swelling  or  inflamma- 
tion in  the  appendix  produces  pain:  thus  the  sal- 
pingitis has  been  existing  for  a  long  period  of  time 
before  symptoms  develop  and  the  physician  consult- 
ed. The  sedimentation  rate  does  increase  in  ap- 
pendicitis after  48  hours  and  is  more  rapid  in  gan- 
grene and  peritonitis  cases  than  in  simple  acute  con- 
ditions. 

This  procedure  is  also  of  value  in  deciding  when 
to  operate  on  the  pelvic  inflammatory  cases  and 
is  more  accurate  than  the  leucocyte  or  temperature 
curve  as  these  vary  according  to  time  of  day  while 
the  sedimentation  rate  does  not. 

The  test  is  valuable  in  differentiating  between 
functional  and  organic  gastrointestinal  conditions. 
A  simple  ulcer  gives  a  normal  rate  but  with  activ- 
ity there  is  an  increase.  There  have  been  cases 
reported  where  sedimentation  rate  remained  high 
in  spite  of  a  symptomatic  cure  of  the  ulcer  which 
later  perforated.  Lorie  never  labels  a  case  "func- 
tional neurosis"  unless  there  is  a  normal  sedimenta- 
tion rate.  If  this  test  continues  normal,  organic 
diseases  can  be  ruled  out. 

The  procedure  will  aid  in  differentiating  between 
infectious  and  non-infectious  arthritis.  It  has  defi- 
nitely assumed  a  place  in  indicating  the  progress 
of  cure  in  tuberculosis.    Palmer  states  he  would  not 


give  permission  for  one  of  his  tuberculous  patients 
to  become  pregnant  regardless  of  symptomatic  cure 
unless  the  sedimentation  rate  is  below  ten. 

The  rate  has  been  found  to  be  normal  or  de- 
creased in  pertussis.  According  to  Denes  and  Latos 
a  diagnosis  of  this  condition  can  be  made  in  any 
infant  with  a  cough,  a  leucocyte  count  above  10,000 
with  a  normal  or  below  normal  sedimentation  rate. 
Asthma  usually  lowers  the  rate.  In  pregnancy  the 
rate  increased  each  month  after  the  third  and  is 
about  IS  for  the  9th  month  and  returns  to  normal 
four  weeks  after  delivery.  In  toxemias  the  rate  is 
10  to  15%  higher  than  the  corresponding  normal 
for  the  month. 

The  writer  has  recently  run  28  tests  in  his  office 
along  with  the  routine  physical  examinations:  50% 
of  these  were  found  to  be  within  normal  limits 
while  the  others  were  higher  than  normal.  Among 
the  cases  with  a  normal  sedimentation  rate  the  fol- 
lowing diagnoses  were  made:  chronic  infection  of 
sinus  twice,  enlarged  tonsils,  low-grade  cold  with 
moderately  positive  tuberculin  test,  cardiac  irregu,- 
larity  with  some  tenderness  over  the  appendix  but 
a  normal  temperature,  low-grade  diabetes,  and  a 
clinical  cure  of  syphilis  nine  months  after  beginning 
treatment  with  a  rate  of  2  mm.  for  one  hour. 

Among  the  abnormal  rates  six  were  cases  of  tu- 
berculosis— two  of  them  arrested  cases  in  which 
pneumothorax  had  been  discontinued,  with  rate  of 
lOJ/2  and  11  mm.,  two  apparently  arrested  cases 
with  artificial  pneumothorax  whose  rate  was  15, 
one  with  a  rate  of  28  which  resulted  fatally  four 
months  later,  another  with  a  rate  of  22  when  the 
diagnosis  was  first  made;  a  case  of  bronchiectasis 
with  a  rate  of  13;  subacute  pelvic  inflammatory 
disease,  rate  30.5;  a  four-plus  Wassermann  with  a 
rate  of  19. 

One  very  instructive  case  was  that  of  a  colored 
woman  complaining  of  diarrhea,  pain  on  defecation 
and  blood  in  stools.  An  examination  with  very  lit- 
tle cooperation  revealed  only  hemorrhoids,  but  her 
sedimentation  rate  of  25 — 22  of  that  in  first  20 
minutes — made  me  suspicious  of  something  more 
serious,  so  the  patient  was  admitted  on  charity  ser- 
vice. Proctoscopic  examination  failed  to  reveal  any 
disease  in  the  rectum  so  the  hemorrhoids  were  re- 
moved. A  month  later  the  rate  was  still  25  with 
the  patient  still  complaining  of  pain  and  failing  to 
regain  weight  and  strength.  The  diagnostic  study 
is  not  complete  in  this  case. 

Summary 

The  writer  believes  that  the  sedimentation  rate 
of  red  cells  is  a  definite  aid  in  diagnosis  in  office 
practice,  as  an  adjunct  to  a  proper  physical  exam- 
ination. If  the  rate  is  high  a  careful  study  should 
be  made  to  find  the  disease  condition.  If  the  rate 
is  normal  an  active  disease  process  is  absent.     It 


June,  1036 


SOUTHERN  MEDICINE  AND  SURGERY 


is  also  of  value  in  checking  the  progress  of  recovery, 
and  the  value  of  the  treatment. 

Cutler  states,  "The  sedimentation  test  will  not 
make  a  good  doctor  out  of  a  poor  one  but  it  will 
undoubtedly  make  a  keener  and  better  physician 
out  of  a  good  one.  The  physician  and  not  the  test 
must  determine  the  nature  of  the  pathology  it 
points  out  to  him.  The  test  has  served  its  purpose 
in  diagnosis  when  it  has  indicated  the  existence  of 
disease  and  thus  warned  the  physician  to  make  an 
unremitting  search  for  the  source  of  the  disturb- 
ance." 


Clinical  Interpret.-vtion  of  Jaundice 
(Victor  Knapp,  Asbury  Park,  in  Jl.  Med.  Soc.  N.  J.,  Apr.) 
Hemolytic  jaundice  does  not  attain  the  deep  staining  seen 
in  obstructive  jaundice,  nor  is  itching  as  frequent;  and  the 
patient  refers  his  symptoms  away  from  the  hepato-biliary 
system.  Where  jaundice  is  due  to  liver  cell  damage,  the 
complaints  are  referable  to  the  causative  agent,  such  as 
occurs  in  metallic  poisoning,  and  the  jaundice  is  merely  an 
incident  to  the  disease.  Such  a  patient  suffers  a  varying 
degree  of  toxicity  depending  on  the  extent  of  damage  to 
his  liver  and  other  organs.  The  regional  icterus  of  pul- 
monary infarct  and  intraperitoneal  hemorrhage  appear  rap- 
idly and  fade  as  quickly,  and  its  clinical  diagnosis  is  usually 
apparent. 

It  is  to  the  laboratory  that  we  must  look  for  confirma- 
tion of  our  diagnosis  and  prognosis.  As  a  guide  for  our 
therapy  it  is  our  problem  to  determine  the  extent  of  injury 
being  done  to  the  liver  by  the  disease  producing  the  jaun- 
dice, for  it  is  liver  damage,  to  a  large  extent,  that  deter- 
mines the  outcome  of  the  disease. 


PEDIATRICS 

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


Prophylactic  Immunizations 
The  oldest  prophylactic  inoculation  is  smallpox 
vaccine,  popularized  by  Jenner  140  years  ago. 
Ever  since  its  inception  it  has  had  a  stormy  ca- 
reer. Out  of  ignorance  the  anti-vaccinationists 
have  fought  it  and  now  it  is  meeting  with  new 
opposition  because  of  the  incidence  of  post-vac- 
cinal  encephalitis  occurring  chiefly  on  the  conti- 
nent of  Europe.  This  sequela  seldom  occurs  in 
the  U.  S.,  but  no  one  can  prophesy  that  it  will  not 
arise  here.  The  cause  is  unknown.  The  literature 
contains  no  report  of  post-vaccinal  encephalitis 
in  the  first  year  of  life;  therefore  the  safest  time 
to  vaccinate  is  before  the  second  year.  The  dura- 
tion of  a  successful  vaccination  varies  widely,  seven 
years  being  accepted  as  average  duration.  A  new 
product  of  the  Eli  Lilly  Co.,  made  from  chick- 
embryo  membrane  inoculation,  has  many  advan- 
tages to  recommend  its  use,  chief  of  which  is  the 
reduction  in  local  and  systemic  reactions. 

Typhoid  jever  does  occur  in  infancy.  Because 
of  its  infrequency  and  the  generally  improved  san- 
itary conditions  of  the  cities,  this  vaccine  is  sel- 
dom advised  before  the  child  is  five  years  old.    Be- 


fore the  eighth  year,  one-half  of  the  adult  dosage 
is  used,  the  full  adult  dosage  after  the  eighth  year. 
Reactions  following  the  use  of  the  vaccine  seem  to 
be  less  severe  in  children.  The  duration  of  the 
protection  is  probably  three  years.  About  a  three- 
months  period  is  required  to  develop  complete 
immunity. 

.Alum  precipitate  toxoid  has  earned  its  rightful 
place  as  the  active  immunization  agency  of  choice 
against  diphtheria.  The  natural  immunity  acquir- 
ed from  the  mother  expires  at  about  the  sixtJi 
month.  It  is  then  that  diphtheria  protection  should 
be  given.  A  negative  Schick  test  following  in  six 
weeks  probably  means  protection  for  life. 

Measles  prophylaxis  has  been  described  in  this 
column  within  the  past  two  months.  Suffice  it  to 
to  say  here  that  from  3  to  5  c.c.  of  convalescent 
serum  given  before  the  6th  day  following  exposure 
will  usually  produce  satisfactory  modification  of 
the  attack.  Recently  an  immune  globulin  has  been 
placed  on  the  market  by  two  reliable  biological 
houses.  This  product  makes  available  a  prophy- 
lactic serum  against  measles  without  the  bother 
of  collecting  and  preparing  blood  from  a  donor. 

The  best  available  statistical  recommendation 
for  the  Sauer  pertussis  vaccine  is  that  in  vaccinated 
children  who  had  been  knowingly  exposed  to  the  dis- 
ease after  immunization,  85  per  cent,  had  not  de- 
veloped the  disease.  This  report  represents  the 
composite  answer  received  from  72  physicians  rep- 
resenting 24  different  States.  Dr.  Sauer  now  rec- 
ommends the  administration  of  10  to  12  c.c.  of 
vaccine  to  all  children  over  three  years  of  age, 
instead  of  the  previously  recommended  dose  of 
8  c.c. 

Protection  against  scarlet  jever  by  the  use  of 
dilute  toxoid  is  not  permanent  and  the  reactions 
are  too  severe  to  justify  its  use. 

B.  C.  G.  vaccine  against  tuberculosis  has  not 
been  accepted  by  .American  physicians. 

The  Kolmer  and  Brodie  vaccines  against  polio- 
myelitis have  been  generally  discarded  as  being 
either  unsafe  or  useless. 

My  own  routine  office  practice  for  the  adminis- 
tration of  the  different  vaccines  is  to  begin  with 
the  Sauer  vaccine  at  the  third  month.  Since  it  re- 
quires four  months  to  develop  complete  immunity 
from  this  vaccine  I  feel  it  should  be  given  as  early 
as  possible.  The  death  rate  from  whooping  cough 
is  greatest  during  the  first  year.  At  this  early  age 
I  have  always  given  the  full  8-c.c.  dose  of  vaccine. 
Since  Dr.  Sauer  requests  that  no  additional  vaccine 
be  given  during  the  four  months  that  the  body  re- 
quires to  produce  immunity  against  pertussis,  I 
v^ait  until  the  7th  month  to  give  diphtheria  toxoid. 
This  is  followed  in  6  weeks  by  a  Schick  test.  // 
the  7th  month  birthday  jails  in  a  winter  month  I 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


usually  vaccinate  against  smallpox  at  the  same  time 
that  I  protect  against  diphtheria.  Reactions  against 
smallpox  vaccine  are  less  severe  in  the  winter 
months.  Routinely  I  advise  smallpox  vaccination 
in  the  first  year. 

Following  the  administration  of  any  vaccine  I 
advise  the  mother  not  to  take  the  child's  tempera- 
ture. 


Nicotine  Poisonkg  in  a  Nursing  Infant 
(Irene  Greiner,  in  Jahrbuch  fur   Kinderheilkunde,   via 

International  Med.  Digest,  May) 
The  infant's  birthweight  had  been  3,600  Gm.  (S  lbs.) 
At  the  age  of  11  days,  when  he  was  brought  to  the  writer's 
notice,  his  weight  was  3,470  Gm.  (7  3/5  lbs.),  although  he 
had  been  having  regular  breast  feeding  ever  since  birth — 
5  times  a  day,  totaling  a  daily  average  of  400  Gm.  He 
was  restless,  had  diarrhea,  vomiting  and  only  6  to  8  wet 
diapers.  When  given  the  breast  6  times  a  day,  there  seemed 
to  be  a  slight  improvement,  up  to  the  22nd  day;  violent 
vomiting  several  times  during  the  day.  Colics,  refused  to 
take  food,  pale,  wrinkled,  drew  up  his  legs  and  cried 
much.    The  fontanel  was  sunken,  pupils  narrow. 

Mother  smoked  35  to  40  cigarettes  a  day.  It  sufficed  to 
stop  the  smoking  for  one  day  to  calm  the  baby,  bring  back 
appetite  and  sleep,  although  cramps  and  vomiting  persisted. 
No  smoking  permitted.  With  10  meals  a  day  at  the  breast, 
and  cold  tea  and  sugar  freely,  the  vomiting,  cramps  and 
oliguria  relented;  sleep  for  several  hours,  plenty  of  wet 
diapers,  stools  after  oil  enema,  etc.  The  weight,  after  hav- 
ing decreased  300  Gm.  during  the  2  days  of  into.xication, 
began  to  rise,  a  very  precarious  situation  was  remedied  by 
a  very  simple  measure — abstention  from  smoking. 


Vaccination  Ninety  Years  Ago 
(Howard  Jones,  CirclevlUe,  Ohio,  in  Med.  Rec,  ilay  20th) 
In  1S46  and  thereafter  it  was  considered  good  form  to 
vaccinate  all  babies  as  soon  as  they  showed  they  were 
growing  and  healthy,  usually  before  the  4th  week  of  age. 
Vaccination  was  looked  upon  as  a  duty  which  devolved 
upon  the  medical  attendant  at  delivery  of  a  baby. 


back  gently,  have  some  one  flip  a  little  cold  water  on  the 
back;  a  little  ether  is  more  effective.  If  we  are  consuming 
too  much  time  immerse  it  in  a  pan  of  water  to  keep  up 
body  temperature,  while  we  perform  artificial  respiration. 
Lay  the  baby  on  the  palms  of  both  hands  with  the  thumbs 
on  the  chest  and  upper  abdomen,  fold  the  child  together 
gently  and  then  open  it  out  in  full  distention,  allowing  the 
arms  to  drop  back.  If  this  fails  after  it  has  been  kept  up 
for  a  short  time  at  the  rate  of  almost  16  times  to  the 
minute  pass  No.  16  catheter  into  lungs  and  use  oxygen  if 
available. 


Resuscitation  or  the  New  Born 
(C.  S.  Sherman,  Millwood,  in  Ky.   Med.  J  I.,  April) 

With  a  foot  or  breech  delivered  and  pressure  of  the  cord 
as  the  after  coming  head  passes  through  the  canal  in  a 
primipara,  we  might  dilate  the  external  parts  under  a  light 
anesthetic  until  a  closed  fist  will  slip  through  the  ostium 
with  ease.  Be  careful  with  asepsis.  Another  very  frequent 
cause  of  suspended  animation  in  the  baby  is  the  use  of 
pituitrin  before  the  first  stage  of  labor  is  complete,  really 
it  is  a  dangerous  weapon  to  use  at  any  stage. 

Another  cause  is  the  giving  of  opiates  too  close  to  the 
time  of  deUvery.  Still  another  is  chloroform  or  ether  to  the 
surgical  degree  at  or  just  about  the  time  the  head  slips 
through.  It  has  been  suggested  that  we  saturate  the  mother 
at  this  stage  with  oxygen  but  this  is  quickly  eliminated  and 
too  it  is  not  practicable  to  have  oxygen  in  the  home.  First 
clear  the  mouth  and  nose  of  the  child,  slip  the  finger  up 
and  see  if  the  cord  is  wound  around  the  chUd's  neck,  if  so, 
and  if  it  can  be  lifted  over  the  occiput,  do  so  and  free  it 
of  all  tension.  If  this  can't  be  accomplished  and  you  can't 
stimulate  a  pain  quickly  by  passing  the  finger  up  and  into 
the  armpit,  clamp  the  cord  with  two  hemostats  and  cut 
between,  deliver  as  hurriedly  as  possible  by  making  traction 
on  the  armpits.  As  soon  as  the  baby  is  born  hold  it  up 
by  the  heels,  and  in  that  way  get  the  advantage  of  gravity 
to  clear  the  air  passages  of  mucus  and  other  secretions.   Rub 


Positive  and  Permanent  Identification  of  the  New 

Born 

(G.    P.   Pond,  Oak  Park,    in    III.    Med.   Jl.,   April) 

Infant  identification  footprints  are  inadequate.  A  tech- 
nique for  printing  newborn  infant  palms  has  been  perfect- 
ed and  an  entirely  new  classification  of  palm  prints  has 
been  devised  for  the  purpose  of  establishing  a  standard 
method  of  positive  and  permanent  identification  of  the 
newborn  infant  for  general  use. 

If  this  method  were  generally  adopted  it  would  provide 
incontrovertible  proof  of  birth  for  the  life  of  the  individual; 
it  would  protect  hospitals  and  parents  against  the  possible 
mixing  of  newborn  infants;  it  would  provide  a  means  of 
identifying  abandoned  children  and  foundlings  and  kidnaped 
children,  regardless  of  time,  either  dead  or  alive;  a  meam 
of  identifying  children  after  major  disasters  such  as  the 
San  Francisco  earthquake  or  Iriquois  Theatre  fire  where 
thousands  were  unidentifiable ;  it  would  disprove  false 
claims  of  parenthood  of  a  given  infant  and,  eventually,  it 
would  be  as  acceptable  in  courts  of  law  as  finger  prints  at 
the  present  time;  it  is  devoid  of  the  odium  popularly 
attached  to  fingerprints. 


GENERAL  PRACTICE 

Wingatz  M.  Johnson,  M.D.,  Editor,  Winston-Salem,  N.  C. 


A  Personal  Word 

If  I  did  not  appreciate  deeply  the  action  of  the 
State  Society  at  Asheville  in  selecting  me  as  its 
President-elect,  I  would  not  be  human.  I  will  not 
pretend  that  it  came  altogether  as  a  surprise,  for 
a  few  of  my  good  friends  had  intimated  that  my 
name  was  being  considered  for  the  place;  but  these 
same  friends  know  that  I  rather  shrank  from  the 
responsibility  that  goes  with  the  position.  The  fact 
that  it  came  absolutely  unsought  makes  me  appre- 
ciate the  honor  all  the  more.  It  also  makes  me 
feel  even  more  keenly  the  obligation  to  justify  the 
confidence  of  my  friends  in  the  society — and  I 
trust  that  this  includes  the  whole  society,  for  I  do 
covet  the  privilege  of  calling  every  member  my 
friend. 

It  is  a  wise  provision,  certainly,  that  gives  ons 
a  year  of  observation,  meditation  and  preparation 
before  he  assumes  the  task  of  leading  the  great 
profession  of  this  great  State.  I  hereby  pledge 
myself  to  give  my  best  effort  to  the  undertaking: 
but  I  can  not  do  it  without  help,  both  Divine  and 
human.  During  the  next  two  years — including  my 
year  of  preparation  as  well  as  of  action — I  want 
and  need  the  support  and  encouragement  of  all  the 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


doctors  of  North  Carolina.  The  messages  I  have 
had  from  numbers  of  friends  have  heartened  me 
mightily  already;  and  I  want  every  doctor  in  the 
State  to  feel  free  to  offer  suggestions,  advice,  and 
criticism  at  any  time  the  spirit  moves  him  to  do  so, 
with  the  assurance  that  he  will  be  given  full  con- 
sideration. 

The  a.  M.  A.  Meeting  in  Kansas  City 
The  87th  annual  meeting  of  the  American  Med- 
ical Association  was  held  in  Kansas  City  May 
11th  to  ISth.  It  was  my  privilege  and  responsi- 
bility, with  Dr.  M.  L.  Stevens  of  Asheville,  to 
represent  our  state  society  as  a  delegate.  Both  of 
us  were  present  at  every  meeting  of  the  House. 

There  were  many  unusual  features.  For  the 
first  time  in  its  history,  the  President-elect  was 
unable  to  be  present.  Dr.  J.  Tate  Mason,  of  Se- 
attle, was  considered  fatally  ill.  His  address  to 
the  House  of  Delegates  was  read  by  Dr.  Brian 
King,  his  personal  physician.  The  first  evidence 
of  electricity  in  the  atmosphere  was  when  the  Ju- 
dicial Council,  in  giving  its  report,  gave  it  as  its 
opinion  that  the  situation  in  regard  to  the  installa- 
tion of  President-elect  Mason  was  covered  by  Ar- 
ticle 6,  Section  2  of  the  Constitution  of  the  A.  M. 
A.  which  states  that  the  officers  of  the  association 
"shall  be  elected  annually  and,  except  the  Trustees, 
shall  serve  for  one  year  or  until  their  successors 
are  elected  and  installed"  and  Chapter  IV,  Section 
8  of  the  by-laws;  "The  President  shall  be  installed 
at  the  opening  general  meeting  of  the  Scientific  As- 
sembly of  the  annual  session  following  that  at  which 
he  was  elected.'  The  interpretation  given  by  the 
Judicial  Council  was  that  Dr.  McLester  should 
continue  in  office  for  another  year.  Although  the 
Council  is  considered  the  Supreme  Court 
of  the  A.  M.  A.,  this  decision  was  reversed  in 
short  order  by  the  House.  A  motion  was  made 
to  install  Dr.  Tate  Mason  in  absentia,  and  in  the 
rather  stormy  debate  which  followed  Dr.  Follans- 
bee  remarked  that  there  was  danger  of  installing 
a  corpse:  whereupon  a  motion  was  made  "to  install 
Tate  Mason  tonight  if  he  is  living."  Dr.  Flippin, 
of  Virginia,  very  pertinently  pointed  out  that  un- 
less this  were  done,  the  precedent  established  might 
debar  a  president-elect  disabled  by  an  acute  ton- 
stillitis  or  a  fractured  leg  from  assuming  office. 
When  the  motion  was  finally  put  to  a  vote,  it  went 
over  so  enthusiastically  that  not  even  the  members 
of  the  Judicial  Council  dared  vote  in  the  negative. 
.'Another  interesting  situation  developed  when 
two  Chicago  men  were  both  nominated  for  Presi- 
dent-elect— Dr.  Charles  E.  Humiston,  a  surgeon, 
and  Dr.  Isaac  Abt,  well  known  as  a  pediatrician. 
Other  nominees  were  Dr.  Eagleton,  of  New  Jersey, 


and  Dr.  J.  H.  J.  Upham  of  Ohio.  As  might  be 
expected,  the  Chicago  men  killed  each  other  off, 
and  Dr.  Upham  was  elected. 

The  election  of  vice-president  was  of  unusual 
imf>ortance,  since  it  was  generally  understood  that 
he  would,  in  all  probability,  have  to  act  as  Presi- 
dent during  the  coming  year.  Drs.  Abt  and  Humis- 
ton were  each  put  up  again,  and  the  name  of  Dr. 
Charles  Gordon  Heyd,  of  New  York,  added.  Dr. 
Abt's  name  was  withdrawn  at  his  request,  and  Dr. 
Heyd  was  then  elected  by  an  almost  two  to  one 
majority.  He  is  a  former  president  of  the  New 
York  State  Medical  Society,  is  Professor  of  Sur- 
gery in  the  New  York  Post  Graduate  Medical 
School,  and  has  the  reputation  of  being  a  forceful, 
dynamic  individual,  a  good  organizer  and  a  good 
speaker.  My  feeling  is  that  the  A.  M.  A.  will  be 
in  safe  hands  next  year. 

When  it  came  to  selecting  a  place  for  meeting 
next  year,  Philadelphia  and  Atlantic  City  had  each 
extended  invitations  and  were  voted  on — Atlantic 
City  winning  by  one  vote,  70  to  69.  Evidently  a 
few  delegates  had  trickled  out  of  the  room,  as  there 
were  163  votes  recorded  in  the  first  ballot  for  presi- 
dent-elect. Atlantic  City  boasts  the  record  attend- 
ance, in  the  1935  meeting — and  it  would  seem 
holds  somewhat  the  relation  to  our  national  asso- 
ciation that  Pinehurst  does  to  the  state  society. 

Two  resolutions  were  passed  in  the  House  which 
gave  North  Carolina  a  rather  unfavorable  place 
in  the  limelight.  One  was  to  make  an  effort  to 
tighten  up  the  vigilance  of  the  various  States  in 
the  matter  of  dealing  with  violators  of  the  Harrison 
narcotic  law;  the  other,  not  to  allow  any  physician 
to  be  a  member  of  the  A.  M.  A.  for  a  period  of  a 
year  after  he  had  been  convicted  of  a  felony  or 
served  a  term  in  prison.  Dr.  Woodward,  legal 
counsel  for  the  A.  M.  A.,  told  us  that  the  two 
most  flagrant  violations  of  the  Harrison  .'\ct  oc- 
curred in  another  State  the  name  of  which  I  forgot, 
and  in  North  Carolina.  In  the  North  Carolina 
case  the  offender  "in  a  period  of  a  little  more  than 
a  year  and  a  half,  had  purchased  16,000  >4-grain 
tablets  of  morphine  sulphate,  and  5500  >4 -grain 
tablets.  He  plead  guilty  to  indictments  in  seven 
counts.  There  were  several  sales  of  J^ -grain  tab- 
lets and  one  sale  of  32  ounces  of  paregoric  to  a 
person  who  had  no  medical  need  for  the  narcotics 
and  the  conversation  overheard  by  the  agent  indi- 
cated that  the  doctor  had  no  professional  interest 
in  the  patient."  This  quotation  is  from  a  letter 
written  Dr.  Woodward  by  H.  J.  Anslinger,  Com- 
missioner of  Narcotics,  and  shown  me  by  Dr. 
Woodward,  along  with  other  correspondence  re- 
garding this  case.  Dr.  Woodward  assured  us  that 
unless  the  States  themselves,  through  their  licensing 
boards,  took  more  initiative  in  dealing  with  flagrant 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


violators  of  the  law,  the  Federal  government  would 
save  them  the  trouble  by  greatly  tightening  up  its 
own  enforcement  machinery. 

It  was  a  pleasure  to  see  the  presiding  officer, 
Dr.  Nathan  B.  van  Etten,  of  New  York,  in  action. 
After  the  Cleveland  meeting,  I  remarked  that  Dr. 
Warnshuis,  who  was  for  years  the  Speaker  of  the 
House,  was  the  best  presiding  officer  I  ever  saw; 
but  Dr.  van  Etten  is  just  as  good,  if  not  a  shade 
better.  Strikingly  handsome,  dignified,  uniformly 
courteous  and  absolutely  impartial  in  his  rulings,  a 
perfect  master  of  parliamentary  practice,  he  never 
lost  his  poise  and  never  once  let  the  discussion  get 
out  of  control.  Incidentally,  it  is  generally  under- 
stood that  he  was  put  in  the  place  of  Dr.  Warnshuis 
last  year  because  the  latter  was  leaning  a  little 
too  much  to  the  side  of  socialized  medicine. 

Dr.  Olin  West,  for  many  years  the  Secretary  and 
General  Manager  of  the  A.  M.  A.,  is  another  ex- 
ceedingly popular  and  able  individual.  It  is  re- 
markable how  much  he  knows  of  medical  affairs 
over  the  whole  country.  When  the  formality  of  his 
re-election  was  over,  he  was  given  a  vote  of  confi- 
dence in  the  form  of  long-continued  and  hearty 
applause. 

Kansas  City  was  a  royal  host.  It  is  a  beautiful 
city,  and  the  weather  during  the  meeting  was  ideal, 
so  not  until  the  last  day  did  I  realize  that  I  had 
been  entirely  comfortable  during  the  whole  time. 
It  was  neither  hot  nor  cold,  damp  nor  dry,  windy 
nor  stifiingly  calm,  but  just  right.  The  local  com- 
mittee on  arrangements  had  arranged  an  enjoyable 
dinner  for  the  delegates  and  officers  of  the  asso- 
ciation on  Monday  night  and  the  same  sort  of 
luncheon  Tuesday.  The  auditorium  in  which  the 
meeting  was  held  providing  ample  room  for  exhib- 
its, both  commercial  and  scientific,  an  arena  large 
enough  for  the  general  sessions  and  smaller  rooms 
for  section  meetings. 

Since  Kansas  City  straddles  the  line  between 
Kansas  and  Missouri  the  opening  meeting  was  fea- 
tured by  seven  addresses  of  welcome,  beginning 
with  the  mayor,  and  including  the  presidents  of 
both  local  county  societies,  of  both  State  societies 
and  the  Governors  of  both  States.  Governor  Lan- 
don  was  given  a  real  ovation  and  made  a  good  im- 
pression. He  made  a  special  hit  with  the  ladies 
by  including  the  auxiliary  in  his  salutation,  after 
all  the  others  had  forgotten  it. 

The  address  of  Tate  Mason  was  read  by  Vice 
President  Kenneth  M.  Lynch,  of  Charleston,  who 
handled  a  delicate  situation  by  asking,  at  the  end 
of  the  address,  that  the  audience,  instead  of  ap- 
plauding, pay  Dr.  Mason  the  silent  tribute  of 
standing  for  a  moment.  Dr.  Mason's  address, 
"Modern  Trends  in  Surgery,"  will  be  found  in  the 
Journal  of  the  A.  M.  A.  for  May  16th. 


My  duties  as  delegate  and  member  of  the  refer- 
ence committees  interfered  with  attendance  on  the 
scientific  sessions,  and  this  paper  is  already  too 
long.  It  will  have  to  suffice  to  say  that  the  papers 
that  impressed  me  most,  of  those  I  heard,  were 
"The  Regression  and  Disappearance  of  the  Signs 
of  Rheumatic  Heart  Disease,"  read  by  T.  Duckett 
Jones;  the  Frank  Billings  lecture,  by  George  Blum- 
er,  on  "Pericarditis";  "Habitual  Hyperthermia,"  by 
H.  .\.  Reimann;  "The  Common  Cold,"  the  chair- 
man's address  in  the  section  on  medicine  by  William 
J.  Kerr;  "The  Clinical  Use  of  Diuretics,"  by  Jo- 
seph ]M.  Hayman;  "Clinical  Evaluation  of  Fever 
Therapy,"  by  Stafford  L.  Warren.  These  will  all 
appear  in  the  Journal  oj  the  A.  M.  A.,  and  I  advise 
you  all  to  look  out  for  them. 

The  long  trip  to  Kansas  City  was  made  pleasant 
by  the  delightful  companionship  of  fellow  physi- 
cians. Dr.  Charles  Lucas  boarded  the  train  at 
Charlotte  and  was  also  on  the  return  trip.  Inci- 
dsntally,  he  had  the  signal  honor  of  reading  a 
paper  on  "The  Calculation  of  the  Dosage  of  Ra,- 
dium  in  the  Treatment  of  Carcinoma  of  the  Cer- 
vix '  to  the  American  Radium  Society,  which  met 
just  preceding  the  A.  M.  A.  Among  new  friends 
made  on  the  train  were  Dr.  Kenneth  M.  Lynch,  of 
Charleston,  vice  president  of  the  A.  M.  A.;  Dr. 
J.  N.  Baker,  State  Health  Officer  of  Alabama  and 
President  of  the  National  .Association  of  Licensing 
Boards;  Dr.  M.  Y.  Dabney,  of  Birmingham,  Edi- 
tor of  the  Southern  Medical  Journal,  and  his  charm- 
ing wife,  who  is  the  .Associate  Editor  and,  he  con- 
tided,  the  real  power  behind  the  throne. 


Where  the  Fieid  of  the  Oculist  Meets  Th.-\t  of  the 
Practitionee 

(B.    F.   Hodson,   Miami,   in  Jl.   Fla.    Med.   Assn.,   April) 

The  family  physician  could  make  use  of  the  electric 
ophthalmoscope  in  his  daily  practice  and  become  as  fa- 
miliar with  its  use  as  with  the  stethoscore.  He  may  thus 
combat  that  feeling  which  prompts  him  to  shrink  from 
all  cases  of  injury  or  diseases  of  the  eye,  and  not  neglect 
the  opportunities  for  making  an  early  diagnosis  when 
immediate  treatment  is  essential  to  prompt  recovery. 

Usually  the  thing  that  calls  the  family  doctor  into  the 
so-called  field  of  the  oculist  is  an  injury  to  the  eye.  His 
first  guide  is  the  patient's  vision.  If  the  vision  appears  to 
be  normal,  the  pupils  active  and  equal  in  size,  there  is 
little  to  be  feared;  but  nevertheless  an  examination  should 
be  made  w'ith  the  ophthalmoscope  and  the  usage  of  an 
electric  ophthalmoscope  is  so  simple  that  any  doctor  can 
easily  master  it. 

What  a  patient  terms  a  "sore  eye"  may  or  may  not 
prove  to  be  iritis.  The  doctor  may  hesitate  to  give  atro- 
pine. He  may  not  be  sure  it  is  iritis  and  suspect  glaucoma. 
If  that  family  doctor  had  mastered  the  technique  of  the 
luminous  ophthalmoscope,  he  would  have  gained  confidence 
in  himself  and  have  favorably  impressed  the  patient  as 
well.  By  its  use,  he  wUl  so  increase  his  knowledge  about 
conditions  of  the  eye  that  the  oculist's  office  will  not  be 
filled,  as  at  present,  with  many  simple  cases.  The  case 
that  is  promptly  and  properly  diagnosed  has  every  advan- 
tage. 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


331 


Acute  glaucoma  is  a  condition  frequently  overlooked  in 
general  practice.  There  may  be  unilateral  pain  in  the 
head  and  behind  the  eye.  .\  similar  pain  may  be  present 
in  iritis  but  the  presence  of  a  large  fixed  pupil,  the  cloudy 
cornea,  poor  vision,  stone-like  feeling  of  the  globe  and 
the  shallow  anterior  chamber  should  make  a  diagnosis, 
with  aid  of  reflected  light  and  ophthalmoscope,  a  simple 
one.  Again,  the  family  doctor  is  called  to  remove  foreign 
bodies  from  the  cornea  which  may  be  easily  overlooked. 
The  patient  may  insist  there  is  still  some  trash  in  the  eye, 
so  it  is  necessar\-  to  make  a  careful  examination  with  a 
focal  light  ophthalmoscope  and  with  2%  fluorescein  or 
1%  mercurochrome,  in  order  to  be  sure  that  no  abrasian 
of  the  cornea  or  minute  ulcer  be  overlooked. 

Owing  to  the  carelessness  of  some  patients,  it  may  be 
dangerous  to  prescribe  eye  drops  for  use  at  home. 

The  family  doctor  can  know  many  of  the  essentials  of 
the  eye  and  the  patient  has  a  perfect  right  to  expect  him 
to  know  these  essentials  well  enough  to  be  able  to  judge 
whether  his  trouble  is  serious  and  whether  an  oculist 
should  be  consulted.  Such  service  may  cost  oculists  some 
practice  but  it  is,  nevertheless,  a  service  that  the  patient 
has  a  right  to  expect  from  his  true  friend,  his  family 
doctor. 

I  know  of  no  better  way  for  the  doctors  in  small  towns 
to  hold  their  clientele  with  railroad  connections  than  the 
adoption  of  the  practice,  when  making  routine  or  general 
examinations,  of  examining  the  eyes  with  an  electric  oph- 
thalmoscope and  thus  becoming  as  familiar  with  its  use 
as  is  a  neurologist  who  depends  a  great  deal  on  ophthal- 
moscopic examination  in  diagnosis. 


The  General  Practitioner  in  the  Tre.a.tment  and 
Prevention  of  Tuberculosis 

(F.    M.    Pottenger,  Monrovia,   Calif.,   in   Dis.   of  the   Chest, 
April) 

The  medical  man  who  first  sees  the  tuberculous  patient 
can  advise  him  how  to  conduct  himself  so  as  to  minimize 
the  danger  of  further  spread  of  the  disease  and  of  its  fur- 
ther breaking  down. 

The  death  of  the  tuberculous  patient  4  or  5  years  after 
the  disease  has  been  discovered  is  no  less  the  result  of  a 
failure  to  properly  advise  than  the  death  in  appendicitis 
which  takes  place  a  few  days  after  improper  advice  is 
given. 

Active  tuberculosis  calls  for  immediate  rest  and  the  estab- 
lishment of  a  properly  devised  hygienic  and  physiologic 
regimen  just  as  much  as  appendicitis  calls  for  surgery. 
What  further  will  be  needed  is  not  so  urgent. 

The  general  physician  must  know  the  principles  of 
treatment  and  see  that  they  are  applied  at  once  on  a  diag- 
nosis of  active  tuberculosis  having  been  made.  Bed  rest 
should  be  ordered  until  it  is  definitely  determined  how 
and  by  whom  the  patient  is  to  be  treated.  If  the  physi- 
cian is  able  and  sufficiently  interested  to  carry  out  the 
treatment  himself,  the  permanent  regimen  should  be  estab- 
lished at  once.  If  not,  the  patient  should  be  quickly  re- 
ferred. If  the  physician  does  not  have  confidence  in  his 
own  ability  to  handle  the  acute  phases  of  the  disease,  he 
could  advantageously  send  his  patient  to  some  well  con- 
ducted sanatorium  for  education  and  treatment  until  this 
phase  has  passed.  This  education  phase  of  sanatorium 
treatment  has  not  been  sufficiently  emphasized. 

The  general  physician  who  has  confidence  in  his  ability 
to  render  service  to  the  tuberculous  patient,  diagnose  the 
disease  and  establish  and  decide  the  nature  of  the  treat- 
ment, can  render  another  great  ser\'ice  by  examining  those 
who  have  come  intimately  in  contact  with  open  cases;  a 
tuberculin  test  is  nothing  that  any  graduate  in  medicine 
can  not  do  after  a  few  moments  of  instruction. 


In  case  any  one  who  has  come  in  contact  with  an  open 
case  reacts  to  tuberculin,  an  x-ray  examination  should  be 
taken  to  see  if  the  pulmonary  tissue  is  involved.  If  the 
picture  shows  the  infection  to  be  confined  to  the  primary 
focus  and  regional  glands,  and  if  no  evidence  of  activity 
is  present,  no  treatment  need  be  instituted.  However, 
reactors  should  be  re-examined  at  intervals  of  from  3  to  6 
months,  and  at  any  time  should  there  be  any  evidence  of 
interruption  of  the  normal  well-being. 

The  physician  should  be  careful  to  explain  that  while 
reaction  means  infection,  it  does  not  mean  disease.  The 
test  is  protective,  particularly  in  children,  in  that  it  puts 
the  family  physician  in  possession  of  the  knowledge  of 
the  fact  of  infection  and  permits  him  to  guide  the  child 
during  the  period  of  development. 

This  is  the  type  of  service  that  general  physicians  can 
take  the  responsibiUty  of  rendering  if  only  they  will.  This 
is  the  type  of  service  that  will  insure  a  continuation  of 
the  dechne  in  the  death  rate  of  tuberculosis,  and  a  merited 
confidence  in  medicine  on  the  part  of  the  public. 


Itemized  Bills 
(G.   B.   L.,  in  Clin.   Med.  &.  Surg.,  April) 

If  medical  men  desire  and  expect  to  keep  their  financial 
affairs  in  reasonably  good  shape,  and  to  have  a  satisfactory 
balance  at  the  bank,  they  will  do  well  to  adopt  certain 
recognized  business  practices,  important  among  which  is 
the  regular  sending  of  monthly  itemized  mills. 

Make  an  accurate  record  of  all  services  rendered  at  the 
time  they  are  rendered.  This  record  should  show  the  date 
(and  perhaps  the  hour),  the  nature  of  the  service,  and  the 
exact  person  to  whom  it  was  given,  as  well  as  the  amount 
of  the  fee  for  such  service. 

The  recipient  of  such  an  itemized  bill  will  not  have 
heart  failure  nor  get  the  idea  he  is  being  gouged,  especially 
if  he  receives  one  every  month,  while  the  services  received 
are  still  fresh  in  his  memory. 


THERAPEUTICS 

Frederick  R.  Taylor,  B.S.,  M.D.,  F.A.C.P.,  Editor 
High  Point,  N.  C. 


A  Dialog  With  the  Gout* 

Dated  at  midnight.   22  October.  1780. 
By  BENJAMIN  FRANKLIN 

Franklin.  Eh!  Oh!  Eh!  What  have  I  done  to 
merit  these  cruel  sufferings? 

Gout.  Many  things;  you  have  ate  and  drank 
too  freely,  and  too  much  indulged  those  legs  of 
yours  in  their  indolence. 

Franklin.    Who  is  it  that  accuses  me? 

Gout.    It  is  I,  even  I,  the  Gout. 

Franklin.     What!   my  enemy  in  pjerson? 

Gout.    No,  not  your  enemy. 

Franklin.  I  repeat  it;  my  enemy;  for  you  would 
not  only  torment  my  body  to  death,  but  ruin  my 
good  name;  you  reproach  me  as  a  glutton  and  a 
tippler;  now  all  the  world  that  knows  me  will  allow 
that  I  am  neither  the  one  nor  the  other. 

Gout.  The  world  may  think  as  it  pleases;  it  is 
always  very  complaisant  to  itself,  and  sometimes 
to  its  friends;  but  I  very  well  know  that  the  quan- 
tity of  meat  and  drink  proper  for  a  man  who  takes 


•From    The    Best    of    the    World's    Classics,    edited    by 
Henry  Cabot  Lodge,  Funk  &  Wagnalls  Co.,  1909. 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


a  reasonable  degree  of  exercise,  would  be  too  much 
for  another,  who  never  takes  any. 

Franklin.  I  take — Eh!  Oh! — as  much  exercise — 
Eh! — as  I  can,  Madam  Gout.  You  know  my  sed- 
entary state,  and  on  that  account,  it  would  seem, 
Madam  Gout,  as  if  you  might  spare  me  a  little, 
seeing  it  is  not  altogether  my  own  fault. 

Gout.  Not  a  jot;  your  rhetoric  and  your  polite- 
ness are  thrown  away;  your  apology  avails  nothing. 
If  your  situation  in  life  is  a  sedentary  one,  your 
amusements,  your  recreations,  at  least  ,should  be 
active.  You  ought  to  walk  or  ride;  or,  if  the 
weather  prevents  that,  play  at  billiards.  But  let  us 
examine  your  course  of  life.  While  the  mornings 
are  long,  and  you  have  leisure  to  go  abroad,  what 
do  you  do?  Why,  instead  of  gaining  an  appetite 
for  breakfast,  by  salutary  exercise,  you  amuse  your- 
self with  books,  pamphlets,  or  newspapers,  which 
commonly  are  not  worth  the  reading.  Yet  you  eat 
an  inordinate  breakfast,  four  dishes  of  tea,  with 
cream,  and  one  or  two  buttered  toasts,  with  slices 
of  hung  beef,  which  I  fancy  are  not  things  the 
most  easily  digested.  Immediately  afterward  you 
sit  down  to  write  at  your  desk,  or  converse  with 
persons  who  apply  to  you  on  business.  Thus  the 
time  passes  till  one,  without  any  kind  of  bodily  ex- 
ercise. 

But  all  this  I  could  pardon,  in  regard,  as  you 
say,  to  your  sedentary  condition.  But  what  is 
your  practice  after  dinner?  Walking  in  the  beau- 
tiful gardens  of  those  friends  with  whom  you  have 
dined  would  be  the  choice  of  men  of  sense;  yours 
is  to  be  fixt  down  to  chess,  where  you  are  found 
engaged  for  two  or  three  hours!  This  is  your  per- 
petual recreation,  which  is  the  least  eligible  of  any 
for  a  sedentary  man,  because,  instead  of  accelerat- 
ing the  motion  of  the  fluids,  the  rigid  attention  it 
requires  helps  to  retard  the  circulation  and  ob- 
struct internal  secretions.  Wrapt  in  the  specula- 
tions of  this  wretched  game,  you  destroy  your  con- 
stitution. What  can  be  expected  from  such  a  course 
of  living  but  a  body  replete  with  stagnant  humors, 
ready  to  fall  a  prey  to  all  kinds  of  dangerous  mala- 
dies, if  I,  the  Gout,  did  not  occasionaly  bring  you 
relief  by  agitating  these  humors,  and  so  purifying 
or  dissipating  them?  If  it  was  in  some  nook  or 
alley  in  Paris,  deprived  of  walks,  that  you  played 
awhile  at  chess  after  dinner,  this  might  be  excus- 
able; but  the  same  taste  prevails  with  you  in  Passy, 
Auteuil,  Montmartre,  or  Savoy,  places  where  there 
are  the  finest  gardens  and  walks,  a  pure  air,  beau- 
tiful women,  and  most  agreeable  and  instructive 
conversation;  all  which  you  might  enjoy  by  fre- 
quenting the  walks.  But  these  are  rejected  for  this 
abominable  game  of  chess.  Fie,  then,  Mr.  Frank- 
lin!     But  amidst   my   instructions,   I   had   almost 


forgotten  to  administer  my  wholesome  corrections; 
so  take  that  twinge — and  that. 

Franklin.  Oh!  Eh!  Oh!  Ohhh!  As  much  in- 
struction as  you  please,  Madam  Gout,  and  as 
many  reproaches;  but  pray.  Madam,  a  truce  with 
your  corrections! 

Gout.  No,  sir,  no — I  will  not  abate  a  particle  of 
what  is  so  much  for  your  good — therefore — 

Franklin.  Oh!  Ehhh!  It  is  not  fair  to  say  I 
take  no  exercise,  when  I  do  very  often,  going  out  to 
dine  and  returning  in  my  carriage. 

Gout.  That,  of  all  imaginable  exercises,  is  the 
most  slight  and  insignificant,  if  you  allude  to  the 
motion  of  a  carriage  suspended  on  springs.  By  ob- 
serving the  degree  of  heat  obtained  by  different 
kinds  of  motion  we  may  form  an  estimate  of  the 
quantity  of  exercise  given  by  each.  Thus,  for  ex- 
ample, if  you  turn  out  to  walk  in  winter  with  cold 
feet,  in  an  hour's  time  you  will  be  in  a  glow  all 
over;  ride  on  horseback,  the  same  effect  will  scarce- 
ly be  perceived  by  four  hours'  round  trotting;  but 
if  you  loll  in  a  carriage,  such  as  you  have  mer^- 
tioned,  you  may  travel  all  day,  and  gladly  enter  the 
last  inn  to  warm  your  feet  by  a  fire.  Flatter  your- 
self no  longer,  then,  that  half  an  hour's  airing  in 
your  carriage  deserves  the  name  of  exercise.  Provi- 
dence has  appointed  a  few  to  roll  in  carriages,  while 
he  has  given  to  all  a  pair  of  legs,  which  are  ma- 
chines infinitely  more  commodious  and  serviceable. 
Be  grateful,  then  ,and  make  a  proper  use  of  yours. 
Would  you  know  how  they  forward  the  circulation 
of  your  fluids,  in  the  very  action  of  transporting 
you  from  place  to  place;  observe  when  you  walk 
that  all  your  weight  is  alternately  thrown  from  one 
leg  to  the  other;  this  occasions  a  great  pressure  on 
the  vessels  of  the  foot,  and  repels  their  contents; 
when  relieved,  by  the  weight  being  thrown  on  the 
other  foot,  the  vessels  of  the  first  are  allowed  to 
replenish,  and,  by  a  return  of  this  weight,  this  re- 
pulsion again  succeeds,  thus  accelerating  the  cir- 
culation of  the  blood.  The  heat  produced  in  any 
given  time  depends  on  the  degree  of  this  accelera- 
tion; the  fluids  are  shaken,  the  humors  attenuated, 
the  secretions  facilitated,  and  all  goes  well;  the 
cheeks  are  ruddy,  and  health  is  established.  Be- 
hold your  fair  friend  at  Auteuil*;  a  lady  who  re- 
ceived from  bounteous  nature  more  really  useful 
science  than  half  af  a  dozen  of  such  pretenders  to 
philosophy  as  you  have  been  able  to  extract  from 
all  your  books.  When  she  honors  you  with  a  visit, 
it  is  on  foot.  She  walks  all  hours  of  the  day,  and 
leaves  indolence,  and  its  concomitant  maladies,  to 
be  endured  by  her  horses.  In  this  see  at  once  the 
preservative  of  her  health  and  personal  charms. 
But  when  you  go  to  Auteuil,  you  must  have  your 


•Madame   Helvetius.    a   widow    to    whom   Franklin    pro- 
posed marriage. 


June.  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


carriage,  though  it  is  no  farther  from  Passy  to 
Auteuil  than  from  Auteuil  to  Passy. 

Gout.  I  stand  corrected.  I  will  be  silent  and 
continue  my  office;  take  that,  and  that. 

Franklin.    Ohl  Ohh!  Talk  on,  I  pray  you. 

Goiif.  No,  no:  I  have  a  good  number  of  twinges 
for  you  tonight,  and  you  may  be  sure  of  some  more 
tomorrow. 

Franklin.  What,  with  such  a  fever!  I  shall  go 
distracted.     Ohl   Eh  I   Can  no  one  bear  it  for  me? 

Gout.  Ask  that  of  your  horses;  they  have  served 
you  faithfully. 

Franklin.  How  can  you  so  cruelly  sport  with 
my  torments? 

Gout.  Sport!  I  am  very  serious.  I  have  here 
a  list  of  offenses  against  your  own  health  distinctly 
written,  and  can  justify  every  stroke  inflicted  on 
you. 

Franklin.     Read  it,  then. 

Gout.  It  is  too  long  a  detail;  but  I  will  briefly 
mention  some  particulars. 

Franklin.    Proceed.    I  am  all  attention. 

Gout.  Do  you  remember  how  often  you  have 
promised  yourself,  the  following  morning,  a  walk 
in  the  grove  of  Boulogne,  in  the  garden  de  la 
Muette,  or  in  your  own  garden,  and  have  violated 
your  promise,  alleging  at  one  time  it  was  too  cold, 
at  another  too  warm,  too  windy,  too  moist,  or  what 
else  you  pleased;  when  in  truth  it  was  too  nothing 
but  your  insuperable  love  of  ease? 

Franklin.  That  I  confess  may  have  hapfjened 
occasionally,  probably  ten  times  in  a  year. 

Gout.  Your  confession  is  very  far  short  of  the 
truth;  the  gross  amount  is  one  hundred  and  ninety- 
nine  times. 

Franklin.     Is  it  possible? 

Gout.  So  possible  that  it  is  a  fact;  you  may 
rely  on  the  accuracy  of  my  statement.  You  know 
Mr.  Brillon's  gardens,  and  what  fine  walks  they 
contain;  you  know  the  handsome  flight  of  a  hun- 
dred steps,  which  lead  from  the  terrace  above  to 
the  lawn  below.  You  have  been  in  the  practice  of 
visiting  this  amiable  family  twice  a  week,  after 
dinner,  and  it  is  a  maxim  of  your  own,  that  "a 
man  may  take  as  much  exercise  in  walking  a  mile 
up-  and  down-stairs  as  in  ten  on  level  ground." 
What  an  opportunity  was  here  for  you  to  have  had 
exercise  in  both  these  ways!  Did  you  embrace  it, 
and  how  often? 

Franklin.  I  cannot  immediately  answer  that 
question. 

Gout.    I  will  do  it  for  you;  not  once. 

Franklin.    Not  once? 

Gout.  Even  so.  During  the  summer  you  went 
there  at  six  o'clock.  You  found  the  charming  lady, 
with  her  lovely  children  and  friends,  eager  to  walk 
with  you,  and  entertain  you  with  their  agreeable 


conversation;  and  what  has  been  your  choice? 
Why,  to  sit  on  the  terrace,  satisfying  yourself  with 
the  fine  prospect,  and  passing  your  eye  over  the 
beauties  of  the  garden  below,  without  taking  one 
step  to  descend  and  walk  about  in  them. 

On  the  contrary,  dear  sir,  you  call  for  tea  and 
the  chess-board;  and  lo!  you  are  occupied  in  your 
seat  till  nine  o'clock,  and  that  besides  two  hours' 
play  after  dinner;  and  then,  instead  of  walking 
home,  which  would  have  bestirred  you  a  little,  you 
step  into  your  carriage.  How  absurd  to  suppos; 
that  all  this  carelessness  can  be  reconcilable  with 
health,  without  my  interposition! 

Franklin.  I  am  convinced  now  of  the  justness 
of  Poor  Richard's  remark  that  "Our  debts  and 
our  sins  are  always  greater  than  we  think  for." 

Gout.  So  it  is.  You  philosophers  are  sages  in 
your  maxims,  and  fools  in  your  conduct. 

Franklin.  But  do  you  charge,  among  my  crimes, 
that  I  return  in  a  carriage  from  Mr.  Brillon's? 

Gout.  Certainly;  for  having  been  seated  all  the 
while,  you  can  not  object  the  fatigue  of  the  day, 
and  can  not  want,  therefore,  the  relief  of  a  car- 
riage. 

Franklin.  What,  then,  would  you  have  me  do 
with  my  carriage? 

Gout.  Burn  it,  if  you  choose;  you  would  at 
least  get  heat  out  of  it  once  in  this  way,  or,  if  you 
dislike  that  proposal,  here's  another  for  you;  ob- 
serve the  poor  peasants,  who  work  in  the  vineyards 
and  grounds  about  the  villages  of  Passy,  Auteuil, 
Chaillot,  etc.;  you  may  find  every  day,  among  these 
deserving  creatures,  four  or  five  old  men  and  wo- 
men, bent  and  perhaps  crippled  by  weight  of  years 
and  too  long  and  too  great  labor.  After  a  most 
fatiguing  day,  these  people  have  to  trudge  a  mile  or 
two  to  their  smoky  huts.  Order  your  coachman 
to  set  them  down.  This  is  an  act  that  will  be  good 
for  your  soul;  and,  at  the  same  time,  after  your 
visit  to  the  Brillons,  if  you  return  on  foot,  that  will 
be  good  for  your  body. 

Franklin.     Ah!   How  tiresome  you  are! 

Gout.  Well,  then,  to  my  office;  it  should  not  be 
forgotten  that  I  am  your  physician.     There. 

Franklin.    Ohhhl  what  a  devil  of  a  physician! 

Gout.  How  ungrateful  you  are  to  say  so!  Is  it 
not  I,  who,  in  the  character  of  your  physician,  have 
saved  you  from  the  palsy,  dropsy  and  apoplexy?, 
one  or  other  of  which  would  have  done  for  you  long 
ago  but  for  me. 

Franklin.  I  submit,  and  thank  you  for  the  past, 
but  entreat  the  discontinuance  of  your  visits  for 
the  future;  for,  in  my  mind,  one  had  better  die 
than  be  cured  so  dolefully.  Permit  me  just  to 
hint  that  I  have  also  not  been  unfriendly  to  you. 
I  never  feed  physician  or  quack  of  any  kind,  to 
enter  the  list  against  you;  if,  then,  you  do  not  leave 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


me  to  my  repose,  it  may  be  said  you  are  ungrateful, 
too. 

Gout.  I  can  scarcely  acknowledge  that  as  any 
objection.  As  to  quacks,  I  despise  them;  they  may 
kill  you,  indeed,  but  can  not  injure  me.  And  as  to 
regular  physicians,  they  are  at  last  convinced  that 
the  gout,  in  such  a  subject  as  you  are,  is  no  disease, 
but  a  remedy;  and  wherefore  cure  a  remedy? — but 
to  our  business — there. 

Franklin.  Oh!  Oh!  for  Heavens  sake  leave  me; 
and  I  promise  you  faithfully  never  more  to  play  at 
chess,  but  to  take  exercise  daily  and  to  live  temper- 
ately. 

Gout.  I  know  you  too  well.  You  promise  fair; 
after  a  few  months  of  good  health  you  will  return 
to  your  old  habits;  your  fine  promises  will  be  for- 
gotten like  the  forms  of  the  last  year's  clouds.  Let 
us  then  finish  the  account,  and  I  will  go.  But  leave 
you  with  an  assurance  of  visiting  you  again  at  a 
proper  time  and  place;  for  my  object  is  your  good, 
and  you  are  sensible  now  that  I  am  your  real 
friend. 


Edema  of  Obscure  Origin  and   General  Treatment 

(L.   M.  Warfield,  Milwaukee,   in  Wise.    Med.  Jl.,  Feb.) 

The  simplest  form  is  that  due  to  congestive  heart  failure, 
the  result  of  increased  venous  pressure  where  absorp- 
tion can  not  take  place  by  the  venules.  A  daily  ration  of 
one  liter  whole  milk,  15  to  20  gms.  unsalted  butter,  60  to 
80  gms.  unsalted  crackers  or  bread  is  a  good  start. 

Bed  rest,  digitalis  or  digitalis-like  preparations,  venesec- 
tion if  necessary,  salt-free  limited  water  diet  as  above,  a 
mercurial  diuretic  (salyrgan)  if  the  kidneys  are  function- 
ally adequate  alternating  with  some  theophylline  prepara- 
tion. At  times  large  daily  doses  (60  grains)  of  ammonium 
chloride  or  amonium  nitrate  with  salyrgan  reduces  the 
€dema._  Undernutrition — iron  should  be  given  in  large 
doses. 

The  edema  of  chronic  nephritis  should  not  be  treated 
with  a  low-protein  diet.  Vegetable  protein  is  not  as  effi- 
cacious as  animal  protein.  Restriction  of  sodium  chloride 
is  important.  The  flatness  of  the  salt-free  diet  may  be 
mitigated  by  potassium  or  ammonium  chloride.  It  is  gen- 
erally believed  that  the  mercur\--containing  diuretics  should 
not  be  used  in  cases  of  damaged  kidney.  The  use  of  the 
theophylline  group  appears  to  be  logical.  Purging  and 
sweating  are  no  longer  practiced. 

Treatment  of  the  nutritional  edemas  consists  in  an  ade- 
quate protein  ration,  not  less  than  1  gm.  of  protein  per 
kilo  of  body  weight  and  should  consist  in  great  part  of 
animal  protein. 

For  the  edemas  of  obscure  origin  when  the  plasma  albu- 
min is  not  decreased,  salt-restriction  and  diuretics  intra- 
venously and  by  mouth  may  help  to  keep  down  the 
edema. 


Some  Problems  in  Treating  the  Aged 


We  must  not  take  too  much  for  granted  in  treating  the 
aged.  They  will  tell  you  that  they  eat  everything  they 
should,  that  they  bathe  regularly,  that  they  have  a  daily 
bowel  movement.  Their  minds  are  quite  apt  to  think 
along  lines  of  things  that  they  want  to  believe. 

It  is  surprising   how  many  cases  of  hypothyroidism  will 


be  found  in  old  age.  .A  high  blood  cholesterol  and  sensi- 
tiveness to  cold  suggest  a  thyroid  deficiency. 

In  administering  thyroid  extract  in  old  age,  we  may 
precipitate  coronary  thrombosis.  If  there  is  the  slightest 
oppression  in  the  chest,  the  dose  should  be  diminished 
immediately. 

We  are  inclined  to  be  pessimistic  in  dealing  with  patients 
of  advanced  years. 

There  are  many  old  women  to  whom  life  has  become  a 
nightmare  because  of  cholecystitis,  prolapsus  uteri  or  cys- 
tocele.  It  would  be  better  to  correct  those  abnormalities 
at  the  age  of  50  or  60,  but  there  is  no  reason  why  persons 
past  70  or  SO  should  not  be  given  a  chance  to  live  a  little 
longer  and  comfortably.  It  is  amazing  to  see  a  man  of 
S5  undergo  an  operation  for  peptic  ulcer,  rally  and  go  on 
to  recovery. 

The  aged  patient  should  be  out  of  bed  soon  after  oper- 
ation, if  his  condition  warrants  it.  Some  surgeons  get 
their  old  patients  out  of  bed  on  the  2nd  or  3rd  day  and 
home  on  the  7th  following  appendectomy. 

Two  of  the  most  important  considerations  in  the  treat- 
ment of  the  aged  are  to  keep  the  intestines  active  and  to 
l:eep  patients  out  of  bed  when  ill. 


Newer  Concepts  in  the  Treatment  of  Furunculosis 
(Duval   Prey  &  J.   M.  Foster,  Denver,   in  Col.   Med.,  May) 

The  value  of  prophylaxis  against  furunculosis  has  been 
so  highly  appreciated  by  the  French  government  that  the 
military  surgeons  ordered  the  flaming  of  the  buttocks  of 
their  cavalrymen. 

That  furunculosis  may  be  associated  with  high  blood 
sugar  is  common  knowledge,  .•^s  long  as  furunculosis 
causes  more  fatalities  than  any  other  skin  disease,  the 
common  boil  must  be  treated  with  respect. 

During  the  past  year  we  have  discarded  all  other  meth- 
ods of  therapy,  because  of  excellent  results  obtained  by 
the  intravenous  injection  of  colloidal  animal  charcoal. 

In  almost  1,000  injections  both  of  our  own  and  those 
reported  in  the  literature  there  has  not  been  a  single  in- 
stance of  an  alarming  reaction  following  the  intravenous 
injection  of  colloidal  animal  charcoal. 

The  immediate  improvement  is  astonishing. 

The  preparation  we  have  used  comes  in  3-  and  S-c.c. 
ampules.  In  the  milder  infections  we  have  found  the  dos- 
age of  3  c.c.  to  have  been  ample.  The  injection  may  be 
repeated  in  42  hours,  with  perfect  safety.  A  lubricant  is 
necessary  to  prevent  the  sticking  of  the  syringe ;  a  small 
amount  of  vaseline  in  the  water  of  the  sterilizer  while 
boiling  the  syringe  and  the  needle  suffices. 

A  well-developed  boil  which  is  causing  extreme  discom- 
fort should  have,  in  conjunction  with  the  charcoal  treat- 
ment, the  local  application  of  contractile  colloidion  applied 
by  means  of  a  saturated  swab  around  and  on  the  boil, 
leaving  a  small  opening  where  the  boils  seem  to  be  point- 
ing. The  collodion  should  be  applied  thickly  and  should 
extend  well  beyond  the  edge  of  the  furuncle. 


A  New  Treatment  for  Enuresis  in  the  Male 
(L.  H.  Baretz,  Brooklyn,  in  Urol.  &  Cuta.   Rev.,  May) 
In  about   90%   of  cases  of   enuresis  the  incontinence  is 
nocturnal,  and  where  there  is  no  etiological  organic  path- 
ology, the  treatment  consists  in  the  application  of  a  penis 
clamp. 

The  writer  has  used  the  clamp  of  the  Zipser  type,  the 
jaws  of  which  have  been  encased  in  rubber.  This  may 
be  adjusted  at  will,  and  when  properly  applied,  will  not 
interfere  with  circulation.  The  patient  applies  the  clamp 
just  beyond  the  corona,  before  retiring.  Should  the  desire 
to  void  occur  during  the  night,  he  removes  the  clamp, 
and   empties   the   bladder.     The   clamp   is   then    reapplied. 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


The  procedure  is  continued  for  several  days. 

The  immediate  effect  is  the  marked  psychic  improve- 
ment— the  great  joy  of  awakening  in  a  dry  bed.  In  about 
a  week,  the  patient  should  not  awaken,  and  the  clamp 
remains  in  situ  throughout  the  night.  Then  a  test  is  made 
of  retiring  witnout  the  clamp  and,  frequently,  much  to 
the  patient's  delight,  he  will  find  that  enuresis  no  longer 
exists. 

In  case  of  failure,  the  method,  as  outlined,  should  be 
repeated. 

The  results  obtained  in  the  several  cases  have  been  sc 
gratifying  as  to  warrant  the  publication  of  this  pre'.iminan,' 
report. 


SURGERY 

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


Impaired  Liver  Function  as  a  Cause  of  Death 
After  Gallbladder  Surgery 

W.  J.  Mayo  once  wrote  a  paper  on  Gallstones 
Without  Symptoms  and  Symptoms  Without  Gall- 
stones. It  is  well  recognized  that  gallbladder  dis- 
ease may  be  comparatively  latent  and  may  not  be 
manifested  by  definite  symptoms.  This  is  proved 
by  the  high  incidence  of  gallstones  found  at  autopsy 
in  women  after  the  age  of  40  in  whom  the  condition 
had  not  been  suspected  during  life.  It  is  also 
proved  by  the  frequent  recognition  of  unsuspected 
stones  in  women  of  middle  life  when  they  are  be- 
ing operated  upon  for  pelvic  disease.  We  believe 
that  25%  of  women,  fat  and  40,  as  we  meet  them 
in  the  street  and  in  active  life,  have  gallbladder 
disease.  The  fact  should  be  stressed  that  its  in- 
sidiousness  is  but  a  cloak  that  hides  the  progressive 
liver  deterioration  that  is  slowly  but  surely  resulting 
from  biliary  stasis  and  infection. 

The  liver  plays  a  varied  and  an  important  role 
in  the  biochemistry  of  the  body.  Besides  secreting 
and  excreting  bile  it  is  actively  concerned  in  both 
carbohydrate  and  protein  metabolism,  in  making 
fibrinogen  on  which  the  power  of  the  blood  to  clot 
depends,  and  finally  in  exerting  a  deto.xifying  effect. 
Because  of  these  multiple  functions  physiologists 
and  laboratory  workers  have  been  unable  to  find 
an  adequate  test  for  the  liver  comparable  to  the 
pthalein  test  for  the  kidney.  If  such  a  test  were 
available  major  surgery  would  be  contraindicated 
in  badly  impaired  livers  and  the  so-called  liver  death 
prevented. 

Clinicians  generally  have  known  for  a  number 
of  years  that  although  most  deaths  after  gall- 
bladder surgery  are  from  hemorrhage,  shock,  infec- 
tion, embolism,  and  the  ordinary  causes,  there  is  a 
definite  group  in  every  large  series  that  is  charac- 
terized by  early  and  constantly  increasing  high 
fever,  anuria  more  or  less  complete,  weak  pulse, 
falling  blood  pressure,  coma  and  death.  When  the 
detoxifying  function  of  the  liver  is  lost  or  impaired 
this  protective  work   is  delegated   to  the  kidneys. 


and  in  time  they  undergo  degenerative  change  from 
this  cause.  After  operation  the  patients  have  a 
liver-kidney  shock  which  terminates  in  uremia. 

A  stout  white  woman,  56  years  old,  while  cooking 
a  meal  was  taken  with  abdominal  pain,  nausea  and 
vomiting.  On  admission  into  the  hospital  two  days 
later  she  was  tender  over  the  upper  abdomen  and 
there  was  some  rigidity  on  the  right  side,  moderate 
distention  and  evident  jaundice.  The  temperature 
was  102;  the  leucocytes  were  15,000  with  90% 
polys.,  the  urine  concentrated  and  bile  stained,  and 
containing  albumin  and  casts.  On  exploration 
there  was  found  a  black  gangrenous  gallbladder 
distended  with  pus  and  foul-smelling  bile,  and  a 
large  non-faceted  stone  blocking  the  cystic  duct  and 
pressing  upon  the  common  duct.  The  gallbladder 
was  removed  except  for  a  portion  of  the  wall  which, 
after  the  removal  of  the  necrotic  mucosa,  was  left 
attached  to  the  liver.  The  patient  left  the  table 
apparently  in  as  good  condition  as  before  operation. 
Glucose  and  saline  solution  in  maximum  quantities 
were  repeatedly  given.  We  hoped  for  her  recovery. 
At  the  end  of  24  hours  her  temperature  was  104° 
and  only  two  ounces  of  urine  had  been  passed,  this 
by  catheter.  At  the  end  of  48  hours  one  ounce  of 
urine  was  obtained  by  catheter,  although  she  had 
been  given  a  total  of  10  quarts  of  fluid  by  needle 
in  the  two  days.  She  died  in  uremic  coma  with 
an  antemortem  temperature  of  107. 

Although  obviously  a  poor  risk,  operation  was 
indicated  for  it  gave  the  one  chance  of  relief.  How- 
ever, liver  and  kidney  impairment  made  the  condi- 
tion lethal  in  spite  of  treatment.  Operation  should 
have  been  done  months  before  the  onset  of  the 
acute  attack  and  gangrene. 

The  lesson  to  be  impressed  from  this  is  that  gall- 
bladder disease  should  not  be  considered  only  a 
local  malady.  Its  effects  are  progressive  and  are 
far-reaching.  The  practitioner  who  gives  morphine 
for  repeated  attacks  of  biliary  colic,  or  the  clinician 
who  treats  his  patients  for  months  and  years  by 
medical  drainage  of  the  gallbladder,  assumes  a  great 
responsibility  in  keeping  the  patient  from  operative 
removal  which  is  the  only  effective  cure  for  a  dis- 
eased gallbladder. 


The  Present  Status  of  Ether  Anesthesia 

(S.  C.Vy/iggin,  Boston,  in  Anest.  &  Analg.,  May-June) 

Among   the    great    majority    of    surgeons    who    formerly 

used  spinal  anesthesia  exclusively,  ether  is  now  being  used 

by  them  in  about  -J^ths  of  their  operations. 

Ether  is  the  anesthesia  with  the  widest  margin  of  safety 
for  the  physician  not  thoroughly  experienced  in  the  ad- 
ministration of  the  other  anesthetics;  it  is  the  most  easily 
controlled  anesthesia ;  in  emergency  operations  requiring 
relaxation,  ether  is  the  most  adaptable  agent;  it  is  of 
great  value  in  supplementing  the  other  anesthetic  agents. 

The  disadvantages  of  ether  are  its  disagreeable  odor; 
irritation  of  the  respiratory  mucous  membrane;  the  danger 
of    postoperative    pulmonary    complications,    especially    in 


336 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


the  presence  of  acute  respiratorj-  infections ;  production  of 
pulmonan-  edema;  danger  of  respiratory  paralysis  with 
deep  concentrations;  its  liability  to  cause  nausea  and 
vomiting  and  acidosis;  it  is  an  irritant  to  the  kidneys. 
These  disadvantages  are,  however,  overcome  to  a  great 
extent  by  the  perfection  in  the  preparation  of  the  patient 
and  the  administration  of  the  anesthetic. 

The  patient  should  be  visited  by  the  anesthetist  the  day 
before  operation  at  the  request  of  the  surgeon  to  make 
his  own  examination  including  history  and  laboratory  data, 
in  order  to  determine  the  method  of  anesthesia  most  suit- 
able for  the  individual.  The  choice  of  anesthetic  should 
be  made  only  after  consultation  with  the  surgeon  and 
the  patient,  as  an  anesthetic  may  be  desired  which  is  not 
suitable  for  the  condition. 


Appendicitis:   Diagnosis,  Treatment  and  End  Results 
(C.    O.   Cooke   and   J.    M.    Beardsley,    Providence,    in    R.    I. 
Med.  Jl.,  May) 
The  mortality  in  acute  appendicitis  is  due  to  three  fac- 
tors: 

1.  Delay  in  diagnosis 

2.  Administration  of  cathartics 

3.  Faulty  surgical  management. 

Delayed  diagnosis  is  due  to  several  factors,  the  most 
important  of  which  is  failure  to  call  the  family  physician 
at  the  onset  of  the  disease.  The  administration  of  mor- 
phine to  relieve  pain  before  the  diagnosis  is  made  is  an- 
other factor  in  delay. 

Catharsis  stimulates  peristalsis  and  causes  rupture  of 
the  appendix.  Cathartics  should  never  be  administered, 
therefore,  until  appendicitis  has  been  ruled  out. 

The  operative  mortality  of  experienced  surgeons  is  not 
increasing.  The  operation  for  acute  appendicitis  should 
be  performed  only  by  men  who  have  had  adequate  experi- 
ence in  abdominal  surgery. 


Diabetic  Coma 

(T.    P.    Sharkey,    Ohio    State    Jl.,    Feb..    via    International 
Med.   Digest,  May) 

Infection,  however  slight,  may  transform  the  mild  dia- 
"betic  or  the  well-controlled  diabetic  into  a  desperate  ill 
patient  in  24  hours.  In  all  patients  with  coma,  infection 
should  be  searched  for.  The  type  of  infections  most  com- 
monly seen  are  those  involving  the  upper  respiratory  tract ; 
infections  of  the  skin  such  as  carbuncles,  abscesses,  gan- 
grene, bums,  etc.;  and  infections  of  the  urinary  tract,  the 
last  appearing  more  commonly  than  is  generally  appreci- 
ated. 

Kussmaul's  breathing  is  the  most  characteristic  sign  of 
diabetic  coma. 


INTERNAL  MEDICINE 

Paul  H.  Ringer,  A.B.,  M.D.,  F.A.C.P.,  Editor 
Asheville,  N.  C. 


The  Heredity  Factor  in  Obesity 
It  is  with  a  great  deal  of  pleasure  that  I  resume 
the  editorship  of  the  Department  of  Internal  Med- 
icine in  Southern  Medicine  &  Surgery  after  my 
Sabbatical  leave.  I  would  like  to  e.xpress  in  this 
column  my  appreciation  to  Dr.  W.  Bernard  Kinlaw 
for  the  most  interesting  contributions  that  he  has 
made  during  the  past  twelve  months,  and  to  assure 
him  that  I  feel  he  has  raised  the  standard  of  the 
department  to  a  degree  which  I  will  have  to  strive 
hard  to  emulate  and  cannot  hope  to  surpass. 


In  the  Archives  of  Internal  Medicine  for  March 
is  a  brief  but  very  interesting  article  entitled: 
"The  Hereditary  Factor  in  Obesity,"  by  Dr.  Rams- 
dell  Gurney,  of  Buffalo.  He  says  that  while  definite 
progress  in  the  treatment  of  obesity  has  been  made 
in  recent  years  due  to  studies  in  water  balance,  a 
better  understanding  of  the  glands  of  internal  secre- 
tion, a  more  intelligent  conception  of  dietary  re- 
quirements and,  finally,  the  pressure  of  fashion 
which  dictates  that  women  shall  be  thin,  confusion 
and  uncertainty  have  continued  to  rule  in  the 
classification  of  obesity,  whether  on  an  etiologic  or 
a  clinical  basis. 

No  one  cause  by  itself  explains  obesity,  but  Dr. 
Gurney  states  that  four  facts  seem  to  stand  out 
clearly: 

1.  Obese  persons  lose  weight  on  a  restricted 
caloric  intake 

2.  Obesity  occurs  in  patients  with  hypopitui- 
tarism 

3.  Obesity  occurs  in  patients  with  hypothyroid- 
ism 

4.  Heredity  plays  more  than  a  coincidental 
part. 

And  then  Dr.  Gurney  proceeds  to  discuss  this 
last  factor.  He  states  that  the  findings  of  Dr. 
Davenport'  seem  to  indicate  that  body  build  fol- 
lows the  mendelian  laws  of  inheritance.  By  study- 
ing the  progeny  of  parents  of  similar  and  dissimilar 
builds,  he  concluded  that  there  are  three  gametic 
factors,  of  which  one  may  correspond  to  dystrophy 
of  the  thyroid,  one  to  dystrophy  of  the  pituitary, 
and  the  third  may  be  a  metabolic  factor  that  affects 
the  metabolism  of  the  cells  themselves.  If  this 
hereditary  factor  is  accepted,  the  onset  of  obesity 
in  one  person  as  opposed  to  that  in  another  who  is 
subject  to  the  same  environmental  influences  and 
who  is  even  receiving  the  same  diet  may  be  more 
readily  understood. 

Dr.  Gurney  studied  75  stout  women  in  the  out- 
patient department  in  Buffalo  General  Hospital 
along  the  following  lines: 

1.  The  factors  associated  with  the  onset  of 
obesity  as  compared  with  the  same  factors 
occurring  in  a  nonstout  control  group. 

2.  The  incidence  of  obesity  in  the  parents  of 
the  stout  group  as  opposed  to  that   in  the  J 
parents  of  the  nonstout  control  group. 

3.  The  body  build  of  the  progeny  of  different 
matings  with  special  reference  to  mendelian 
inheritance  of  build. 

Fifty-five  women  who  were  definitely  not  stout 
were  chosen  at  random  as  controls.  None  with  a 
debilitating  illness  was  selected.  They  came  from 
approximately  the  same  age  group  and  had  approx 
imately  the  same  incidence  of  operations  and  preg 


. 


June,  1Q36 


SOUTHERN  MEDICINE  AND  SURGERY 


337 


nancies — the  two  most  common  factors  apparently 
associated  with  the  onset  of  obesity. 

"table  1— age  distribution  of  stout  and  control  croups 
Decade 


Stout    _-. 

Nonstout 


table    2 CAUSES    OF    THE    ONSET   OF    OBESIT\'    IN    WOMEN 


!=3 

•  ••r. 


;5l 

13" 


of  stout  parents  are  more  variable  than  those  of  nonstout 
parents  suggests,  as  pointed  out  by  Davenport,!  that  stout 
persons  carry  gametes  for  stoutness.  As  a  corollary  to  this, 
regression  to  a  more  normal  build  as  a  result  of  these 
gametes  for  slenderness  can  be  seen  in  the  offspring  of 
stout  parents  to  a  considerably  greater  degree  than  in  the 
offspring  of  slender  parents." 

TABLE  3 — INCIDENCE  OF  OBESITy  IN  THE  PARENTS  OF  PATIENTS 
IN  THE   STOUT  AND  IN   THE  CONTROL  GROUP 


Sixty-three  women  in  the  stout  group  gave  a  re- 
liable history  as  to  the  onset  of  obesity.  Of  the 
41  of  these  who  bore  children — 65  per  cent,  of  the 
total — 29 — 71  per  cent. — stated  that  there  was  a 
direct  association  between  pregnancy  and  the  onset 
of  obesity.  Of  the  24  who  had  major  operations — 
38  per  cent,  of  the  total — 7 — 29  per  cent. — stated 
a  direct  association  between  the  operation  and  the 
onset  of  obesity.  Thus,  in  67  f>er  cent,  of  the  stout 
group,  the  onset  of  obesity  was  apparently  associ- 
ated with  some  physiologic  or  physical  episode. 
However,  in  another  group  of  women  of  approxi- 
mately the  same  age  period  and  subject  to  the 
same  physiologic  and  physical  episodes,  obesity  did 
not  occur. 

"When  one  studies  the  builds  of  the  parents  of  the  stout 
and  the  control  group  a  very  definite  and  real  difference 
in  the  incidence  of  obesity  is  apparent  (table  3).  Of  the 
61  stout  women  whose  family  history  seemed  unquestion- 
ably reliable,  26 — 43  per  cent. — had  a  stout  mother;  9 — 
IS  per  cent. — had  a  stout  father  ,and  15 — 25  per  cent. — 
had  both  a  stout  mother  and  a  stout  father,  making  a 
total  of  SO — 82  per  cent. — having  either  one  or  both  parents 
stout.  In  contrast  to  this,  of  the  47  nonstout  patients 
with  an  equally  reliable  family  history,  14 — 30  per  cent. — 
had  a  stout  mother;  1 — 2  per  cent. — had  a  stout  father, 
and  3 — 6  per  cent. — had  both  a  stout  mother  and  a  stout 
father,  making  a  total  of  IS — 38  per  cent. — with  either 
one  or  both  parents  stout,  as  opposed  to  82  per  cent,  in  the 
stout  group  *  *  * 

A  study  of  the  progeny  of  different  matings  in  this  group 
shows  a  definite  tendency  in  variability  (table  4).  There 
were   80   offspring    from    matinirs   of    stout    pr,=on>.    65 — 73 

per   cent. — of   whom   were   stout 

and  24 — 27  per  cent. — of  whom  were  not  stout.  Of  the 
170  offspring  of  matings  of  a  stout  and  non-tout  person, 
70 — 41  per  cent. — were  stout,  and  100 — 5<)  per  cent. — were 
not  stout.  Of  the  176  offsprings  of  matini's  of  nonstout 
persons,  only  16 — 9  per  cent. — were  stout,  in  contrast  to 
the  160 — 91  per  cent. — who  were  not  stout.  Thus,  there  is 
present  a  marked  difference  in  variability  in  the  progeny  ol 
different  matings,  with  the  offspring  of  a  stout  and  a  non- 
stout parent  th-j  most  variable  and  the  offspring  of  non- 
stout parents  the  least  variable.    The  fact  that  the  offspring 


Ekco        gci&.to    SnfeZ 


Stout    26 

Nonstout  14 


TABLE   4 DATA   ON    THE  VARIABILITY    OF    THE    PROGENY    OF 

DIFFERENT  MATINGS 

Stout  Nonstout 

Matings                                                Progeny  Progeny 

Stout  and  stout 65  24 

Stout  and  nonstout  70  100 

Nonstout  and  nonstout  16  100 

Dr.  Gurney  reaches  the  following  conclusions: 

"Pregnancy  or  a  major  operative  procedure  appeared  to 
be  the  most  common  factor  associated  with  the  onset  of 
obesity  in  a  group  of  63  stout  women. 

Obesity  did  not  develop  in  another  group  of  women  from 
approximately  the  same  age  group  and  with  approximately 
the  same  incidence  of  pregnancies  and  operations. 

The  incidence  of  obesity  in  the  parents  of  the  stout 
group  was  markedly  greater  than  in  the  parents  of  a  group 
of  nonstout  women. 

A  study  of  the  progeny  of  different  parents  indicates 
segregation,  which  is  evidence  for  mendelian  inheritance  of 
build. 

It  is  suggested  that  consideration  of  the  hereditary  factor 
in  obesity  may  help  to  explain  the  apparent  inconsistency 
of  build  in  persons  subject  to  the  same  environmental  influ- 
ence." 

To  the  editor  this  is  a  very  practical  and  import- 
ant bit  of  clinical  research.  There  are  many  such 
problems  presenting  themselves  today  in  internal 
medicine — problems  which  demand  attention  and 
solution.  The  idea  nowadays  seems  to  be  largely 
prevalent  that  no  really  first-class  research  work 
can  be  done  without  elaborate  laboratory  equip- 
ment. Dr.  Gurney  refutes  that  idea;  and  it  is  a 
challenge  to  our  powers  of  observation,  to  our  ac- 
curacy in  recording  and  to  our  truthful  correlation 
of  facts  and  correct  deduction  of  the  results  to  be 
gleaned. 

1.  Davenport,  C.  B.  Body-Build  and  Its  Inheritance. 
Washington.    D.    C.    Carnegie   Institution   of   Washington. 

I!i2.'5. 


Oxvc.EN  Axn  Carbon  Dioxide  in  Carbon  Monoxide 

Poisoning 

(Kenzo    Hasimoto,  Tnkohu  Imperial  Univ.,    in   Tohoku   Jl. 
Exp.    Medr.,  April) 

The    writer    conducted    inhalation    of    carbon    monoxide 

on    rabbits   and    is    able    to    find    definitely    the    beneficial 

effect   of   adding   carbon   dioxide  to   oxygen   for  treatment 


338 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


of  carbon  monoxide  poisoning  clearly  superior  to  the  pure 
oxygen.  Carbon  monoxide  is  more  rapidly  eliminated,  the 
oxygen  content  of  blood  is  more  rapidly  restored  and  the 
carbon  dioxide  content  of  blood  more  rapidly  still.  One 
must  take  care  of  its  dosage. 


ABSTRACTS   OF   THREE   ARTICLES   ON    DIABETES 

FROM  THE  BULLETIN  OF  THE  N.  Y.  ACADEMY 

OF  MEDICINE  FOR  M.AY 

The   Epfects   of   Cakbohydr.^tes   on   Bacterial   Growth 

AND  Development  of  Infection 

(Stanhope- Bayne  Jones,   New  Haven) 

In   my   opinion,    1)    the    concentration   of   sugar   in    the 

blood  of  diabetics  has  little  or  nothing  to   do  with  their 

states  of  resistance  or  susceptibility  to  infection;   2)   such 

factors  as  loss  of   water  may   operate   through   effects   on 

some  mechanism  not  yet  disclosed;   and  3)    the  causes  of 

these  changes  in  resistance  may  be  found  in  the  interlocked 

influences  of  organs  of  internal  secretion  affecting  not  only 

sugar  metabolism,  but  also  the  unknown  means  by  which 

the  body  cells  resist  bacterial  invasion  and  the  deleterious 

effects  of  bacterial  products. 

Blood  Sug.ar  in  Experimental  Di.abetes 
(H.  E.  Himwich,  Albany) 
1)  The  level  of  the  blood  sugar  is  a  resultant  of  the 
activity  of  various  endocrine  glands.  It  is,  therefore,  not 
necessarily  an  index  of  impaired  ability  of  the  islands  of 
Langerhans  but  may  indicate  instead  hyperfunction  of  the 
adrenal,  the  thyroid  and  particularly  of  the  anterior  pitui- 
tary glands.  2)  During  diabetes,  as  in  the  normal  state, 
an  increased  concentration  of  blood  sugar  serves  as  a  stim- 
ulus to  carbohydrate  metabolism  and  therefore  is  not  to 
be  combatted  unless  accompanied  by  a  definite  glycosuria. 
3)  Dehydration  may  be  a  result  of  glycosuria.  A  marked 
glycosuria  should,  therefore,  never  be  permitted  to  con- 
tinue even  for  short  periods.  4)  And  finally,  as  a  result 
of  the  three  previous  conclusions,  it  follows  that  the  glu- 
cose content  of  the  urine  rather  than  that  of  the  blood 
should  be  taken  as  the  criterion  of  the  amount  of  insulin 
indicated  in  diabetes  mellitus. 

B.-OOD  SuG.AR  in  Diabetes  Mellitus 
(Edward  Tolstoi,  New  York) 

1)  The  determination  of  the  blood  sugar  is  of  greatest 
value  in  th^  diagnosis  of  diabetes  mellitus.  It  is  of  help 
as  a  single  fasting  specimen  or  as  a  series  of  specimens  fol- 
lowing any  of  the  tolerance  tests.  In  the  evaluation  of 
such  tests  diseases  of  the  biliar.^  tract  and  the  previous  diet 
of  the  patient  must  be  reckoned  with. 

2)  A  single  blood  sugar  determination  is  of  little  value 
in  determining  the  severity  or  prognosis  of  a  case  of  dia- 
betes mellitus. 

3)  In  the  treatment  a  sugar-free  urine  is  a  satisfactor\' 
laboratory  criterion.  In  the  young  diabetic  the  blood  sugar 
will  approximate  normality  under  such  conditions;  in  the 
older  patient  let  the  blood  sugar  seek  its  level,  even  though 
high.  There  is  little  evidence  to  prove  that  such  a  hyper- 
glycemic state  is  deleterious  and  there  is  considerable  evi- 
dence that  it  is  desirable. 

Disctission  on  the  Symposium,  Significance  Blood  Sugar: 

Dr.  H.  R.  Geyelin:  The  incidence  of  infection  in  dia- 
betics seems  to  me  to  be  more  readily  affected  by  the  nutri- 
tional state  of  the  individual  rather  than  by  the  blood 
sugar  level.  Diabetics  who  are  adequately  nourished,  free 
from  glycosuria  and  maintaining  normal  weight  are  less 
apt  to  have  an  infection  than  are  those  who  are  kept  in 
moderate  or  extreme  degrees  of  undernutrition. 

The  importance  of  a  blood  sugar  test  in  the  management 


of  diabetics  is  overrated.  Many  of  us  are  inclined  to  attach 
too  much  significance  to  a  degree  of  hyperglycemia  which 
is  little  above  the  normal  level  of  spilling,  i.e.,  170  mg. 
Also,  we  must  not  forget  that  very  often  one  blood  sugar 
determination  gives  us  no  picture  of  what  the  blood  sugar 
may  show  at  every  other  S-minute  period  of  the  day  and 
night. 

Normal  nutrition  by  means  of  normal  diet  should  be  the 
therapeutic  goal  of  every  clinician  who  treats  diabetes. 
Both  overnutrition  and  undernutrition  are  to  be  avoided. 

Dr.  F.  M.  Allen:  It  seems  to  me  only  necessary  to 
realize  that  diabetes  is  a  specific  impairment  of  nutrition, 
affecting  all  the  cells  of  the  body,  and  in  this  way  the 
susceptibility  to  infection  and  all  the  compHcations  and 
degenerations  accompanying  diabetes  can  be  rationally  ex- 
plained. The  fat  diabetic  is  often  the  very  one  who  de- 
velops boils,  carbuncles  and  other  infections. 

Under  the  arrangement  of  this  program  it  is  scarcely 
possible  that  I,  as  the  only  advocate  of  a  normal  blood 
sugar,  should  attempt  in  5  minutes  to  answer  a  whole 
array  of  speakers  on  the  opposite  side. 

The  idea  of  the  benefit  of  high  blood  sugar,  especially 
in  heart  disease,  is  based,  it  seems  to  me,  upon  a  curious 
misconception — the  idea  that  a  high  blood  sugar  due  to 
impaired  utilization  of  sugar  is  equivalent  to  the  high 
blood  sugar  created  by  intravenous  injections  in  the  pres- 
ence of  normal  utilization. 

Dr.  Herjlan  O.  MosENTiL-iL:  The  textbooks  on  diabetes 
and  the  dictum  of  various  diabetes  specialists  are  distinctly 
at  fault  when  they  state  that  a  normal  blood  sugar  is 
readily  achieved  and  easily  maintained.  My  observations 
lead  me  to  believe  that  hyperglycemia  without  glycosuria 
does  not  harm  the  patient. 

I  have  yet  to  see  a  case  of  diabetic  gangrene,  cataract 
or  arteriosclerosis  where  there  has  not  been  persistent 
glycosuria  for  at  least  5  years.  This  would  indicate  that 
glycosuria  and  polyuria,  that  is  malnutrition  and  desicca- 
tion, are  the  causes  for  complications  in  the  diabetic  and 
not  a  hyperglycemia  without  glycosuria. 

Dr.  Edw.^rd  Tolstoi  (closing  discussion):  If  diabetes 
or  hyperglycemia  be  responsible  for  gangrene  or  retinitis, 
why  is  it  so  infrequent  in  the  young  where  diabetes  is 
most  usually  severe.  Gangrene  and  retinitis  occur  in  people 
who  have  vascular  disease,  and  whether  the  diabetes  pre- 
cedes or  follows  the  vascular  disease,  I  am  in  no  position 
to  state. 


HOSPITALS 

R.  B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  Editor,  Greensboro,N.  C. 


The  Doctor's  Routine 

If  every  doctor  could  serve  on  the  nursing  service 
for  six  months  before  he  entered  medicine  it  would 
give  him  a  wonderful  insight  of  the  value  of  having 
a  routine. 

It  must  be  remembered  that  all  hospitals  must 
have  a  rotating  nursing  staff,  whether  the  hospital 
operates  a  training  school  or  uses  graduate  nurses 
only.  Where  a  training  school  is  being  operated 
there  is  a  new  group  of  nurses  every  year.  If  grad- 
uate service  is  used  the  rotation  is  more  rapid  as  a 
rule.  Oftentimes  a  graduate  nurse  who  has  been 
doing  private  duty  for  several  years  will  decide 
that  for  the  winter  months  she  will  take  floor  duty 
in  an  institution,  or  if  private  work  gets  dull  any 


June,  1036 


SOUTHERN  MEDICINE  AND  SURGERY 


time  in  the  year  she  will  apply  for  a  job  at  an 
institution  on  the  floor  service.  All  changes  neces- 
sitate some  lost  motion,  some  inefficiency  and  a 
great  deal  of  inconvenience. 

If  a  doctor  has  a  routine  concerning  his  hospital 
work  it  operates  for  the  good  of  the  nursing  staff, 
his  patients  and  himself.  It  soon  becomes  com- 
mon knowledge  for  instance,  that  Dr.  Brown  usually 
visits  his  patients  between  8:30  and  9:30  in  the 
morning,  and  between  4:30  and  6:30  in  the  after- 
noon. This  knowledge  is  valuable  to  the  nurses 
because  they  can  expect  him  and  report  to  him 
any  changes  in  the  patients,  which  reports  other- 
wise would  have  to  be  made  over  the  telephone, 
and  perhaps  to  his  secretary  or  nurse. 

The  routine  preoperative  treatment  that  a  sur- 
geon uses  should  be  known  by  all  floor  nurses.  This 
will  enable  the  nurses  to  do  their  work  efficiently 
and  easily.  They  will  seldom  have  to  call  the  doc- 
tor to  find  out  the  preoperative  treatment  if  they 
know  the  diagnosis. 

In  the  operating  room  it  is  highly  essential  that 
the  whole  operating-room  force  know  the  routine 
as  to  instruments,  preparation  of  the  field  of  opera- 
tion, etc.  This  is  conducive  to  speed  and  efficiency, 
and  is  economical  in  that  only  the  instruments 
wanted  need  be  boiled  and  put  on  the  table.  The 
postoperative  treatment  on  the  various  common 
diseases  could  be  more  or  less  grouped  into  a  rou- 
tine without  jeopardy  to  the  patient's  recovery,  and 
with  much  help  to  the  floor  nurses. 

Pre-delivery  treatment  of  the  obstetrician  and 
the  instruments  used  in  the  usual  case  should  be 
known  to  all  who  are  expected  to  help  with  a  de- 
livery at  any  time. 

The  medical  man  should  at  least  have  some  gen- 
eral routine  of  nursing  treatment  of  the  various 
common  diseases,  such  as  pneumonia,  pleurisy,  gas- 
tric ulcer,  asthma. 

The  routine  treatment  of  contagious  diseases  is 
vitally  important  to  the  reputation  of  the  hospital, 
and  the  pediatrician  will  do  well  to  emphasize  over 
and  over  again  certain  definite  principles  which 
should  be  ever  present  in  the  minds  of  the  nurses 
when  a  contagious  disease  is  on  their  hall. 

I  have  known  many  physicians  to  become  rather 

peeved    over    being   called   over    the    telephone    so 

many  times  about  their  patients.     This,  of  course, 

is  unwise,  unkind  and  unjust.     The  nursing  staff 

can  do  no  other  way  but  notify  the  physician  of 

any  change  to  be  noted  in  the  patients  and  ask  for 

■  further  advice.     But  a  great  many  telephone  calls 

[would  not  be  necessary  if  the  doctor  would  have  a 

I  routine.     The  writer  does  not  wish  to  leave  the 

impression  that  patients  should  be  pigeonholed  and 

standardized   in   order   to   make  everybody  s   work 

easy,  but  he  does  wish  to  call  attention  to  the  eco- 


nomical and  essential  value  of  having  some  definite 
plan  for  treating  the  same  disease  in  the  same  type 
of  patient. 

It  is  desired  to  make  this  suggestion:  That  the 
regular,  active,  staff  members  who  are  accustomed 
to  having  patients  in  the  hospital  all  of  the  time 
adopt  a  routine  and  write  such  routine  in  a  book  to 
be  kept  on  each  floor  and  in  the  operating  room. 
This  would  enable  the  nursing  staff  to  acquaint 
themselves  almost  immediately  with  what  a  physi- 
cian likes  to  have  on  a  tray  when  he  does  a  trans- 
fusion or  spinal  puncture,  and  what  kind  of  dress- 
ings in  the  usual  appendectomy  as  well  as  a  thou- 
sand other  little  things,  which,  when  left  off,  would 
irritate  the  doctor  and  cause  the  nurse  to  have  to 
run  her  feet  off  in  order  to  supply  the  instruments 
or  dressings  that  the  physician  wants. 

It  has  been  my  experience  that  doctors  are  not 
as  considerate  of  nurses  as  the  nurses  are  of  the 
doctors,  and,  in  their  behalf  I  wish  to  plead  with 
the  medical  profession  to  prepare  a  book  of  routine 
instructions  for  every  hospital  which  they  visit. 


Food  Prejudices 

(From    Anomalies    &    Curiosities    of    Medicine,    Gould    & 
Pyle) 

.Almost  all  food  prohibitions  spring  from  totemism.  In 
Old  Egypt  the  sheep  could  not  be  eaten  in  Thebes,  nor 
the  goat  in  Mendes,  nor  the  cat  in  Bubastis,  nor  the  croco- 
dile at  Ombos,  nor  the  rat,  which  was  sacred  to  Ra,  the 
sun-god.  However,  the  people  of  one  place  had  no  scru- 
ples about  eating  the  forbidden  food  of  another  place. 

One  Roman  gens.  The  Piceni,  took  a  woodpecker  for  its 
totem,  and  every  member  of  this  family  refused,  of  course, 
to  eat  the  flesh  of  the  woodpecker.  These  local  rites  in 
Roman  times  caused  civil  brawls,  for  the  customs  of  one 
town  naturally  seemed  blasphemous  to  neighbors  with  a 
different  sacred  animal.  Thus  when  the  people  of  dog- 
town  were  feeding  on  the  fish  called  o.xyrrhyncus,  the  citi- 
zens of  the  town  which  revered  the  oxyrrhyncus  began  to 
eat  dogs.    Hence  arose  a  riot. 


RADIOLOGY 

Wright  Clakkson,  M.D.,  and  Allen  Barker,  M.D., 
Editors,  Petersburg,  Va. 


Pituitary  Basophilism  (Cushing's  Syndrome) 
In  1932  Gushing'  reported  twelve  examples  of  a 
peculiar  and  clinically  unmistakable  polyglandular 
syndrome.  These  patients  presented  rather  definite 
clinical  symptoms  and  signs,  which  he  attributed  to 
basophile  adenomas  arising  from  the  basophile  cells 
of  the  pituitary  gland. 

In  a  second  paper  published  the  same  year  he 
described  a  group  of  fourteen  patients,  mostly 
young  women,  who  presented  the  same  syndrome. 
It  becomes  evident  that  the  disease  is  not  so  rare 
as  is  ordinarily  supposed,  but  it  escapes  detection 
because  of  a  lack  of  familiarity  with  it,  which  In 
turn  is  the  result  of  a  scarcity  of  literature  on  the 
subject. 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


The  malady  is  most  often  encountered  in  young 
adults,  especially  women,  and  is  characterized  by 
a  rapidly  acquired  plethoric  adiposity,  affecting  the 
face,  neck  and  trunk,  the  extremities  being  spared. 
In  women  it  is  associated  with  hypertrichosis  and 
amenorrhea.  The  patients  are  extremely  asthenic, 
and  often  there  is  an  altered  basal  metabolic  rate. 
Other  characteristic  features  are  vascular  hyperten- 
sion, purplish  striae  distensae  of  the  abdomen; 
often  a  peculiar  cyanosis  of  the  extremities,  espe- 
cially of  the  hands  and  feet,  and  the  skin  bruises 
easily.  Pigmentation  of  the  skin  in  unusual  distri- 
butions may  occur.  Hyperglycemia  with  diminish- 
ed sugar  tolerance  occurs  frequently,  and  occasion- 
ally polvcvthemia.  which  may  reach  seven  to  eight 
million  "red  blood  cells  per  cm.  Of  particular  in- 
terest to  roentgenologists  is  the  peculiar  softening 
of  the  skeletal  system  which  frequently  occurs  and 
which  is  readily  demonstrable  on  roentgenograms. 
As  a  result  of  the  generalized  loss  of  calcium,  there 
may  be  impaction  of  the  vertebral  bodies  and  a 
decrease  in  the  patient's  height.  Spontaneous  frac- 
tures of  the  long  bones  may  occur.  Because  of 
the  generalized  decalcification,  the  roentgen  signs 
quite  often  suggest  parathyroidism,  and  the  clinical 
findings  should  be  correlated  with  the  roentgen  find- 
ings before  attempting  to  differentiate  between  the 
two. 

The  duration  of  life  in  the  fatal  cases  averages  a 
little  more  than  five  years.  Before  Cushing's  re- 
ports, it  was  thought  that  the  entire  syndrome  was 
the  result  of  a  primary  adrenal  disorder,  for  the 
reason  that  cortical  hyperplasia  is  often  found  post- 
mortem. However,  in  his  second  report,  five  of  the 
eight  cases  that  had  come  to  autopsy  showed  an 
unusual  pituitary  adenoma  and  three  of  these  were 
composed  of  basophilic  elements.  He  identified 
these  little-understood  cells,  which  form  small, 
sometimes  microscopic,  but  potent  adenomas,  as 
the  primary  pathologic  entity  in  the  disease.  In 
view  of  these  things,  it  is  believed  that  evidences 
of  disordered  function  of  the  other  endocrine  glands 
arc  wholly  secondary  expressions  of  a  general  en- 
docrine derangement.  Since  the  pituitary  is  recog- 
nized as  the  master  key  of  the  entire  endocrine  sys- 
tem, it  is  reasonable  to  suspect  that  its  stimulation 
of  the  parathyroids  causes  the  generalized  skeletal 
decalcification;  that  its  stimulation  of  the  gonads 
is  responsible  for  the  changes  in  secondary  sex 
characteristics,  and  that  its  stimulation  of  the  pan- 
creas accounts  for  the  hyperglycemia  and  glycos- 
uria. Either  stimulation  or  suppression  of  the  thy- 
roid is  responsible  for  the  altered  metabolic  rate. 

While  no  specific  treatment  has  yet  been  discov- 
ered, it  has  been  suggested  that  these  tumors  may 
respond  to  radiation  therapy.  The  basophile  cells 
are  derived  from  the  mother  cell  of  the  pituitary 


body,  just  as  are  the  acidophile  cells,  which  are  the 
primary  factor  in  acromegaly.  Since  these  latter 
cells  are  known  to  respond  well  to  irradiation,  it  is 
reasonable  to  believe  that  the  basophile  cells  will 
respond  also.  In  case  14  reported  by  Gushing, 
there  was  marked  and  prompt  relief  following  roent- 
gen irradiation  but  further  study  on  many  other 
cases  is  necessary  before  definite  conclusions  can  be 
reached.  Surgery  can  be  of  no  value  because  of 
the  minute  size  of  the  lesions  and  because  their 
exact  location  in  the  pituitary  is  always  uncertain. 
At  the  present  time,  therefore,  radiation  therapy 
seems  to  be  the  only  recourse  in  the  treatment  of 
this  rather  rare,  but  frequently  fatal,  malady. 

If  physicians  will  keep  basophile  adenomas  in 
mind  when  studying  patients  with  symptoms  of  a 
polyglandular  syndrome,  it  is  believed  that  many  of 
these  tumors,  now  undetected,  will  be  discovered, 
and  soon  we  shall  have  a  better  understanding  of 
this  interesting  clinical  condition. 

References 

1.  Gushing,  H.:  The  Basophile  .Adenomas  oi  the  Pitui- 
tar>'  Body  and  Their  Clinical  Manifestations.  (Pitui- 
tary Basophilism.)  Bull.,  Johm  Hopkins  Hospital, 
March,  1932,  50:137-195. 

2.  Gushing,  H.:  Further  Notes  on  Pituitary  Basophilism. 
/.  A.  M.  A.,  July  23rd,  1932,  99:281-284. 

3.  Editorial:  Pituitary  Basophilism.  Am.  Jl.  Roenl.  & 
Rod.  Therapy,  June,  1933,  20:845-486. 


Pre-C.^vncerous   Dermatoses 


The  term  precancerous  is  applied  to  a  great  many  lesions. 
Included  in  this  group  are  keratosis  senilis,  verruca  sebor- 
rheica, leukoplakia,  radio-dermatitis,  xeroderma  pigmentosa, 
comu  cutaneum,  the  melanoses,  kraurosis  valvae,  and 
Bovven's  pre-cancerous  dermatosis. 

Cancer  mortality  has  been  considerably  reduced  by  the 
lay  and  medical  publics.  Most  skin  cancers  develop  on  an 
antecedent  lesion  or  defect.  Early  recognition  and  proper 
treatment  of  pre-cancerous  lesions  will  substantially  reduce  I 
the  incidence.  Lesions  of  the  skin  or  orificial  mucosa  can  I 
be  easily  recognized  and  most  of  them  can  be  successfully 
treated. 


PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  G. 
Pitt  County  Health  Officer 


Swimming  Pools  .4nd  Bathing  Beaches 
Summer  is  often  referred  to  as  the  swimming 
season.  The  fatalities  from  swimming  appear  much 
on  the  increase.  I  wonder  if  we  could  reduce  the 
number  of  these  fatalities  if,  instead  the  swim- 
ming season,  we  referred  to  it  as  the  drowning 
season.  Certain  it  is  that  something  should  be 
done  to  reduce  the  toll  of  deaths  from  drowning. 

Not  only  should  we  do  something  to  reduce  the 
deaths  caused  by  this  form  of  recreation,  but  we 
should   attempt    to   prevent   middle-ear   and    sinus 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


disease — two  conditions  which  are  often  the  direct 
result  of  swimming  and  diving.  These  troubles 
may  be  of  a  simple,  mechanical  origin  or  they  may 
be  infectious. 

We  know,  of  course,  that  bathing  is  a  very  stim- 
ulating, healthful  and  delightful  form  of  exercise. 
If  done  with  little  risk  to  life  in  water  reasonably 
free  from  pollution  and  by  a  person  with  no  sinus 
or  middle-ear  trouble,  I  feel  that  all  physicians 
would  be  justified  in  recommending  swimming  as 
a  beneficial  form  of  exercise. 

You  may  say  that  these  prerequisites  can  not  be 
easily  met.  My  reply  is  that,  swimming  and  bath- 
ing are  not  sufficiently  important,  either  from  the 
standpoint  of  pleasure  or  any  other  standpoint,  to 
justify  the  disregard  of  these  prerequisites. 

Some  of  you  may  feel  that  a  discussion  of  this 
question  is  hardly  appropriate  as  reading  matter 
for  physicians,  but  I  am  of  the  opinion  that  no 
group  of  people  can  do  so  much  to  reduce  the 
mortality  from  drowning  or  the  morbidity  from 
bathing,  as  can  the  physicians.  A  word  of  warn- 
ing to  the  parent  and  to  the  children  from  the 
family  physician  will  carry  more  weight  than  all 
the  instructions  received  from  the  school  teacher, 
the  scoutmaster,  the  campfire  director,  the  director 
of  the  4-H  clubs  or  all  the  warnings  given  through 
the  daily  press. 

Among  the  warnings  which  I  think  the  physi- 
cian could  very  properly  and  profitably  give  to  his 
patients  who  visit  swimming  pools,  swimming  holes 
and  bathing  beaches  would  be: 

Don't  go  in  swimming  anywhere  unless  there  is 
a  life  guard,  or  a  boat  and  a  companion  who  could 
come  to  your  rescue  in  an  emergency. 

Don't  go  in  swimming  anywhere  if  you  have 
ever  had  ear  disease  or  sinus  trouble. 

Don't  go  in  swimming  where  you  think  the 
water  is  not  reasonably  safe  from  the  sanitary 
standpoint. 

Don't  dive  until  you,  yourself,  have  examined 
the  place  within  the  past  hour,  and  found  the  water 
deep  enough  and  free  from  logs,  sunken  boats,  and 
so  on,  on  which  you  would  break  your  neck. 

I  am  of  the  opinion  that,  if  all  physicians  would 
issue  these  four  simple  warnings  to  all  their  patients 
at  the  beginning  of  the  swimming  season,  the  mor- 
tality from  drowning  and  the  morbidity  from  mid- 
dle-ear and  sinus  disease  could,  in  one  season,  be 
reduced  50  per  cent. 

Of  course,  I  can  hear  some  of  you  skeptical  fel- 
lows say  to  yourself:  "It  is  one  thing  to  give  a 
warning  and  altogether  another  matter  to  have  it 
observed."  There  is  no  argument  here.  I  simply 
answer,  that  unless  you  do  give  this  warning  you 
have  not  done  your  duty  and  when  you  have  given 
this  warning,  you  have  done  your  duty.     I   think 


you  will  agree,  also,  that  there  is  no  argument  here. 
And  many  will  heed  the  warnings. 

Another  thought:  Every  high  school  in  the 
State  ought  to  make  proficiency  in  artificial  res- 
piration a  prerequisite  to  graduation,  this  to  include 
girls  as  well  as  boys.  If  the  high  school  in  your 
community  is  not  teaching  artificial  respiration,  why 
not  ask  the  Superintendent  of  Schools  to  add  it  to 
the  curriculum. 


RuRAi.  Sanitation  .i^s  Affecting  City  Dwellers 

(From  State  Dept.  of  Health,  in  Jl.   Iowa  State  Med.  Soc, 
May) 

Within  the  past  two  years  a  serious  outbreak  of  typhoid 
fever  occurred  in  one  of  Iowa's  large  cities.  The  epidemic 
was  traced  to  raw  milk,  to  flies  carrj-ing  infection  to  milk 
utensils  from  a  filthy  privy  pit  used  by  demonstrated  ty- 
phoid carriers.  Thus  one  insanitary  privy  several  miles 
away  from  a  sewered  city  resulted  in  sickness  among  25 
city  dwellers. 

Every  sewered  city  and  town  in  Iowa  [or  N.  C. — Editor] 
has  a  fringe  of  unsewered  homes  at  the  outskirts.  Milk 
and  vegetables  are  consumed  by  all  urban  dwellers  in 
Iowa.  Therefore  the  safe  disposal  of  excreta  in  unsewered 
areas  becomes  the  concern  of  all  people  whether  of  urban 
or  rural  residence. 

The  mere  mention  of  an  outdoor  privy  elicits  chuckles 
and  smiles  from  most  people,  but  to  the  victim  of  intestinal 
disease  an  insanitary  privy  is  no  laughing  matter.  The 
State  Department  of  Health  offers  no  apology  for  the  pro- 
gram which  it  is  sponsoring  because  it  believes  the  pro- 
gram is  on  a  sound  public  health  basis  and  will  pay  big 
public  health  dividends  if  carried  out  to  its  ultimate  com- 
pletion. 


HUMAN  BEHAVIOR 

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


Our  Inner  Selves* 
When  the  long-distance  conversation,  provoked 
by  a  telephone  call  long  after  midnight,  had  been 
concluded,  I  was  so  thoroughly  awake  that  I  turned 
for  solace  to  the  few  books  in  my  room.  My  hand 
came  upon  the  Pickwick  Papers.  I  had  not  asso- 
ciated with  that  immortal  company  since  I  was  a 
small  boy  in  Iredell.  Recollection  of  the  details 
of  their  journeys  and  adventures  had  been  dimmed 
by  the  mists  of  the  years,  but  I  had  thought  of  their 
experiences  only  as  ludicrous  portrayals  of  certain 
phases  of  English  life.  The  Pickwick  Papers  to 
which  I  turned  a  few  months  ago  at  three  in  the 
morning  was  a  different  volume  entirely.  What 
had  happened?  Nothing  in  the  book;  not  a  word 
of  the  Dickens  text  had  been  changed;  the  illus- 
trations were  the  same.  What  had  occurred? 
Changes  had  taken  place  in  me.  I  had  aged.  The 
years  had  rolled  over  me.  Within  those  years  I 
had  experienced  what  the  community's  old  minister 
in  Iredell  always  thanked  God  for  in  his  long 
prayer — some  of  the  vicissitudes  of  life.     I  had  no 


•Spoken  by  invitation  to  the  graduating  class  of  the 
Dorothea  Dix  School  of  Nursing  of  the  State  Hospital  at 
Itak-igh.  X<irth  Carolina,  May  20th,  1936. 


342 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


idea  at  that  time  what  the  word  vicissitude  meant. 
Now  I  think  I  linow,  but  I  am  not  yet  certain  that 
one  can  always  sincerely  thank  God  for  those 
mutations  of  fortune,  many  of  which  seem  to  be 
misfortunes.  But  I  have  at  least  acquired  some 
understanding  of  the  meaning  of  a  word  that  was 
no  more  than  a  polysyllabic  sound  in  my  youthful 
ears.    Time  teaches  remorselessly. 

Many  years  ago  merely  the  inexperienced  eyes 
of  a  country  lad  read  the  Pickwick  Papers.  A  few 
months  ago  a  man,  well  in  the  latter  half  of  life, 
read  again  the  same  volume — but  the  man  was  no 
longer  the  boy.  He  had  experienced  some  of  the 
vicissitudes  of  life.  He  had  lived  for  many  years 
with  people  who  suffer;  some  of  whom  had  recov- 
ered; some  of  whom  had  died;  some  of  whom  had 
continued  to  wring  their  hands  in  despair.  For 
one  reads  always  as  much — nay,  even  more— into  a 
book  than  one  reads  out  of  it.  One  reads  always 
not  merely  with  one's  eyes,  but  always  also  with 
one's  experiences.  When  I  read  the  immortal  crea- 
tion of  Dickens  in  the  early  nineties  1  read  a  funny 
book;  when  I  read  the  Papers  again  a  few  months 
ago  I  read  a  terrific  satire  of  English  society.  Time 
and  experience  had  changed  my  spectacles.  I  read 
from  the  book,  but  I  read  into  the  book  also — the 
experiences  of  my  own  life.  And  so  it  is  and  must 
be  always. 

At  certain  places  here  and  there  mechanical  de- 
vices have  been  set  up  that  record  the  slightest 
vibrations  of  the  earth.  Such  mechanisms  respond 
to  the  mere  tremors  caused  by  an  earthquake  thou- 
sands of  miles  away.  But  a  human  being  is  much 
more  responsive;  much  more  susceptible  to  stim- 
ulation; much  more  sentient,  than  any  mechanism 
man  can  devise.  We  are  responsive  to  influences 
that  arise  both  within  and  without  us.  We  are 
influenced  from  within  ourselves  by  the  long  ac- 
cumulations of  memory,  biologic  and  psychologic; 
by  those  experiences  that  have  become  stored  up 
within  us.  We  may  become  the  masters  of  our 
future;  we  are  undoubtedly  the  servants  of  our 
past;  for  we  can  not  change  our  past.  It  is  irrev- 
ocably fixed.  We  are  so  susceptible  to  stimuli,  to 
influences,  that  we  must  be  changed  in  some  degree 
by  every  change  in  our  environment,  however  in- 
finitesimal that  change  may  be.  That  thought  is 
not  my  discovery,  but  it  is  momentous,  and  I  fear 
it  is  true.  That  thought  deterred  me  from  speaking 
to  you.  You  should  be  spoken  to  by  some  one  more 
competent  to  lift  up  your  eyes  to  the  still  higher 
hills. 

You  are  seven.  Both  the  crap-shooter  and  the 
Biblical  scholar  will  tell  you  that  is  a  lucky  num- 
ber. I  am  sure  that  you  will  leave  this  hospital 
not  as  you  found  it  upon  your  matriculation  here 
three  years  ago.     You  have  helped  to  make  it  a 


better  hospital;  the  hospital  has  helped  to  make 
each  of  you  a  better  young  woman.  You  have  been 
profoundly  changed  by  your  experiences  while  in 
the  training  school;  much  more  than  you  now 
realize.  Tarboro  and  Scotland  Neck  and  Youngs- 
ville  and  Whitakers  and  Zebulon  and  Union  and 
Roseboro  will  not  see  you  again — not  the  young 
ladies  whom  they  sent  to  Dix  Hill  three  years  ago. 
Here  you  have  lived  with  those  whose  emotions 
and  whose  thinking  have  been  changed  by  forces 
within  and  forces  without.  Many  of  them  live  in 
a  world  of  their  own  fantastic  creation.  But  you 
have  discovered  that  they  differ  from  the  rest  of 
us  quantitatively  rather  than  qualitatively.  We 
are  all  much  more  alike  than  unlike.  No  one  of 
us  is  competent  to  think  wholly  rationally  or  to 
reason  always  logically.  And  are  we  not  always 
trying,  whether  we  be  sick  or  whether  we  be  well, 
to  escape  from  the  hard  world  of  every-day  reality 
and  bricks  and  mortar  and  meat  and  bread  and 
obligations  and  duties  by  adventures  into  that  more 
delightful  land  of  things-as-they-should-be?  In 
that  hope  we  read  poetry  and  romance  and  biogra- 
phy and  history  and  fairy  stories  and  we  attend 
church  and  we  go  to  movies  and  to  baseball  games 
and  to  balls  and  to  prize  fights  and  to  political 
speakings  and  to  wrestling  matches.  Whatever  we 
mortals  may  be  we  are  undoubtedly  mechanisms  that 
are  constantly  elaborating  energy,  and  this  energy 
is  constantly  seeking  an  outlet  through  the  instincts, 
the  emotions,  and  the  intellect.  The  problem  with 
which  each  of  us  has  to  deal  is  to  find  a  wholesome 
outlet  for  this  energy.  Those  who  are  mentally 
not  well  experience  more  difficulty  in  directing  their 
energy.  Conflicts  occur  within  between  opposing 
streams  of  energy.  All  of  us,  even  those  who  are 
most  robust,  experience  constant  difficulties  on  ac- 
count of  such  inner  conflicts.  But  the  proper  func- 
tion of  the  mind  is  to  enable  the  individual  to 
understand  himself,  to  understand  somewhat  the 
world  around  him,  and  to  try  to  live  tolerably  with 
himself  and  in  that  world  that  surrounds  him. 
Those  individuals  whose  parts  or  attributes  engage 
in  conflicts  with  other  parts  and  with  other  attri- 
butes of  themselves  become  incapacitated  on  that 
account  for  the  struggle  of  life,  and  they  come,  for 
understanding  and  sympathy  and  help  and  encour- 
agement, into  such  a  blessed  haven  as  this  asylum. 
Of  all  the  fabrications  formulated  by  the  mind 
of  man  the  most  useful  is  not  the  wheel  nor  any 
other  mechanical  device.  The  most  useful  thing 
brought  into  being  by  man  is  the  alphabet.  Through 
the  innumerable  arrangements  of  the  twenty-six 
constituent  symbols  of  our  English  alphabet  we 
have  our  words,  without  which  we  should  be  rela- 
tively helpless.  And  words  are  the  mightiest  things 
in  the  world.     We  should  know  more  about  them 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


and  use  them  more  carefully  and  more  accurately 
and  less  carelessly.  When  used  recklessly,  as  they 
often  are,  words  are  more  dangerous  than  firearms. 

We  have  projected  an  unhappy  meaning  into 
many  words  whose  ancestry  and  whose  character  is 
good.  We  have  treated  in  such  fashion  the  good 
old  word  asylum.  We  should  have  respected  its 
original  meaning  and  kept  it  in  good  standing.  We 
have  slandered  and  libeled  it.  In  distant  days, 
when  the  times  might  have  been  as  turbulent  as 
they  are  now,  some  one  with  a  touch  of  inspiration, 
conceived  of  the  notion  of  a  city  of  refuge.  If  one 
could  only  reach  such  a  place,  one  would  be  safe 
from  arrest  and  molestation  and  accusation  and 
abuse,  regardless  of  one's  deeds.  Even  more  was 
implied  in  the  word  asylum.  Those  who  succeeded 
in  escaping  into  such  a  blessed  sanctuary  would  b? 
kindly  treated.  Their  bodies  would  not  be  assault- 
ed, neither  would  their  emotions  nor  their  minds 
be  traumatized.  In  such  a  retreat  the  distressed 
person  would  have  the  opportunity  and  the  en- 
couragement to  reorganize  his  life,  and  to  be  born 
again.  .Asylum,  I  think  it  should  be  asylon,  is  an 
old  word  and  a  holy  word,  and  we  should  not  let 
it  be  driven  from  our  vocabulary  by  our  misunder- 
standing of  its  meaning.  In  an  asylum,  in  ancient 
days,  there  was  no  reproof  of  one  by  another;  no 
condemnation;  no  adverse  opinion;  no  punishment; 
no  abuse  of  mind  or  of  body;  no  pessimism;  but 
understanding  and  sympathy  and  helpfulness  and 
encouragement  and  inspiration  and  love. 

And  we,  you  nurses  and  we  doctors,  if  we  are 
true  to  our  vows  and  to  ourselves,  do  not  ever  draw 
aside  our  skirts  nor  lift  our  brows.  If  there  be  sin 
and  evil  and  filth  and  degradation  and  we  cannot 
live  amongst  such  things  and  emerge  uncontami- 
nated,  then  we  have  not  been  consecrated,  and  we 
belong  outside  nursing  and  outside  medicine.  Our 
function,  yours  and  mine,  is  not  to  accuse  nor  to 
condemn  nor  to  punish,  but  to  understand  and  to 
help  others  to  understand,  in  order  that  there  may 
be  correction  where  correction  is  needed,  and  that 
there  may  be  order  where  disorder  prevails.  I  am 
not  certain  that  we,  nurses  and  doctors,  should 
think,  in  our  daily  activities,  in  terms  of  right  and 
wrong,  or  that  we  should  make  use  of  the  words 
moral  and  immoral.  We  should  merely  try  to 
understand.  I  am  not  certain  that  condemnation, 
except  that  applied  by  self  to  self,  is  ever  benefi- 
cent; or  that  the  application  of  punishment,  except 
that  applied  by  one's  own  intelligent  conscience  to 
one's  own  self,  is  ever  salutary.  Society  is,  I  fear, 
as  stupid  and  as  cruel  and  as  vengeful  as  the  most 
depraved  criminal. 

Here  in  these  halls  and  on  these  grounds  you 
young  ladies  have  lived  with  phases  of  life  that 
the  world  hears  occasionally  of  but  knows  little  of. 


It  has  been  said  that  science  knows  no  mysteries. 
Human  behavior  is  the  mental  state  made  obvious. 
Behaviour  is  probably  no  more  mysterious  than 
perspiration  or  respiration.  You  have  learned 
things  about  mortals  that  you  could  not  have  im- 
agined ten  or  five  years  ago.  Here  you  have  walked 
anew  with  God.  You  have  learned  to  think  more 
understandingly  of  human  beings — of  others  and 
of  yourselves.  You  have  acquired  a  deeper  appre- 
ciation of  the  meaning  of  tolerance  and  of  sympa- 
thy and  of  the  needs  of  helpfulness  and  of  the 
many  different  ways  in  which  help  may  be  rendered. 
You  will  not  hereafter  look  down  in  disapproval 
upon  your  digressing  fellow-being,  nor  up  to  him 
or  to  her  because  of  difference  in  station  or  in 
fortune.  None,  so  well  as  nurse  and  doctor,  knows 
of  the  intimate  kinship  betwixt  Judy  O'Grady  and 
the  supercilious  high-brow  wife  of  the  Colonel. 

You  are  the  spiritual  children  of  the  childless 
Dorothea  Dix  and  of  James  Cochran  Dobbin  and 
of  his  wife,  Louisa  Holmes  Dobbin,  who,  in  the 
providence  of  God,  had  to  give  her  life,  that  this 
magnificent  asylum  might  come  into  existence. 
Wherever  you  go  you  will  carry  with  you  as  a 
blessed  halo  wholesomeness  and  understanding  and 
sympathy  for  those  in  distress,  and  your  daily  lives 
will  constitute  an  obeisance  to  the  blessed  Mother 
of  God.  You  are  the  splendid  representatives  of 
the  magnificent  young  womanhood  of  a  great  state. 
I  salute  you,  and  I  bow  in  reverence  to  you. 


Doctors  Who  Submit  to  Imposition  Lose  the  Respect 

OP  All 

(From  Edi.,   Maine   Med.  JI.,  May) 

The  physician  is  robbed  of  his  rest,  time,  leisure,  skill 
and  fee,  for,  far  too  frequently,  the  bill  never  is  paid.  By 
whom?  By  persons  without  much  conscience  in  all  walks 
of  life  whose  commercial  credit  rating  is  fair  or  good, 
but  whose  medical  credit  rating  is  zero  minus.  With 
brazen  impertinence  they  demand  a  service  for  the  payment 
of  which  they  simply  manifest  a  supreme  indifference. 
When  sickness  again  overtakes  them,  they  appeal  to  an- 
other altruistic  ass  (synonym  for  doctor)  whom  they  have 
not  fleeced  previously,  with  the  same  result  so  far  as  the 
doctor  is  concerned. 

The  remedy  for  correcting  this  outrageous  situation  in 
part,  at  least,  lies  with  the  medical  profession.  It  consists 
in  tempering  mercy  for  others  with  justice  to  them  and  to 
ourselves;  in  preserving  our  self-respect  and  dignity  as  a 
profession  by  assuring  ourselves  reasonably  well  whom  we 
are  serving  at  the  beginning  of  treatment,  by  inquiry  into 
their  willingness  and  ability  to  pay  through  the  organiza- 
tion of  a  medical  credit  system  comparable  to  that  in  use 
by  merchants.  The  plan  is  feasible,  easy  of  accomplish- 
ment, inexpensive,  and  calculated,  as  nothing  else  will,  to 
cause  persons  to  improve  and  maintain  their  medical  credit 
rating.  To  continue  to  submit  to  the  stealing  racket  prac- 
ticed by  pirates  and  parasites,  spongers  and  sidesteppers, 
without  making  any  effort  to  check  an  intolerable  and 
disgraceful  abuse  is  to  forfeit  the  respect  of  the  people, 
including  the  dodgers,  and  to  justify  the  use  by  them  of 
the  phrase,  "Gee,  doctors  are  easy.  They  always  come 
when  they  are  called." 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


Southern  Medicine  and  Surgery 

Official  Organ  of 

Tei-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 
Eye,  Ear  and  Throat  Hospital  Group Charlotte,  N.  C. 

Orthopedic   Surgery 

O.  L.  Miller,  M.D )^ Charlotte,  N.  C. 

John  Stuart  Gaul,  M.D.) 

Urology 

Hamilton  W.  McKay,  M.D  (  Charlotte,  N.  C. 

Robert  W.  McKay,  M.D.     -  j 

Internal    IVIedlcine 

W.  Bernard  Klnlaw,  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 

Chas.  R.  Robins,  M.D Richmond,  Va. 

Pediatrics 

G.  W.  KuTSCHER,  JR.,  M.D - .  .Asheville,  N.  C. 

General    Practice 

WiNGATE  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.  Gilmore,  A.B.,  M.D Greensboro,  N.  C. 

Public   Health 

N.  Thos.  Ennett,  M.D.  .- _._ ...Greenville,  N.  C. 

Radiology 

Allen  Barker,  M.D ( Petersburg,  Va. 

Wright  Clarkson,  M.D. ) 


Offerings  for  the  pages  of  this  Journal  are  requested 
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The  President  of  the  Medical  Society  of  the 
State  of  North  Cakolina 

Dr.  Charles  Franklin  Strosnider,  our  new- 
President  of  the  State  Medical  Society,  vfas  born 
in  Strasburg,  Va.,  December  16th,  1881,  the  son 
of  C.  W.  and  Anna  R.  Strosnider.  After  attending 
schools  in  Strasburg,  Oranda  and  Richmond,  he 
was  graduated  from  the  Medical  School  of  the 
University  of  Maryland  in  1909  and  came  at  once 
to  North  Carolina  where  he  has  spent  his  profes- 
sional life. 

Following  an  interneship  in  the  James  Walker 
Memorial  Hospital  in  Wilmington  he  worked  with 
the  International  Health  Commission  for  the  Rock- 
efeller Foundation  from  1911  to  1914.  From 
1914  to  1916  he  practiced  in  Mount  Olive  and 
Wilmington,  coming  to  Goldsboro  to  locate  in  1917. 

During  the  World  War  he  first  served  on  the 
local  Examining  Board  and  in  the  early  part  oi 
1918  he  entered  active  service  as  a  First  Lieutenant 
in  the  School  of  Internal  Medicine  at  Greenleaf, 
Ga.  He  was  a  chest  specialist  at  Camp  Hancock, 
Ga.,  in  charge  of  all  pneumonia  work  at  the  Base 
Hospital,  serving  in  this  capacity  until  the  demobili- 
zation of  the  hospital  in  1919.  He  then  returned 
to  Goldsboro. 

Always  very  active  in  organized  medicine  he 
has  served  as  Secretary  and  President  of  the  Wayne 
County  Medical  Society,  and  the  Fourth  District 
Medical  Society.  For  three  terms  he  has  been 
Councilor  for  the  Fourth  District.  He  is  a  former 
member  of  the  Nurses'  Examining  Board,  a  mem- 
ber of  the  Advisory  Board  to  the  Director  of  Relief 
and  Chairman  of  the  Committee  on  Economics  of 
the  State  Medical  Society. 

Always  eager  to  improve  himself  and  thus  give 
better  service  to  his  patients,  he  has  taken  post- 
graduate work  at  the  University  of  Maryland,  Johns 
Hopkins,  Harvard,  New  York  Post-graduate  School 
and  the  New  York  Medical  Center. 

A  man  of  original  ideas  he  easily  falls  into  the 
position  of  leadership. 

The  Medical  Society  of  the  State  is  fortunate  in 
having  one  who  will  keep  a  watchful  eye  over  the 
rights  of  the  profession  and  who  will  lead  and  stim- 
ulate its  progress. 

—DON NELL  B.   COBB. 


SOUTHERN  MEDICINE  AND  SURGERY 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


The  Impingement  of  Public  Health  Activities 
ON  Private  Practice* 

In  many  States  of  the  Union  public  health  offi- 
cers and  private  practitioners  have  come  into  active 
if  not  acrimonious  conflict.  No  such  conflict  has 
taken  place  in  North  Carolina  and  this  happy  state 
of  affairs  is  due,  to  a  great  degree,  to  the  fact  that 
our  health  officials  have  been,  and  are,  well  bal- 
anced men,  with  a  strong  sense  of  justice,  who  have 
borne  it  constantly  in  mind  that,  whoever  is  State, 
County  or  City  health  officer,  it  is  the  doctor  in 
private  practice  who  has  always  done,  does  now, 
and  must  continue  to  do,  the  bulk  of  the  work  of 
preventive  medicine. 

My  choice  of  a  title  startled  some  of  my  friends 
into  thinking  an  attack  on  public  health  work  was 
to  be  made.  Possibly  this  misconception  came 
from  confusion  with  the  word,  infringement,  from 
jrangere,  to  break.  It  is  said  that  impinge  comes 
from  an  old  Latin  word  meaning  to  agree,  and  I  use 
it  in  the  sense  of  coming  in  contact  with  and  going 
along  with. 

It  has  fallen  to  my  lot  to  function  as  quarantine 
and  vaccination  officer,  as  water  analyst,  as  super- 
visor of  sewage  disposal  and  mosquito  and  fly  de- 
stroyer; and  I  have  even  been  engaged  by  a  town 
to  bury  a  victim  of  smallpox.  So  it  would  seem 
possible  for  me  to  see  both  sides  of  problems  which 
arise  from  private  practitioners  and  health  officers 
coming  in  contact  with  and  going  along  with  each 
other. 

Apparently  it  is  inevitable  that  every  man  will 
think  his  own  job  more  important  than  it  is;  so  a 
health  officer  is  not  blameworthy  for  thinking  of 
his  proper  field  as  larger  than  it  really  is,  and  no 
more  is  a  private  practitioner  to  be  blamed  for 
feeling  aggrieved  when  it  appears  that  his  field  is 
being  invaded  by  public  health  officials.  Blaming 
is  futile  anyhow.  When  one  encroaches  on  your 
rights,  it's  idle  to  waste,  in  blaming  him,  the  time 
and  energy  which  could  be  properly  and  effectively 
used  in  making  him  stop  it.  Remember  the  verdict 
of  the  backwoods  magistrate:  "Not  guilty;  now 
quit  doin'  it  an'  everything  'ill  be  all  right." 

It  may  be  true  that  to  exp>ect  to  be  given  credit 
for  a  worthy  act  is  little  different  from  expecting 
payment  in  coin.  However  that  may  be,  in  the 
present  stage  of  more  or  less  human  development  it 
rather  riles  us  to  see  others  claim  or  be  given 
credit  for  what  we  have  done.  And  just  as  the 
garden  variety  of  doctor  can  count  on  being  lauded 
twice  before  he  is  buried,  and  twice  only — in  his 
graduation  and  in  his  funeral — so  he  can  count  on 
getting  a  limited,  reflected,  subordinate  glory  from 

•Presented  to  the  Section  on  Public  Health  and  Educa- 
tion of  the  Medical  Society  of  the  State  of  North  Carolina, 
Asheville,  May  5th. 


his  expenditure  of  energy  in  keeping   folks   from 
getting  sick. 

Several  months  back  the  bulletin  of  a  State 
health  board  carried  a  glowing  account  of  how  the 
doctors  of  a  certain  community  had,  under  the 
leadership  of  a  representative  of  the  Board,  im- 
munized all  the  school  children  free,  regardless  of 
parents'  ability  to  pay.  I  commented  at  the  time 
that  the  doctors  should  be  ashamed  of  themselves; 
that  many  of  those  children  would  be  taken  in 
new  cars  to  comfortable  summer  resorts,  while  many 
of  the  doctors'  families  stayed,  perforce,  at  home 
and  the  doctors  rattled  over  the  hot  hills  in  ancient 
Fords.  For  the  well-to-do  to  give  to  the  poor  is 
blessed;  but  the  Italians  have  a  proverb,  "When 
the  poor  give  to  the  rich  the  Devil  laughs." 

The  public  health  authorities  are  in  position  to 
head  off  any  such  unjust  demand  on  doctors  who 
must  get  a  living,  if  at  all,  from  fees  paid  by  those 
who  are  able  to  pay. 

A  few  years  ago  (and  it  may  happen  every  year 
for  all  I  know),  to  meet  the  requirements  of  a  pub- 
lic health  ordinance,  in  at  least  one  of  our  North 
Carolina  cities,  each  doctor  who  declined  to  exam- 
ine free  any  girl  applying  to  him  who  wished  to 
use  a  public  swimming  pool  was  made  to  appear 
ungenerous  and  lacking  in  public  spirit. 

To  my  certain  knowledge  the  fathers  of  many 
of  those  girls  had  dollars  to  the  pennies  at  the 
command  of  the  doctors  whose  services  they  were 
filching.  \  little  forethought  on  the  part  of  the 
health  authorities  would  have  arranged  the  stage 
for  these  Naiads  going  to  their  own  doctors  by 
appointment  and  paying  him  for  his  services  in- 
stead of  being  parceled  out  to  those  doctors  who 
would  allow  themselves  to  be  imposed  on. 

We  can  give  thanks  that  baby  shows  are  on  the 
decline.  However,  within  this  present  year  I  saw 
a  lot  of  babies  that  had  been  assembled  by  a  benev- 
olent order  being  "examined"  and  blanks  being 
filled  out  amid  noise  and  confusion  which  made  it 
impossible  to  determine  the  answers  to  the  ques- 
tions printed  on  the  blanks.  So  far  as  I  know  the 
public  health  authorities  had  nothing  to  do  with 
this;  but  it  seems  that  such  bringing  together  from 
hither  and  yon  of  scores  of  naked  babies  should  be 
under  control  of  those  charged  with  disease  pre- 
vention. 

Frequently  we  hear  doctors  blamed  for  not  im- 
munizing all  their  patients  against  the  diseases  they 
would  be  likely  to  contract  and  for  which  we  have 
immunizing  agents.  That  many  of  us  are  not  as 
persistently  zealous  in  this  cause  as  we  should  be 
is  admitted:  but  it  is  well  to  remember  that  doctors 
have  no  power  to  compel  their  patients  to  accept 
inoculations;  that  inoculations  are  neither  sure  to 
prevent  disease  nor  entirely  devoid  of  danger;  and 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


that  a  doctor  who  gives  honest  answers  to  ques- 
tions on  these  points  is  apt  to  give  fewer  inocula- 
tions than  is  the  doctor  who  represents  them  as 
absolutely  certain  and  safe.  The  recklessness  of  tell- 
ing any  patient  that  any  surgical  procedure  is  safe  is 
illustrated  by  a  case  in  the  papers  within  the  past 
week,  in  which  it  was  alleged  a  wart  was  removed 
from  a  man's  abdominal  wall  with  the  assurance 
that  it  was  a  very  trivial  matter,  entirely  safe,  and 
that  he  would  be  all  right  in  a  day  or  two;  but  in 
a  few  days  the  patient  was  dead. 

My  own  answer  to  the  question,  "Is  it  safe?"  is, 
"There  is  nothing  absolutely  safe  but  death."  I 
go  on  to  say  that  it  is  safer  to  have  it  done  than 
not  to  have  it  done. 

We  don't  know  as  much  about  preventive  or  cura- 
tive medicine  as  we  pretend.  My  own  lukewarm- 
ness  to  periodic  examinations  is  because  of  this, 
and  a  few  other  things.  As  it  now  stands  it  is 
doubtful  if  the  good  accomplished  by  the  detection 
of  early  remediable  disease  would  outweigh  the  evil 
from  doctors  interpreting  as  pathological  what  is 
really  only  abnormal,  and  from  many  patients'  de- 
veloping health  obsessions.  Besides,  pretty  nearly 
all  remediable  disease  conditions  announce  them- 
selves. 

The  combined  knowledge  of  public  health  offi- 
cials and  private  practitioners  is  as  necessary  for 
working  out  public  health  programs  as  their  com- 
bined action  is  necessary  for  putting  these  programs 
into  e.xecution. 

There  is  a  field,  though,  in  which  public  health 
officials  can,  alone,  accomplish  wonders  for  the 
health  of  the  people.  Indeed  the  help  of  the  private 
doctors  would  be  a  hindrance  in  this  field. 

To  Dr.  Thomas  F.  Wood  the  State  Board  of 
Health  of  North  Carolina  owes  its  origin.  Dr. 
Wood  said  in  his  presidential  address  to  the  Medi- 
cal Society  of  the  State  in  1882  that  the  functions 
of  this  Board  "necessarily  include  the  protection 
of  the  people  against  the  malpractice  of  unauthor- 
ized medical  men."  The  health  officers  of  the  State 
and  its  subdivisions  are  looked  upon  as  the  sentries 
on  guard  over  the  people's  health.  The  people 
think  these  carefully-chosen  sentries  know  what  will 
be  injurious  to  their  health,  that  they  are  alert  to 
detect  injurious  influences  and  that  they  will  be 
swift  to  raise  an  alarm  when  the  people's  health  is 
threatened.  Therefore,  when  impostors  of  many 
kinds  come  among  us  blatantly  advertising  their 
ability  to  cure  cancer,  high  blood-pressure,  diabetes, 
Bright's  disease — any  and  everything — by  some 
.secret  expensive  process;  silence  of  those  chosen 
and  paid  to  "protect  the  people  against  the  mal- 
practice of  unauthorized  medical  men"  is  certainly 
reasonable  evidence  that  these  quacks  can  do  all 
they  profess  to  be  able  to  do.     If  a  County  Med- 


ical Society,  or  an  individual  practitioner  prose- 
cute, the  answer  is  ready:  The  paid  protector  of 
the  public  health  has  not  raised  his  voice,  it  is 
obvious  that  these  doctors  are  actuated  by  envy 
and  greed.  The  same  applies  to  the  State  Board 
of  Medical  Examiners,  for  the  Board  is  made  up 
of  private  practitioners.  By  every  law  of  reason, 
of  right  and  of  expediency  the  health  officials  in 
North  Carolina  are  the  proper  persons  to  lead  in 
persistently  enforcing  the  Medical  Practice  Act; 
and  it  would  be  appropriate  for  them  to  exert  them- 
selves in  the  enforcement  of  the  speed  regulations, 
for  all  that  prevents  unnecessary  death  is  within 
their  province.  If  every  doctor  would  do  his  ut- 
most to  have  enacted  a  proper  law  requiring  that 
every  automotive  vehicle  operated  on  the  roads  or 
streets  of  North  Carolina  be  equipped  with  a  gov- 
ernor set  at  the  legal  speed  limit,  it  would  mean 
the  saving  of  a  world  of  profitless  work  to  most 
of  us  and  of  the  lives  of  a  good  many  of  us.  Doc- 
tors have  to  travel  at  all  hours  of  day  and  night, 
however  unsafe  reckless  speeders  may  be  making 
the  roads. 

We  rarely  hear  now,  as  it  was  common  to  hear 
ten  and  fifteen  years  ago,  that  in  a  short  time  the 
average  life  span  will  be  a  hundred  or  a  hundred 
and  twenty  years.  I  never  took  any  stock  in  such 
wild  tales,  and  all  along  I  have  taken  the  position 
that  little  prolongation  of  life  beyond  the  scriptural 
four-score  could  be  expected;  and  that  such  pro- 
longation, could  it  come  to  pass,  would  be  calami- 
tous indeed.  In  his  lecture  to  the  New  York  Acad- 
emy of  Medicine  last  December,  Dr.  Alexis  Carrel 
used  the  plain  if  not  blunt  words:  "Civilized  coun- 
tries are  encumbered  with  those  who  should  be 
dead."  I  would  not  adopt  his  words,  but  my  rea- 
soning goes  along  with  his  that  the  success  of  our 
battle  against  death  has  almost  suppressed  natural 
selection  through  which  the  strong  and  intelligent 
persisted  to  develop  the  great  races.  Yet  not  one 
year  has  been  added  to  the  life-span  of  the  indi- 
vidual. 

Dr.  Carrel's  subject  is  The  Mystery  of  Death 
and,  because  of  the  peculiar  concern  of  doctors 
with  death,  I  give  a  concluding  sentence  of  his 
which  is  full  of  meaning  for  us  all:  "In  general, 
death  is  like  the  end  of  a  dull,  mediocre,  sad  day; 
sometimes  the  peace  of  sunset  in  the  mountains; 
or  the  rest  of  the  hero  after  the  battle;  exception- 
ally the  immersion  of  the  soul  in  the  splendor  of 
God." 

We  often  hear  it  argued  that  by  giving  their 
services  in  examining  and  operating  campaigns 
doctors  in  private  practice  eventually  profit  by 
reason  of  the  educational  value  of  the  work  done 
There  is  such  a  thing  as  giving  out  so  many  free 
samples  as  to  automatically  cut  off  sales,  as  many 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


a  drug  firm  has  learned  to  its  sorrow.  My  own 
opinion  is  that  the  free,  or  almost-fee,  school  clinic 
has  about  served  its  time.  Some  public  health 
orators  tell  us  we  private  practitioners  could  make 
more  than  half  our  living  preventing  disease.  I 
would  like  to  see  a  demonstration. 

The  argument  that  since  the  State  attempts  to 
educate  children  it  should  provide  that  they  be 
examined  to  learn  if  they  are  healthy  enough  to 
take  an  education  is  specious,  unless  we  want  to 
accept  the  whole  program  of  the  Socialist  party.  It 
is  obvious  that  food,  shelter  and  clothing  are  ne- 
cessities for  every  child;  while  the  medical  exam- 
ination will  disclose  important  remediable  defects 
in  only  a  ]ew;  so,  if  the  State  assumes  the  obliga- 
tion of  bringing  the  child  to  the  class-room  in  good 
physical  condition,  it  must  assume  the  obligation 
of  sheltering,  feeding  and  clothing  him;  and  if  it 
must  do  these  things  for  the  school-child,  it  must 
do  them  for  those  too  young  to  go  to  school  and 
for  the  parents,  for  how  can  a  child  put  his  mind 
on  his  studies  when  he  knows  his  little  brothers 
and  sisters  and  his  parents  have  not  these  necessities 
of  life? 

It  is  a  striking  fact  that  the  great  majority  of 
those  who  proclaim  that  we  doctors,  ourselves, 
must  make  a  radical  change  in  our  way  of  render- 
ing medical  service,  or  some  outside  body  is  going 
to  make  the  change,  are  those  who  would  not  b3 
injured  by  such  a  development.  There  is  no  evi- 
dence to  support  this  statement:  there  is  a  world 
of  evidence  on  the  other  side.  Doctors  in  private 
practive  have  better  than  average  sense  and  they 
make  better  than  average  use  of  it;  and  they  are 
the  ones  who  would  be  most  immediately  injured 
by  the  taking  over  of  Medicine  by  the  State.  Some- 
how, I  just  can't  work  up  much  alarm  when  sala- 
ried doctors  tell  us  that  unless  we  voluntarily  sur- 
render a  great  part  of  our  field  of  endeavor  and  a 
great  part  of  our  living  to  salaried  Medicine,  some 
mysterious  agency  is  going  to  take  over  the  whole 
of  the  field.  Well-meaning  as  a  good  many  of  these 
warnings  are,  I  believe  they  are  based  mostly  on 
inaccurate  observation  and  unsound  reasoning;  and 
I  shall  continue  to  put  my  trust  in  the  opinions  of 
those  whose  daily  and  nightly  ministrations  enable 
them  to  learn  what  the  people  think  and  whose 
concern  for  their  very  existence  would  cause  them 
to  take  alarm  if  there  were  any  general  sentiment 
for  a  radical  change  in  rendering  medical  care. 

Finally,  I  would  love  to  see  the  valuable  material 
published  now  in  the  Bulletin  of  the  State  Board  of 
Health  reach  the  people  through  the  daily  papers 
of  the  State.  I  do  not  believe  any  one  thinks  that 
material  published  in  a  bulletin  gets  the  same  read- 
ing or  consideration  as  that  appearing  in  the  daily 
papers,  and  I  would  love  to  see  those  fine  things 


that  are  written  and  got  together  by  Dr.  G.  M. 
Cooper  put  before  the  people  in  the  most  effectual 
way.  Possibly  it  might  be  well  to  continue  the 
Bulletin,  printing  in  smaller  numbers  to  reach  some 
who  do  not  read  the  daily  papers.  I  am  confident 
the  large  papers  of  the  State  would  contribute  space 
to  the  State  Board  of  Health,  as  I  know  some  of 
them  do  to  local  health  agencies.  Through  the 
daily  papers,  besides  such  matter  as  is  now  carried 
in  the  Bulletin,  statements  of  the  essential  facts 
about  cancer,  tuberculosis,  appendicitis,  pellagra, 
high  blood  pressure,  Bright's  disease,  diabetes  and 
so  on,  could  be  repeated  frequently  enough  to  have 
a  tremendous  influence  in  guiding  the  people  aright 
and  in  preventing  them  from  being  hurtfully  influ- 
enced by  whatever  quack  propaganda  may  be  con- 
spicuously before  the  people  at  the  time. 

Mr.  Chairman,  and  gentlemen,  I  believe  when 
these  recommendations  are  carried  into  effect  the 
result  will  be  for  the  good  of  the  Public  Health 
Organizations  of  the  State  and  of  Medicine  in  the 
State;  and  that  the  greatest  good  will  accrue  to 
those  we  jointly  serve — the  people  of  the  State. 


Protecting  the  Public  and  Protecting  the 
Rights  of  Regular  Licensed  Doctors 

This  journal  believes  firmly  that  the  protection 
of  the  people  of  North  Carolina  against  pretenders 
to  medical  knowledge  is  a  duty  of  health  officers, 
and  that  this  is  one  of  the  most  important  duties  of 
every  health  officer.  It  believes  that  it  also  is  the 
duty  of  health  officers  to  protect  licensed  doctors 
against  the  competition  of  these  pretenders,  be- 
cause, after  the  pretenders  are  allowed  to  take  all 
their  money  these  poor  victims  must  be  taken  care 
of  by  regular  licensed  doctors;  and  for  the  further 
reason,  as  stated  by  Judge  E.  J.  Hasten,  of  Chi- 
cago, in  a  recent  decision,  "Quack  doctors  are  death 
dealers  and  a  menace  to  the  reputable  medical  pro- 
fession. In  reality,  they  prevent  ignorant,  gullible 
persons  from  getting  the  services  of  competent  phy- 
.^icians.  Instead  of  healers  they  become  killers  in- 
directly." 

Are  the  Health  Departments  indifferent  to  the 
activities  of  quack  doctors,  who  instead  of  healers 
beccm.e  killers?  Since  private  practitioners  have, 
by  the  very  erection  of  Health  Departments,  tied 
their  own  hands — in  this  State — are  health  officers 
going  to  continue  to  regard  with  a  shrug  this  men- 
ace to  the  reputable  medical  profession? 

It   seems  to   be  rather   general  practice   in   the 
various  States  to  charge  the  State  Board  of  Medi-  a 
cal  Examiners  with  prosecuting  those  who  infringe,] 
the  laws  made  for  the  protection  of  health. 

Our  recollection  is  clear  of  efforts  of  the  Board 
of  Medical  Examiners  of  North  Carolina  to  per- 
form this  service,  and  of  how  those  efforts  were 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


frustrated  by  delays,  postponements,  appeals  and 
other  tricks  of  The  Law:  so  there  is  no  disposition 
here  to  hold  it  against  our  Board  that  we  never 
hear  of  its  beins;  successful  in  getting  convictions. 

It  seems,  though,  that  at  least  one  Board  of 
Medical  Examiners  has  been  able  to  impress  these 
malefactors  with  the  fact  that  it  is  not  to  be 
flouted. 

According  to  the  May  issue  of  the  Journal  of  the 
Medical  Society  of  New  Jersey: 

The  Board  of  Medical  Examiners  of  New  Jersey  reports 
an  enforcement  of  the  Medical  Practice  Act  since  its  last 
report  (apparently  from  Sept.  1st) :  Sept.  18th — One  mid- 
wife's license  suspended  for  1  year.  Oct.  23rd — One  man 
operating  a  blood-pressure  machine  on  the  Boardwalk  at 
.\t!antic  City  and  a  lecturer  who  diagnosed  and  prescribed 
found  guilty  of  practicing  medicine  without  a  license,  and 
another  who  advertised  his  ability  to  cure  rheumatism  in 
three  days  pleaded  guilty.  Nov.  6th — A  drug  store  pro- 
prietor and  one  who  advertised  by  loud  speaker  a  new 
treatment  for  sinu=  troubles,  hayfever  and  asthma  were 
found  guilty  and  a  naturopath  pleaded  gui'ty. 

November  12th,  a  druggist  pleaded  guilty;  November 
18th,  a  druggist,  and  January  8th,  an  unlicensed  chiroprac- 
tor, pleaded  guilty;  January  10th,  a  man  who  was  practic- 
ing electro-therapy  was  found  guilty  of  practicing  medicine 
without  a  license. 

January  15th,  the  board  revoked  a  license  to  practice 
medicine  and  surgery;  January  30th,  a  man  practicing 
masso-therapy  pleaded  guilty;  February  IPth  a  woman 
who  treated  cancer  by  use  of  a  caustic  paste,  was  found 
guilty  for  the  second  time  of  practicing  medicine  without 
a  license. 

February  26th,  the  board  revoked  a  doctor's  license  to 
practice  medicine  and  surgery. 

In  a  six-months"  period  three  licenses  revoked 
or  suspended,  three  found  guilty  and  six  pleaded 
guilty — thus  evidencing  their  having  given  up  hope 
of  escaping  conviction! 

Jersey  justice  has  a  high  reputation,  and  these 
and  other  recent  happenings  in  that  State  tend  to 
keep  it  high.  ]Most  likely  there  is  some  vital  con- 
nection between  the  making  and  maintaining  of 
this  reputation  and  the  fact  that  the  Constitution 
of  the  State  of  New  Jersey  requires  that  at  least 
two  (we  believe  three)  of  the  members  of  its  high- 
est court  be  non-lawyers! 

We  realize  the  difficulties  under  which  our  own 
Board  labors,  so  we  are  not  condemning.  Rather 
our  attitude  is  that  of  the  rooster  that  brought 
home  an  ostrich  egg,  assembled  his  harem  and  an- 
nounced: "Now,  ladies,  I'm  not  complaining,  only 
showing  you  what  other  ladies  are  putting  out." 

This  for  the  attention  of  our  Board  of  Examiners 
during  the  short  time  before  the  State,  County  and 
City  Boards  of  Health  of  North  Carolina  take  over 
their  rightful  job  of  protecting  the  people's  health 
and  protecting  doctors'  rights. 


Correction 

Our  issue  for  April  carried  an  article  on  Evalua- 
tion of  Various  Treatments  for  Narcotic  Drug  Ad- 
dictions, which  states  (p,  200)  "It  is  unfortunate, 
if  the  drug  |Rossium|  has  merit,  that  it  is  rec- 
ommended only  after  the  morphine  has  been  dis- 
continued." 

The  Medico  Chemical  Corporation  of  .\merica 
sends  us  literature  and  this  information; 

"From  the  enclosed  literature  on  Rossium  in  the 
treatment  of  morphine  addicts  and  alcoholics  it  is 
clear  that  Rossium  is  always  to  be  given  for  the 
first  48  hours  together  with  morphine,  after  which 
time  morphine  is  withdrawn  completely  and  Ros- 
sium is  continued  for  several  days  to  alleviate  the 
withdrawal  symptoms.  This  aspect  of  prescribing 
Rossium  with  morphine  during  the  first  48  hours 
is  the  vital  point  in  the  treatment."  .... 

The  brochure  sent  by  the  company  to  us  bears 
out  the  company's  statement,  and  we  gladly  express 
our  regrets  and  make  this  correction. 


Watchful  w.^iting  for  spontanf.ous  sf-pakation  of  tiik 
PLACENTA  is  much  safer  than  undue  manipulation. 


Does  Keeping  Urine  Sugar-free  Suffice.'' 

Following  Mosenthal's  paper  of  August,  1935, 
on  the  optimum  range  of  blood  sugar  in  diabetes, 
a  symposium  on  the  subject  was  held  in  January 
of  this  year  by  the  Medical  Section  of  the  New 
York  Academy  of  Medicine  and  the  New  York 
Diabetes  Association. 

Dr.  Stanhope  Bayne-Jones  gave  it  as  his  opinion 
that  "the  concentration  of  sugar  in  the  blood  of 
diabetics  has  little  or  nothing  to  do  with  their  state 
of  resistance  or  susceptibility  to  infection."  Dr. 
H.  E.  Himwich,  after  stating  that  "a  high  level  of 
blood  sugar  is  not  necessarily  a  sign  of  impairment 
of  the  functions  of  the  islands  of  Langerhans  but 
may  indicate  instead  a  mobilization  of  liver  glyco- 
gen due  to  overactivity  of  other  endocrine  glands," 
agrees  with  Mosenthal's  suggestion  that  the  disad- 
vantage of  high  blood  sugar  lies  in  the  resulting 
dehydration. 

Dehydration  is  produced  by  two  methods:  first, 
by  the  elimination  of  ketone  bodies,  combined  with 
sodium  salts,  the  loss  of  sodium  being  followed  by 
the  loss  of  water:  second,  marked  glycosuria  is 
accompanied  by  an  increase  in  both  water  and  so- 
dium salts  in  the  urine.  "High  blood  sugar  of 
itself  produces  no  dehydration."  Himwich's  con- 
clusions are:  (1)  The  level  of  the  blood  sugar  is  a 
resultant  of  the  activity  of  various  endocrine  glands. 
It  is,  therefore,  not  necessarily  an  index  of  im- 
paired ability  of  the  islands  of  Langerhans  but  may 
indicate  instead  hyperfunction  of  the  adrenal,  the 
thyroid,  and  particularly  of  the  anterior  pituitary 
glands.  (2)  During  diabetes  as  in  the  normal, 
an  increased  concentration  of  blood  sugar  serves  as 
a  stimulus  to  carbohydrate  metabolism  and  there- 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1036 


fore  is  not  to  be  combat  ted  unless  accompanied  by 
a  definite  glycosuria.  (3)  Dehydration  may  be  a 
result  of  glycosuria.  The  development  of  a  marked 
glycosuria  should,  therefore,  never  be  permitted  to 
continue  even  for  short  periods.  (4)  And  finally, 
as  a  result  of  the  three  previous  conclusions,  it  fol- 
lows that  the  glucose  content  of  the  urine  rather 
than  that  of  the  blood  should  be  taken  as  the  cri- 
terion of  the  amount  of  insulin  indicated  in  diabetes 
mellitus. 

Dr.  Edward  Tolstoi,  after  discussing  the  value 
of  blood  sugar  estimations  in  the  diagnosis  and 
prognosis  of  diabetes  mellitus,  says  that  while  nor- 
mal blood  sugar  in  diabetes  is  the  optimum  goal, 
he  does  not  think  it  advisable  to  lower  blood  sugar 
levels  of  200  to  2S0  mgs.,  "since  there  is  no  clear 
evidence  that  a  hyperglycemia  without  a  glycosuria 
is  damaging  and,  furthermore,  such  a  condition  may 
even  be  desirable  in  a  certain  group  of  diabetic 
patients."  He  believes  that  hyperglycemia  per  se 
does  not  predispose  to  infections  and  that  there  is 
no  sufficient  evidence  that  it  causes  vascular  sclero- 
sis. 

lft-.dia&uasing  these  papers  both  Dr.  Elaine  Ralli 
and  Dr.  H.  R.  Geyelin  stressed  the  relationship  of 
poorly  balanced  nutrition  to  infection  in  diabetes. 
Dr.  Frederick  M.  Allen  on  the  other  hand  was 
strong  in  favor  of  normal  blood  sugar,  being  op- 
posed to  the  idea  that  dehydration  was  responsible 
for  the  susceptibility  of  diabetes  to  infection.  He 
also  pointed  out  that  "diabetes  has  never  been 
proved  to  result  from  disorder  of  any  gland  or 
combination  of  glands  in  the  presence  of  a  normal 
pancreatic  island  function.'' 

Allen  said  in  long-standing  diabetes  he  had  seen 
retinitis  and  gangrene  develop  in  the  presence  of 
high  blood  sugar  and  sugar-free  urine,  and  subside 
with  the  reduction  of  the  blood  sugar.  Mosenthal 
said  he  had  yet  to  see  a  case  of  diabetic  gangrene, 
cataract,  or  arteriosclerosis  in  which  there  had  not 
been  a  preceding  period  of  at  least  five  years  in 
which  there  had  been  persistent  glycosuria. 

Allen  believes  "there  is  no  particular  difficulty 
in  keeping  the  blood  sugar  within  an  approximately 
normal  range,"  while  JNIosenthal  states  that  "text- 
books on  diabetes  and  the  dictum  of  various  dia- 
betes specialists  are  distinctly  at  fault  when  they 
state  that  a  normal  blood  sugar  is  readily  achieved 
and  easily  maintained." 

The  general  practitioner  will  watch  this  contro- 
versy with  interest  because  he  knows  that  after  he 
has  established  his  patient  on  a  maintenance  diet, 
in  some  months  he  will  return  not  only  with  in- 
creased blood  sugar  but  with  intermittent  glycos- 
uria, and  have  to  be  straightened  out  again.  Allen 
years  ago  said  a  diabetic  lost  track  of  was  a  failure. 
—WILLIAM  ALLAN. 


Obituary 

Dr.  Tom  Anderson 

His  doctor  friends  called  him  Dr.  TomAnder- 
son,  just  as  thoitgh  the  name  had  been  one  word. 
Most  likely  nobody  knows  how  this  habit  got  start- 
ed. It  was  so  fitting  that  no  one  thought  to  ask 
for  an  explanation. 

In  the  early  years  of  his  practice  his  town  of 
Statesville  was  among  the  foremost  in  the  State. 
With  the  passing  of  years  other  municipalities  grew 
larger  and  more  populous;  but  for  education,  for 
culture  and  for  the  quality  of  its  professional  men, 
the  Iredell  capital  has  maintained  its  high  rank. 

Dr.  Anderson  always  knew  that  man  is  a  whole, 
that,  well  or  sick,  he  must  be  dealt  with  as  a 
whole,  and  that  the  best  and  most  responsible  post 
in  medicine  is  that  of  family  doctor.  So  he  felt  no 
urge  to  migrate  to  a  city,  and  he  saw  no  occasion 
for  becoming  transformed  into  a  specialist. 

It  was  not  for  him  to  seek:  he  was  sought  out 
and  his  talents  enlisted  for  wide  service  on  the 
Board  of  Medical  Examiners  and  the  Board  of 
Health  of  his  State,  and  for  making  ready  when 
his  Country  was  forced  into  war. 

In  the  fifty  years  and  more  that  he  went  about 
the  streets  and  the  roads  of  his  town  and  county, 
who  would  undertake  to  put  an  estimate  on  the 
cares  lifted,  the  pains  soothed,  the  lives  lengthened 
and  brightened? 

After  more  than  half  a  century  of  devoted  and 
skillful  ministering  to  those  who  called  him  "my 
doctor,"  and  many  months  of  invalidism,  he  rests 
from  his  labors  and  is  eased  of  his  sufferings. 

Successful  in  all  lesser  ways,  he  was  successful 
in  the  highest  way — in  deriving  his  own  full  meas- 
ure of  happiness  from  adding  immeasurably  to  the 
happiness  of  his  patients  and  his  friends. 


NEWS  ITEMS 


.\t  the  semi-annual  meeting  of  the  First  District  Med- 
ical Association,  held  at  Walterboro,  May  28th,  at  4  p. 
m.,  Dr.  Willis  spoke  on  Radiation  Therapy  in  the  absence 
of  Dr.  H.  Rusisell;  Dr.  F.  A.  Hoshall  on  Compound  Frac- 
tures of  the  Leg;  Dr.  Wm.  H.  Prioleau  on  Removal  of 
Needles  from  the  Hand  (lantern  slides)  ;  and  Dr.  Kenneth 
Lynch  gave  notes  on  the  recent  meeting  of  the  A.  M.  A. 

•After  these  interesting  talks  the  following  officers  were 
elected:  Dr.  C.  P.  Ryan  of  Ridgeland,  president;  Dr. 
Riddick  Ackerman,  jr.,  Walterboro,  vice  president;  Dr. 
John  van  de  Erve,  Charleston,  treasurer. 

The  next  meeting  will  be  held  at  Ridgeland  in  Novem- 
ber. 

Dr.  Kenneth  M.  Lynch  and  Dr.  J.  Cannon,  Charleston, 
were  delegates  from  the  South  Carolina  Medical  Associa- 
tion to  the  recent  meeting  of  the  A.  M.  A. 

Dr.  F.  A,  Hoshall,  Charleston,  addressed  the  Charleston 
Kiwanis  Club  May  2Sth,  on  Newly  Established  Crippled 
Children's  Clinic  in  Charleston  Countv. 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


351 


Eli  Lilly  and  Company 


FOUNDED     i  8  76 


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with  pernicious  anemia  in  relapse  and  successfully 
maintain  the  remission  on  a  dosage  which  in  weight 
and  bulk  is  considerably  less  than  is  required  with 
powdered  liver  extract. 

Being  administered  in  capsules  'Extralin'  possesses 
all  of  the  advantages  of  oral  therapy  for  patients  who 
must  continue  treatment  indefinitely. 

'Extralin'  (Liver- Stomach  Concentrate,  Lilly)  is 
supplied  in  bottles  of  84  pulvules  (filled  capsules) 
and  in  bottles  of  500  pulvules. 


Prompt  Attention  Qivett  to  Professional  Jncfuiries 

PRINCIPAL    OFFICES    AND    LABORATORIES,    INDIANAPOLIS,    INDIANA,    U.S.A. 


Please  Mention  THIS  JOURNAL  When  Writing  to  Advertisers 


352 


SOUTHERN  MEDICINE  AND  SURGERY 


June,  193(3 


Declaring  that  "with  proper  prenatal  care  we  can  make 
maternity  a  safe  adventure,"  Dr.  J.  Sumter  Rhame  of 
Charleston,  addressed  Palmetto  Post  No.  112  of  the  Ameri- 
can Legion  at  its  regular  meeting. 

Dr.  William  R.  Barron  and  Dr.  James  E.  Boone,  senior 
assistant  physician  at  the  South  Carolina  State  Hospital, 
attended  the  National  Convention  of  the  American  Urolo- 
gic  Association  and  the  clinic  which  was  held  in  New  York 
City  in  connection  with  this  convention. 


Buncombe  County  (N.  C.)  Medical  Society,  Asheville, 
regular  meeting  evening  of  May  18th,  50  members  present. 

The  society  was  addressed  by  Dr.  LeGrand  Guerry  of 
Columbia,  S.  C,  on  The  Late  Case  of  Suppurative  Ap- 
pendicitis, the  Management.  He  outlined  his  method  found 
most  successful  from  over  30  years  of  experience.  Ques- 
tions were  asked  by  Drs.  Ward,  Herbert,  Colby,  White, 
Brown,  etc.,  closed  by  the  essayist. 

Dr.  Moore  introduced  the  following  resolution: 

That  the  Buncombe  County  Medical  Society  go  on  rec- 
ord as  expressing  its  deep  appreciation  and  hearty  thanks 
to  Mrs.  L.  M.  Griffith  and  the  ladies  of  her  committee  for 
the  entertainment  afforded  the  members  of  the  Women's 
Auxiliary  during  the  recent  meeting  of  the  Medical  Society 
of  the  State  of  North  CaroUna  and  to  Mrs.  Paul  H.  Ringer 
and  to  Mrs.  G.  Farrar  Parker  for  entertaining  at  the  Bilt- 
more  Forest  Country  Club. 

Resolution  seconded  by  Dr.  Swann.  Carried  unani- 
mously. 

The  president  commended  Dr.  J.  L.  Ward,  the  chairman 
of  the  committee  on  arrangements  for  the  recent  State 
Med.  Soc.  meeting,  for  the  fine  manner  in  which  he  handled 
all  the  details  of  the  meeting.  Dr.  Ward  expressed  his 
thanks.  Dr.  White  moved  that  the  society  give  Dr.  Ward 
a  standing  vote  of  appreciation  and  thanks.  Sec.  and 
carried  and  duly  executed. 

Dr.  Clark  announced  to  the  society  the  spring  meeting 
of  the  10th  District  Medical  Society  at  Spruce  Pine  on 
May  27th. 

The  Tenn.  Valley  Med.  Assn.  meeting  m  Knoxville  on 
June  10th-12th  with  all  visiting  speakers  was  announced 
and  our  members  urged  to  attend. 

Buncombe  County  (N.  C.)  Medicai,  Society,  Asheville, 
regular  meeting  the  evening  of  June  1st  at  the  City  Hall 
Bldg.,  Vice  President  Kutscher  in  the  chair. 

Meeting  called  to  order  and  minutes  of  the  previous 
meeting  of  the  society  read  and  approved,  42  members 
present. 

The  chair  recognized  Rev.  George  Floyd  Rogers  and  Dr. 
R.  F.  Campbell  of  the  Ministerial  Association.  Mr.  Rogers 
introduced  the  matter  of  the  Good  Samaritan  Mission,  an 
organization  to  render  financial  aid  to  our  indigent  sick. 
Dr.  Campbell  spoke  of  the  financial  appeal  that  would 
soon  be  made  to  establish  an  endowment  fund  for  this 
mission  and  asked  our  members  to  send  in  to  that  organi- 
zation the  names  of  certain  persons  in  their  acquaintance 
who  could  be  appealed  to  to  contribute  to  this  endowment 
fund.  Mr.  Rogers  announced  that  a  similar  appeal  would 
soon  be  made  to  large  financial  interests  in  the  North. 

A  moving  picture  of  Obstetrical  Forceps  Operations,  pre- 
pared by  Dr.  J.  B.  DeLee,  of  Chicago,  was  presented  by 
Dr.  John  A.  Watkins. 

(Signed)     M.  S.  Broun,  M.D.,  Sec. 


The  program  presented  in  the  Community  House  was 
a  medical  event  in  this  area,  bringing  to  physicians  of  the 
State  a  symposium  which  was  a  feature  at  the  recent 
meeting  of  the  American  Medical  Association  convention. 
The  session  opened  at  2  and  continued  until  late  at  night 
with  a  banquet  held  at  6. 

Ever\'  phase  of  Gallbladder  Disease  was  discussed  by 
Dr.  R.  Franklin  Carter,  associate  professor  of  surgery, 
and  three  of  his  associates  of  the  Post  Graduate  Medical 
School  and  Hospital  of  New  York.  Coming  here  with  him 
to  take  part  in  the  program  were  Dr.  John  Russell  Twiss, 
Dr.  Milton  A.  Bridges,  and  Dr.  Hubbard  Lynch,  all  of  the 
staff  of  the  New  York  institution. 

The  group  payment  plan  for  providing  hospital  care  for 
persons  of  low  income  was  also  presented  at  the  session  by 
Dr.  Isaac  H.  Manning  of  Chapel  Hill,  former  dean  of  the 
University  of  North  Carolina  Medical  School  and  now 
president  of  the  Hospital  Savings  Association  of  North 
Carolina. 

Visitors  were  unanimous  in  voicing  their  appreciation  of 
the  program.  The  afternoon  session  was  called  to  order 
by  Dr.  J.  B.  Helms,  chairman  of  the  program  committee, 
whose  membership  included  also  Dr.  J.  B.  Riddle  and  Dr. 
J.  W.  Vernon.  Dr.  Vernon  delivered  the  address  of  wel- 
come in  a  dual  capacity  as  a  local  member  of  the  medical 
society  and  as  mayor  of  Morganton.  Dr.  Glenn  R.  Frye, 
of  Hickory,  responded.  Dr.  Douglas  Hamer,  jr.,  of  Lenpir, 
president  of  the  society,  was  called  to  the  chair  at  the  end 
of  the  preliminaries  and  he  presented  the  speakers. 


Catawba  Valley  Medical  Society. — Morganton  physi- 
cians were  hosts  to  ISO  members  of  the  medical  profession 
of  North  Carolina  at  a  meeting  of  the  Catawba  Valley 
Medical  Society,  May  26th,  for  which  they  had  arranged  a 
clinic  by  recognized  authorities. 


Mecklenburg  County  (N.  C.)  Medical  Society',  June 
2nd,  8  o'clock.  Medical  Library,  Charlotte. 

Symposium  on  Renal  Calculi:  Influence  of  Trauma  on 
the  Formation  of  Renal  Stones,"  Dr.  C.  B.  Squires;  Cystin 
Stones,  Dr.  Robert  W.  McKay;  Address  by  Dr.  W.  M. 
Coppridge,  Durham,  Prevention  of  Recurrence  of  Renal 
Stones. 


Dr.  T.  H.  Hardy,  of  Farmville,  was  elected  president  of 
the  Fourth  District  (Va.)  Medical  Society  at  the  annual 
meeting  at  Waverly,  May  28th.  Other  officers  for  the  en- 
suing year  include  Dr.  J.  L.  H.a.mner.  of  Mannboro,  first 
vice  president;  Dr.  W.  W.  Wilkinson,  of  LaCrosse,  second 
vice  president;  Dr.  C.  E.  Martin,  of  Emporia(  re-elected), 
secretary-treasurer. 


A  Card. —  Lincolnton,  May  2Qth. 

Dear  Dr.  Northington: 

I  read  your  notice  of  my  candidacy  in  5.  M.  &  S.     I 
changed  my  plans  and  withdrew  my  candidacy. 
Yours  very  truly, 

—L.  A.   CROW  ELL,  JR. 


Dr.  J.  K.  Hall,  Richmond,  and  Dr.  H.  C.  Henry,  Su- 
perintendent of  the  Central  State  Hospital,  Petersburg, 
spent  the  night  of  May  30th  at  the  State  Hospital,  Raleigh. 
Dr.  Hall  spoke  to  the  graduating  class  of  nurses. 


Dr.  Jean  McAlister,  of  the  Children's  Hospital,  Phila- 
delphia, daughter  of  Mr.  and  Mrs.  A.  W.  McAlister,  of 
Greensboro,  has  been  appointed  camp  physician  for  Camp 
Yonahlossee,  Blowing  Rock,  for  the  summer  season. 


MARRIED 

Dr.  James  Carr  Eagle  and  Miss  Sadie  Mondell  Ellen- 
burg  were  married  at  the  bride's  home  in  Salisbury  on 
May  16th.     Dr.  Eagle  practices  in  Spencer. 


June,  1036 


SOUTHERN  MEDICINE  AND  SURGERY 


QJletrazol 


^<^i*° 


-d^"^ 


INJECT  I  or  2  ampules  Metrazol  as  a  restorative 
in  circulatory  collapse  and  shock,  respiratory 
distress,  deep  anesthesia,  and  in  morphine  and 
barbiturate  poisoning.  For  circulatory  stimulation 
in  the  emergencies  of  pneumonia  and  other  over- 
whelming infections,  and  in  congestive  heart  failure, 
give  V/i  to  3  grains  Metrazol  three  times  a  day. 

METRAZOL    (pentamethylentetrazoO  Councll  Accepted 

Uniform  dosage:  I  Ampule  (l  cc.)  =  I  Tablet  =  l^2  grain  Metrazol  Powder, 


BILHUBER-KNOLLCORR    l54  0GDENAVE..JEJlSEyCITy.N.J. 


Dr.  Morton  Morris  Pinckney,  Richmond,  and  Miss  Louise 
Lippitt  Sinnickson,  Bryn  Mawr,  Pennsylvania,  were  mar- 
ried in  the  home  of  the  bride  on  May  16th. 


Dr.  Jackson  Townsend  Ramsaur,  of  Cherryville,  and 
Miss  Lucile  Byrd  Draughon,  of  Durham,  were  married  at 
the  home  of  the  bride  on  May  30th. 


Dr.  Norman  Owen  Spikes,  of   Durham,  and  Miss  Vera 
Beatrice  Baldwin,  of  Atlanta,  were  married  there  on  May 

24th. 


Deaths 

Dr.  Charles  Sidney  Tate,  for  over  40  years  a  practic- 
ing physician  and  surgeon  in  Ramseur  and  Randolph  Coun- 
ty, died  May  2Sth.  He  had  been  in  failing  health  since 
last  fall  when  he  underwent  a  major  operation.  Following 
his  graduation  from  the  State  University,  he  entered  the 
Baltimore  Medical  College  and  was  graduated  in  Medicine 
in  1S93.  He  had  served  as  county  coroner,  member  of  the 
local  school  board,  the  county  board  of  health  and  at  the 
time  of  his  death  was  president  of  the  Randolph  County 
Medical  Society.  He  was  also  a  member  of  the  North 
CaroHna  Medical  Society  and  the  American  Medical  As- 
sociation. 


Dr.  Callie  P.  Capps,  68  (M.  C.  V.,  '95),  native  of 
Greensboro,  died  at  his  home  in  Meherrin,  Va.  Death 
was  caused  by  a  heart  attack,  but  he  had  been  ill  for 
several  months. 


Dr.  Charles  C.  Ramsay  died  in  Baltimore  on  May  10th, 
and  was  buried  at  his  old  home  at  Hickory,  North  Caro- 
lina. 


Anal-  Sed 


Analgesic,   Sedative   and   Antipyretic 

.Affords  relief  in  migraine,  headache,  sciatica  and 
neuralgia.  Rheumatic  symptoms  are  frequently  re- 
lieved by  a  few  doses. 

Description 
Contains   35/2    grains   of    Amidopyrine,    yz    grain    of 
Caffeine  Hydrobromidc  and   IS  grains  of  Potassium 
Bromide  to  the  teaspoonful. 

Dosage 
The  usual  dose  ranges  from  one  to  two  teaspoonfuls 
in  a  little  water. 

How  Supplied 
In  pints  and  gallons  to  physicians  and  druggists. 


Burwell  &  Dunn  Company 

Manujacitiring    {^^^^   Pharmacists 
F^lnhtislird    IS&^     in    1SIS7 


CHARLOTTE,  N.  C. 

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


SOUTHERN  MEDICINE  AND  SURGERY 


June,  1936 


..Refreshing 


Our  Medical  Schools 


Delicious    and 
Refreshing 


WHOO^IiG   OOUGH 


Elixir     Bromaurate 

Cuts  short  the  imiod  ui  tlu'  illness,  reduces  the 
frequency  of  the  attacks,  relieves  the  distressing 
cough  and   gives  the  child  rest  and  sleep. 

Also   valuable    in    BRONCHITIS    and 

BRONCHIAL  ASTHMA 

IN   FOUR-OUNCE   ORIGINAL   BOTTLES— A   teaspoonful   every 

DOCTOR: — We  will  be  glad  to  send  you  a  valuable 
booklet  on  "Gold  in  the  Treatment  of  Whoopmg 
Cough    and    other    Diseases."      Kindly    drop    us    a 


GOLD    PHARMACAL    CO. 


NEW    YORK 


MULL-SOY 

VEGETABLE     MILK  SUBSTITUTE 


A  VALUABLE   FOOD  IN  ALL  TYPES  OF 
MILK    SENSITIVITIES 


Send  for  frc.  sample  and  lileralure 

THE  MULLER   LABORATORIES 

2935   FREDERICK   AVENUE 


Duke 


On  April  23rd,  Dr.  William  J.  Dieckmann,  Associate 
Professor  of  Obstetrics,  University  of  Chicago,  lectured  to 
the  staff  and  students  on  Blood  Volume  Changes  in  Eclamp- 
sia. 

On  May  7th  and  8th,  Dr.  WilUam  P.  Murphy,  Associate 
in  Medicine,  Harvard  Medical  School,  lectured  on  Granu- 
locytopenia and  Deficiencies  and  their  Control  in  Anemia, 
respectively. 

On  May  8th,  the  North  Carolina  Dietetic  Association 
held  its  third  annual  meeting  at  Duke  Hospital,  attended 
by  approximately  90  dietitians. 

The  following  seniors  were  elected  recently  to  Alpha 
Omega  Alpha  Honorarj-  Fraternity:  Elijah  E.  Menefee 
and  Charles  P.  Stevick. 


Medical  College  or  Virginla 


Dr.  William  B.  Porter,  Professor  of  Medicine,  attended 
the  annual  meeting  of  the  South  Carolina  Medical  Associa- 
tion at  Greenville,  giving  a  paper  on  The  Relation  of 
Nutritional  Deficiences  to  Heart  Failure. 

Promotions  in  the  adjunct  faculty  for  the  session  1936-37 
were  as  follows: 

Dr.  Nathan  Bloom  from  Assistant  in  Medicine  to  In- 
structor; Dr.  H.  C.  Spalding  from  Instructor  in  Obstetrics 
to  Associate;  Dr.  W.  T.  Oppenheimer,  jr.,  from  Assistant 
in  Radiology  to  Instructor;  Dr.  Charles  M.  Nelson  from 
Assistant  in  Surgery  to  Instructor;  Dr.  George  D.  Ver- 
-milya  from  Assistant  in  Surgery  to  Instructor.  In  the 
School  of  Dentistrv-,  Dr.  H.  T.  Knighton  was  promoted 
from  Instructor  in  Operative  Dentistry  to  Associate. 

Dr.  RoUand  J.  Main,  Associate  Professor  of  Physiology, 
will  spend  the  summer  month?  in  Europe  visiting  various 
institutions  and  observing  teaching  methods. 

Dr.  Lewis  E.  Jarrett,  Superintendent  of  the  Hospital 
Division,  has  been  re-elected  president  of  the  Virginia 
Hospital  .Association. 

The  fourth  annual  visiting  day  was  held  .April  24th 
with  students  from  12  colleges  attending.  The  group  was 
welcomed  by  the  president  in  the  morning  after  which 
tours  were  made  of  the  various  departments  of  the  institu- 
tion. Luncheon  was  served  to  the  visitors  at  Cabaniss 
Hall. 

Dr.  Harvey  B.  Haag,  Professor  of  Pharmacology,  attend- 
ed the  annual  meeting  of  the  American  Medical  Association 
in  Kansas  City,  discussing  a  paper  on  teaching  and  re- 
search in  pharmacology. 


BOOK  REVIEWS 


THE  COLLECTED  PAPERS  OF  THE  M.AYO  CLINIC 
AND  THE  MAYO  FOUND.ATION.  Edited  by  Richard 
M.  Hewitt,  B.A.,  M.A.,  M.D.  .Lloyd  G.  Potter  and  A.  B. 
Nevling,  M.D.  Volume  XXVII  (Papers  of  1935— Pub- 
lished 1936).  Octavo  of  1353  pages  with  256  illustrations. 
Philadelphia  and  London:  W.  B.  Saunders  Company,  1936. 
Cloth,  ,S12.00  net. 

The  initial  paper  deals  with  esophagitis,  a  condi- 
tion which  few  have  ever  recognized.  Something 
can  be  done  about  it.  All  the  aspects  of  stomach 
lesions  are  well  considered.  The  persistence  of 
symptoms  after  cholecystectomy,  jejunal  ulcer  and 
carcinoma,  obstruction  by  mesenteric  bands,  acute 


June,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


anal  pain,  foods  that  commonly  disagree  with  peo- 
ple, modern  prostate  treatment,  progress  in  goiter 
knowledge,  the  physiologic  approach  to  the  treat- 
ment of  heart  failure,  allergy  and  cataracts,  deter- 
mining the  limits  of  safety  in  roentgenography,  ad- 
vances in  general  anesthesia,  is  the  public  swamp- 
ed with  regard  to  vitamines? — all  these  are  atten- 
tion-arresting subjects. 

An   excellent   volume   for   the   family   doctor   or 
the  specialist. 


F^OR 


DISEASES  OF  THE  RESPIRATORY  TRACT.  Clinical 
Lectures  of  the  Eighth  Annual  Graduate  Fortnight  of  the 
New  York  .\cademy  of  Medicine,  by  21  contributors.  418 
pages  with  56  illustrations.  Philadelphia  and  London: 
W.  B.  Saunders  Company,  1936.     Cloth,  $5.50  net. 

The  declared  object  is  to  offer  the  busy  practi- 
tioner "the  last  word  on  a  given  topic."  Among 
the  subjects  treated  of  in  this  series  are  the  relation 
of  allergy;  the  common  cold;  sinus  disease  from 
infancy  to  old  age;  diseases  of  the  larynx,  trachea 
and  main  bronchi;  bronchoscopy;  bronchiectasis; 
influenza;  chronic  pneumonitis;  pneumonia  in  child- 
hood; tuberculosis;  emphysema:  chronic  empyema; 
pulmonary  abscess,  gangrene,  thrombosis  and  em- 
bolism; atelectasis  and  lung  carcinoma. 

Of  allergy  we  are  told  that  we  must  work  toward 
the  goal  of  a  more  or  less  general  desensitization. 
For  the  common  cold  the  treatment  advised  is  di- 
rected to  preventing  the  patient  harming  himself 
and  others  by  ex-posure  in  the  first  few  days  of  the 
disease  and  toward  palliation.  Sinus  disease  infor- 
mation is  given  briefly  and  to  the  point. 

The  book  lives  up  to  the  promise  in  its  preface 
to  supply  reliable  information  in  few  words. 


ANIMAL  MICROLOGY:  Practical  Exercises  in  Zoolog- 
ical Micro-Technique,  by  Michael  F.  GtrvER,  Professor  of 
Zoology  in  the  University  of  Wisconsin,  with  a  chapter 
on  drawing  by  Elizabeth  A.  (5MiTn)  Bean,  Former  As- 
sistant Professor  in  Zoology  in  the  University  of  Wisconsin. 
Fourth  revised  edition.  The  University  of  Chicago  Press, 
Chicago.     1936.     §2.50. 

This  is  an  excellent,  detailed  and  reliable  guide 


/'  IIVPERTEN 

0J'      HVPERTEN 
ARTERIOS< 


SION    (any    cause) 
PERTENSIVE    CARDIO-RENAL    DISEASE 
ARTERIOSCLER.     CAKDIO-VASCUL.    DISEASE 


DIURBITf)L 

rCRANT)  ■ 


rheobrom.    Sod.    Salyc.         3  gr.  — Dose— 

Phenobarbltal  Vt  BT.  2    tablets 

Calc.  Lact.  I'/i  gr.         3  times  a  day 

tablets;  bottles  oJ  100,  500  (for  hospital  use).  1000 
(dispensing). 

Write    for    Price   List   and   Literature 
GRANT   CHEMICAL   COMPANY 

St   77th   St.  New    York 


PAIN 


The  majority  of  the  phy- 
sicians  in  the   Oarolinas 
are  prescribing  our  new 
tablets 


AND 


751 


Analgesic  and  Sedative     ^  parts      5  parts       I  part 
Aspirin   Phenaeetin   Caffeln 

fFe  will  mail  professional  samples  regularly 
with  our  compliments  if  you  desire  them. 
Carolina  Pharmaceutical   Co.,    Clinton,   S.   C. 


for  Students  of  micro-giology.  The  previous  editions 
have  enjoyed  such  great  popularity  as  to  necessitate 
revision  and  reprinting  at  intervals,  and  now  the 
fourth  edition,  maintaining  the  character  estab- 
lished by  its  predecessors,  becomes  available  for 
those  eager  for  a  book  containing  in  small  compass 
all  that  one  will  need  to  know  about  micro-tech- 
nique in  the  study  of  zoology. 


BIPEPSONATE 


An  antiseptic,  demulcent  corrective  designed 
for  use  in  the  treatment  of  intestinal  disorders, 
especially  those  of  children. 

Average  Dosage 
For  Children — Half  drachm  every  fifteen  min- 
utes for  six  doses,  then  every  hour  until  re- 
lieved. 
For  Adults — Double  the  above  dose. 

How  Supplied 
In  Pints,  Five-Pints  and  Gallons  to  Physicians 
and  Druggists  only. 


Burwell  &  Dunn  Company 


Manufacturing  (^Ssr^    Pharmacists 
Established  iBM')        in    1S87 

CHARLOTTE,  N.  C. 

iple   sent   to  any   physician   in   the   U.    S.   on 


356 


June,  1936 


SECURITY  AGAINST  SICKNESS.  A  Study  of  Health 
Insurance,  by  I.  S.  Falk,  Doubkday,  Doran  &  Co.,  Inc., 
Garden  City,  N.  Y.,  1936,  $4.00. 

This  is  repetition  and  rehash  of  the  report  of 
the  defunct  Committee  on  the  Costs  of  Medical 
Care.    With  that  report  most  of  us  are  familiar. 


Some  Important  Contributions  to  Medical  Science  by 

Military  Surgeons 
(Mai.  Gen.  Robt.  U.  Patterson,  U.  S.  Army,  Retired,  Dean, 
Univ.  of  Oklahoma  Med.  School,  in  Jl.  Okla.  State  Med. 
Assn.,  May) 

Physicians  in  early  times  took  a  much  larger  part  in 
public  life  than  they  do  now.  Many  medical  men  were 
legislators,  judges  and  governors,  or  occupied  other  posi- 
tions of  dignity  and  distinction.  The  medical  man  was 
more  of  a  publicist  and  a  civil  leader  than  is  now  the 
case  on  the  western  hemisphere,  except  in  Latin  American 
countries.  To  cite  a  few  examples  of  medical  men  who 
became  distinguished  outside  of  professional  lines  in  the 
early  days  of  our  country: 

Samuel  Holton,  a  doctor,  was  President  of  Congress  in 
1780. 
Dr.  Arthur  Lee  was  Minister  to  France  in  1776. 
Dr.  John  Bartlett  cast  the  first  vote  for  the  adoption 
of  the  Declaration  of  Independence  and  was  the  first  to 
sign  it  immediately  after  the  President  of  Congress.  Later 
he  was  Chief  Justice  and  then  Governor  of  New  Hemp- 
shire. 

Five  of  the  56  signers  of  the  Declaration  of  Independ- 
ence, and  23  members  of  the  Provincial  Congress  of  Massa- 
chusetts in  1774-75  were  medical  men. 

Dr.  Joseph  Warren  became  a  Major  General  of  the  Mili- 
tia and  was  killed  at  Bunker  Hill. 

Dr.  Oliver  Prescott  became  a  Major  General.  He  was 
the  brother  of  Colonel  Prescott  of  Bunker  Hill  fame. 

Dr.  John  Brooks  was  a  Major  General  and  Governor  of 
Massachusetts. 

Dr.  John  Beatty  served  as  a  Colonel  and  later  was  a 
member  of  Congress. 

Dr.  John  Thomas  became  a  Major  General  and  followed 
Montgomery  in  his  fateful  expedition  to  Quebec,  and  died 
there  of  smallpox. 

Dr.  Hugh  Mercer  was  a  Brigadier  General  of  the  line 
and  was  killed  at  the  battle  of  Princeton. 

Dr.  Arthur  St.  Clair  rose  to  the  grade  of  a  Major  Gen- 
eral. 

Dr.  Edward  Hand  was  a  Brigadier  General. 
Dr.  Henry  Dearborn  served  as  a  Colonel  in  the  Conti- 
nental Army,  and  later  became  a  Major  General. 

Dr.  James  McHenry,  who  entered  the  Revolution  as  a 
surgeon,  filled  the  office  of  Secretary  of  War  during  the 
presidencies  of  Washington  and  Adams.  Fort  McHenry 
was  named  in  his  honor. 

Another  surgeon  in  the  Revolution  was  Dr.  William 
Eustis,  who  served  in  the  legislature  of  Massachusetts, 
was  successively  a  member  of  Congress,  Secretary  of  War, 
Minister  to  Holland,  and  Governor  of  Massachusetts.  Fort 
Eustis  is  named  in  his  honor. 

Of  the  3,500  men  who  were  practicing  medicine  in  the 
U.  S.  at  the  time  of  the  Revolution  only  200  had  medical 
degrees. 

Surgeon  Jonathan  Letterman  of  the  Medical  Depart- 
ment of  the  U.  S.  Army  during  the  Civil  War  was  the  first 
medical  man  to  organize  an  effective  and  complete  ambu- 
lance and  evacuation  service  for  any  army.  Letterman's 
evacuation  plan  became  the  model  for  all  other  armies,  and 
is  still  the  basis  for  our  modern  organization. 


In  sentencing  a  former  barber  (/V.  Y.  State  Jour,  of 
Med.,  Feb.  ISth)  named  Kenneth  Barron  to  jail  for  prac- 
ticing medicine  without  a  license.  Judge  Erwin  J.  Hasten 
of  Chicago  said:  "Quack  doctors  are  death  dealers  and  a 
menace  to  the  reputable  medical  profession.  In  reality, 
they  prevent  ignorant,  gullible  persons  from  getting  the 
services  of  competent  physicians.  Instead  of  healers  they 
become  killers  indirectly."  Barron  operated  the  "Madison 
Western  Clinic"  which  advertised  medical  service  at  cut- 
rate  prices. 


The  great  majority  of  children  who  have  leg  pains  are 
not  suffering  from  rheumatism.  These  non-rheumatic 
pains  are  worse  soon  after  going  to  bed  and  gone  in  the 
morning;  rheumatic  pains  worse  on  arising  and  tend  to 
disappear  when  gets  warm  in  bed. — Shapiro. 


CHUCKLES 

Incontrovertible 

The  Prince  of  Wales  who  was  to  become  King  Edward 
VII  was  visiting  Sir  Tatton  Sykes. 

Sir  Tatton  asked  a  tenant  of  his  to  show  the  gameness 
of  the  tenant's  Airdale  and  a  bag  of  rats  was  brought  out 
and  dumped  into  a  pen.  The  dog  jumped  in  the  pen  and 
killed  every  rat.  This  aroused  the  admiration  of  the 
Prince  who  offered  the  man  a  boar  and  three  sows  of  his 
famed  strain  of  "Middleweights,"  then  rated  as  the  best 
bacon  pig,  to  which  the  man,  in  a  respectful  manner  re- 
phed,  "I  thank  thee,  Master,  for  thy  kind  offer.  It  would 
give  us  a  chance  to  raise  some  good  bacon.  The  Missus, 
the  little  ones  and  I  are  fond  of  bacon,  but  I  put  it  up 
to  thee,  Master,  as  a  sportsman;  the  only  recreation  I  gets 
is  to  take  yon  tyke  on  Saturday  afternoons  down  to  the 
Red  Lion  Inn  to  compete  in  the  rat-killing  contest,  and 
would  I  not  look  a  fool  if  I  appeared  with  a  boar  and 
three  sows  to  compete  in  the  contest?" — Medical  Pocket 
Quarterly. 


An  ex-patient  returned  to  his  old  job  as  office  boy  for 
a  large  firm. 

One  day  he  was  half  an  hour  late  in  reporting  to  work. 
He  was  met  at  the  entrance  by  his  boss. 

"You  ought  to  have  been  here  at  8  o'clock,"  the  boss 
said,  looking  at  the  clock  on  the  wall. 

"Why,  what  happened?"  the  ex-patient  asked. 


Doctor:  "What  you  need  is  an  absolute  change  in  the 
work  you  are  doing.  You  shouldn't  do  any  head  work  at 
all." 

Patient:  "That's  tough  on  me.  Doctor.  You  see,  I'm 
a  barber." 


"My  boy  friend  is  just  crazy  about  me,"  said  a  girl 
patient  to  her  porchmate. 

"Don't  take  all  the  blame  upon  yourself,"  the  other  girl 
replied.    "He  was  that  way  before  you  met  him." 


"So  you  decided  to  follow  the  example  of  George  Wash- 
ington, have  you?" 

"In  what  way — always  telling  the  truth?" 
"No.     In  marrying  a  rich  widow." 


"My   uncle  left   over  500   clocks." 

"Indeed!  then,  it  must  have  taken  some  time  and  effort 
to  wind  up  his  estate." 


Boy  Patient:     I  have  a  picture  of  you  in  my  mind  all 
the  time." 

Girl  Patient:     "How  small  you  make  me  feel!" 


June,  1936 


PROFESSIONAL  CARDS 


357 


GENERAL 


Nalla  Clinic   Building 


THE  NALLE 

Telephone— 3-2U1  (If  no 
General  Surgery 

BRODIE  C.  NALLE,  M.D. 
Gynecology  &  Obstetrics 

EDWARD  R.  HIPP,  M.D. 

Traitmatic  Surgery 

PRESTON  NOWLIN,  M.D. 
Proctology  &  Urology 


412  North  Church  Strsst 


Consulting  Staff 

DOCTORS  LAFFERTY  &  PHILLIPS 
Radiology 

HARVEY  P.  BARRET,  M.D. 
Pathology 


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  BIdg. 

Charlotte,  N.  C. 

Phone  4392 


CLINIC 

answer,  call  3-2621) 

General  Medicine 

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  of  Infants  &  Children 

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


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.  Dentist 

A.  W.  SCHEER  X-ray  Technician 

Miss  Etta  Wade  Clinical  Pathologist 


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June,  1936 


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INTERNAL  MEDICINE 
DISEASES  OF  THE  CHEST 

Pine  Crest  Manor,  Southern  Pines,  N.  C. 


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Diagnosis 

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Medical  Arts  Bldg.  Charlotte,  N.  C. 


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in 
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PROFESSIONAL  CARDS 


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DOCTORS  GRIFFIN  and  GRIFFIN 

NERVOUS  and  MENTAL  DISEASES, 
and  ADDICTIONS 


M.  A.  Griffin.  M.D 


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DOCTORS  McKAY  and  McKAY 

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Hours  by  Appointment 

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June,  1936 


SURGERY 


G.  CARLYLE  COOKE,  M.D. 
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R.  B.  Mcknight,  m.d. 

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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. 


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SOUTHERN 


Journal 

of 

MEDICINE 


&  SURGERY 


Vol.  XCVIII 


Charlotte,  N.  C,  July,   1936 


No.  7 


Economics  and  State  Medicine* 

A.  P.  Willis,  M.D.,  Candler,  North  Carolina 


STATE  MEDICINE,  the  ownership  and  oper- 
ation cf  medical  practice  by  the  State  through 
a  system  of  general  taxation,  controlled  by 
politicians  and  performed  by  hired  doctors,  is  a 
potential  issue  in  this  country  which  may  be  brought 
forward  for  decision  at  any  time. 

I  am  satisfied  to  have  practiced  medicine  for 
more  than  thirty  years,  but  regret  that  I  look  into 
future  practi;e  with  less  equanimity  than  has  ex- 
isted 'n  the  past,  for  the  reason  that  before  we 
recover  from  this  glamorous  program  of  economic 
and  social  security  there  is  danger  of  our  being  car- 
ried along  with  the  other  basic  institutions  to  the 
creation  of  a  socialistic  government. 

The  contention  over  our  medical  service  is  high 
cost,  iuefficiency  and  irregular  distribution.  The 
following  acrid  incrimination  by  a  New  England 
doctor  is  representative  of  those  calling  for  state 
medicine:  to  quote:  "Since  the  medical  profession 
has  signally  failed  to  furnish  the  proper  service  at 
a  reasonable  cost,  the  only  means  of  completely 
and  efficiently  organizing  the  profession,  for  the 
betterment  of  medical  practice,  is  through  a  Gov- 
ernment bureau  of  medicine  and  surgery." 

It  would  indeed  be  a  wonderful  program  which 
would  eradicate  all  the  acute  infectious  diseases, 
now  under  fair  control,  repair  all  the  lacerated 
cervices  before  their  sequelae  follow,  deliver  all 
women  in  modern  hospitals  with  painless  procedure, 
remove  all  foci  of  infection  before  irreparable  dam- 
age is  done — in  fact,  to  carry  all  that  modern  med- 
icine has  to  offer  to  all  the  humblest  homes  in  the 
land.  But  when  the  cold  reality  of  doing  the  job 
arrives,  such  an  idealistic  and  dreamy  program  will 
be  seen  to  be  manifestly  impossible. 

That  our  economic  and  sociologic  instability  is 
becoming  more  acute  is  apparent  to  us  all,  in 
spite  of  the  fact  that  it  is  challenging  the  best 
thought  and  effort  of  our  people.  While  inability 
to  provide  the  basic  necessities  of  welfare — food, 
fuel,  housing,  clothing,  medical  and  dental  care — 
must  produce  distress,  the  sins  of  omission  or  com- 
mission by  the  medical  profession  have  had  little 


or  nothing  to  do  with  its  development. 

That  every  child  should  have  such  hygienic  and 
scholastic  facilities  as  will  fit  it  for  its  sphere  and 
function  in  life  is  agreed.  That  hygiene  and  pre- 
ventive and  curative  medicine  are  necessary  for  all, 
and  vital  to  the  welfare  and  safety  of  any  people 
is  granted,  but  a  revolutionary  change  to  state  medi- 
cine is  unnecessary,  unjustified  and — in  the  sense 
of  adequate  medical  service — impossible. 

The  care  of  charity  is  a  herculean  task  from  any 
angle.  However,  if  and  when  medical  care  of 
the  destitute  is  accepted  as  a  public  charge  just  as 
is  the  provision  of  other  necessities  for  these  un- 
fortunates, we  will  be  getting  somewhere  in  the 
solution  of  the  problem.  There  are  now  some  200 
plans  being  tried  out  by  the  profession  in  connec- 
tion with  local  financial  units,  in  trying  to  find  a 
satisfactory  solution  for  the  medical  care  of  the 
very  poor  and  the  low-income  groups.  They  are 
being  scrutinized  by  representatives  of  the  Amer- 
ican Medical  Association  in  the  hope  that  some- 
thing will  be  found  which  will  be  applicable  on  a 
large  scale.  The  comple.xities  of  our  social  life 
are  such  that  no  one  plan  can  be  suitable  for  all 
communities. 

Just  how  complete  a  service  does  society  demand 
for  charity?  And  how  much  can  society  afford  to 
pay  for  its  care?  Any  and  all  service  costs  some- 
body something,  even  though  it  is  rendered  through 
a  state  agency.  The  profession  has  been  trying, 
and  it  is  making  progress  toward  adjusting  itself 
to  conditions  resulting  from  our  financial  crash.  It 
has  suffered  in  proportion  to  other  classes  of  so- 
ciety. That  we  have  carried  on  altruistically  and 
effectually  during  all  these  lean  years  is  evidenced 
by  the  morbidity  and  mortality  statistics  of  our 
large  insurance  companies.  Such  statistics  are  more 
favorable  with  us  than  in  countries  where  social 
insurance  has  been  in  force  for  more  than  SO  years. 
The  present  relationship  between  our  Board  of 
Health  and  the  profession  in  the  main  is  satisfac- 
tory, because  they  realize  the  child  is  not  yet  the 
parent. 


•Presented  to  the  Tenth  District   (N.    C.)    Medical  Society,  meeting  at  Spruce  Pine,  May  27th. 


ECONOMICS  &  STATE  MEDICINE— WUlis 


July,  1936 


That  a  complete  socialized  medical  program  car- 
ried in  all  its  phases  to  all  the  people  would  necessi- 
tate an  unbearable  rise  in  taxes  and  build  a  colossal 
organization  of  red  tape  and  political  corruption, 
there  is  not  a  scintilla  of  doubt;  and  doctors  would 
have  about  the  same  degree  of  security  as  now 
exists  in  the  case  of  school  teachers  and  other 
valuable  political  employes.  It  is  immediately  bu- 
reaucratic and  destructive  to  free  institutions,  but 
a  powerful  weapon  in  the  hands  of  a  dictator.  Mr. 
Foster  stated  in  his  radio  debate  on  socialized 
medicine  that  the  politicians  would  not  wield  the 
knife  in  the  operating  room  nor  their  hands  in 
the  delivery  room,  but  he  cannot  truthfully  deny 
that  their  shadow  would  be  cast  over  the  work  in 
every  operating  room  and  at  every  bedside.  There 
are  many  types  and  degrees  of  social  insurance  in 
other  countries,  none  of  which  would  be  satisfactory 
to  us,  which  fact  is  admitted  by  our  politicians  and 
others  in  authority. 

Further  encroachment  by  Government  on  organ- 
ized medicine  cannot  fail  to  cause  deterioration  of 
the  personal  interest  and  enthusiasm  which  has 
had  much  to  do  with  our  achievement.  Following 
in  the  wake  of  such  confiscation,  the  State  may 
find  the  problem  of  medical  education  as  well  as 
practice  its  responsibility,  unless  it  is  willing  to 
accept  lower  standards  of  efficiency  and  personnel. 
The  present  cost,  the  years  required,  the  energy 
and  application  necessary  in  meeting  the  require- 
ments for  admission  to  practice  are  incompatible 
with  the  political  preferment  and  regimentation  of 
socialization.  Under  such  a  system  malingering 
would  pdace  an  unjust  burden  on  the  public  and 
many  unreasonable  exactions  on  the  profession  as 
surely  as  day  follows  night. 

Our  rapidly  developing  machine  age,  with  its 
increasing  efficiency  gradually  though  surely  mini- 
mizing the  need  for  human  hands,  coupled  with 
the  fact  that  our  poor  and  dep)endent  classes  are 
going  on  with  less  attention  and  practical  judg- 
ment in  the  reproduction  of  their  kind  than  we 
now  give  to  our  hogs  and  cattle,  creates  the  serious 
problems  of  the  present  and  probably  those  of  the 
future. 

Is  it  not  infinitely  better  to  discard  this  silly 
sentimentality  about  contraceptive  procedure  and 
give  our  poor  such  information,  encouragement  and 
help  as  they  need  in  regulating  the  size  of  their  fam- 
ilies in  keeping  with  their  ability  to  care  or  them; 
rather  than  to  have  enormous  numbers  of  human 
beings  born  and  brought  up  in  dire  poverty,  with 
next  to  no  chance  in  the  world,  to  have  our  already 
excessive  load  of  charity  made  far  heavier,  by  turn- 
ing loose  at  maturity  increasing  hordes  to  swell 
our  army  of  unemployed?  While  we  reverence  the 
holy  and  sacred  function  of  reproduction,  it  surely 
was  not  intended  for  the  destruction  of  mothers. 


the  creation  of  poverty  and  the  perpetuation  of  war. 
Have  we  not  had  sufficient  demonstrations  that 
millions  in  ignorance  and  poverty  mean  nothing  in 
modern  warfare? 

The  days  of  "Go  West,  young  man,"  are  gone. 
Gone  also  are  too  many  of  our  beautiful  forests 
and  much  of  our  fertile  soil,  and  gone  with  them 
is  the  reasonable  opportunity  of  finding  productive 
employment. 

We  will  find  no  emergency  measures  which  will 
cure  our  ills.  The  stupendous  appropriations  by 
Congress  one  year  ago  will  have  been  80  per  cent. 
exp)ended  by  July  first  of  this  year,  with  little  last- 
ing relief  in  sight.  As  fast  as  private  industry  re- 
moves one  from  the  rolls,  a  new  face  appears  to 
take  his  place.  One  of  the  serious  phases  of  our 
relief  program  is  our  ever-increasing  pauper  psych- 
ology. Does  anyone  believe  these  staggering  sums 
can  long  be  expended  without  insolvency  or  some- 
thing worse? 

Shall  we  go  on  beyond  the  point  of  saturation 
until  we  find  ourselves  like  Europe  and  the  Orient, 
population  and  resources  out  of  balance.  If  it  is 
the  State's  bounden  duty  to  provide  for  those  who 
cannot  care  for  themselves,  is  it  not  her  right  to 
look  into  and  control  the  sources  of  such  burdens? 

I  do  not  believe  the  people  of  this  country  care 
to  relinquish  the  right  to  employ  the  doctor  of  their 
choice  in  caring  for  their  medical  problems.  They 
recognize  as  well  as  we  that  the  deep  interest  and 
sensitive  responsibility  they  now  enjoy  has  no  sat- 
isfactory substitute.  To  abandon  the  sacred  and 
beautiful  attributes  of  private  practice  for  the  im- 
personal ministration  of  the  daily  routine  of  a  sala- 
ried doctor  will  sicken  the  heart  and  soul  of  med- 
ical practice.  State  medicine  can  change  human 
relationships,  but  never  human  nature. 

If  the  politicians,  economists,  sociologists  and 
philanthropists  will  apply  themselves  to  the  prob- 
lems of  unemployment,  conservation  and  recon- 
struction of  our  natural  resources,  immigration, 
birth  control  and  capital  and  labor,  leaving  med- 
icine unhampered  by  the  shackles  of  politics,  the 
salutary  situation  of  freedom  of  choice  and  com- 
petition with  their  resulting  efficiency,  will  continue 
to  give  the  American  people  the  most  desirable  tj^e 
of  medical  service  available. 


So    FAR  AS    I   CAN    SEE    THIS    CASE    IS    UNIQUE    (W.    L.    Pcple, 

in  Bui.  McGuire  Clinic  &■  St.  Luke's  Hasp.,  June)  in  that 
it  was  demonstrated  by  the  cholecystogram  that  we 
had  one  diseased,  functionless  gallbladder  and  another  func- 
tioning normally  close  by  its  side.  And  furthermore,  had 
the  stones  been  of  the  non-opaque  variety,  all  of  our  scien- 
tific studies  would  have  resulted  in  a  report  that  the  patient 
had  a  normally  functioning  gallbladder.  Some  writer  with 
a  flare  for  catchy  headlines  might  very  properly  use  this 
caption:  Twin  Gallbladders  with  Dual  Personalities,  or  the 
Woman  with  a  Spare. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Fragility  of  the  Veins  as  a  Factor  in  the  Production  of 
Arsphenamine  Poisoning 

Groesbeck  Walsh,  M.D.,  F.A.C.F.,  and  Courtney  S.  Stickley,  B.S.,  M.D., 

Fairfield,  Alabama. 

From  the  Medical  Section  Employees  Hospital 


THE  preponderance  of  women  in  groups  of 
patients  suffering  from  arsphenamine  pois- 
oning has  excited  comment  from  Cole,  De- 
Wolf  et  al,^  Ireland-  and  others. 

Of  the  six  cases  of  serious  arsphenamine  poison- 
ing reported  by  Scarfs  three  occurred  among  wo- 
men— an  unduly  high  proportion,  we  believe,  when 
we  consider  the  fact  that  many  more  doses  of  ars- 
phenamine are  given  to  men  than  to  women. 

Four  cases  are  described  at  length  in  the  pajjer 
of  Cole,  DeWolf  et  al.  These  cases  are  so  de- 
scribed in  order  to  illustrate  various  phases  of  pois- 
oning from  arsphenamine.  We  think  it  is  of  sig- 
nificance that  three  out  of  four  of  these  were  wo- 
men. 

In  a  previous  communication  the  authors*  re- 
ported eleven  cases  of  arsphenamine  poisoning  ad- 
mitted to  the  Employees  Hospital  from  the  years 
1930  to  1934,  inclusive.  In  this  period  fourteen 
cases  of  arsphenamine  pxaisoning  were  admitted, 
eleven  as  noted  among  negro  women.  In  the  same 
communication  observations  were  made  upon  the 
fragility  of  the  veins  of  the  negresses.  Several 
of  these  eleven  women  presented  veins  the  structure 
of  which  made  the  use  of  intravenous  therapy  dif- 
ficult. 

Ore  of  the  cases,  Case  No.  7,  possessed  veins  of 
such  a  character  that  it  was  impossible  for  us  to 
obtain  enough  blood  for  a  blood  chemistry  exam- 
ination. 

Since  the  publication  of  this  last  contribution 
tv.o  negresses  have  been  admitted  to  the  hospital, 
both  suffering  from  arsphenamine  poisoning  and 
both  presenting  veins  very  difficult  of  access. 

We  believe  that  the  report  of  these  two  cases 
v.ill  add  color  to  the  idea  that  arsphenamine  pois- 
oning occurs  more  frequently  among  women  on 
account  of  the  perivenal  infiltration  which  takes 
place  during  the  attempts  to  give  them  intraven- 
ous arsphenamine. 

Case  I. — A  negress,  aged  29  years,  was  admitted  to  the 
hospital  February  25th,  and  discharged  March  24th,  1936. 
Diagnosis — Arsphenamine  poisoning.  Chief  complaints  were 
generalized  eruption  and  a  severe  sore  throat  of  five-weeks 
duration.  The  urine  was  loaded  with  albumin.  Her 
blood  count  on  admission  was  2,100,000  and  hemoglobin 
45%.  The  blood  was  negative  for  sickle-cell  anemia.  In 
the  month  previous  to  admi.ssion  she  had  four  intravenous 
injctions  of  neoarsphenamine.  During  her  stay  in  the 
ho.pit::!  she   developed   hematuria,   which   the  c>'Stoscopist 


stated  originated  in  the  bladder.  On  admission  her  blood 
pressure  was  elevatd  to  160/100. 

Treatment. — On  admission  liver  was  given  intramuscu- 
larly, and  glucose  intravenously ;  250  c.c.  of  citrated  whole 
blood  was  administered  March  14th,  with  most  beneficial 
results.  The  veins  of  the  patient  were  in  such  condition 
that  it  was  necessary  to  cut  down  on  the  veins  in  order 
to  obtain  entrance.  The  veins  were  extremely  small,  with 
very  narrow  lumen.  Under  this  regimen  the  patient  showed 
marked  improvement.  She  gained  in  strength.  The  tem- 
perature declined  to  normal.  She  was  up  and  about  the 
ward  before  she  left  the  hospital,  although  her  blood  on 
discharged  showed  only  60%  hemoglobin.  This  condtion 
of  her  blood  remained  about  stationary.  The  temperature 
was  high  on  admission  and  remained  at  a  peak  of  102° 
for  three  days,  declining  to  normal  a  week  after  admission, 
with  some  erratic  febrile  disturbances  after  that.  The 
icteric  index  was  4.5,  blood  sugar  90  mgs.,  npn.  ii  mgs., 
and  creatinine  1.6  mgs.  The  red  blood  count  on  discharge 
was  2,325,000.  Her  convalescence  was  complicated  by  the 
development  of  atelectasis  in  the  right  lower  lung,  which 
came  on  about  the  time  of  her  admission.  This  cleared 
up,  however,  before  her  discharge. 

Case  2. — A  negress,  aged  31  years,  was  admitted  to  the 
hospital  December  20th,  1935,  and  discharged  February 
Sth,   136.     Diagnosis — Arsenical  dermatitis. 

History. — In  April,  1935,  some  type  of  rash  developed 
on  the  patient's  face.  \  doctor  informed  her  that  she  had 
bad  blood,  and  antisyphilitic  treatment  was  given,  including 
four  intravenous  doses  of  what  was  presumably  neoars- 
phenamine, in  May,  1935.  The  eruption  still  remained  on 
her  face.  On  July  5th  she  consulted  another  physician  in 
a  different  city,  who  began  giving  her  intravenous  injections 
of  neoarsphenamine.  Three  such  intravenous  treatments 
were  given  with  no  ill  effects.  Following  the  fourth  dose, 
however,  she  broke  out  with  a  generalized  eruption  in- 
volving her  entire  body.  The  eruption  apparently  was  at 
its  height  in  August — four  months  before  her  admission  to 
the  hospital.  The  chief  complaint  on  admission  was  X\v 
annoyance  created  by  the  rash  and  the  sores  qn  the  face, 
scalp,  vulva  and  inguinal  regions.  There  was  considerabli 
albumin  in  the  urine,  with  pus  cells  and  infrequent  casts 
These  urinary  findings  persisted  during  her  stay  in  the 
hospital.  The  blood  count  on  admission  showed  hemo- 
globin 70%,  w.  b.  c.  6,000  and  r.  b.  c.  3,000,000.  Her 
blood  was  examined  on  three  different  occasions,  and  its 
chemistry  was  found  to  be  normal  each  time.  She  ran  a 
continuous  temperature  during  her  stay  in  the  hospital, 
averaging  100°  to  102°,  as  a  number  of  arsenical  poisoning 
cases  have  done. 

Treatment. — Treatment  consisted  of  local  applications  of 
various  descriptions  to  her  head  and  body,  liver  extract 
intramuscularly,  dietary  treatment,  and  metaphyllin,  intra- 
muscularly. The  patient's  veins  were  extremely  small  and 
difficult  of  entrance.  Intravenous  glucose  therapy  was 
accomplished  only  with  great  difficulty.  The  patient  made 
little,  if  any,  improvement  during  her  stay,  and  was  taken 
out  of  the  hospital  by  her  relatives  with  a  most  unfavorable 
prognosis. 


364 


FRAGILE  VEINS  &■  ARSPHEN AMIN E—Waish  &  Stickley 


July,  1936 


StJMMARY 

Between  the  years  1930  and  1936  sixteen  cases 
of  poisoning  due  to  neoarsphenamine  have  been 
admitted  to  the  Employees  Hospital.  Thirteen  of 
these  cases  have  been  negresses.  From  the  evidence 
at  our  disposal  we  believe  that  the  small  size  of 
the  negresses'  veins,  their  fragility  and  ease  of  rup- 
ture explain  in  part  at  least  the  preponderance  of 
females  in  our  cases  of  arsphenamine  poisoning. 

References 

1.  Cole,  H.  N..,  DeWolf,  H.,  et  al:  Toxic  Effects  Fol- 
lowing Use  of  the  .^rsphenamines.  J.  A.  M.  A.,  97:897, 
1931. 

2.  Ireland,  F.  A.:  Reactions  Following  the  Administra- 
tion of  Arsphenamines  and  the  Methods  of  Prevention. 
Am.  Jl.  Syph.,  16:21,  1932. 

3.  Scarp,  M.:  Serious  Arsphenamine  Reactions  with  Ref- 
erence to  Thejr  Prevention.  J.  A.  M.  A.,  102:2159, 
1934. 

4.  Walsh,  G.,  and  Stickley,  C.  S.:  Am.  Jl  of  Syphilis 
and  Neurology,  vol.  19,  no.  3,  p.  323,  July,  193S. 


B.4CTERL\L  Aspects  of  Puerper.al  Sepsis 

(H.    D.   Wright,  Univ.   of  Liverpool,   in  Liverpool   Medico- 

Chirurg.  Jl.,  Part  I,  1936) 

When  I  first  approached  the  study  of  puerperal  sepsis 
some  S  or  9  years  ago  it  was  in  the  search  for  examples  of 
blood  infection  with  organisms  of  high  virulence,  and  I 
had  the  impression  that  this  was  a  not  unusual  occurrence 
in  the  practice  of  any  obstetric  hospital,  and  also  that 
even  if  blood  invasion  was  not  very  frequent,  infection  of 
the  uterine  cavity  with  a  haemolytic  streptococci  developed 
in  a  high  percentage  of  puerperal  women  and  that  fever 
in  the  puerperium  meant  streptococcal  infection  of  the 
uterus.  The  first  point  I  wish  to  make  is  that  none  of  these 
impressions  was  well  founded. 

The  cases  investigated  were  selected  on  the  basis  of 
the  British  Medical  Association  standard  of  morbidity, 
which  is  "a  temperature  above  100°  F.  occurring  on  any 
two  occasions  between  the  end  of  the  first  36  hours  and 
the  end  of  the  8th  day."  Of  125  cases  studied  the  fever 
was  due  in  50  to  causes  outside  the  genital  tract,  in  48 
to  genital  sepsis,  and  in  27  the  cause  was  not  determined 
with  certainty.  In  these  latter  cases  of  undetermined  origin 
the  fever  was  of  short  duration  and  no  organism  of  im- 
portance was  isolated  from  the  uterine  cavity. 

When  fever  occurs  in  the  puerperium,  no  assumptions  can 
be  made  either  as  to  the  seat  of  the  infection  or  as  to  the 
bacterial  cause  without  the  fullest  clinical  and  bacteriologi- 
cal investigation,  and  all  conclusions  as  to  the  merits  of  any 
particular  method  of  prophylaxis  or  treatment  which  is 
not  adequately  checked  are  really  worthless. 

Although  in  this  particular  series  of  cases  rather  less 
than  one-third  were  due  to  hemolytic  streptococci,  in  severe 
cases  these  organisms  are  of  the  greatest  importance. 

Before  delivery  in  the  examination  of  1,123  women  we 
found  haemolytic  streptococci  on  32  occasions  (2.7%). 

On  looking  into  the  subsequent  history  of  the  32  cases, 
in  none  of  them  could  any  reason  be  found  to  consider 
that  these  organisms  had  given  rise  to  any  infection;  and 
we  were  forced  to  conclude  that  the  organisms  present 
in  the  vagina  prior  to  delivery-  were  of  little  significance 
in  relation  to  infection  which  subsequently  might  develop. 

"What  is  a  haemolytic  streptococcus?"  Most  workers 
in  the  past  were  content  to  accept  as  a  haemolytic  strep- 
tococcus any  organism  which  produced  some  degree  of 
hemolysis  on  blood  agar  without  paying  particular  atten- 
tion to  the  conditions  under  which  the  lysis  occurred.  It  is 
to  this  fact  and  the  failure  to  distinguish  between  the  dif- 


ferent kinds  of  haemolytic  streptococci  that  the  oft-quoted 
and,  as  I  think,  entirely  erroneous  idea  is  due  that  the 
non-hemolytic  streptococci  of  the  normal  genital  tract  read- 
ily change  to  the  pathogenic  haemolytic  streptococci  and, 
with  that  idea,  departs  the  main  support  for  the  view  that 
puerperal  sepsis  is  endogenous  in  its  origin  in  most  cases. 

In  the  course  of  our  investigation  we  met  with  a  case  of 
fatal  puerperal  sepsis  due  to  pneumococcus  type  I,  we 
sought  for  this  type  in  the  mouths  of  those  who  had  been 
in  any  way  associated  with  the  case.  A  pneumococcus  of 
the  same  type  was  found  in  the  mouth  of  one  of  the  resi- 
dent staff  who  had  applied  forceps  and  who  happened  at 
the  time  to  be  suffering  from  a  "cold." 

The  cases  investigated  number  148.  In  30  the  source  of 
infection  could  not  be  traced;  in  15  it  remained  doubtful. 
Of  the  remaining  103  cases,  99  had  been  traced  to  a  nose 
or  throat,  79  to  someone  in  attendance  on  the  patient  or 
in  her  immediate  environment,  20  to  the  patient  herself. 
Four  only  remain  which  were  derived  from  a  septic  focus 
outside  the  respiraton,'  tract. 

A  parturient  woman  in  an  environment  which  contains 
haemolytic  streptococci  of  a  particular  kind  (Group  A)  is 
in  a  situation  of  some  danger,  whether  they  are  in  her  own 
nose  or  throat  or  in  the  respiratory  tracts  of  her  attendants 
or  of  the  members  of  her  family  or  in  a  septic  focus  in  her 
own  or  some  other  body.  .\\\  possibilities  have  to  be  con- 
sidered, but  there  seems  little  doubt  that  the  greatest  danger 
lies  in  the  respiratory  tract.  Prevention  consists  in  the 
detection  of  carriers  or  infected  persons  and  masking. 


Tetanus  Neonatorltm 

(E.  A.   Hines,  jr.,  Seneca,  S.  C,  in  Am.  Jl.  Dis.  of  Child., 

Mar.) 

A  colored  girl,  aged  7  days,  of  normal  delivery  seen  at 
the  Roper  Hospital,  Charleston,  in  1927,  onset  occurred  at 
5  days  with  stiffness  of  the  limbs  and  neck;  would  not 
nurse  and  had  spasms  several  times  a  day;  t.  106,  eyes 
tightly  closed  and  face  wrinkled  into  the  risus  sardonicus, 
edema  around  lids,  trismus  and  rigidity  of  the  neck,  abdo- 
men and  knee  reflexes  were  absent,  umbilical  stump  red 
and  swollen,  no  discharge;  white  cells  30,520 — p.  70,  1.  26, 
m.  4 — spinal  fluid  cloudy  and  blood  tinged,  under  slight 
pressure  and  contained  globulin  and  10  cells. 

On  admission  3  c.c.  of  ampule  of  10,000  units  of  tetanus 
antitoxin  intrathecally,  the  rest  intramuscularly,  and  cal- 
cium bromide  5  grs.  and  chloral  hydrate  2  grs.  every  4 
hours  for  20  days.  Magnesium  sulphate  2  c.c.  intramus- 
cularly once  daily  for  13  days.  Discharged  as  cured  on 
the  2Sth  day. 

Tetanus  neonatorium  is  not  an  uncommon  disease  in  the 
United  States.  Greater  care  should  be  exercised  and  more 
stringent  laws  enforced  in  regard  to  the  treatment  of  the 
umbilical  cord  after  birth.  Cerebrospinal  meningitis  result- 
ing from  "sepsis  neonatorum"  should  be  differentiated  from 
tetanus  neonatorum. 

The  treatment  of  infants  with  this  disease  is  mainly 
symptomatic  and  is  as  yet  inefficient.  Magnesium  sulphate 
seems  to  give  the  best  results.  Tetanus  antitoxin  has  not 
proved  of  any  great  value. 

In  those  localities  in  which  the  disease  is  common,  taking 
the  lives  of  thousands  of  infants  annually,  it  would  be 
interesting  and  perhaps  useful  to  give  a  prophylactic  dose 
of  tetanus  antitoxin  to  a  series  of  mothers  shortly  before 
the  birth  of  the  baby  and  to  record  the  results. 


It  is  not  improbable  that  the  anatomical  lectures  of 
Giles  Firmany  which  were  delivered  prior  to  1647  and  are 
the  earliest  example  of  public  medical  instruction  in  the 
United  States,  were  given  at  Harvard  College.— /o/t.  Herr- 
mann Baas,  "History  of  Medicine,"  1889. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


365 


Ano-Rectal  Hemorrhage* 

In  Brief  Review 
C.  C.  Massey,  M.D.,  Charlotte,  North  Carolina 


BLOOD  LOSS  through  the  rectal  outlet  is 
either  obvious  or  occult,  recognizable  by 
the  unaided  eye  or  requiring  chemical  tests 
for  its  detection. 

Usually  the  presence  of  blood  in  gross  quantity, 
either  free,  or  mixed  with,  or  on  the  feces,  indicates 
recent  bleeding  in  the  distal  part  of  the  large 
bowel,  while  black  blood  or  occult  blood  indicates 
bleeding  in  the  stomach  or  small  intestine.  Some- 
times blood  from  a  lesion  in  the  proximal  colon 
may  remain  in  the  large  bowel  long  enough  to 
become  black  as  a  result  of  decomposition. 

Bleeding  may  be  the  result  of  trauma,  of  dis- 
ease, or  of  both.  When  due  to  trauma  the  cause  is 
usually  obvious.  Grave  secondary  anemia  may 
result  from  a  slight  blood  loss  if  the  bleeding  per- 
sists. In  some  cases  other  symptoms  may  be  so 
predominant  that  the  patient  does  not  mention 
the  loss  of  blood  unless  asked  specifically  about  it. 

I  would  like  to  present,  briefly,  the  following 
conditions: 

Internal  hemorrhoids  account  for  most  rectal 
bleeding.  The  blood  follows  congestion  and  ero- 
sion of  the  mass  of  dilated,  sacculated  venous  chan- 
nels which  compose  the  main  bulk  of  the  pile.  As 
a  rule,  the  three  primary  hemorrhoids,  following 
the  distribution  of  the  superior  hemorrhoidal  ves- 
sels are  a  left  lateral,  a  right  anterior  and  a  right 
posterior.  Trauma  incident  to  the  passage  of  a 
hard,  dry  stool  is  the  commonest  cause  for  blood 
loss  from  this  condition.  The  amount  lost  at  any 
one  time  may  be  of  little  consequence,  but  not 
infrequently  slight  hemorrhages  daily  over  a  long 
period  may  result  in  high-grade  anemia  and  even 
serious  systemic  disease. 

The  diagnosis  of  internal  hemorrhoids  is  usually 
easy,  provided  the  patient  is  examined.  This  ex- 
amination calls  for  the  use  of  few  accessories — a 
comfortably  fitting  glove,  a  suitable  lubricant  and 
a  proctoscope.  The  hemorrhoidal  masses  may  pro- 
trude through  the  anus  or  they  may  be  seen 
through  the  instrument.  Gentleness  is  essential 
even  after  the  patient's  confidence  has  been  gained. 
The  treatment  is  surgical  removal.  For  simple  un- 
complicated piles  the  injection  treatment  often 
proves  satisfactory. 

Anal  fissure  is  the  most  painful  of  all  lesions 
found  in  this  region.  This  is  because  of  the  rich 
sensory  nerve  supply  from  the  cerebrospinal  sys- 
tem. The  acute  anal  fissure  usually  bleeds  with 
every  bowel  movement,  whereas  from  the  chronic 


fissure  may  come  occasional  brisk  bleeding.  In 
fissure  the  blood  is  always  bright  red  and  the  stools 
are  streaked.  The  location  of  the  fissure  is  usually 
in  the  posterior  midline  of  the  anal  canal.  Trauma 
figures  prominently  in  this  condition.  Large  hard 
stools  cause  tears  in  the  anal  canal  which  do  not 
heal  readily.  Rectal  pain  out  of  proportion  to 
the  size  of  the  lesion,  bleeding  at  stool  and  spasm, 
ment  is  sufficient  dilation  of  the  sphincter  muscles 
are  characteristic.  Chronic  anal  fissure  must  be 
differentiated  from  anal  epithelioma,  primary  sore, 
and  tuberculous  ulceration  of  the  anus.  The  treat- 
ment is  sufficient  dilation  of  the  sphincter  muscles 
for  relaxation,  and  incision,  trimming  away  over- 
hanging edges  of  skin  and  mucous  membrane  up 
to  the  mucocutaneous  junction.  This  puts  the 
sphincter  mechanism  at  rest  and  establishes  ade- 
quate drainage  while  the  wound  heals. 

External  thrombotic  hemorrhoids  when  ruptured 
cause  some  loss  of  blood. 

Adenomata  and  papillomata,  frequent  precursors 
of  rectal  and  sigmoid  cancer,  bleed  freely.  Their 
presence  is  revealed  through  an  instrument.  Early 
fulguration  through  a  sigmoidoscope  is  the  treat- 
ment of  choice  here. 

Rectal  cancer  causes  foul  bloody  discharges  when 
well  established  and  in  later  stages  when  ulceration 
has  occurred. 

Stricture  oj  the  rectum  or  pelvic  colon,  whether 
congenital,  traumatic,  or  inflammatory,  produces 
infection  and  ulceration  of  the  mucosa  above  the 
lesion  with  resultant  bleeding. 

Polyps,  more  common  in  children,  sometimes 
bleed.  These  may  be  single  or  multiple.  When 
single  and  attached  to  the  rectal  mucosa  by  a 
pedicle,  they  may  be  ligated  and  removed  by  snare. 
Otherwise  removal  by  fulguration  is  satisfactory. 

Fecal  impaction  causes  bloody  passages.  The 
most  common  sites  for  this  condition  are  the 
ampulla  of  the  rectum  and  the  sigmoid.  The  pa- 
tient may  have  what  he  believes  to  be  normal  bowel 
movements,  liquid  or  semiformed  stools  being 
forced  alongside,  around,  or  even  through  the  im- 
pacted mass.  A  feeling  of  pressure  and  pelvic  pain 
is  usually  present.  In  the  badly  obstructed  cases 
there  may  be  a  constant  desire  to  go  to  stool  and 
the  going  prove  disappointing.  Strong  bowel  con- 
tractions forcing  the  fecal  column,  with  its  head 
obstructed  at  the  rectosigmoid  union  or  at  the 
anorectal  junction,  produce  considerable  trauma 
tn  the  mucosa  of  the  bowel:  and  when  the  obstruc- 


•Presented  to  the  Mecklenburg  County  Medical  Society,  May  10th. 


ANORECTAL  HEMORRHAGE— Massey 


July,   1936 


tion  is  low  down,  injury  to  the  vascular  hemor- 
rhoidal area  causes  free  bleeding  and  sometimes 
pressure  necrosis.  This  condition  must  be  differen- 
tiated from  carcinoma  and  neoplasm. 

Foreign  bodies  in  the  rectum  and  sigmoid  pro- 
duce bleeding  as  part  of  the  clinical  picture.  Pain 
and  tenesmus  are  usually  the  predominating  symp- 
toms. A  careful  history  and  examination  estab- 
lishes the  diagnosis. 

More  or  less  bleeding  accompanies  rectal  pro- 
lapse. 

Angiomata,  apparently  congenital,  may  give  rise 
to  alarming  hemorrhages.  Their  favorite  site  is 
the  lower  segment  of  the  colon. 

Ulcerative  lesions  of  the  colon  and  rectal  mu- 
cosa, with  or  without  diarrhea  and  tenesmus,  may 
be  the  source  of  exhausting  hemorrhages.  I  am 
thinking  of  chronic  ulcerative  colitis,  amebic  entero- 
colitis, colon  tuberculosis,  and  also  bacillary  dys- 
entery. 

Gonorrheal,  chanchroidal  and  syphilitic  lesions 
of  the  rectum  probably  occur  oftener  than  we  sus- 
pect and  are  usually  characterized  by  some  blood 
loss. 

Many  of  the  more  serious  constitutional  diseases 
like  nephritis,  diabetes,  biliary  cirrhosis,  typhoid 
fever,  marasmus  in  infants,  and  allergic  phenomena, 
may  be  responsible  for  serious  hemorrhages  from 
the  large  bowel. 

Bleeding  jrovi  the  rectum  at  the  time  of  men- 
struation can  nearly  always  be  traced  to  organic 
disease  which  has  been  aggravated  by  the  concur- 
rent pelvic  congestion. 

The  best  methods  at  our  disposal  for  locating 
pathology  of  the  terminal  bowel  are  insjsection, 
palpation  and  x-ray  examination.  Proctosigmoid- 
oscopy should  be  done  as  a  routine  procedure,  and 
as  a  part  of  the  inspection  phase  of  the  examina- 
tion. Cultures  or  biopsy  material  may  be  ob- 
tained at  this  time  if  desired.  If  there  is  reason 
to  suspect  a  lesion  above  the  reach  of  the  sig- 
moidoscope, x-ray  examination  with  opaque  enema 
should  be  employed.  This,  however,  should  always 
be  the  last  examination  made  and  should  not  be 
made  the  same  day  as  the  instrumental  manipu- 
lation because  the  latter  may  cause  a  traumatic 
irritability  confusing  to  the  roentgenologist.  The 
roentgenologic  difficulty  is  greatest  in  the  rectum 
and  lower  sigmoid  due  to  superimposition  of  loops 
of  bowel,  and  for  this  reason  negative  x-ray  find- 
ings in  this  region  are  not  dependable.  With  the 
sigmoidoscope,  however,  this  region  can  be  exam- 
ined with  extreme  accuracy.  For  this  reason,  and 
because  the  majority  of  colonic  lesions  are  to  be 
found  in  the  lower  part  of  the  sigmoid,  palpation 
and   proctosigmoidoscopy   are    the    most   valuable 


diagnostic  procedures  at  our  disposal. 

SUMM.WY 

"Internal  hemorrhoids,  the  commonest  source  of 
rectal  bleeding,  may  coexist  with  other  local  lesions 
of  the  lower  bowel,  such  as  fissure,  adenoma,  pa- 
pilloma, carcinoma,  or  coloproctitis.  Systemic  dis- 
turbances, especially  portal  obstruction  as  in  cirrho- 
sis of  the  liver,  tricuspid  insufficiency,  abdominal 
or  pelvic  tumors,  uterine  displacements,  pregnancy, 
pelvic  inflammatory  disease,  and  prostatism  cause 
hemorrhoidal  varices.  Therefore,  one  should  never 
diagnose  hemorrhoids  as  an  abdominal  physiologi- 
cal state  per  se,  unless  a  possible  primary  contrib- 
utory cause  can  be  ruled  out." 
Conclusion 

1.  Blood  loss  from  the  rectal  outlet  is  a  symptom 
that  is  frequently  neglected. 

2.  The  bleeding  itself  can  be  the  cause  of  se- 
vere secondary  anemia. 

Cancer  of  no  other  region  of  the  body  offers  bet- 
ter chance  of  cure  than  that  of  the  rectum  and 
colon,  provided,  the  diagnosis  is  made  early  and 
radical  treatment  is  given  promptly. 

4.  The  importance  of  investigating  the  cause 
of  anorectal  bleeding  should  be  borne  in  mind. 

5.  There  is  often  marked  disproportion  between 
symptomatology  and  pathology  in  this  field. 

6.  All  that  glitters  is  not  gold.  Not  every  hem- 
orrhage from  this  outlet  comes  from  an  internal 
pile. 

References 

.\lley.  R.  C:  Bleeding  from  the  Rectum.  A'v.  Med. 
Jour.,  vol.  30,  no.  11,  Nov.,  1932. 

D.ANiELS,  E.  .\.:  Rectal  Hemorrhage.  The  Can.  Med. 
Assoc.  Jour.,  33:287,  1935. 

Smith,  F.  C:  Bleeding  from  .\nu5  and  Rectum.  Sym- 
posium of  Gastrointestinal  Diseases.  Med.  Jour,  and  Rec. 
Sept.,  1932. 


Fistulas  connecting  the  urinary  bladder  and  bowel 
are  discussed  (Herbst,  R.  H.,  &  Miller,  E.  M.,  Chicago) 
in  the  //.  of  the  A.  M.  A.,  of  June  20th.  Cases  are  re- 
viewed in  which  a  needle  passed  from  the  appendix  into 
the  bladder  and  became  the  nucleus  of  a  large  stone;  of  a 
piece  of  slate  pencil,  swallowed  6  mos.  before,  being  re- 
moved from  the  bladder;  of  the  passage  of  many  gall- 
stones by  urethra;  and  of  a  rabbit's  femur,  a  hairpin, 
an  aerometer,  a  wood  splinter,  a  crochet  needle  and  various 
other  things  entering  the  bladder  from  the  bowel.  The 
authors  report  a  case  in  which  the  offending  agent  was  a 
chicken  bone. 


.4.V  OL'TL\G  MEETING  will  go  far  to  correct  the 
conditions  which  existed  (7/.  Med.  Soc.  of  N.  J.,  June) 
openly  in  one  County  Society  as  late  as  1SS2,  when  its 
minutes  record  the  trial  of  a  physician  on  charges  brought 
by  a  fellow  member,  that  the  offending  doctor  had  vio- 
lated the  medical  code  of  ethics  in  that,  since  he  had  been 
called  as  a  consultant,  he  had  claimed  precedence  over  the 
family  doctor  in  the  procession  at  the  funeral  of  the 
patient. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Cystin  Stones 

Robert  W.  McKay,  :M.D.,  Charlotte,  North  Carolina 


A  MOTHER  recently  brought  her  fourteen- 
year-old  son  to  us  for  the  avowed  purpose 
of  obtaining  some  medicine  to  prevent  his 
passing  numerous  stones. 

Upon  inquiry  she  stated  that  for  the  past  three 
or  four  years  the  child  had  passed  so  many  stones 
that  she  had  ceased  to  count  them.  We  were  some- 
what sceptical  of  this  statement,  so  to  prove  her 
assertion  she  produced  an  envelope  containing  a 
number  of  amorphous,  waxy  crystals. 

We  obtained  the  following  history.  The  patient 
was  fourteen  years  old.  He  had  four  brothers  and 
sisters  all  of  whom  were  living  and  apparently  well. 
A  careful  investigation  into  the  family  history  re- 
vealed no  predisposition  to  stone  formation.  The 
mother  further  stated  that  none  of  her  other  chil- 
dren had  any  similar  difficulty  and  as  far  as  she 
knew  none  of  her  forebears  had.  The  child,  ap- 
parently, had  enjoyed  e.xcellent  health  up  until 
about  three  years  before  the  present  illness  at 
which  time  he  began  to  have,  from  her  descrip- 
tion, typical  attacks  of  kidney  colic,  occurring  on 
both  sides  and  followed  almost  invariably  by  the 
painful  passing  of  stones  of  various  sizes.  Previous 
to  our  seeing  him  he  had  seen  other  competent 
urologists  who  had  made  cystoscopic  and  x-ray 
examinations,  and,  apparently,  had  found  shadows 
in  the  area  of  the  right  kidney  suggesting  stone. 

The  patient  was  a  well  nourished  boy  appar- 
ently in  excellent  health,  lips  and  visible  mucous 
membrane  good  color.  Physical  examination  was 
essentially  negative.  No  congenital  defects  or  ab- 
normalities. 

V^oided  specimen  of  urine  showed  specific  gravity 
1.012,  slight  trace  of  albumin,  no  sugar,  w.  b.  c. 
one-plus,  r.  b.  c.  one-plus  and  typical  cystin  crys- 
tals. 

With  these  findings  cystoscopy  was  postponed. 
.■\  flat  plate  was  taken  of  the  urinary  tract  which 
revealed  shadows  in  the  area  of  the  right  renal 
pelvis. 

A  diagnosis  of  cystinuria  with  cystin  stone-for- 
mation was  made.  The  patient  was  given  20  grains 
of  sodium  bicarbonate,  three  times  a  day,  and  put 
on  a  limited  protein  intake.  At  the  expiration  of 
two  weeks  he  again  passed  more  cystin  crystals 
and  the  dose  of  sodium  bicarbonate  was  increased 
to  30  grains  and  he  was  given  a  protein-free  diet 
for  one  week.  At  the  expiration  of  this  time  the 
sodium  bicarbonate  was  dropped  to  10  grains  and 
he  was  put  back  on  a  protein-restricted  diet.  Since 
that  time  he  has  had  two  attacks  of  renal  colic  but 
otherwise  has  been  in  excellent  condition,  attending 


school  and  taking  light  exercise. 

The  condition  of  cystin  stone  formation  and 
cystinuria  has  long  been  recognized.  As  early  as 
1810  Wollaston  first  described  two  bladder  stones 
formed  of  a  substance  called  by  him  cystin  oxide. 
Brezelius  in  1833  introduced  the  term  cystin.  Since 
that  time  the  subject  has  appeared  at  long  intervals 
in  the  literature.  In  1916  Kretschmer  was  able 
to  collect  107  cases  of  cystin  lithiasis.  Contani 
in  1881,  because  of  the  fact  that  the  cystin  is 
soluble  in  an  alkaline  solution,  advocated  treat- 
ment by  the  internal  administration  of  ammonium 
carbonate. 

Chemistry. — The  chemical  formula  of  cystin  is: 
C  H.,S  S  C  Ho 


C  H  .  N  Ho 


C  H  .  N  Ho 


CO.O.H  CO.  OH 

It  is  an  amino-acid  and  is  the  chief  sulphur- 
containing  chemical  which  results  from  the  hydro- 
lysis of  protein.  Dietetic  experiments  have  proven 
that  this  amino-acid  is  necessary  for  the  mainte- 
nance of  growth.  In  normal  metabolism  the  nitro- 
genous portion  of  the  amino-acid  is  converted  into 
urea  and  the  sulphur-containing  portion  is  usually 
excreted  as  inorganic  sulphate.  It  is  soluble  in 
ammonia  and  the  alkaline  carbonates  and  insoluble 
in  acetic  acid. 

Etiology. — The  literature  is  replete  with  theories 
concerning  the  etiology  of  this  interesting  and  rare 
condition.  .Apparently  the  cause  of  the  metabolic 
error  is  unknown  and  a  satisfactory  explanation 
has  not  as  yet  been  forthcoming. 

Robson  carried  out  immense  experimental  work 
in  the  feeding  of  pure  cystin  to  cystinuric  patients 
with  the  surprising  result  that  cystin  fed  by  mouth 
did  not  increase  the  quantity  of  cystin  in  the  urine. 
.Apparently  the  excessive  amounts  of  the  compound 
v.ere  oxidized  by  the  body  into  the  organic  sul- 
phates instead  of  increasing  the  amount  of  cystin 
in  the  urine.  On  the  other  hand,  in  patients  with 
cystinuria  the  amount  of  cystin  in  the  urine  varies 
directly  with  the  amount  of  protein  fed  by  mouth. 

Heredity. — Search  of  the  literature  reveals  there 
are  numerous  instances  in  which  heredity  appears 
to  play  an  extremely  strong  part!  Kretschmer  re- 
ported   the   condition    in    twin    brothers.      Robson 


CYSTIX  STOXES—McKav 


July,  1936 


observed  twelve  cases  in  three  generations.   Graves 
found  eight  cystinuric  patients  in  two  generations. 


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No.    1.     Cystin    calculi    obtained   from   the   patient.      They 

are     waxy    in    appearance,     friable    and    granular    when 

crushed. 

Lithiasis. — The  finding  of  cystin  crystals  in  the 
urine  is  highly  suggestive  but  does  not  necessarily 
indicate  that  the  patient  has  a  cystin  stone.  Garrod 
believes  that  infection  of  the  urinary  tract  probably 
plays  an  important  part  in  the  formation  of  cystin 
stones;  however,  there  are  definite  cases  of  for- 
mation of  cystin  stones  in  the  presence  of  sterile 
urine.    They  are  frequently  bilateral.    Pure  cystin 


stones  are  waxy,  granular,  and  rather  soft  and 
friable,  although  attention  should  be  directed  to 
the  fact  that  a  deposit  of  the  ordinary  urinary 
salts  may  be  made  upon  and  around  a  cystin  nu- 
cleus. There  is  also  much  discussion  as  to  the 
degree  of  opacity  of  cystin  stones  to  x-ray.  This 
probably  arises  from  the  fact  that  not  all  of  the 
stones  reported  as  cystin  are  composed  entirely  of 
the  pure  chemical. 

Interesting  reports  are  made  of  children  with 
cystinuria  who  suffered  from  inanition  and  general- 
ized debility  over  long  periods  of  time,  whose 
autopsies  revealed  deposits  of  cystin  in  the  liver 
and  other  organs.  Lewis  suggests  that  in  these 
cases  since  cystin  is  so  essential  to  growth  of  the 
individual  the  inability  of  the  body  to  utilize 
amino-acid  terminated  fatally.  Adults  afflicted 
similarly  frequently  have  attacks  of  "gout  and 
rheumatism"  and  the  theory  has  been  advanced 
that  such  attacks  are  caused  by  a  deposit  of  cystin 
crystals  in  the  tissues  of  the  body. 

Treatment. — The  dissolving  of  impassable  uri> 
nary  calculi  has  long  been  the  dream  of  every 
physician.  Apparently  cystin  stones  are  the  only 
ones  which  respond  in  any  way  to  medication  by 
mouth.  Because  of  the  early  recognition  that  they 
were  soluble  in  dilute  alkalies,  serious  efforts  were 
made  by  Cantani,  Klemplar  and  Jacoby  to 
dissolve  them  by  giving  such  solutions  by  mouth. 
Ammonium  carbonates  in  dosages  as  large  as  SO 
grains  per  day  over  a  period  of  a  year  have  been 


No.  2.      Hexagonal    cy.stin    crystals    obtained    from    a    centrifugalized    specimen    of    urine.      The 
shape  of  the  crystals  is  diagnostic  of  cystinuria. 


July,  11336 


CYSTIX  STOyES—McKay 


No.    3.    The  arrow  points  to  the  faint  shadow  cast  by  cystin  stones  in  the  pelvis  of  the  kidnej'. 


reported.  A.  J.  Crowell  in  1924  was  the  first  to 
add,  in  addition  to  the  alkalies  by  mouth,  lavage 
of  the  kidney  pelvis  with  ''alkaline  antiseptic  solu- 
tions." 

Apparently  all  cystin  stones  do  not  readily  re- 
spond to  alkaline  therapy.  Patch  in  1934  cited  a 
case  in  which  he  had  the  patient  under  constant 
observation  for  two  years  on  160  grains  of  sodium 
bicarbonate  per  day.  At  the  end  of  this  time  the 
urine  had  reached  a  pH  7.7  and  x-ray  examination 
showed  no  diminution  in  the  size  and  number  of 
the  stones  in  either  kidney. 

After  reviewing  the  literature  which  is  replete 
with   the   immediate   recurrence   of   cystin   stones 


after  operation,  we  are  forced  to  conclude  that  sur- 
gery should  be  resorted  to  only  in  case  of  dire 
necessity,  such  as  cases  of  marked  interference  with 
urinary  drainage,  severe  pain  or  infection.  Silent 
cystin  stones  should  be  severely  left  alone.  In 
spite  of  the  fact  that  radical  treatment  is  not 
always  successful,  limiting  the  protein  intake  and 
rendering  the  urine  alkaline  is  the  best  means  at 
our  disposal  of  treating  the  condition. 
Conclusions 
The  cause  of  cystinuria  with  the  production  of 
cystin  stones  is  evidently  an  error  in  metabolism, 
although  the  precise  mechanism  which  causes  it  is 
imperfectly  understood. 


CYSTIN  STONES— McKay 


July,  1936 


Surgery  should  be  used  only  in  cases  of  extreme 
necessity  as  they  tend  to  recur  speedily. 

The  occurrence  of  cystin  crystals  in  the  urine  is 
not  indicative  but  is  highly  suggestive  of  the  for- 
mation of  cystin  stones. 

Medical  treatment  consisting  of  low-protein  in- 
take and  alkalization  of  the  urine  should  certainly 
be  given  a  trial  in  each  case. 


This  method  can  be  mastered  by  anyone  who  chooses  to 
devote  a  few  conscientious  hours  in  acquiring  a  knowledge 
of  the  anatomy  and  technical  details. 

Chronic  Gasoline  Poisoning 


Hernia — Its   Cure  By  the  Injection   of  Irritating 

Solutions 

(C.    O.    Rice,    Minneapolis,    in    Jl.    Iowa    State    Med.    Soc, 

June) 

Three  years  ago  this  method  was  instituted  at  the  Min- 
neapolis General  Hospital  primarily  for  the  purpose  of 
using  it  in  poor  surgical  risks  and  also  to  relieve  the  con- 
gestion in  the  surgical  wards.  We  obtained  such  satisfac- 
tory results  that  we  soon  extended  its  use  to  others  who 
did  not  wish  to  have  operations.  It  was  not  long  before 
we  found  our  hernia  clinic  greatly  congested.  These  cases 
taught  us  many  new  experiences.  We  obtained  cures,  but 
when  we  were  asked  how  these  cures  were  obtained  we 
could  only  postulate.  Therefore  it  became  our  problem  to 
prove  our  theories. 

Individuals  who  did  not  know  whether  or  not  they  de- 
sired the  injection  method  we  offered  the  privilege  of 
changing  their  minds  after  they  had  received  one  or  two 
injections.  Biopsies  of  the  tissues  in  the  inguinal  canal  at 
the  site  of  injection  obtained  from  18  hrs.  to  42  days  after 
the  injection  reveal  the  typical  inflammatory  reaction  in 
which  the  reparative  processes  predominated.  We  mean 
by  infection  the  reaction  which  takes  place  in  the  issues 
after  injur>'  and  during  the  course  of  healing. 

Investigations  proved  that  phenol,  tannic  acid  or  alcohol 
produced  more  of  the  destructive  and  exudative  phase  of 
the  inflammation  than  seemed  desirable.  The  sodium  salt 
of  psyllium  seed  (sylnasol)  seemed  to  produce  less  of  the 
destructive  and  exudative  phase,  less  pain,  no  observable 
systemic  effects  from  its  injection  intravenously,  an  abund- 
ance of  healthy  looking  fibrous  tissue. 

This  treatment  has  been  found  most  satisfactory  in  the 
small  indirect  inguinal  hernias.  If  the  external  ring  is 
more  than  3  cm.  in  diameter  it  is  likely  to  prove  difficult 
to  close  by  this  method.  The  size  of  the  mass  in  the 
scrotum  cannot  be  used  as  a  factor  in  determining  the  size 
of  the  defect. 

This  method  is  also  applicable  in  the  direct  inguinal 
hernia  if  the  external  ring  is  not  too  large.  These  usually 
require  more  injections  and  the  technic  is  somewhat  more 
difficult.  I  have  used  it  in  femoral  hernia  with  success. 
In  these  cases  it  is  much  more  difficult,  due  to  the  greater 
inaccessibility  of  the  defect.  It  has  proved  to  be  successful 
in  postoperative  inguinal  hernias  if  the  defect  through  the 
fascia  is  not  too  large,  and  in  postoperative  abdominal 
incisions  if  the  fascial  separation  is  not  greater  than  2  cm. 
I  have  not  used  it  in  any  but  the  very  small  umbilical 
hernias.  For  umbilical  hernias  in  infants  strapping  has 
been  successful  in  a  large  percentage  of  cases. 

Injection  is  definitely  contraindicated  in  any  hernia  which 
cannot  be  reduced  or  maintained  with  a  suitably  fitting 
truss;  or  in  chronic  cough  until  the  cough  has  been  con- 
trolled. Prostatic  hypertrophy  should  be  "tended  to" 
before  attempting  to  repair  the  hernia.  Ascites,  cancer  or 
decompensating  heart  disease  or  undescended  testicle  makes 
this  method  inadvisable. 

The  injection  method  for  the  cure  of  hernia  has  proved 
to  be  sound.  Indications  and  contraindications  can  be 
definitely  determined.  Skillful  technic  and  good  judgment 
will  play  a  large  factor  in  producing  excellent  end  results. 


(F.   Lemere,  Dencer,  in  Col.   Med.,  June) 
.According   to  Henderson  and  Haggard,  the  composition 
of  ordinary  commercial  gasoline  is  as  follows: 

A.  Benz/ne — a  group  of  paraffin  hydrocarbons  distilled 
from  crude  petroleum:  and 

B.  Benzene  (Benzol) — an  aromatic  hydrocarbon  distilled 
from  coal  tar. 

From  20  to  90%  of  benzene  is  added  to  the  petroleum 
distiUate.     Benzene  is  more  toxic  than  benz/ne. 

Chronic  gasoline  poisoning  arises  from  the  inhalation  of 
fumes.  A  concentration  of  1%  gasoline  vapor  is  toxic  even 
when  inhaled  for  a  short  time.  Exposure  is  especially  apt 
to  occur  in  garages,  in  the  petroleum,  dry  cleaning,  and 
rubber  and  paint  industries  using  gasoline  as  a  solvent. 

Gasoline  may  also  be  absorbed  through  the  skin.  There 
have  been  a  few  instances  of  addiction  to  gasoline  includ- 
ing the  habit  of  inhaling  fumes  from  the  gas  tanks  of  auto- 
mobiles. 

Symptoms:  poor  appetite  with  abdominal  pain,  nausea, 
and  vomiting;  anemia  with  weakness,  a  dull  heavy  feeling 
in  the  head,  dizziness,  and  occasionally  hemorrhagic  pur- 
pura; neuritis  with  paraesthesias,  paresis,  and  paralyses, 
tremor,  ataxia,  nystagmus,  slurred  speech,  retrobulbar  neu-" 
ritis,  and  cranial  nerve  paralyses ;  anxiety,  sleep  disturb- 
ances, depression  or  euphoria,  amnesia,  confusion,  and  a 
mental  condition   resembling  feeble-mindedness. 

A  tailor  for  at  least  12  years,  pressed  gasoline-cleaned 
clothes  in  his  small  apartment  and  the  fumes  often  caused 
him  to  feel  that  he  was  floating  in  the  air  and  he  would 
lose  consciousness.  Gasoline  had  also  been  used  for  cooking 
and  illumination  and  neighbors  had  complained  frequently 
of  fumes  emanating  from  the  patient's  apartment. 

A  S6-year-old  white  man  in  fair  general  nutrition,  a 
slight  inflammation  of  the  pharynx,  a  moderately  enlarged 
heart  with  a  slight  arteriosclerosis,  and  a  b.  p.  of  150/100, 
small  petechial  hemorrhages  into  the  skin  of  both  lower 
extremities,  ataxia,  slurred  speech,  and  peripheral  nerve 
pain,  optic  discs  were  pale. 

The  histor>'  of  the  wife  was  essentially  the  same.  She 
helped  him  with  his  work  and  was  equally  exposed  to 
gasoline  fumes.  Before  admission  to  the  hospital,  she  had 
had  two  "strokes'"  with  loss  of  consciousness  and  inconti- 
nence. 

Two  cases  within  the  arteriosclerotic  age  bracket,  whose 
symptoms  suggest  a  toxic  agent  rather  than  arteriosclero- 
sis. 

That  gasoline  intoxication  is  relatively  more  severe  in 
women  is  well  borne  out  in  these  two  cases;  the  wife  died 
two  months  after  admission  while  her  husband  survives  in 
an  extremely  deteriorated  condition. 


Gangrene  and  Death  Following   Ergotamine  Tartrate 

(Gynergen)  Therapy 
(S.  E.  Gould,  A.  E.  Price  &  H.  I.  Ginsberg,  Eloise,  Mich., 
in  J.  A.  M.  A.,  May  9th) 
A  middle-aged  woman  developed  gangrene  of  both  lower 
extremities  immediately  after  the  institution  of  ergotamine 
tartrate  (gynergen)  therapy.  Postmortem,  all  the  arterioles 
examined  were  found  to  be  contracted.  The  work  of  Mc- 
Grath  on  rats,  demonstrated  the  production  of  gangrene 
following  the  injection  of  gynergen.  The  vascular  disease 
present  would  seem  to  have  predisposed  to  the  development 
of  the  gangrene.  It  is  suggested  that  the  use  of  drugs  of 
this  type  be  avoided  in  cases  of  vascular  disease  such  as 
atherosclerosis,  Buerger's  disease,  coronary  sclerosis,  and 
syphilitic  narrowing  of  the  mouths  of  the  coronary  arteries. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


The  Constitutionally  Inadequate* 

W.  T.  Rainey,  M.D.,  Fayetteville,  North  Carolina 
Highsmith  Hospital 


When  you  can  measure  what  you  are  speaking  about 
and  express  it  in  nunabers,  you  know  something  about 
it,  but  when  you  cannot  measure  it,  when  you  cannot 
express  it  in  numbers,  your  knowledge  is  of  a  meagre 
and  unsatisfactory-  kind. — Lord  Kelvin. 

COXSTITUTION.\L  INADEQUACY  may 
be  defined  as  a  state  of  bodily  and  mental 
make-up  which  handicaps  the  individual  in 
his  adjustment  to  the  various  environmental 
stresses.  The  greater  the  degree  of  inadequacy, 
the  more  readily  the  individual  presents  evidences 
of  what  might  be  called  decompensation. 

It  is  to  this  group  that  I  want  to  direct  your 
attention.  They  are  found  in  every  branch  of 
medicine  and  comprise  a  large  percentage  of  our 
clientele.  In  our  rush  we  are  prone  to  underesti- 
mate their  complaints  and  fail  to  give  them  the 
careful  handling  and  sympathetic  encouragement 
they  require  and  must  have  to  enable  them  to 
fight  life's  battles.  It  is  the  lack  of  proper  care 
which  causes  such  patients  to  pass  into  the  hands 
of  the  quacks  who,  with  their  sales  talks  and 
manipulations,  ofttimes  gain  their  confidence  and 
lead  them  into  a  state  of  well-being  much  to  the 
chagrin  of  the  medical  profession. 

This  type  of  patient  is  very  difficult  to  describe 
accurately,  but  a  large  number  of  them  consist  of 
those  variously  diagnosed  as  neurasthenic,  psych- 
asthenic, hysteric  and  all  those  classed  by  the  laity 
and  profession  as  nervous.  There  is  a  difference 
of  opinion  relative  to  these  terms  by  different 
physicians,  but  we  all  see  them  and  I  think  roughly 
understand  what  patients  are  placed  in  this  group. 
Cardiac  and  gastric  neurosis,  chronic  appendicitis 
and  intestinal  intoxication  are  some  of  the  diagnoses 
given  them,  yet  under  treatment  they  do  not  im- 
prove because  we  do  not  understand  the  under- 
lying pathologic  physiology.  We  all  see  patients 
from  whom  the  appendix  has  been  removed  and 
sometimes  this  followed  by  operations  for  "adhe- 
sions," removal  of  the  gallbladder  and  suspension 
or  perhaps  removal  of  the  uterus — yet  they  still 
complain  of  their  old  abdominal  symptoms.  These 
symptoms  are  the  expression  of  some  physical  or 
mental  decompensation.  It  may  go  into  the  field 
of  allergy  and  include  a  few  of  the  sufferers  from 
hayfever,  asthma  and  certain  skin  conditions. 
There  are  others  who  will  have  a  certain  chain  of 
symptoms  with  every  disease  to  which  they  fall 
heir,  and   it   is   this   which   makes   them   different 

rPresented  to  the  Section  on  Practice  of  Medicine  of  the 


from  the  ordinary  sick  person  who  has  the  same 
disease  without  the  other  clinical  phenomena.  The 
treatment  may  not  be  altered  by  these  phenomena 
but  we  must  recognize  them  and  weigh  their  value. 
In  the  specialties  one  is  apt  to  center  his  attention 
on  the  disease  for  which  the  patient  seeks  relief 
and   disregard   these  seemingly  irrelevant   matters. 

At  present  there  is  a  tendency  to  refer  these 
patients  to  neuropsychiatrists  for  opinion  and 
study,  hoping  that  they  will  solve  the  problem. 
Sometimes  this  will  clear  the  condition  but  often 
it  will  only  muddy  the  waters.  The  family  phy- 
sician must  be  prepared  to  handle  the  majority  of 
them,  and  his  success  will  be  proportionate  to  his 
understanding  of  them. 

We  all  see  patients  who  are  continually  com- 
plaining of  one  thing  or  another  while  others  may 
break  only  under  relatively  great  stress.  The  de- 
gree of  education  does  not  enter  into  this  consid- 
eration. Those  talented  in  the  various  arts  often 
show  evidences  of  constitutional  inadequacy  in  spite 
of  their  special  talents.  So  often  the  inventor, 
artist  and  even  the  athlete  enter  the  group  under 
discussion.  Hyslop  expressed  it  well  when  he  said, 
"Individuals  with  constitutional  inadequacy  might 
be  referred  to  as  human  beings  inade  out  of  spare 
parts  which  have  been  poorly  assembled,  without 
regard  to  whether  the  spare  parts  fit  each  other 
or  not.  Hence,  constitutionally  inadequate  indi- 
viduals go  clanking  through  life  very  much  like  the 
poorly  assembled  automobile  which  rattles  its  way 
down  the  street." 

'Tis  true  that  we  rarely  see  an  individual  in 
whom  all  the  systems  are  working  in  harmony  at 
one  and  the  same  time.  To  many,  the  idea  that 
the  constitution  is  merely  a  sum  total  of  the  indi- 
vidual characteristics  of  the  separate  organs  and 
tissues  is  not  acceptable.  Pende  says  that  the 
constitution  is  the  morphological,  physiological  and 
psychological  resultant  of  the  properties  of  all  the 
cellular  and  humoral  elements  of  the  body. 

The  state  of  the  constitution  therefore  does  not 
depend  solely  upon  the  functional  capacity  of  the 
separate  organs,  but  must  include  the  reciprocal 
correlations  of  its  various  parts  as  well. 

Various  methods  have  been  devised  as  aids  in 
determining  the  state  of  the  constitution. 

The  older  physicians  placed  great  stress  on  what 
they  called  diathesis,  by  which  they  meant  the  pre- 
disposition to  certain  diseases.    Due  to  an  inability 

Medical  Society  of  the  State  of  North  Carolina  atAsheville, 


372 


THE  CONSTITUTIONALLY  INADEQUATE— Rainey 


July,  1936 


to  express  it  in  definite  terms  it  has  been  somewhat 
discarded,  still  there  may  be  something  to  it. 

Draper  and  others  in  their  investigations  have 
shown  by  anthropological  studies  that  certain  type 
individuals  are  more  susceptible  to  certain  diseases 
and  have  been  able  to  recognize  an  ulcer  type,  a 
gallbladder  type  and  a  pernicious-anemia  type. 

Constitutional  inadequacy  may  be  mental  or 
physical  or  both.  It  must  be  remembered  that  no 
person  is  absoutely  normal  in  all  respects  as  we 
have  our  individual  peculiarities  and  traits  without 
which  the  world  would  be  quite  monotonous.  Oft- 
times  it  is  difficult  to  differentiate  the  normal  from 
the  abnormal  as  a  few  abnormalities  are  not  suffi- 
cient to  label  one  as  abnormal.  The  mental  and 
physical  life  history  must  be  studied,  the  clinical 
picture  outlined  and  the  past  history  thoroughly 
gone  into.  The  physician  must  understand  these 
cases  before  he  can  get  from  them  or  their  relatives 
the  necessary  information.  We  must  remember  the 
physical  and  mental  instability  associated,  I  might 
say,  normally  with  adolesence  and  the  climacte- 
rium. These  periods  of  life  are  usually  passed 
through  with  greater  difficulty  by  those  showing 
some  form  of  constitutional  inadequacy.  Changes 
in  the  endocrine  and  vegetative  nervous  systems 
may  be  found  without  any  anatomic  abnormality 
and  their  presence  must  be  sought  for. 

Frequently  severe  infections  in  these  patients 
will  result  in  physical  and  mental  disturbances. 
These  may  be  a  change  in  personality,  gastrointes- 
tinal malfunction,  nervous  instability,  cardiac  dis- 
tress, lowered  resistance  to  infections  or  fatigability. 
Lax  ligments  and  poor  muscle  tone  from  infection 
may  result  in  painful  feet,  visceroptosis  and  skele- 
tal posture  defects  associated  with  these  dis- 
orders of  body  function.  These  patients  may  be 
emotionally  unstable  and  have  a  reduced  capacity 
for  intellectual  effort.  They  can  not  stand  respon- 
sibility. They  recognize  their  mental  and  physical 
incapacities  and  may  date  the  beginning  of  these 
symptoms  from  a  certain  infection. 

What,  then,  are  some  of  the  evidences  of  consti- 
tutional inadequacy,  physical  or  psychic?  Among 
the  psychic  are:  1 — Disorders  of  conduct  as  vicious 
habits,  various  intemperances  including  drug  ad- 
diction: 2 — defects  of  emotional  control — as  abnor- 
mal seclusiveness,  phobias,  irrationality  and  mood- 
iness; 3 — mental — as  egotism,  stubbornness  and 
destructiveness. 

The  physical  manifestations  may  be  anatomical 
or  physiological.  Among  the  anatomical  character- 
istics are  deviations  of  structure  and  proportion  in 
comparison  with  the  normal  in  view  of  the  indi- 
vidual race  and  parentage.  Of  greater  importance 
are  such  developmental  defects  as  abnormal  palate, 
irregular   spacing  and  disproportionate  shape  and 


size  of  the  teeth,  abnormal  distribution  of  hair  and 
secondary  sexual  characteristics  of  the  opposite  sex. 

The  physiological  evidences  are  chiefly  those 
referable  to  the  vegetative  nervous  system  and  en- 
docrines,  the  most  important  of  which  are  vasom- 
otor instability  and  cardiac  and  gastric  neuroses. 

Some  forms  of  migraine  and  convulsive  states 
may  be  expressions  of  physiological  inadequacy. 

.'\n  individual  markedly  deficient  in  all  three  of 
these  forms  would  be  practically  a  hopeless  cripple; 
usually,  however,  one  form  predominates  with 
slight  or  no  changes  in  the  others  and  such  indi- 
viduals may  go  through  life  without  decompensat- 
ing, making  useful  citizens.  However,  when  put 
under  a  strain  they  frequently  break. 

The  treatment  of  these  cases  is  difficult  and 
ofttimes  unsatisfactory.  There  is  no  form  of  ther- 
apy which  can  be  applied  to  all  of  them.  Examine 
them  carefully  and  thoroughly.  Satisfy  yourself 
that  they  belong  to  this  class  before  beginning  any 
form  of  treatment.  They  are  definitely  sick  and 
cannot  be  passed  by  lightly  with  a  prescription  for 
a  tonic  or  sedative,  though  occasionally  this  is  as 
good  as  any.  Listen  to  their  stories  with  interest 
and  avoid  asking  leading  questions.  They  require 
careful  handling  and  sympathetic  encouragement, 
but  be  careful  not  to  show  too  much  sympathy. 
Every  measure  at  our  command  from  psychother- 
apy through  diet,  physiotherapy  and  drugs  down  to 
skillful  neglect  may  be  employed — and  then  result 
in  failure.  Sometimes  it  is  necessary  to  go  into  the 
fields  of  economics  and  sociology  to  bring  about 
relief. 

.'\gain,  let  me  say,  give  these  patients  your  time 
and  interest  because  theeir  condition  is  real  to 
them,  else  they  will  pass  from  one  doctor  to  another 
and  finally  to  the  quack  unless  nature  intervenes 
and  cures  them. 


The  Successful  Doctor  and  the  Human  Side  of 

Practice 

(J.  B.  Herrick,  Chicago,  in  The  Diplomate,  May) 

Many  a  practitioner  would  be  awakened  to  a  new  life 
if  he  were  not  wedded  to  the  belief  that  experience,  intui- 
tive hunches,  practical  results,  were  the  all  in  all  of  medi- 
cine, or  if  he  were  not  so  timid  as  to  think  he  dare  not 
enter  the  sanctum  sanctorum  reserved  for  research. 

"Doctor,"  a  new  patient  said  to  me,  "I  do  hope  you 
will  be  different  from  the  other  doctors  whom  I  have  con- 
sulted. I  trust  you  will  look  less  at  the  x-ray  picture  and 
more  at  me."  The  busy  attending  man  with  his  following 
of  students  and  house  staff  was  bustling  down  the  ward  to 
see  the  interesting  case  at  the  end  of  the  row  of  beds.  The 
Irishman  in  bed-1  leaned  over  to  the  Swede  in  bed-2  and 
said,  "Ole,  we  ought  to  be  a  hell  of  a  lot  better.  The 
professor  has  just  walked  by."  There  is  a  practical  sermon 
on  ethics  in  those  two  incidents. 


Pedro  Ponce  de  Leon  (died  15S4)  should  be  mentioned 
with  honor  as  the  founder  of  a  system  of  instruction  for 
the  deaf  and  dumb. — Baas.  , 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


373 


The  Incidence  of  Meningococcus  Meningitis  and  Some  Related 

Problems* 

Wyndham  B.  Blanton,  M.D.,  Richmond,  Virginia 


I 

FROJNI  some  points  of  view  meningococcus 
meningitis  is  a  new  disease.  The  histori- 
cally-minded may  challenge  this  statement, 
but  it  is  nevertheless  true  that  the  first  clinical 
description  of  the  malady  dates  from  1805  and 
was  given  by  a  Frenchman  named  Vieusseux.  Cu- 
riously enough  the  very  next  year  "a  singular  and 
very  mortal"  epidemic,  as  it  was  described,  oc- 
curred in  far-away  Massachusetts.  Since  that  time 
the  disease  has  been  recognized  all  over  the  world. 
It  was  prevalent  in  the  United  States  from  1805- 
1830,  and  in  France  from  1837-1850,  and  again  in 
the  United  States  from  1854-1874.  It  occurred 
extensively  in  this  country  in  1898-1899,  and  in 
New  York  in  1904-1905  there  were  6,755  cases, 
with  3,455  deaths.  During  the  World  War,  as  will 
be  remembered,  there  were  a  number  of  outbreaks, 
a  particularly  severe  one  was  reported  from  Camp 
Jackson  in  this  country. 

In  Virginia  Robert  Dunbar  of  Winchester  de- 
scribed an  epidemic  occurring  in  the  Valley  of 
Virginia  in  the  year  1812-1813.  In  1864  in  the 
Engineer's  Camp  on  the  Nine  Mile  Road,  five  miles 
from  Richmond,  an  epidemic  of  64  cases  developed 
with  a  mortality  of  60  per  cent.  In  1895  between 
40  and  50  people  died  of  the  disease  in  Roanoke, 
and  in  Richmond  in  1898  occurred  our  most  severe 
epidemic.  Here  were  reported  during  the  period 
from  January  to  July,  98  deaths  from  meningitis, 
one-seventeenth  of  the  total  death  rate  of  the  city 
for  that  year. 

Although  meningococcus  meningitis  is  also  an 
endemic  disease,  sporadic  cases  are  rarely  encoun- 
tered by  the  average  physician.  In  private  practice 
I  can  recall  but  one  during  the  last  fifteen  years. 
In  one  of  Richmond's  private  hospitals  among 
some  thirty  thousand  admissions  covering  an  equal 
length  of  time  only  four  cases  have  been  admitted. 
II 

Meningococcus  meningitis  is  on  the  increase. 
In  the  United  States  in  1934  there  were  about  2,000 
cases  (2,186).  During  1935  there  were  about 
5,000  cases  (5,378).  During  the  first  fifteen  weeks 
of  last  year  there  were  approximately  2,000  cases 
(1,984).  For  the  same  period  this  year  there  were 
3,509  cases.  If  the  present  rate  of  increase  con- 
tinues, the  year  1936  will  show  nearly  five  times 
as  many  cases  of  meningococcus  meningitis  in  the 
United  States  as  were  reported  in  1934. 

The  situation  in  Virginia  is  reflected  in  the  na- 


tional statistics.  For  the  first  fifteen  weeks  of 
1935,  79  cases  of  the  disease  were  reported  in  this 
State.  During  a  corresponding  number  of  weeks 
this  year,  226  cases  have  been  reported.  When 
compared  with  measles,  of  which  there  were  more 
than  700,000  in  the  United  States  in  1935,  or 
with  scarlet  fever,  of  which  there  were  more  than 
240,000  cases,  the  meningococcus  incidence  appears 
to  be  trifling,  but  this  is  not  the  view  taken  by 
those  familiar  with  the  fatality  rates  of  the  dis- 
ease. 

In  Richmond  during  the  last  ten  years  meningo- 
coccus meningitis  has  occurred  as  follows:  in  1926, 
one  case;  in  1927,  3  cases;  1928,  4  cases.  Then 
in  1929,  24  cases;  in  1930,  28  cases,  and  in  1931, 
16.  In  1932  there  were  three  cases;  in  1933,  2; 
in  1934,  7;  in  1935,  12  cases;  and  for  the  first 
four  months  of  1936,  26  cases.  In  Richmond  there- 
fore up  until  January,  1936,  a  period  covering  ten 
years,  we  have  had  a  total  of  110  cases,  an  aver- 
age of  11  a  year.  Of  these,  48  have  died, — a  43 
per  cent,  mortality.  The  mortality  among  the  26 
cases  of  the  first  months  of  1936  has  been  much 
higher, — 57  per  cent,  to  be  exact. ^ 

Two  questions  will  occur  to  the  reader, — the 
cause  of  the  country-wide  increase  in  meningitis  at 
this  time,  and  the  reason  for  the  high  fatality  rates 
among  our  own  recent  cases.  I  wish  I  could  an- 
swer them. 

Ill 

Interest  naturally  centers  in  the  place  and  in 
the  manner  of  treatment  of  our  own  Richmond 
cases.  In  this  connection  there  is  an  extraordinary 
circumstance.  In  the  last  five  years,  1931-1936, 
we  have  had  76  cases  of  meningococcus  meningitis 
in  Richmond.  Seventy-one  of  these  cases — (all  ex- 
cept five)  were  treated  in  the  hospitals  of  the  Med- 
ical College  of  Virginia.  I  venture  to  say  that 
during  the  last  five  years,  no  other  acute  disease 
has  occurred  among  us,  93  per  cent,  of  the  instances 
of  which  have  been  entirely  cared  for  in  the  wards 
of  one  institution. 

For  an  understanding  of  meningococcus  menin- 
gitis in  Richmond  during  recent  years  one  there- 
fore naturally  turns  to  the  records  of  the  Memo- 
rial, St.  Philip  and  D(X)ley  Hospitals.  I  have 
recently  reviewed  the  records  of  70-odd  recent  cases 
in  those  institutions.  Although  this  survey  has 
gone  into  the  records  of  only  the  last  few  years,  it 


♦Read  before  the  Staff  Meeting,  St.   Luke's  Hospital,  Richmond,  Va.,  May  23rd. 


374 


MENINGOCOCCUS  MENINGITIS— Blanlon 


July,   1936 


has  nevertheless  revealed,  I  believe,  some  important 
findings. 

First  as  to  fatality  statistics.  It  is  usually  stated 
that,  the  world  over,  the  mortality  from  meningo- 
coccus meningitis  prior  to  the  introduction  of  serum 
(1906)  was  75  per  cent.,  and  that  since  that  time 
it  has  dropped  to  30  per  cent.  Now  of  the  71 
Medical  College  of  Virginia  cases  studied,  practi- 
cally all  of  which  fall  into  the  serum-treated  group, 
31  of  the  patients  died,  a  mortality  rate  of  43  per 
cent.  These  71  cases  were  distributed  as  follows: 
patients  under  IS  years,  34,  32  per  cent,  of  whom 
died;  over  IS  years,  37,  S4  per  cent,  of  whom  died; 
over  30  years  of  age,  11,  72  per  cent,  of  whom  died. 
In  this  locality  during  the  period  covered,  meningo- 
coccus meningitis  has  apparently  not  been  a  dis- 
ease sharply  limited  to  young  people.  In  this  series 
the  children  have  succumbed  less  readily  than  the 
adults.  The  mortality  above  30  years  of  age  is 
striking.  Last  year  Hoyne  of  Chicago  published  a 
large  group  of  figures  which  express  the  age  factor 
very  much  as  do  ours. 

In  the  accompanying  table  we  have  attempted  to 
show  the  effect  of  early  treatment  upon  mortality 
statistics.  The  figures  of  Flexner,  Netter  and  Dop- 
ter  are  well  known  and  argue  strongly  for  the 
prompt  administration  of  serum.  For  comparison 
these  figures  have  been  placed  along  with  our  own. 

COMPARATIVE  MORTALITY  IN   TERMS  OF  WHEN 
TREATMENT  WAS  BEGUN 
Treatment  Begun 
Before  Srd  day  4th  to  7th  day  After  7th  day 

%                             %  % 

Flexner  18.1                      27.2  36.S 

Netter 7.1                      11.1  23.5 

Dopter    8.2                      14.4  24.1 

Christomanos 13.0                      25.9  47.0 

Levy 13.2                      20.4  28.6 

Flack  -      9.09  SO. 

Hospital  Division     45.                        31.  44. 

Med.  Col.  Va (35  cases)           (16cases)  (9cases) 

In  these  figures  the  high  mortality  among  our 
patients  received  at  the  hospitals  before  the  third 
day  is  striking.  Assuming  that  the  statements  of 
fact  upon  the  charts  are  correct,  it  is  to  be  ex- 
plained, I  believe,  on  the  basis  of  the  high  incidence 
of  fulminating  cases  which  fall  into  this  group.  It 
would  appear  that  very  sick  patients  are  sent  to 
the  hospital  in  the  first  hours  of  the  disease.  Delay 
is  apt  to  occur  in  those  cases  in  which  the  disease 
comes  on  more  gradually.  These  figures  may  indi- 
cate that  in  determining  the  ultimate  results  the 
type  of  organism  is  of  more  importance  even  than 
the  promptitude  with  which  serum  therapy  is  insti- 
tuted. 

Among  S8  hospital  cases  (this  being  all  upon 
which  data  were  available)  in  only  three  instances 
was  meningitis  diagnosed  before  entering  the  hos- 
pital, and  only  two  had  received  spinal  puncture 


and  serum  therapy  prior  to  admission.  The  ma- 
jority of  the  patients  were  admitted  with  a  history 
of  having  had  a  cold,  influenza  or  a  digestive  upset. 
A  great  many  of  them  were  in  the  various  stages 
of  coma. 

The  statement  is  made  in  the  textbooks  that 
meningitis  is  not  a  particularly  communicable  dis- 
ease, that  doctors,  nurses  and  orderlies  (although 
they  often  become  carriers)  rarely  contract  the 
disease.  In  this  respect  meningococcus  meningitis 
resembles  acute  poliomyelitis.  It  ttacks  only  sus- 
ceptibies  and  in  every  community  there  are  only 
a  few  susceptibles.  In  roughly  testing  the  truth  of 
this  statement  among  our  series  of  cases  we  found 
this  grouping  of  patients:  one  father  and  son,  one 
mother  and  two  children,  three  children  in  one 
family;  and,  finally,  six  members  of  one  Church 
Hill  family,  five  of  whom  died.  Is  this  just  an 
exceptional  grouping  of  susceptibles, — individuals 
minus  that  specific  protection  afforded  by  specific 
antibodies?  or  is  it  the  work  of  a  particularly  viru- 
lent strain  of  organism? 

Fifty-three  or  70  per  cent,  of  the  cases  we  have 
reviewed,  occurred  in  the  months  from  November 
to  April  inclusive,  bearing  out  the  well  known  fact 
that  meningitis  is  a  winter  disease,  in  contrast  to 
acute  anterior  poliomyelitis,  for  example.  Forty- 
one  of  this  series  of  cases  were  of  colored  people, 
of  whom  18  died,  a  fatality  rate  of  43  per  cent. 
Thirty  were  of  whites,  of  whom  13  died,  a  fatality 
rate  of  43  per  cent.  From  a  racial  standpoint  these 
seventy-odd  cases  were  almost  evenly  divided,  with 
the  colored  morbidity  rates  slightly  in  excess  of 
the  white,  but  the  fatality  rates  are  the  same. 

There  were  42  males  and  29  females  among  these 
71  patients.  Twenty-two  of  the  31  total  deaths 
occurred  among  the  males,  a  fatality  rate  of  S2  per 
cent.:  only  9  of  the  females  died,  a  fatality  rate  of 
31  per  cent.;  from  which  it  would  appear  that  a 
male  has  a  distinctly  greater  chance  of  getting  the 
disease,  and  twice  the  opportunity  of  dying  of  it 
once  he  has  contracted  it. 

All  of  these  hospital  cases  of  course  had  spinal- 
fluid  studies.  I  have  analyzed  the  results  in  70 
cases.  Some  of  these  spinal  fluids  showed  only 
polymorphonuclear  leucocytosis;  some,  organisms 
only  in  smear;  others,  only  in  culture.  In  a  larger 
number,  organisms  were  found  in  both  smear  and 
culture.  These  findings  are  summarized  as  fol- 
lows: 

Fluids  with  polys,  only  H 

Fluids  with  organisms  in  smear  only 16 

Fluids  with  organisms  in  culture  only- — 21 

Fluids  with  organisms  in  both  smear  and  culture  _-  22 

70 

These  figures  indicate  the  importance  of  cultur- 

ing  the  spinal  fluid  as  well  as  making  smears.    The 


July,   1036 


MENINGOCOCCUS  MENINGITIS— Blanton 


37S 


secret  of  cultures  is  in  plating  the  fluid  heavily 
upon  suitable  media  at  the  bedside.  It  is  also 
helpful  to  leave  the  spinal  fluid  in  the  incubator 
for  a  number  of  hours  before  culturing.  The  num- 
ber of  cases  in  which  polys,  only  were  found  per- 
haps indicates  the  prominent  feature  that  autolysis 
plays  in  the  disease.  Zinsser  advocates  bedside 
staining  and  search  for  the  meningococci,  while  the 
needle,  ready  for  serum  introduction,  still  remains 
in  the  spinal  canal.  An  acute  meningitis  with  poly- 
morphonuclear pleocytosis,  in  the  absence  of  or- 
ganisms, is  safely  regarded  as  of  meningococcus 
origin.  It  is  said  to  be  e.xceedingly  rare  not  to 
find  the  pneumococcus  or  the  streptococcus  when 
either  bears  an  etiological  role  in  meningitis.  In 
this  connection  it  should  be  said  that  since  Jan- 
uary, 1936,  with  one  e.xception,  every  spinal  fluid 
examined  in  the  hospitals  of  the  ^Medical  College  of 
Virginia  has  been  successfully  cultured. 

In  view  of  Herrick's  contribution  to  our  under- 
standing of  the  disease  during  the  premeningitic 
stage  we  turn  to  the  question  of  blood  cultures  with 
particular  interest.  Herrick  you  remember  ob- 
served an  epidemic  of  208  cases  at  Camp  Jackson 
in  1918.  He  laid  down  the  dictum  that  "the  dis- 
ease is  in  most,  probably  in  all,  instances  a  primary 
meningococcus  sepsis  with  usual,  but  not  neces- 
sarily universal,  secondary  meningitis.  The  diag- 
nosis can  be  made  in  at  least  SO  per  cent,  in  the 
premeningitic  stage  of  sepsis."  In  36  per  cent,  of 
his  cases  positive  blood  cultures  were  reported  in 
the  early  stage  of  the  disease. 

Turning  to  our  cases  it  was  somewhat  disap- 
pointing to  find  only  four  instances  in  which  blood 
cultures  for  meningococcus  were  recorded,  and  only 
two  in  which  the  organism  was  found.  The  expla- 
nation probably  lies  in  the  fact  that  many  cases 
were  received  into  the  hospital  late  in  the  menin- 
gitic  stage;  but  it  does  appear  that  some  interesting 
light  might  have  been  thrown  upon  the  disease, 
particularly  in  the  group  of  early  cases,  had  the 
practice  of  making  routine  blood  cultures  at  the 
time  of  admission  been  in  vogue. 

Throat  cultures  for  the  presence  of  the  meningo- 
coccus were  recorded  as  having  been  carried  out 
in  18  cases.  In  only  one  case  were  they  reported 
as  positive.  There  is  no  reference  to  the  technique 
employed,  whether  the  West  tube  was  used  or  how 
soon  they  were  inoculated  after  they  were  made. 
The  importance  of  this  examination  in  the  control 
of  carriers  is  obvious  and  three  routine  negative 
cultures  from  the  throat  should  be  required  of  all 
cases  before  dismissal. 

About  a  year  ago  Banks  in  England  and  Hoyne 
in  this  country  reported  their  experience  with  the 
new  meningococcus  antitoxin  of  Ferry.  The  latter's 
cases  were  from  the   Cook   County   Hospital   and 


numbered  295.  Two  hundred  and  eleven  received 
the  new  antitoxin.  In  85  the  old  antimeningococcus 
serum  was  used.  The  new  treatment  is  said  to 
have  reduced  the  mortality  from  45  per  cent,  to  23 
per  cent.  Hoyne  gave  from  60-100  c.c.  of  anti- 
toxin intravenously,  30-60  c.c.  intramuscularly,  and 
20-40  c.c.  intraspinally.  He  laid  stress  chiefly  upon 
a  large  intravenous  dose,  and  advised  against  lum- 
bar punctures  more  frequently  than  once  in  24 
hours.  He  considered  cisternal  puncture  rarely  in- 
dicated. 

During  the  last  year  in  the  hospitals  of  the 
Medical  College  of  Virginia  antitoxin  has  been 
given  a  trial.  It  was  employed  intravenously  in 
conjunction  with  antimeningococcus  serum  intra- 
spinally.   The  results  were  not  striking. 

Ferry  is  extending  the  use  of  meningococcus 
toxin  and  antitoxin  to  skin  testing  for  susceptibility 
and  active  immunization  of  nonimmunes.  His  work 
is  not  above  criticism  and  some  of  our  best  bac- 
teriologists believe  he  is  simply  producing  another 
antimeningococcus  serum  in  a  slightly  different 
way. 

In  spite  of  the  emphasis  placed  upon  intravenous 
therapy  by  Herrick,  Hoyne  and  others,  there  are 
still  strong  advocates  of  intraspinal  treatments  only. 
Some  time  ago  another  Chicago  report,  this  one 
of  338  cases,  emphasized  a  65  per  cent,  mortality 
in  cases  treated  intravenously  and  advocated  intra- 
spinal therapy  only. 

In  reviewing  the  therapy  of  our  cases  it  is  ap- 
parent that  reliance  (outside  of  drainage)  has  been 
placed  chiefly  on  intraspinal  antimeningococcus  se- 
rum. The  usual  intraspinal  dose  was  10  c.c,  given 
once  or  twice  in  twenty-four  hours.  It  was  notable 
that,  regardless  of  age,  children  as  well  as  adults 
tended  to  receive  this  standardized  10-c.c.  dose. 
In  16  cases  no  intravenous  serum  was  given  at  all. 
These  were  undoubtedly  instances  in  which  the 
stage  of  the  disease  contraindicated  it.  Serum  that 
was  known  to  be  type-specific,  serum  in  larger 
initial  doses,  serum  early  in  the  disease,  riiight  have 
reduced  our  case  fatality  rates  in  the  series  of  cases 
under  treatment  since  January  1st. 

There  can  be  no  disagreement  with  the  assertion 
that  prevention  and  treatment  in  the  management 
of  meningococcus  meningitis  are  interlocked  and 
are  of  the  first  importance.  It  should  be  empha- 
sized that  prevention  must  not  be  entirely  relegated 
to  departments  of  Public  Health  which  are  already 
encroaching  voraciously  upon  private  practice. 
Prevention  is  a  matter  of  the  carrier.  The  carrier 
is  the  convalescent  patient  or  one  who  has  been 
e.xposed  to  him.  He  is  not  easy  to  identify  and 
not  easy  to  cure.  In  civil  life  we  are  told  that 
from  2  to  5  per  cent,  of  the  population  are  carriers 
of  the  meningococcus.    These  figures  are  probably 


MENINGOCOCCUS  MENINGITIS— Blanton 


July,  1936 


too  high.  Amoncr  §00  nasopharyngeal  cultures  for 
meningococci  made  by  me  at  Camp  Custer  in  1918 
approximately  .3  per  cent,  were  positive.  In  a  very 
much  larger  series, — 30,000  cases, — workers  at 
Camp  Travis  found  .6  per  cent.  Mathers  and 
Herrold  at  the  Great  Lakes  Naval  Training  Station 
showed  among  contacts  on  the  other  hand  a  carrier 
rate  as  high  as  36  per  cent.  In  considering  these 
figures  it  is  well  to  remember  that  there  are  at 
least  three  other  gram-negative  diplococci  recover- 
able from  the  nasopharynx  and  that  morphological 
and  cultural  identification  of  the  meningococcus  in 
this  locality  is  difficult. 

Undoubtedly  the  carrier  is  a  constant  source  of 
danger  in  a  community.  The  termination  of  the 
carrier  state  in  the  convalescent  is  the  business  of 
the  attending  physician.  The  recognition  and  cure 
of  the  carrier  state  in  contacts  (orderlies,  nurses 
and  doctors)  is  also  the  business  of  the  attending 
physician.  In  carrying  out  these  responsibilities 
he  must  recognize  the  difficulty  just  mentioned  of 
identifying  the  meningococcus  in  postnasal  cultures, 
viewing  it  as  a  highly  technical  bacteriological  pro- 
cedure. 

Unfortunately  there  is  no  specific  treatment  for 
the  meningococcus  cairrier,  although  it  is  now 
pretty  well  recognized  that  an  unhealthy  mucous 
membrane  harbors  the  meningococcus,  and  demands 
attention.  Fresh  air  and  sunshine  accomplish  most 
in  the  treatment  of  carriers. 

There  are  several  ways  of  viewing  a  wave  of 
increased  incidence  of  a  disease  like  meningococcus 
meningitis.  It  may  be  primarily  a  question  of  the 
carrier,  whose  numbers  may  be  increased  by  crowd- 
ing (as  in  army  life);  by  the  prevalence  of  res- 
piratory infections  (as  in  the  winter  season);  by 
physical  depletion  (as  among  the  poor  and  hard- 
worked).  In  an  outbreak  such  as  we  had  in  Rich- 
mond in  1898,  in  1930  and  again  this  year  the 
type  of  organism  seems  to  be  an  equally  crucial 
factor.  The  number  of  fulminating  cases  such  as 
we  have  had  in  recent  months  appears  to  bear  this 
out. 

This  question  of  the  type  of  organism  is  the 
deciding  one  when  we  turn  to  therapy.  Serum 
therapy  is  type  specific.  We  recognize  this  in 
pneumonia.  We  know  that  for  type-I  only  type-I 
serium  is  of  value.  Roughly  speaking  the  same 
thing  applies  in  the  treatment  of  meningitis.  Up 
until  the  time  of  the  war,  four  types  of  meningo- 
coccus were  recognized  and  a  polyvalent  serum 
protective  against  all  of  these  types  was  available. 
During  the  war,  outbreaks  of  meningitis  occurred 
against  which  the  commercial  types  of  serum  were 
entirely  ineffective.  On  the  basis  of  these  failures, 
fresh  and  energetic  study  revealed  the  fact  that 
among  the  classical  four  groups  there  were  many 


subgroups  or  different  strains  with  their  own  spe- 
cific agglutinins.  From  40  to  60  such  strains  were 
identified.  The  manufacture  of  sera  containing 
many  new  strains  followed  with  an  encouraging 
improvement  in  results.  It  was  later  shown  that 
"by  the  selection  of  strains  within  the  four  types 
but  possessing  wide  antigenic  valencies,  the  num- 
ber of  strains  required  for  injection  into  a  horse 
to  produce  polyvalent  serum  can  be  reduced."  On 
this  principle  the  New  York  State  Board  of  Health 
now  puts  out  a  polyvalent  serum  in  the  preparation 
of  which  only  four  to  six  strains  are  used.  These 
facts  make  it  incumbent  upon  the  physician  re- 
sponsible for  the  serum  treatment  of  a  case  of 
meningococcus  meningitis  not  only  to  type  the  or- 
ganism recovered  from  the  blood  or  spinal  fluid 
but  to  see  to  it  that  the  serum  being  used  in  treat- 
ment actually  has  the  power  of  agglutinating  the 
patient's  own  organism  in  dilutions  of  at  least  1- 
500.  Obviously  this  sort  of  procedure  is  largely  a 
bacteriological  one. 

Meningococcus  meningitis  is  a  medical  emer- 
gency. It  a  case  for  team  work,  for  speed  and  for 
accuracy.  Rarely  does  an  independent  physician 
have  at  his  disposal  all  the  technical  help  necessary 
in  the  proper  management  of  such  a  case.  To  do 
so  with  the  proper  finesse  a  hospital  with  a  bac- 
teriological department  especially  prepared  for  this 
kind  of  work  is  necessary.  Few  hospitals  receive 
enough  meningitis  cases  to  justify  the  expense  of 
keeping  on  hand  all  the  sera  and  animals  required 
for  the  proper  typing  of  the  organism.  We  have 
seen  that  practically  all  of  the  cases  of  meningitis 
in  the  City  of  Richmond  in  recent  years  have 
been  treated  in  the  Hospital  Division  of  the  Medi- 
cal College  of  Virginia.  Perhaps  this  is  a  recogni- 
tion of  the  fact  that  here,  more  than  anywhere  else 
in  the  city,  a  superior  t3^e  of  treatment  should  be 
available  in  the  management,  particularly  the  se- 
rum therapy,  of  acute  meningococcus  meningitis. 


Illuminating  Gas  fok  Whooping-cough  (Flint's  Prac. 
of  Med.,  7th  edi.,  1894) — It  having  been  observed  that 
children  living  in  the  vicinity  of  gas-works  suffered  but 
little  from  whooping  cough  and  recovered  after  a  short 
career  of  the  affection,  the  effect  was  tried  upon  a  lai 
scale,  and,  as  stated  in  reports  to  the  French  Academy,  with 
signal  benelit  to  a  large  proportion.  Patients  should  inhale 
the  fumes  at  the  place  where  the  gas  is  purified,  for  2  hours 
at  a  time,  for  12  consecutive  days.  It  would  appear  from 
the  statements  by  Blache,  Barthex,  and  Roger  that  this 
measure  is  often  inefficacious.  It  is,  however,  sometimes 
promptly  curative. 


RuYSCH  advanced  anatomy  by  the  formation  of  anatomi- 
cal collections,  one  of  which  was  brought  into  Russia  by 
Peter  the  Great  the  expense  of  about  $75,000.  The  Russian 
transporters  of  the  collection,  however,  drank  the  alcohol  in 
which  the  preparations  were  preserved,  and  a  portion  of  it 
was  thus  ruined. — Baus. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


The  Dominance  of  Fear* 

Louis  G.  Beall,  M.D.,  Black  Mountain,  North  Carolina 
Beallmonl     Park  Sanatorium 


MR.  PRESIDENT  and  Members  of  tin-  Tri-State  Associa- 
tion: 

IA!M  very  happy  to  be  with  you  today  and 
renew  my  allegiance  to  this  Association.  Dr. 
Orr  has  asked  me  to  present  a  paper  and  I 
hope  that  some  thoughts  advanced  by  me  may  bs 
worthy  of  a  place  upon  the  program. 

One  can  be  in  practice  but  a  short  time  before 
he  begins  co  realize  that  the  emotions  have  much 
to  do  w'th  physical  being  and  mental  state.  It 
seems  to  me  that  I  have  been  able  to  trace  the 
effects  of  one  of  these  emotions  in  almost  every 
patient  that  has  come  under  my  care.  So  if  this 
paper  be  worthy  of  a  name,  we  might  call  it  The 
Dominance  of  Fear. 

All  will  agree  that  fear  exerts  a  very  potent  ef- 
fect on  the  body.  We  have  all  seen  the  sudden 
blanching  of  the  features,  the  dilation  of  the  pu- 
pils, the  trembling  of  the  limbs,  the  cold,  clammy 
sweat  appearing  upon  the  forehead,  the  sudden 
preparation  for  flight,  or  indeed  the  sudden  flight, 
of  one  who  has  been  frightened.  If  sudden  fright 
will  cause  so  great  reactions  in  the  physical  being, 
can  we  wonder  that  a  state  of  fear  will  not  only 
cause  great  physical  reactions  but  will  dominate 
the  mind  itself  and  be  the  cause  of  many  bodily 
ills  and  mental  maladjustments. 

The  state  of  fear  known  as  anxiety  neurosis  is 
characterized  by  apparently  unmotivated  anxiety 
accompanied  by  general  irritability  in  prolonged 
periods  of  vague  but  intense  fear,  feeling  of  im- 
pending death,  dread  of  serious  disease  or  insanity, 
or  other  threatening  calamity.  The  spells  of  sud- 
den panic  and  anguish  may  be  devoid  of  any 
rational  content  and  may  come  on  without  any 
apparent  reason  or  may  be  precipitated  by  trivial 
occurrences.  With  the  fears  there  are  generally 
associated  marked  palpitation,  a  sensation  of  gid- 
diness or  even  true  vertigo,  shortness  of  breath, 
trembling,  sweating  or  other  vasomotor  disturb- 
ances a  feeling  of  nausea,  diarrhea,  and  numerous 
other  physiologic  disturbances.  These  symptoms 
may  appear  quite  suddenly  at  night  without  evident 
cause. 

These  fears  may  take  definite  forms  and  become 
actual  phobias,  such  as  fear  of  animals,  fear  of 
open  spaces,  fear  of  crowds,  fear  of  closed  rooms, 
fear  of  contamination,  and  many  others.  These 
unreasoning  fears  and  abnormal  anxieties  must  be 
distinguished  from  the  anxiety  which  represents  a 


normal  biologic  defense  mechanism  or  preparedness 
against  recognized  danger  from  without. 

Whether  fear  is  an  instinct  born  with  us  or  one 
which  develops  in  early  life  is  a  disputed  question. 
Walton  says  that  the  only  fears  born  with  us  are 
the  fear  of  falling  and  the  fear  of  loud  and  unex- 
pected noises.  This  instinct  of  fear  is  in  the  nature 
of  a  defense  reaction  inherited  from  primitive  man 
which  served  its  purpose  in  his  fight  for  life.  The 
person  under  the  dominance  of  fear  may  be  likened 
unto  an  engine  without  a  governor  turning  a  ma- 
chine in  which  there  is  no  material.  The  power 
is  being  consumed,  the  machinery  is  racing  at  top 
speed,  but  no  effective  work  is  being  done.  In 
fact,  the  engine  and  the  machine  may  be  shaken 
to  pieces.  The  person  under  stress  of  worry,  anx- 
iety and  fear  is  rapidly  using  up  his  energy  and 
wearing  out  his  nervous  mechanism  prematurely. 

It  is  to  be  regretted  that  almost  from  the  mo- 
ment of  birth  children  are  taught  to  fear.  They 
are  threatened  into  submission — "A  black  bear  will 
get  you  if  you  don't  eat  your  food."  "If  you  do 
that  again  I  shall  call  a  policeman  and  he  will  lock 
you  up."  "If  you  don't  take  this  medicine  I  shall 
call  the  doctor  and  he  will  take  you  away."  These 
and  many  other  threats  instill  into  the  minds  of 
children  ideas  of  fear.  Later  in  life  these  fears  are 
transmuted  into  physical  and  mental  reactions. 

The  depressed  patient  is  anxious  about  the  past, 
worries  about  the  present  and  is  fearful  of  the 
future.  He  fears  the  condemnation  of  his  God  and 
his  fellowmen,  and  he  condemns  himself.  The  past 
black  with  crime,  the  present  a  horrible  nightmare 
and  the  future  holding  out  no  hope,  can  we  wonder 
that  these  patients  are  overcome  by  their  fears 
and  attempt  to  end  such  an  intolerable  existence. 

The  most  common  fear  of  all  is  the  fear  of 
failure,  and  we  see  it  exemplified  by  many  patients 
within  the  walls  of  our  State  hospitals.  It  is 
brought  about  by  the  demands  upon  an  individual 
beyond  his  mental  and  physical  capabilities.  These 
fears  overwhelm  him  and  cause  him  to  abandon 
the  world  of  reality  and  create  within  his  own 
mind  and  imagination  a  world  in  which  he  can 
live  in  greater  comfort.  I  question  whether  Dante 
pictures  an  inferno  more  terrible  or  a  hell  more 
horrible  than  that  which  is  now  pictured  in  the 
minds  of  some  of  the  patients  in  State  hospitals, 
caused  by  fear  of  some  kind.  Fear  of  the  past, 
fear  of  the  present,  or  fear  of  the  future. 

•Presented  to  the  Tri-State  Medical  Association  of  the  Carolinas  and  Virginia,   meeting-  at   Columbia,    South  Caro- 


lina, February  17th  and  18th. 


FEAR—Bcall 


July,  1936 


Those  of  us  who  had  read  A  Mind  That 
Found  Itself  remember  how  the  constant  dread 
or  fear  of  becoming  an  epileptic  finally  dethroned 
this  man's  reason,  caused  him  to  attempt  suicide, 
and  culminated  in  an  acute  and  fearful  manic  at- 
tack in  which  he  was  dominated  by  fears  and  fore- 
bodings, suspicious  of  everyone;  without  confidence 
even  in  his  best  loved  relatives;  agitated,  restless, 
unable  to  sleep,  combative,  destructive,  filled  with 
delusions,  and  from  which  his  recovery  was  a  long 
and  tedious  process. 

In  my  own  experience  I  have  felt  that  I  could 
trace  the  effects  of  fear  in  practically  every  patient 
who  has  come  under  my  care.    Instances: 

A  woman  56  years  old,  depressed  and  agitated,  ac- 
cuses herself  of  moral  shortcomings.  She  has  a  dis- 
tressing burning  and  itching  of  the  skin  which  she 
has  scratched  until  her  shoulders  and  body  are  ex- 
coriated. She  is  unable  to  sleep,  her  appetite  is  poor, 
her  blood  pressure  is  slightly  elevated.  Her  Was- 
sermann  is  negative,  there  is  no  albumin  or  sugar 
in  her  urine,  her  heart  shows  no  abnormality,  she 
is  well  nourished  and  her  lungs  are  clear.  Careful 
examination  fails  to  reveal  anything  organic  to 
account  for  her  condition.  Her  husband  has  died 
recently.  Indefinite  fears  and  anxiety  for  the  fu- 
ture, of  being  unable  to  support  herself,  are  being 
transmuted  into  her  physical  and  mental  reactions. 

A  well  developed,  well  nourished  man  now  37 
years  of  age,  left  an  orphan  at  an  early  age,  was 
put  through  school  and  college  by  his  widowed 
mother,  working  himself  to  help  defray  expenses. 
He  developed  normally,  was  honest,  industrious  and 
faithful,  and  made  many  friends.  For  the  past  14 
years  he  had  held  a  responsible  position  and  had 
become  one  of  the  most  respected  citizens  of  his 
town.  His  life  had  been  of  an  uneventful  nature 
until  a  few  months  before  his  admission.  At  that 
time  while  doing  some  work  for  another  employee 
who  was  away  on  leave,  he  discovered  a  shortage 
in  the  employee's  accounts.  This  shortage  was  re- 
ported to  his  chief  and  when  no  further  action 
was  taken  he  went  over  the  head  of  the  chief  and 
reported  the  shortage  to  the  authorities.  Officials 
were  sent  to  make  an  investigation  and  his  infor- 
mation was  found  to  be  correct.  These  officials 
assured  him  that  there  was  no  blame  to  be  at- 
tached to  his  action  or  past  conduct.  This  patient 
then  began  to  fear  that  he  had  done  something 
wrong,  that  detectives  were  watching  him.  He 
began  to  see  faces  at  his  windows,  to  have  ideas 
of  reference  and  to  accuse  himself  of  many  short- 
comings and  showed  extreme  fear  of  the  future. 
Upon  admittance  he  could  not  sleep,  was  restless, 
agitated,  fearful  and  suspicious,  with  his  fears 
taking  many  and  varied  forms. 

A  man  68  years  of  age,  well  nourished  and  well 


preserved,  whose  examination  revealed  no  abnor- 
mality except  a  slight  arteriosclerosis.  His  blood 
pressure  is  normal,  his  Wassermann  reaction  neg- 
ative. He  has  been  a  very  active  and  successful 
lawyer  and  has  been  elected  to  many  public  offices. 
He  is  a  devout  churchman  and  a  highly  respected 
citizen.  Fear  of  having  contracted  syphilis  a  few 
months  before  admittance,  although  denying  ex- 
posure or  ability,  caused  him  to  become  despondent, 
restless,  agitated  and  unable  to  sleep.  He  felt  that 
he  was  disgraced  and  that  all  his  friends  knew  of 
his  condition.  He  became  so  fearful  of  the  future, 
which  to  him  was  filled  only  with  forebodings,  that 
he  attempted  suicide  but  failed  in  his  attempt  be- 
cause the  pocket  knife  used  was  not  sharp  enough 
to  reach  the  jugular  vein. 

Dr.  H.  was  the  most  active  and  busy  physician 
in  his  city.  Unable  to  answer  all  the  calls  made 
upon  him,  to  enable  himself  to  carry  on  he  began 
to  take  narcotics.  He  soon  had  to  manipulate  his 
lecords  in  order  to  get  enough  of  the  drug.  Not  be- 
ing able  to  keep  his  record  correct,  he  was  indicted 
and  placed  under  bond.  He  then  began  to  fear 
the  disgrace  which  a  conviction  and  sentence  would 
bring  upon  himself  and  family.  He  came  to  me 
for  help  and  was  cured  of  the  habit.  While  he 
was  so  fearful  and  depressed  he  took  a  bottle  con- 
taining about  two  ounces  of  carbolic  acid  from  my 
grip  and  drank  the  greater  part  of  the  contents. 
Prompt,  vigorous  treatment  saved  his  life  and  by 
means  of  a  retained  stomach  tube  the  development 
of  stricture  of  the  esophagus  was  prevented.  Final- 
ly he  was  arraigned  for  trial  and  sentenced  to  pay 
a  fine  and  spend  some  time  in  the  penitentiary. 
As  he  was  returning  from  the  trial,  he  stopped  at 
a  drug  store  and  obtained  another  supply  of  car- 
bolic acid.  He  made  a  success  of  this  attempt  and 
was  found  dead  in  the  bathroom — a  victim  of  fear. 

Discussion 
Dk.  James  K.  Hall,  Richmond: 

I  realize  that  in  talking  about  this  particular  emotion 
that  is  referred  to  as  fear  I  am  talking  of  something  about 
which  I  know  very  little,  but  that  does  not  mean  that  the 
thing  is  either  insignificant  or  unimportant  or  without 
influence.  I  heartily  agree  with  what  Dr.  Beall  says  and 
with  what  he  intimates  with  reference  to  fear  as  a  causa- 
tive factor  in  what  our  friend  Dr.  Tom  Williams  used  to 
speak  of  as  mental  perturbation.  I  have  the  feeling,  Mr. 
President,  that  we  do  not  deal  honestly  either  with  our 
fears  or  with  ourselves  when  we  are  afraid  and  that  a 
great  deal  of  the  difficulty  arises  right  there.  The  animals 
below  man — if  there  are  any  further  down  the  scale — 
behave  perfectly  naturally  with  reference  to  their  fear, 
so  far  as  I  know.  When  they  become  afraid  they  respond 
to  the  fear  in  a  perfectly  rational  fashion,  and  when  the 
occasion  for  that  fear  is  ove  rthey  offer  no  apologies  for 
their  fear  when  they  were  afraid.  When  a  dog  bounces  a 
rabbit,  the  rabbit  does  the  natural  thing  and  takes  to 
flight ;  and  if  the  rabbit  survives  he  makes  no  apologies 
for   running   away.     I   don't   know   what   patients  say   to 


July,  1936 


FEAR—Beall 


379 


selves  from  what  they  think  is  cowardice.  I  thought  of 
that  during  the  reading  of  the  first  paper  on  the  program, 
Dr.  Zemp's.  Dr.  Zemp  spoke  about  it,  and  Dr.  Beardsley 
spoke  of  it  in  discussing  the  paper.  I  think  a  great  many 
people  tr\'  to  transfer  their  fears  into  physical  states.  They 
talk  about  nervous  indigestion,  about  nervous  colitis;  that 
is  a  physical  state  and  can  be  talked  about  to  a  doctor. 
Of  course,  we  are  all  living  now  in  a  state  of  fear.  We 
are  afraid  of  the  depression,  but  we  try  to  conceal  our 
fears. 

Dr.  Jas.  M.  Northington,  Charlotte: 

We  read  in  Proverbs,  "The  fear  of  the  Lord  is  the  be- 
ginning of  knowledge."  I  am  convinced  the  translators 
of  the  King  James  Version — all  honor  to  these  translators 
for  writing  the  grandest  English  that  has  ever  gone  forth 
on  the  tongues  or  from  the  pens  of  men — I  am  satisfied 
they  had  a  different  conception  of  fear  from  what  we 
have  today.  Indeed,  some  concordances  give  reverence  as 
a  synonym.  Words  undergo  many  transitions.  The 
Frenchman  says:  "Je  demande";  but  that  does  not  mean 
that  he  demands;  he  requests.  The  German  means  by 
the  word  stub!,  not  a  chair  without  a  back,  but  a 
sure-enough  chair.  We  have  changed  the  spelling  to  stool 
and  taken  off  the  back.  He  speaks  of  a  bank,  meaning  a 
bench.  Our  word  bankrupt  had  an  interesting  origin. 
The  banker  used  to  have  a  bench  in  the  market  place 
which  he  sat  behind,  and  when  he  could  not  meet  the  de- 
mands upon  him  by  holders  of  his  paper  his  bench  was 
taken  up  and  broken  to  pieces;  he  was  bankrupt.  These 
e.xamples  show  how  words  undergo  changes.  "The  fear 
of  the  Lord  is  the  beginning  of  knowledge";  but  this  fear 
does  not  mean  a  state  of  terror.  It  means  a  dread.  A 
poet  was  writing  about  the  lovely  trees  and  the  green  pas- 
tures when  a  bull  came  along  and  interrupted  his  medita- 
tions and  he  had  to  find  refuge  in  flight  and  in  climbing 
a  tree.  From  his  refuge  he  concluded  the  poem  with  these 
lines; 

"It  is  not  fear  that  brings  me  here; 
But  only  a  sort  of  a  dread." 

Now,  there  is  a  sort  of  dread  that  I  think  these  gentle- 
men mean  by  fear,  not  a  state  of  terrorism.  I  see  it  in 
children  who  rejoice  to  see  their  father  come  home;  are 
sorry  to  see  him  leave;  but  when  the  father  says  "Go," 
they  go;  and  when  he  says  "Come,"  they  come.  I  am  old- 
fashioned  enough  to  believe,  in  spite  of  all  that  some 
psychiatrists — maybe  pseudopsychiatrists — say,  that  that  is 
the  right  way,  and  that  allowing  the  young  idea  to  sprout 
and  follow  its  own  bent  is  responsible  for  more  people  in 
the  reformatories  (and  also  on  the  scaffold)  than  any 
other  one  thing.  It  may  be  heresy;  it  may  be  ancient 
stuff;  but  I  believe  it.  The  fear  of  the  Lord  is  the  begin- 
ning of  knowledge,  but  when  those  translators  chose  the 
word  10  express  Solomon's  idea,  they  did  not  mean  the 
fear  that  make;  men  shake.  They  meant  the  knowledge 
that  transgression  is  followed  by  punishment,  that  if  a  man 
does  not  obey  he  will  be  punished.  The  harmful  fear  that 
Dr.  Beall  has  told  us  about  is  a  perversion  or  distortion 
of  this  wholesome  fear  that  is  the  beginning  of  knowledge. 

Dr.  Beverley  R.  Tucker,  Richmond: 

I  think  Dr.  Beall  has  done  a  very  good  thing  in  bringing 
us  a  paper  on  fear.  Still,  we  may  have  fears  of  different 
kinds.  I  do  not  fear  the  Lord  as  Dr.  Northington  does, 
but  I  fear  the  automobile  and  things  of  that  kind. 

A  man  may  create  a  great  deal  of  hazard  for  himself 
and  for  others  by  not  obeymg  the  dictates  of  certain  fears. 
The  whole  thing,  I  believe,  resolves  itself  into  the  condition- 
ing of  fears.  Fears  are  relative.  They  are  harmful  at 
times,  terribly  harmful.     They  are  beneficial  at  times,  ex- 


ceedingly beneficial,  and  we  have  to  condition  these  fears, 
to  live  in  adaptability  to  our  environment. 

A  man  fifty  years  old  came  to  me  with  his  first  very 
slight  apoplexy.  Two  or  three  weeks  later  he  had  another 
very  slight  attack,  and  three  or  four  weeks  after  had  an- 
other. By  that  time  we  had  gotten  in  some  pretty  active 
treatment  and  had  gotten  him  in  very  good  condition. 
His  blood  pressure  was  running  around  ISO  systoUc.  He 
was  head  of  a  large  tobacco  company,  and  I  told  him  that 
I  thought  he  would  live  for  a  good  many  years  and  could 
go  to  work.  But  he  would  not  go  to  work;  he  was  afraid 
he  was  going  to  die.  He  went  to  Florida  in  the  winter 
and  bathed  himself  in  the  sun,  and  went  to  Atlantic  City 
in  the  summer  and  bathed  himself  up  there,  and  then  went 
to  the  mountains.  He  went  to  some  other  doctors,  I  think, 
though  he  never  admitted  it  to  me.  Then  he  came  back 
to  me.  He  was  in  a  state  of  perfect  fear.  I  simply  told 
hira:  Well,  now,  you  are  fifty-one  years  old;  you  have 
made  a  success  in  life;  your  wife  has  plenty  to  live  on; 
you  have  no  children;  you  have  gotten  everything  out  of 
life  that  you  can  get  out  of  it,  and  why  don't  you  go  on 
and  die?  This  is  the  psychological  moment  for  you  to 
die.  The  world  probably  will  not  miss  you,  and  your  wife 
will  probably  get  another  husband.  I  am  telling  you  the 
truth;  it  seems  to  me  the  best  thing  for  you  to  do  is  to 
go  ahead  and  die.  Go  on;  have  another  stroke,  a  big  one; 
and  pass  on  out.  And  I  went  out  of  the  room.  For 
eight  years  now  he  has  been  running  that  tobacco  company. 
He  came  in  the  other  day,  and  I  said:  "I  will  take  your 
blood  pressure."  He  said:  "Oh,  no;  I  am  not  afraid  to 
die  any  more."  Now,  you  can  not  treat  everyone  like 
that.  But  the  psychiatrist  has  to  know  his  patient.  It 
seems  to  me  the  whole  secret  of  treating  fear  is  to  try  to 
get  at  the  bottom  of  it  and  then  try  to  get  at  the  person- 
ality of  the  patient  and  try  to  adjust  his  fears  so  that  his 
fears  will  not  interfere  with  his  living  comfortably  in  his 
environment. 

Dr.  a.  J.  Crowell,  Charlotte: 

I  am  not  a  neurologist,  only  a  simple  urologist;  but  I 
think,  as  I  hear  others  talk,  that  the  fears  might  be  divided 
into  two  classes.  There  is  one  class  in  which  the  psychia- 
trist is  very  valuable  and  can  do  much  in  taking  care  of 
those  cases;  in  the  other  class  you  have  definite  organic 
lesions  in  which  the  fear  follows,  and  that  fear  is  greater. 
And  that  fear,  naturally,  would  have  to  be  handled  differ- 
ently from  that  handled  by  the  psychiatrist.  I  mention 
coronary  thrombosis  and  the  fear  that  follows  coronary 
thrombosis.  The  patient  lives  in  the  fear  that  he  may  not 
live  one  day  or  one  hour  or  a  moment.  That  fear  is 
fearful.  I  have  had  two  near  friends  to  have  coronary 
thrombosis.  One  of  them  was  one  of  the  most  devout 
ministers  I  ever  knew.  The  other  was  a  close  personal 
friend  and  a  near  neighbor.  The  near  neighbor  had  his 
coronary  thrombosis  first.  He  wrestled  for  two  years  with 
his  coronary  thrombosis  in  agony — fear.  He  was  not  the 
man  that  he  was  before  he  had  this  attack;  his  fear  was  so 
fearful  that  finally,  while  his  special  nurse  was  out  of  the 
room,  he  severed  his  radial  arteries  and  died.  The  minister 
talked  to  me  after  this  happened,  and  he  said:  "I  can 
rather  sympathize.  He  did  the  wrong  thing,  but  I  can 
realize  how  tempting  a  thing  it  might  be  to  a  man  suffering 
with  that  condition."  The  minister  has  since  died,  and  I 
know  of  others  that  are  living  in  mortal  agony  today.  But 
those  are  pathological  conditions;  they  can  not  be  handled 
by  the  psychiatrist  as  the  central  nervous  system  can  be 
handled.  I  think  there  are  different  kinds  of  fear  and 
different  causes  of  fear.  The  central-nervous-system  causes 
of  fear  and  those  of  pathological  origin  must  be  handled 
differently. 


380 


FEAR—Beall 


July,  1936 


Dr.  R.  W.  Ruffin,  Ahoskie,  N.  C: 

I  think  fear  is  tlie  most  valuable  aid  that  we  have  in  the 
practice  of  medicine — the  fear  of  pain,  the  fear  of  death, 
the  fear  of  disease,  bring  a  lot  of  our  patients  to  us.  If 
we  did  not  have  fear  we  would  not  have  any  patients  at 
all. 

On  the  other  hand  each  and  every  day  we  are  aware  of 
the  tragedy  of  fear  as  we  go  about  our  work  and  note  the 
individuals  who  are  not  able  to  cope  with  the  difficulties 
of  life.  These  people  would  probably  be  able  to  abort 
fear  under  normal  living  conditions  but  due  to  financial 
reverses  and  unemployment  fear  has  been  rampant  and 
has  wrecked  the  health  of  many  people  and  caused  an 
astounding  number  of  suicides.  It  certainly  is  a  growing 
problem  that  we  can  do  much  for  if  the  proper  psychology 
is  used.  Much  can  be  done  in  the  home  in  the  rearing  of 
children  to  prevent  them  from  growing  up  as  individuals 
afraid  of  life. 

Dr.  W.  C.  Ash  worth,  Greensboro: 

My  experience  with  fear  neuroses  is  that  every  case  is  a 
problem  to  itself.  There  is  no  standardized  treatment. 
These  patients  have  a  feeling  of  inadequacy;  they  can  not 
meet  the  exigencies  of  life.  They  have  a  feeling  of  dread. 
If  there  is  no  opposition  they  are,  practically  speaking,  all 
right;  but  when  the  real  difficulties  of  life  come  on  so  thick 
and  fast,  why,  then  they  get  down.  Dr.  Beall's  paper  is 
fine,  and  we  ought  to  realize  that  we  have  to  treat  every 
case  to  itself. 

(Discussions  of  Drs.  Wilson  and  M.  H.  Wyman  sent 
them  for  revision  and  not  returned.) 

Dr.  Beall,  closing: 

I  thank  the  gentlemen  very  much  for  their  discussion. 
My  short  paper  was  inadequate;  I  felt  it  hardly  worthy 
to  bring  before  this  meeting.  I  feared  that  I  did  not  have 
a  good  one  myself,  and  I  told  the  secretary  that. 

I  had  started  with  one  particular  thought,  and  that  was 
a  symptom  of  disease,  and  I  tried  to  confine  myself  to 
that  one  particular  symptom — not  to  cause;  not  to  cure; 
not  to  what  to  do  with  it  or  anything  of  that  kind;  but  I 
was  attempting  to  show  that  in  the  patients  that  had  come 
under  my  care  this  particular  symptom  was  very  promi- 
nent. We  might  have  asked  ourselves,  in  that  paper,  what 
is  the  cause  of  fear?,  and  I  think  we  would  have  gotten 
into  very  deep  waters.  We  would  not  have  been  able  to 
touch  bottom.  I  would,  I  fear,  have  floundered  in  the 
writing  of  that  paper  and  in  the  presentation  of  it  here 
until  I  would  have  been  in  a  panic  and  may  have  fled 
from  the  hall.  I  do  not  know  what  would  have  happened 
to  me  if  I  had  gotten  into  such  deep  waters.  But  this  one 
thought  I  might  suggest,  and  that  is  how  much  fear  is  due 
to  ignorance,  lack  of  knowledge,  lack  of  the  truth.  It  is 
the  truth  that  makes  you  free,  as  the  Greek  says.  How 
much  of  our  fear  is  due  to  ignorance,  or  tradition;  and, 
even  if  we  know  it  is  due  to  ignorance,  how  are  we  going 
to  remove  that  ignorance?  How  are  we  going  to  tell  our 
patients  the  facts,  tell  them  the  truth?  One  of  the  greatest 
psychiatrists  I  have  ever  listened  to  said:  "Gentlemen, 
always  tell  your  patients  the  truth  with  regard  to  them- 
selves." And  he  paused,  then  went  on:  "If  you  know  the 
truth,  tell  it."  But  when  do  we  know  the  truth  about  our 
patients?  When  do  we  know  when  the  effects  or  end  re- 
sults are  going  to  take  place  in  any  patient  that  we  see? 
We  don't  know.  AU  we  can  do  with  patients  is  to  tell 
them  the  facts  to  the  best  of  our  ability.  Dr.  Hall  sug- 
gested that  our  fear,  our  perturbation,  our  conflict,  may  be 
because  we  are  not  willing  to  recognize  there  is  a  fear.  I 
think  that  is  absolutely  true. 

I  am  glad  Dr.  Tucker  told  us  something  about  the  treat- 
ment of  these  conditions.    I  hope  that  I  have  not  brought. 


a  subject  which  is  so  depressing  that  I  shall  create  in  the 
minds  of  this  audience  a  state  of  fear.  .Although  fear  is 
a  very  depressing  emotion,  there  is  another  side  to  it,  and 
that  is  that  there  is  always  a  silver  Uning  to  our  cloud, 
but  that  will  take  us  so  far  afield  that  we  can  not  discuss 
it  in  the  time  allotted. 

Dr.  Crowell  mentioned  physical  disease  as  the  basis  of 
fear  and  mentioned  coronary  thrombosis  as  the  disease  with 
which  this  particular  person  was  afflicted.  I  question 
whether  these  fears  really  hinged  upon  the  physical  condi- 
tion. There  are  many  men  who  have  serious  physical 
conditions  who  have  no  fear.  Many  men  who  are  dying 
of  cancer  and  other  serious  things  are  as  optimistic  as 
birds  in  the  air  and  as  free  to  go  about  as  if  they  were 
perfect  specimens.  In  fact,  I  knew  the  history  of  one  man 
who  for  several  years  lived  with  a  coronary  disease  which 
caused  him  to  have  frequent  attacks,  and  he  did  not  fear 
death.  Those  people  who  fear,  to  my  mind,  probably  lack 
something — some  endocrine,  perhaps — which  destroys  that 
balance  between  the  glands  of  the  body  which  makes  a 
normal,  activating  mind.  Now,  I  do  not  know  what  that 
does;  I  do  not  know  that  it  has  ever  been  discovered  what 
it  is ;  but  something  gets  wrong  inside  the  body ;  we  do  not 
secrete  the  right  things.  I  am  thoroughly  convinced,  in  a 
manic-depressive,  that  the  internal  secretion  of  that  man 
has  gone  wrong.  I  do  not  know  what  part  of  him;  I  4" 
not  know  which  gland;  I  would  not  know  how  to  treat 
him  if  I  did  know  the  gland.  But  in  these  cases,  as  Dr. 
Wilson  says,  the  body  begins  to  build  up  its  own  resistance 
against  that  condition ;  and  finally  the  regulator  in  the 
body,  whatever  it  is,  begins  to  bring  those  cogs  back  to- 
gether until  finally  they  interlock  and  the  man  is  normal 
again. 

As  to  fear  bringing  us  our  patients,  we  physicians,  I 
believe,  depend  on  the  ver>'  opposite  of  fear  for  all  our 
success.  Any  patient  who  has  not  confidence  in  his  phy- 
sician might  as  well  go  to  a  chiropractor.     (Applause.) 


Shall  We  Legalize  Abortion? 

(F.    A.    Riebel,   Columbus,   O.,    in    Med.    Rec,   May   20th   & 

June  3rd) 

If  our  flare  for  imperialism  has  evanesced,  and  we  posi- 
tively shun  increments  of  even  the  most  desirable  foreign 
elements,  why  can  we  not  prevent  the  birth  of  undesired 
ones  among  ourselves? 

Geographically  and  numerically  we  are  readily  defensible 
from  territorial  aggression.  Why  must  we  increase?  The 
answer,  so  far  as  we  can  now  discern,  is,  we  need  not !  In 
doing  so,  we  exhibit  merely  the  slavery  of  a  racial  habit. 

What  are  legitimate  reasons  for  abortion?  The  law  as 
presently  constituted  recognizes  only  the  saving  of  the  life 
of  the  mother. 

I  feel  that  in  addition  t  othe  one  reason  now  recognized 
by  the  law  as  permitting  abortion  at  least  these  others, 
should  be  added: 

1.  Insanity,  feeblemindedness,  syphilis,  epilepsy  and 
other  hereditary  conditions  which  are  considered  legitimat) 
causes  for  sterilization. 

2.  Incest. 

3.  Illegitimate  pregnancy  in  the  adolescent,  who  by  the 
nature  of  herself  and  her  environment  is  sociologically  in- 
adequate for  motherhood. 

4.  Economic  want  of  the  parents  to  such  a  degree  that 
they  cannot  reasonably  be  expected  to  rear  the  child  in  : 
accordance  with  average  American  standards  of  living. 


I 


1 


The  only  person  to  whom  a  Doctor  can  say  exactly  what 
he  thinks  (//.  Ayurveda,  April)  about  another  Doctor  is. 
his  Wife.  That  is  why  practically  all  Doctors  are  mar- 
ried. 


July,  1Q36 


SOUTHERN  MEDICINE  AND  SURGERY 


381 


Surgical   Observations 

A  Column  Conducted  by 

The  Staff  of  the  Davis  Hospital 
Statesville,  N.  C. 


The   Value    of   Complete   Gastrointestinal 
Examinations 

A  COMPLETE  examination  into  the  state  of  the 
gastrointestinal  system  is  the  only  means  of  learn- 
ing of  the  presence  and  extent  of  disease  of  these 
parts.  Without  scrupulous  care  many  serious  things 
will  be  overlooked.  Ulcerations,  constrictions, 
growths  of  every  kind  and  inflammations  can  be 
well  diagnosed  only  by  the  aid  of  x-ray  examina- 
tion of  the  gastrointestinal  tract.  These  examina- 
tions should  always  be  done  carefully  and  deliber- 
ately. Hurried  examinations  are  not  of  much  value. 
It  should  always  be  e.xplained  to  the  patient  that 
more  than  the  usual  time  is  required  in  these  cases. 

Even  in  young  f>eople  carcinoma  of  the  large 
bowel  is  rather  frequent  and  should  be  looked  for 
before  it  is  too  late. 

Unfortunately  more  cases  of  carcinoma  occur  in 
the  so-called  silent  areas,  such  as  the  ascending 
and  transverse  colon,  and  become  inoperable  be- 
fore any  marked  symptoms  are  presented. 

Patients  sometimes  become  impatient  because  an 
examination  cannot  be  completed  in  a  short  while 
or  even  in  one  day.  The  medical  profession  should 
explain  to  patients  whenever  possible  that  exam- 
inations of  this  kind  require  time  in  order  to  obtain 
accurate  results. 

Colitis 

A  CONDITION  which  is  very  often  overlooked  is 
colitis.  Unless  this  is  kept  in  mind  many  obscure 
abdominal  complaints  will  never  be  explained  and 
sometimes  unnecessary  operations  may  be  avoided 
by  having  a  careful  and  accurate  x-ray  examina- 
tiion  of  the  gastrointestinal  tract  made. 

The  symptoms  of  colitis  vary.  Abdominal  pain 
at  irregular  intervals  may  vary  from  slight  to  se- 
vere or  even  excruciating.  Occasionally  there  is 
only  a  dead  ache — sometimes  a  mere  uncomfort- 
able sensation  is  noticed.  There  may  be  either  a 
'  ii-tipation  or  diarrhea  or  both  or  neither.  At- 
I  !  <  of  diarrhea  may  be  followed  by  periods  of 
lipation,  or  the  reverse. 
:  he  diagnosis  is  based  upon: 

1.  History.  This  should  be  gone  into  in  detail 
as  to  the  duration  and  symptoms,  types  of  foods 
taken  noting  carefully  all  foods  or  drinks  that 
might  have  any  influence  upon  the  disease. 

2.  Locations,  such  as  areas  where  dysenteries 
are  common  or  other  parasitic  intestinal  infesta- 
tion. 

3.  Type  of  pain  and  location  and  lime  yf  onset 


of  pain  and  duration. 

4.  Examination  of  the  lower  intestines  with  the 
proctoscop>e  may  give  valuable  information. 

5.  Examination  of  the  stools  (repeated  exam- 
inations may  be  necessary). 

A  careful  and  exact  x-ray  examination  of  the 
gastrointestinal  tract  will  give  the  best  information 
about  the  condition  of  the  large  intestines  and  will 
often  reveal  the  type  of  colitis  and  sometimes  the 
cause. 

Other  conditions  may  simulate  colitis — such  as 
benign  or  malignant  tumors,  polyps,  diverticula, 
tuberculous  conditions,  ray-fungus  infections,  kinks, 
adhesions,  pelvic  growths  and  various  other  states 
with  symptoms  the  origin  of  which  is  difficult  to 
determine. 

In  every  case,  however,  a  thorough  and  careful 
x-ray  examination  should  be  made  and  every  other 
possible  means  of  making  the  diagnosis  more  ac- 
curate should  be  used. 

In  the  surgical  cases  treatment  should  be  con- 
tinued over  a  long  period  of  time. 

One  of  the  most  difficult  things  to  get  patients 
to  do  is  to  take  the  proper  treatment  for  a  chronic 
colitis.  Patients  do  not  realize  that  a  condition 
which  comes  on  over  a  period  of  years  and  be- 
comes chronic  cannot  be  relieved  in  a  few  days  or 
a  few  weeks  or  even  in  a  few  months.  Also  pa- 
tients do  not  realize  that  one  single  improper  meal 
may  undo  all  the  good  that  careful  treatment  has 
accomplished  over  a  period  of  months.  Unfortu- 
nately when  patients  have  been  taking  treatment 
for  colitis  for  a  few  weeks  they  feel  that  they 
should  be  entirely  relieved  and  get  discouraged  be- 
cause relief  is  not  complete.  For  this  reason  it  is 
very  important  that  these  facts  be  impressed  upon 
them,  and  before  treatment  is  begun  every  patient 
should  be  made  to  understand  that  treatment  in 
colitis  depends  to  a  large  extent  upon  the  patient. 

Another  thing  which  should  be  kept  in  mind  is 
that  the  patient  should  be  under  constant  treat- 
ment, and  reminded  that,  if  for  any  reason  there 
is  any  irregularity  in  coming  to  the  doctor's  office 
for  examinations  and  giving  the  doctor  a  chance 
to  observe  progress  and  make  any  necessary 
changes  in  the  treatment,  the  maximum  results  can- 
not be  expected. 

The  patient's  family  should  be  told  of  the  con- 
dition and  their  help  obtained  in  guiding  the 
patient  about  the  diet,  rest  and  other  details  of  the 
treatment. 

During  the  treatment  of  colitis  other  conditions 
that  may  be  aggravating  should  be  carefully  looked 
into  and  if  necessary  treated.  Diseased  teeth,  dis- 
eased tonsils,  pelvic  conditions,  tumors  and  rectal 
conditions  should  all  be  carefully  looked  for  and  if 
present  treated  appropriately. 


382 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


There  is  nothing  more  discouraging  to  a  patient 
than  to  have  a  chronic  colitis  of  the  type  which 
yields  slowly  to  the  treatment,  and  there  is  nothing 
more  trying  to  a  doctor  than  to  treat  such  a  patient. 
I  might  also  add  that  relief  from  colitis  means  a 
great  deal  to  a  patient,  much  to  the  doctor  and 
the  patient's  family.  It  may  mean  a  very  material 
increase  in  the  congeniality  and  happiness  in  that 
family  where  otherwise  there  was  unpleasantness 
and  discord. 

The  Repair  of  Hernia  in  Children 

Many  small  children  and  new-born  infants  have 
hernias.  Most  of  these  should  be  repaired  at  the 
earliest  possible  time. 

The  dangers  of  strangulation  are  too  great  to 
permit  a  hernia  to  persist  indefinitely.  A  repair 
of  the  hernia  can  be  done  without  any  great  danger 
to  the  patient  and  the  results  are  unusually  good. 
Healing  usually  takes  place  rapidly  and  the  stay 
in  the  hospital  is  short. 

The  use  of  trusses  and  other  appliances  in  in- 
fants and  small  children  for  inguinal  hernias  is 
not  advisable  as  a  rule.  An  umbilical  hernia  may 
be  treated  more  conservatively,  but  even  these 
should  be  treated  surgically  if  the  conservative 
treatment  is  not  successful  in  a  reasonable  length 
of  time. 

Hookworm 

The  incidence  of  hookworm  is  still  high  in  some 
localities. 

A  routine  examination  of  the  specimen  of  stools 
from  every  patient  admitted  to  the  hospital  shows 
a  good  percentage  of  the  patients  from  certain  lo- 
calities to  have  hookworm;  in  other  localities  there 
is  very  little. 

Hookworm  disease  causes  many  curious  and 
bizarre  symptoms.  Patients  are  sometimes  treated 
for  various  diseases  before  a  course  of  treatment 
with  oil  of  chenopodium  removes  the  cause  and 
restores  the  patient  to  health. 

In  the  treatment  there  are  two  factors  that  must 
not  be  ignored.  The  first  is  inadequate  treatment. 
Many  patients  take  one  course  of  treatment  or 
two  when  several  may  be  necessary  to  eradicate 
the  parasites  completely.  The  second  factor  which 
must  be  given  consideration  is  that  a  reinfection 
may  occur.  Doubtless  many  patients  are  exposed 
to  hookworm  infestation  more  or  less  constantly  and 
repeated  tests  of  the  stools  at  regular  intervals  of 
time  should  be  done  in  order  to  determine  whether 
or  not  the  patient  remains  cured.  The  presence  of 
hookworm  ova  in  the  stools  indicates  persistent 
disease  or  a  recurrence — sometimes  both. 

A  young  girl  who  had  all  sorts  of  curious  gastro- 
intestinal disturbances  was  given  general  and  spe- 
cial examinations  including  x-ray  examination  of 


the  gastrointestinal  tract,  with  little  result.  Exam- 
ination of  the  stools  disclosed  hookworm  ova  in 
large  numbers;  the  patient  was  given  three  courses 
of  hookworm  treatments  at  intervals  of  a  week; 
improvement  was  noted  after  the  first  treatment 
and  in  a  few  weeks  after  the  last  treatment  the 
patient  complained  no  more  of  abdominal  symptoms 
and  in  a  few  months  had  gained  20  pounds  in 
weight.  Even  this  patient's  own  friends  would 
hardly  have  recognized  her  six  weeks  after  the 
treatment. 

Whenever  there  is  more  than  one  case  of  hook- 
worm in  a  family,  a  careful  survey  should  be  made 
to  locate  the  source  of  infestation  and  proper  means 
taken  to  destroy  it. 


Weapon-salves  enjoyed  great  esteem  (16th  century). 
These,  however,  were  of  assistance  only  when  the  weapon 
inflicting  the  wound  had  been  preserved,  and  when  neither 
the  heart,  the  brain,  nor  the  liver,  in  a  word  when  no  vital 
organ  was  injured,  in  which  cases  aid  was  of  course  easy. 
The  weapon  was  then  anointed  daily,  or  every  2nd  or  3rd 
day,  wrapped  in  clean  linen  and  kept  in  a  warm  place,  free 
from  dust  and  wind,  etc.  The  weapon-salve  of  Paracelsus 
consisted  of  the  fat  of  very  old  wild  hogs  and  bears  heated 
half  an  hour  in  red  wine,  then  dropped  into  cold  water, 
which  was  next  skimmed  and  the  fat  rubbed  up  with  roasted 
angle-worms  and  moss  from  the  skull  of  a  person  hung, 
scraped  off  during  the  increase  of  the  moon,  to  which  were 
added  bloodstone,  the  dried  brain  of  the  wild  hog,  red 
sandal-wood  and  a  portion  of  a  genuine  mummy ! ! — Baas. 


In  1647  Nicholas  Malebranche  offered  the  thesis  (J.  D. 
Owen,  in  Milwaukee  Med.  Times,  May)  that  all  ovae, 
destined  to  create  mankind  until  our  own  termination  as  a 
race,  were  compactly  stored,  one  within  the  other  in  the 
ovarv'  of  Eve.  Therefore  each  succeeding  female  born  pos- 
sesses one  less  ovum.  His  followers,  called  ovists,  prophesied 
an  abrupt  end  of  the  human  race  after  200,000  generations. 
This  explanation  was  loudly  proclaimed  by  the  Church,  as 
it  reverted  all  life  to  Eve  and  offered  convincing  proof  for 
the  inheritance  of  our  original  sin. 


The  great  Sydenham,  himself  for  more  than  30  years  a 
sufferer  from  this  disease  (gout)  was  led  to  conclude  that 
an  attack  should  not  be  interfered  with.  Regarding  it  as 
an  effort  of  nature  to  get  rid  of  a  noxious  material,  he 
believed  it  to  be  undesirable  to  arrest  or  abridge  it.  The 
propriety  of  non-interference  was  also  advocated  by  Trous- 
seau. Few  physicians,  however,  would  feel  satisfied  to 
fold  their  hands  and  await  the  cessation  of  the  disease, 
and  still  fewer  patients  would  be  content  to  forego  meas- 
ures to  alleviate  their  sufferings.  Nor  is  this  line  of  conduct 
consistent  with  either  reason  or  experience. — Flint's  Prac. 
of  Med.,  7th  edi.,  1894. 


State  Physicians  in  France  had  quite  unheard-of  duties; 
among  these  was,  e.g.,  the  "exact"  proof  of  the  sexual  po- 
tency of  men,  which  question  was  decided  upon  the  declara- 
tion or  sensations  of  a  female  expert  in  the  form  of  an  old 
woman  or  a  midwife  who  submitted  herself  to  the  proof  in 
the  presence  of  the  physicians  or  surgeons. — Baas. 


The  Middle  Ages  introduced  the  institution  of  hospitab. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


DEPARTMENTS 


CLINICAL  CHEMISTRY  &  MICROSCOPY 

C.  C.  Carpenter,  B.A.,  M.D.,  F.A.C.P.,  Editor 
Wake  Forest,  N.  C. 


The  Consideration  of  PhysKXOgy  and 

Pathology  in  Gynecology* 

An  Analysis  of  29ii  Surgical  Specimens 

From  the  Department  of  Pathology,  Wake  Forest  College 

Medical  School 

Abdominal  surgery  began  with  the  gynecolo- 
gists. Following  this  beginning,  the  specialty  of 
gynecology  became  more  intimately  a  part  of  gen- 
eral surgery.  More  recently,  the  specialty  has 
again  begun  to  claim  a  place  of  its  own.  This  place 
is  becoming  emphasized  more  and  more  because  of 
the  realization  that  gynecology  is  not  primarily  a 
matter  of  operations  and  operative  technique,  but 
a  study  of  the  patient  as  a  whole  with  the  separa- 
tion of  physiology  and  pathology  and  an  intimate 
knowledge  of  their  meeting  point.  This  newer 
knowledge  of  physiology  as  it  relates  to  the  normal 
and  abnormal  function  in  women  has  developed  a 
keen  sense  of  appreciation  of  endocrinology.  While 
we  recognize  the  rapid  strides  that  have  been  made 
in  our  knowledge  of  functional  abnormalities  as  ex- 
hibited by  the  endocrines,  in  all  probability  the 
study  is  in  its  infancy.  Therefore,  the  gynecolo- 
gists have  developed  a  just  claim  to  their  specialty 
and  the  pathologist  and  general  surgeon  must  again 
qualify  if  our  claim  to  a  part  in  this  work  is  to  be 
justified. 

As  a  basis  for  this  discussion,  I  have  reviewed 
2933  unselected  surgical  specimens  received  in  our 
laboratory  during  193S.  This  study  is  based  on 
our  diagnoses  of  ovaries,  fallopian  tubes,  uteri,  cer- 
vices and  uterine  curettings  received  from  11  gen- 
eral hospitals  and  physicians  doing  office  practice. 

The  age  of  the  patient  was  given  in  414  of  the 
gynecological  cases.  The  youngest  patient  was  13 
and  the  oldest  66  years  of  age,  giving  an  average 
age  of  35.9  years  (Chart  I). 

Age 

Age,  given 

Youngest 

Oldest 


414  cases 
13  years 
66 
3S.9 

33  cases 

ISO 

86 

23 

6 

Chart  I 

The  age  decade  from  the  20th  to  the  30th  year 
showed  the  highest  number  of  operations — 150 
cases;  that  from  the  30th  to  the  40th  was  second 


Average  age 

10-20  years  of  age_ 

20-30  

30-40 

50-60  

60-70  


with  a  total  of  86  cases;  between  the  13th  and  the 
40th  years  of  age  269 — 90  per  cent. — of  the  oper- 
ations were  done.  It  will  be  observed  that  this  is 
the  period  of  sexual  activity  and  this  fact  alone 
shows  that  physiology  and  pathology  in  this  type 
of  case  must  be  intimately  associated.  It  is  un- 
fortunate that  in  a  large  proportion  of  cases  a  path- 
ology laboratory  is  unable  to  learn  the  age  of  the 
patient  and  the  menstrual  history.  This  knowledge 
would  be  of  immense  value  to  the  pathologist  in 
diagnosis,  especially  as  it  concerns  functional  rather 
than  histologic  abnormalities. 

Obviously,  time  will  not  permit  a  discussion  of 
all  of  these  diagnoses.  Principally  what  may  be 
termed  the  dividing  place  between  physiology  and 
pathology  will  be  considered. 

The  importance  of  gynecology  may  be  further 
emphasized  by  observing  that  in  this  material  there 
was  a  total  of  1137 — 38.4  per  cent,  of  the  speci- 
mens— removed  from  the  female  pelvis  (Chart  II). 
2933  Surgical  Specimens  Examined 


Ovaries    

Fallopian  tubes 

Uteri 

Cervices 


Curettings,  uterus 


Total 

Per  Cent 

322 

10.9 

231 

7.S 

21S 

7.4 

193 

6.5 

173 

5.8 

One  of  these  hospitals  has  two  gynecologists  on 
its  staff  and  three  other  hospitals  claim  one  each. 
This  fact  shows  the  important  position  held  by  the 
general  surgeon  in  gynecological  practice.  Although 
no  tabulation  was  made  on  this  point,  it  was  ob- 
served that,  in  many  instances,  a  higher  percentage 
of  specimens  from  the  female  pelvis  were  received 
from  the  hospitals  that  do  not  have  a  gynecologist 
on  the  staff. 

Ovaries. — An  analysis  of  the  1137  gynecological 
specimens  showed  the  largest  number  of  specimens 
from  the  ovary,  with  a  total  of  322 — 28.3  per  cent. 
(Chart  III). 

1137  Gynecological  Specimens  Examined 


Total 

322 

231 

218 

Per  Cei 
28.3 

20.3 

TTteri 

19.1 

193 

16.9 

Curettings,  uterus 

Chart  III 

173 

15.2 

•Read  before  the  Section  on  Gynecology  and  Obstetrics, 
Medical  Society  of  the  State  of  North  Carolina,  Asheville, 
May  6th. 


A  review  of  our  diagnoses  of  the  ovaries  sub- 
mitted shows  what  may  be  called  involutional  states 
leading  by  a  large  majority.  The  only  diagnosis 
made  by  us  in  a  total  of  179 — 55. 5  per  cent. — was 
one  of  the  numerous  terms  used  for  follicular  cysts 
(Chart  IV). 

Ovaries 

Follicular  cyst  '. 179 

Simple  cyst 36 


384 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


Corpus  luteum  cyst 
Chronic  oophoritis 
Hemorrhagic  cyst 


Pseudomucinous  cystadenoma 

Serous  cystadenoma 

Cystic  adenocarcinoma 
Krukenburg  tumor 
Fibroma 


Dermoid  cyst 2 

Granulosa-cell  cajcinoma : 1 

Chart   IV 

I  feel  that  we  should  approach  the  consideration 
of  these  diagnoses  with  a  big  question  mark  as  to 
whether  they  are  physiological  or  pathological — by 
pathological  meaning  a  lesion  the  removal  of  which 
leaves  the  patient  in  an  improved  state  of  health. 
This  question  was  raised  by  the  writer  about  a 
year  ago.^  Obviously  it  cannot  be  answered  by 
the  pathologist.  A  careful  study  of  the  patient 
over  a  period  of  years  by  the  surgeon  is  the  only 
approach.  But  the  pathologist  must  assume  his 
share  of  the  responsibility.  We  too  often  give  our 
diagnoses  in  some  half-understandable  term  and 
the  surgeon  accepts  it  in  a  manner  that  will  most 
readily  justify  the  of>eration.  Hertzler-  said, 
"Within  a  week  I  read  an  account  by  a  noted  path- 
ologist in  which  an  ovary  was  described  as  'poly- 
cystic' and  showed  'perioophoritis.'  Such  words  as 
these  quite  naturally  appease  the  conscience  of  the 
operator  for.  doing  a  worse  than  useless  operation." 
From  the  standpoint  of  physiology  and  pathology 
we  may  well  consider  the  first  three  most  frequent 
diagnoses  in  this  series  as  essentially  normal  states. 
By  combining  the  diagnoses  of  follicular  cyst,  sim- 
ple cyst  and  corpus-luteum  cyst,  we  find  a  total  of 
248  or  78.9  per  cent,  of  specimens  of  ovary  in  this 
classification.  The  fourth  most  frequent  diagnosis 
is  sometimes  included,  but  our  diagnosis  of  this 
condition  was  considered  a  definite  inflammatory 
condition,  usually  associated  with  a  salpingitis. 

The  primary  function  of  the  ovary  is  to  produce 
and  liberate  ova  and  supply  the  body  with  the 
hormones  estrin  and  progestin.  In  the  ovaries  of 
the  newborn  infant  it  has  been  estimated  that  both 
ovaries  contain  about  400,000  primordial  follicles. 
At  puberty  there  are  from  15,000  to  30,000.=*  Since 
one  ovum  is  discharged  from  each  ovary  during 
each  menstrual  cycle  from  puberty  until  the  men- 
opause, it  is  impossible  for  all  of  the  follicles  to 
fully  develop.  As  the  follicle  develops  and  the 
follicular  liquid  increases,  the  period  of  rupture  is 
reached  and  the  ovum  discharged.  After  the  ovum 
is  discharged,  the  epithelial  cells  and  cells  of  the 
theca  interna  change  rapidly  into  large  pale-staining 
cells  and  the  corpus  luteum  is  formed.  If  the 
average  woman  begins  at  puberty  with  about  15,000 
follicles  in  each  ovary  and  lives  a  life  of  normal 
ovarian  activity  of  about  30  years,  she  will  have 


developed  about  360  ova.  Therefore,  approximate- 
ly 14,640  follicles  will  not  reach  full  development. 

The  usual  sequence  of  events  is  the  death  of  the 
ovum  and  collapse  of  the  follicle,  resulting  in  a 
connective-tissue  scar.  For  some  unknown  reason, 
a  good  many  of  the  unruptured  follicles  fail  to 
undergo  atresia.  The  ovum  dies  and  the  follicular 
liquid  increases,  resulting  in  a  follicular  cyst.  The 
older  explanation  was  that  there  was  a  chronic  in- 
flammatory condition,  resulting  in  a  thickening  of 
the  tunica  albuginea,  that  under  normal  local  con- 
ditions these  follicles  would  have  ruptured.  This 
explanation  was  probably  due  to  the  fact  that 
there  are  cells  in  the  stroma  that  are  associated 
with  the  usual  chronic  inflammatory  condition.  This 
finding  along  with  the  presence  of  the  cyst  also 
serves  to  explain  the  many  synonyms  of  chronic 
oophoritis,  hydrops  follicularis,  polycystic  and 
fibrosclerotic  ovaries.  In  our  diagnoses,  this  small 
pea-sized  cyst  located  around  the  periphery  of  the 
ovary  was  designated  follicular  cyst  or  hydrops  fol- 
licularis. We  used  the  term  simple  cyst  for  tjie 
larger,  usually  single,  non-proliferative  cyst  that 
varies  from  the  size  of  the  end  of  a  man's  thumb 
to  that  of  a  walnut.  These  may  be  a  larger  devel- 
opment of  the  same  process.  The  diagnosis  of 
corpus  luteum  simply  means  the  follicle  after  ovula- 
tion. 

Since  the  development  of  the  knowledge  of  the 
importance  of  the  hormones  estrin  and  progestin  in 
physiology,  the  surgeon  must  consider  in  every  de- 
tail the  symptoms  for  which  he  would  remove  an 
ovary  of  this  type.  More  important,  he  must  study 
the  patient  as  a  whole,  before  focusing  attention 
seriously  on  the  local  complaint. 

Fallopian  Tubes. — We  find  that  fallopian  tubes, 
with  a  total  of  231 — 7.8  per  cent. — constitute  the 
second  largest  number  of  specimens  received  that 
came  from  the  female  pelvis.  Acute  salpingitis  was 
the  most  frequent  diagnosis.  Many  infections 
travel  either  by  the  lymphatics  or  uterus  to  this 
location.  With  the  more  recent  success  in  the 
non-operative  treatment  of  pelvic  inflammatory  dis- 
ease, these  specimens  should  be  markedly  reduced 
in  number.     (Chart  V). 


Fallopian  Tubes 

Acute  salpingitis 

Chronic  salpingitis 

Tubal  pregnancy 

Tuberculosis 


180 

147 

8 

1 


Aside  from  transmitting  the  ovum,  the  fallopian 
tube  plays  a  minor  part  in  physiology.  It  has  been 
shown  to  undergo  changes  in  the  epithelium  with 
the  menstrual  cycle.'*  In  all  probability  the  diag- 
nosis of  chronic  salpingitis,  both  clinically  and 
pathologically,  is  sometimes  an   intrusion   of  this 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


385 


physiological  change. 

Uterus. — The  uterus  was  examined  third  in  fre- 
quency, with  a  total  of  218 — 7.4  per  cent,  of  the 
total  number  of  specimens.  An  analysis  of  these 
diagnoses  show  that  leiomyomata  (fibroids)  were 
found  in  77  specimens.     (Chart  VI). 


Uterus 
Leiomyoma  (fibroid) 


Leiomyoma  and  endometrial  hyperplasia- 
Fibrosis  of  uterus  


Hyperplasia  of  endometrium 

Placental  tissue 

Carcinoma  of  body  . 

Sarcoma 


Leiomyoma  with  endometrial  hyperplasia  was 
diagnosed  21  times,  but  this  is  not  a  true  represen- 
tation of  the  prevalence  of  hyperplasia  associated 
with  leiomyoma  as  in  a  good  many  instances  the 
tumor  nodule  alone  was  received. 

In  this  group  of  diagnoses  the  uterus  showing  only 
hyperplasia  of  the  endometrium  was  diagnosed  sec- 
ond in  frequency,  the  total  of  65  times,  and  is  a 
condition  which  should  claim  our  major  attention. 
Endometrial  hyperplasia  may  be  considered  as  a 
condition  in  which  the  endometrium  is  thicker  than 
is  normally  found.  A  division  between  physiology 
and  pathology  was  not  attempted.  The  thickness 
of  the  endometrium  varied  from  that  seen  in  the 
ordinary  menstrual  cycle  to  what  may  be  termed 
polypoid  hj'perplasia.  The  character  of  the  glands 
also  varied  from  the  long,  straight  type  of  the  rest- 
ing stage  to  the  large  dilated  glands.  If  we  accept 
the  production  of  the  thickened  endometrium  as 
being  due  to  an  excess  estrin  or  deficiency  in  pro- 
gestin, we  would  be  forced  to  agree  that  removal  of 
the  uterus  is  only  treating  the  symptom.  The 
symptom  is  usually  some  disorder  of  menstruation. 
A  few  of  these  uteri,  in  which  the  cervix  was  also 
removed,  showed  chronic  endocervicitis  in  addition 
to  the  hyperplasia.  But  even  if  a  diagnosis  of 
endometrial  hyperplasia  and  chronic  endocervicitis 
is  made,  one  may  question  whether  this  type  of 
treatment  is  justified.  Occasionally  a  hysterectomy 
appears  advisable  in  these  cases  in  order  to  prevent 
a  severe  anemia  from  the  loss  of  blood.  These 
cases  must  be  the  exception  and  in  all  probability 
resorting  to  surgery,  instead  of  correcting  the 
marked  disturbance  in  general  bodily  physiology, 
will  leave  the  patient  in  a  less  improved  state. 

Uterine  fibrosis  was  diagnosed  20  times.  This 
condition  may  follow  an  acute  metritis,  but  in  the 
great  majority  of  the  cases  it  is,  no  doubt,  asso- 
ciated with  changes  that  come  about  with  the  cessa- 
tion of  ovarian  function.  The  most  frequent  symp- 
tom here  is  also  uterine  bleeding,  at  or  near  the 
menopause.  Hysterectomy  in  these  cases  may  be 
more  readily  justified  since  the  uterus  is  at  its  func- 


tional end.     Also  endocrine  disturbances  may  be 
more  difficult  to  correct. 

Cervix. — Chronic  endocervicitis  is  a  very  preva- 
lent condition  and  was  diagnosed  in  this  series  a 
total  of  240  times  (Chart  VII). 


Cervices 

Chronic  endocervicitis  

Chronic  cystic  endocervicitis 
Carcinoma,  squamous  cell 

Fibroma    . 

Sarcoma 


Adenocarcinoma 


126 

114 

14 

1 

1 

2 


Chart  VII 


This  represents  many  types  of  erosion,  laceration 
and  cyst  formation.  These  conditions  may  be  of 
the  so-called  physiological  type  or  due  to  trauma 
with  secondary  infection,  the  most  common  of  which 
is  associated  with  childbirth.  After  establishing  a 
diagnosis  of  chronic  endocervicitis,  either  clinically 
or  by  biopsy,  the  condition  should  be  corrected  in 
the  way  most  advisable.  Since  infection  is  harbored 
in  the  glands,  any  procedure  that  does  not  promote 
free  drainage  or  remove  the  glands  will  probably 
not  correct  the  condition.  This  is  made  doubly  im- 
portant because  it  has  been  shown''  that  from  96 
to  97  per  cent,  of  carcinomata  develop  in  those 
with  a  previously  existing  chronic  endocervicitis. 

Uterine  Ctirettings. — Endometrium  alone  was  ex- 
amined in  a  total  of  173 — 5.8  per  cent,  of  the  cases. 
These  diagnoses  showed  various  degrees  of  hyper- 
plasia in  100  cases  (Chart  VIII). 


Endometrial  Curettings 

Hyperplasia 

Placental  tissue 

Acute  endometritis 

Adenocarcinoma 

Chorio-epithelioma 

Tuberculosis 


100 
56 
10 
2 
1 
1 


For  this  discussion  no  attempt  was  made  to  dif- 
ferentiate the  different  types  and,  as  in  the  case  of 
the  uterus,  all  variations  of  endometrial  change  as 
represented  by  the  menstrual  cycle  were  observed. 
A  majority  of  these  curettings  were  removed  for 
diagnostic  purposes.  This  is  a  most  important  pro- 
cedure and  should  be  encouraged.  To  proceed 
blindly  to  a  more  radical  procedure  can  hardly  be 
justified  except  under  very  unusual  circumstances. 
It  has  been  observed  in  our  laboratory  that  in  re- 
cent months  this  form  of  biopsy  is  being  more  fre- 
quently used,  which,  in  my  opinion,  is  an  indication 
that  the  general  surgeon  and  gynecologist  are  mak- 
ing a  more  thorough  study  of  physiological  and 
pathological  changes  in  women  than  was  formerly 
the  practice. 

References 

1.  Carpenter.    C.    C,    Surgery   and    the    Non-Proliferative 
Ovarian   Cyst.      Southern    Medicine   &   Surgery,    97:85- 

2.  Hertzler,    Arthur    E.,    Surpical    PathoIoEy    of    the    Fe- 
male Generative  Organs.     J.  B.   Lippincott  Co.,  1931. 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


Maximow  and  Bloom,  A  Text-Book  of  Histology,  W. 
B.  Saunders  Co.,   1934. 

Novak  and  Everett,  Cyclical  and  other  Variations  in 
the  Tubal  Epithelium.  Am.  Jl.  of  Obstetrics  and  Gy- 
necology,  16:499,   1928. 

Carpenter,  C,  C,  The  Unrepaired  Cervix  as  a  Cause 
of  MahgTiancy.  Southern  IVIedicine  &  Surgery,  96:125- 
126. 


The  Middle  Ages  are  frequently  misjudged  as  regards 
their  importance  to  the  history  of  civilization,  their  neces- 
sity in  the  development  of  humanity.  Filled  with  classic 
regrets,  wc  would  fain  consider  them  the  dark  epoch  of 
absolute  barbarity  or  semi-barbarism;  the  period  of  history 
during  which  the  glorious  bloom  of  a  by-gone  civilization 
fell  into  the  sere  and  yellow  leaf  and  utterly  withered 
away.  This  view,  however,  is  but  partially  justifiable;  for 
the  Middle  Ages — and  from  their  latter  half  onward  this 
fact  is  in  every  department  plainly  evident — served  not 
to  repress,  nor  even  simply  to  maintain  undisturbed,  but 
actually  to  advance,  the  development  of  humanity  and 
civilization,  and  thus  promoted  also  the  development  of 
medicine. — Baas. 


The  trough  or  the  descending  wave  of  civilization  at- 
tained its  greatest  depth  in  the  west  of  Europe  as  early  as 
the  6th  and  7th  centuries.  At  this  time  only  a  few  of  the 
clergy  could  read  and  write.  As  early  as  the  8th  century 
a  revival  appeared  and  from  the  countries  and  people  of 
the  south,  about  the  time  of  Charlemagne,  advanced  the 
ascending  wave  of  civilization  in  the  West.  To  this  the 
Arabians  of  Spain  and  the  EngUsh  gave  the  chief  impulse. 
The  dawn  of  civilization  had  begun ! — Baas. 


HOSPITALS 

R.  B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  Editor,  Greensboro,N.  C. 


A  Central  Purchasing  Agent 

If  it  pays  the  Ivory  Stores,  the  Piggly  Wiggly 
Stores,  Sears-Roebuck,  Montgomery  Ward  and  a 
host  of  other  businesses  in  North  Carolina  to  have 
a  purchasing  agent,  why  not  the  hospitals  of  the 
State?  There  are  very  few  businesses  or  industries 
in  North  Carolina  which  represent  a  larger  invest- 
ment of  dollars  or  employ  more  people  than  do  the 
hospitals. 

In  serving  as  a  trustee  on  a  hospital  board  the 
writer  is  often  amazed  to  learn  the  difference  be- 
tween the  bulk  price  and  the  small  quantity  price 
of  the  common  supplies  used  in  a  hospital.  It  is 
safe  to  say  that  a  25  per  cent,  saving  could  be  had 
on  all  supplies  and  equipment  if  the  hospital  had  a 
central  purchasing  agent. 

In  one  city  in  the  State  there  have  been  two  gas 
machines  of  the  same  make  and  type  bought  in 
the  last  twelve  months,  and  a  third  will  be  bought 
within  the  next  few  weeks.  All  three  could  have 
been  purchased  in  one  deal  and  shipped  in  one 
shipment.  The  saving  could  have  paid  a  good  part 
of  the  monthly  salary  of  a  purchasing  agent.  The 
manufacturer  would  make  just  as  much  profit  be- 
cause the  sales  forces  could  be  cut  three-fourths  its 
present  size. 

Let  us  also  investigate  the  cost  of  one  drug, 
pantopon,  twenty  1/3-grain  tablets  cost  50  cents 


{Zyi  cents  each)  at  the  wholesale  house.  Bought 
in  lots  of  10,000  the  price  is  1  3/5  cents  each — a 
saving  of  about  40  per  cent.  Again,  allonal  costs 
$1.50  for  fifty  tablets  (3  cents  each);  but  when 
bought  in  large  quantities  of  20,000  the  price  is 
2  1/10  cents  each.  This  gives  a  saving  to  the  hos- 
pital of  about  33  1/3  per  cent.  Vaseline,  in  5-pound 
cans,  costs  40  cents  a  pound,  while  petrolatum 
bought  in  large  quantities  from  an  oil  company 
direct  (and  this  is  just  as  good  for  most  hospital 
purposes)  can  be  bought  in  50-pound  lots  for 
20  cents  per  pound — a  saving  of  50  per  cent.  In 
500-yard  lots  gauze  costs  $3.35  per  bolt,  while  in 
30,000-yard  lots  it  can  be  bought  for  $2.10  a  bolt. 
Here  is  a  saving  of  over  33  per  cent.  In  25-pound 
lots  cotton  costs  23  1/3  cents,  while  in  1,000-pound 
lots  it  costs  18J/2  cents  per  pound — about  a  20  per 
cent,  saving. 

Foodstuffs  and  linens  have  not  been  considered 
but  it  is  obvious  that  a  great  saving  could  be  had 
if  bought  in  large  quantities. 

Why  has  no  concerted  effort  been  made  to  pur- 
chase through  a  central  purchasing  agent?  The 
writer  believes  that  the  only  practical  way  that 
this  can  be  done  is  through  the  Hospital  Associa- 
tion. This  Association  is  and  should  be  of  the 
hospitals,  by  the  hospitals  and  for  the  hospitals. 
If  the  officers  of  this  Association,  who  are  all  prac- 
tical hospital  administrators,  will  set  their  heads  to 
it  this  purchasing  agency  can  be  established  during 
1936.  The  saving  would  amount  to  thousands  of 
dollars  per  year. 

It  is  safe  to  assume  that  the  average  exf)enditure 
of  each  of  one  hundred  of  the  largest  hospitals  in 
the  State  is  $50,000.00  per  year.  A  saving  of  25 
per  cent,  on  all  purchases  would  amount  to  $1,250,- 
000.00.  But,  of  course,  salaries  and  wages  would 
not  be  affected,  and  if  these  consisted  of  50  per 
cent,  of  the  hospitals'  expense  then  there  would  be  a 
saving  still  of  $650,000.00. 

A  capable,  full-time  secretary  of  the  North  Caro- 
lina Association  of  Hospitals  could  handle  this  job 
along  with  his  other  duties.  I  believe  such  a  man 
could  be  had  for  $5,000.00  a  year.  A  first-class 
bookkeeper  and  a  good  stenographer  could  be  had 
for  $1,800.00  and  $1,000.00,  respectively.  The  of- 
fice quarters  and  other  expenses  would  not  run  over 
$1,200.00.  The  total  of  this  expense  would  be 
$9,000.00  per  year.  Let  us  add  another  $1,000.00 
and  make  it  round  figures  of  $10,000.00.  Then 
compare  this  with  the  saving  of  $650,000.00. 

There  are  other  incomes  which  are  available. 
The  office  of  the  secretary  and  purchasing  agent 
would  act  as  a  clearing  house  for  positions  for  doc- 
tors, nurses,  technicians,  etc.  A  small  fee  could 
be  charged  for  this  service.  Also,  a  register  of 
second-hand  equipment  could  be  kept.    Some  small 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


387 


percentage  could  be  charged  for  these  sales.  The 
hospital  membership  would  be  practically  100  per 
cent,  because  of  this  service. 

The  author  of  this  article  does  not  wish  to  be 
held  strictly  to  the  figures  published  because  the 
prices  change  often,  but  he  does  wish  to  stimulate 
thought  along  the  line  of  the  subject  and  he  hopes 
that  the  Hospital  Association  will  see  its  way  clear 
to  render  this  much-needed  service  to  the  hospitals 
of  North  Carolina.  This  plan  was  recommended  in 
the  writer's  presidential  address  to  the  North  Caro- 
lina Hospital  Association  in  1932,  and  he  now 
wishes  to  offer  any  assistance  within  his  power  to 
help  bring  about  this  valuable  service. 


For  tilts  issue,  ].  P.  KENrrecY,  M.D.,  Charlotte,  N.  C. 


Presentation  of  Diplomas  to  a  Class  of 

NUESES* 
MR.  CHAIRMAN,  young  ladies  of  the  graduating  class, 
ladies  and  gentlemen: 
We  have  come  here  tonight  to  do  honor  to  these 
young  ladies  and  it  is  right  that  we  should  do  them 
honor.  This  is  a  red-letter  day  in  their  iives. 
Young  ladies,  you  are  now  on  a  peak  in  your  pro- 
fessional pilgrimage:  from  the  peak  you  can  look 
backward  over  the  course  you  have  come  and 
from  it  you  can  look  forward  in  imagination  and 
anticipation  to  what  lies  before  you.  First  let  us 
look  back  over  the  road  you  have  come.  This  road 
has  not  been  an  easy  one.  It  has  been  traversed 
only  by  determination,  hard  work  and  hard  study; 
as  witness  the  fact  that  half  of  your  original  num- 
ber have  already  fallen  by  the  wayside.  It  is 
possible  that  many  in  this  appreciative  audience 
do  not  realize  just  what  you  have  done  to  arrive 
at  this  milestone.  I  would  remind  them  that  you 
have  put  in  three  long  years;  not  the  academic 
nine-months  years  with  time  off  for  Thanksgiving, 
Christmas,  New  Year,  spring  holidays,  Easter,  and 
three  summer  months  to  play.  No,  your  years 
have  been  years  of  fifty  weeks  in  each  year,  seven 
days  in  each  week,  ten  hours  actual  nursing  each 
day  with  classes  and  study  at  night,  with  no  time 
off  for  illness  or  even  good  behavior.  It  is  equal 
to  four  academic  years  of  nine  months  each. 

Furthermore,  during  all  this  time  you  have  had 
to  serve  three  masters:  your  head  nurses,  the  visit- 
ing doctors  and  your  numerous  patients.  During 
your  working  hours  you  have  been  constantly  at 
the  beck  and  call  of  your  head  nurses,  and  even 
in  your  few  hours  off  duty  you  have  been  under 
their  strict  regulations.  At  times  you  have  proba- 
bly thought  they  believed  in  the  old  adage:  "A 
woman,  a  dog,  a  walnut  tree,  the  more  you  whip 
them  the  better  they  be."     While  at  times  such 


•A  talk  to  the  Graduates  of  the  Presbyterian  Hospital 
Training  School,  May  25th. 


strict  discipline  must  seem  hard  it  has  been  to  your 
best  interest  and  I  want  to  congratulate  your  super- 
visors on  the  splendid  example  they  have  set  for 
you  and  on  the  good  work  they  have  done  in  de- 
veloping this  class  from  provincial  probationers  to 
the  fine  finished  product  I  know  you  to  be.  You 
learn  more  from  precept  and  example  than  from 
didactic  lectures  and  you  should  be  grateful  to 
your  superintendent  and  head  nurses  for  the  high 
ideals  you  have  acquired  from  them. 

And  then,  yOu  have  had  to  try  to  please  all 
these  doctors  and  many  more:  all  with  their  idio- 
syncracies  and  peculiarities.  You  have  had  to 
read  their  writing  when  they  could  not  read  it 
themselves.  You  have  had  to  read  the  doctor's 
minds  when  they  forgot  to  leave  any  orders.  You 
have  had  to  give  mineral  oil  and  Sharp  and 
Dohme's  aromatic  cascara  for  Dr.  White  under 
pain  of  death.  You  have  had  to  laugh  at  Dr.  R.  L. 
Gibbon's  jokes  and  listen  to  Dr.  James  fuss  at 
you  and  call  you  lady  at  the  same  time.  You 
have  been  pleased  when  Dr.  Bost  called  you 
"Babe,"  only  to  find  out  later  that  he  called  all 
his  patients,  young  and  old,  male  and  female, 
"Babe."  You  have  been  awed  by  Dr.  Scruggs 
clearing  his  throat  while  you  ran  to  get  the  saline. 
You  have  had  to  bring  soda  for  Dr.  Blair  morning 
and  night  and  listen  to  him  belch  while  he  sipped 
it.  You  have  worked  and  worried  over  the  diabetic 
charts  of  Dr.  Davis  and  Dr.  Allan.  You  have 
had  to  appear  amused  equally  at  Dr.  Oren  Moore's 
racy  tales  and  at  Dr.  Ranson's  dry  wit.  In  short, 
you  have  had  to  appear  all  things  to  all  doctors. 

But  this  is  not  all:  During  this  time  you  have 
had  to  nurse  and  humor  and  cajole  all  sorts  of 
sick  folks  and  many  of  them;  9,887,  to  be  exact, 
in  the  past  three  years.  You  have  seen  them  at 
their  worst  and  at  their  best.  You  have  nursed 
them  back  to  health  and  in  return  they  have  made 
you  what  you  are — good  nurses.  To  have  survived 
these  long  and  full  three  years,  serving  all  the 
time  three  masters,  is  indeed  something  to  rejoice 
in.  I  for  one  rejoice  with  you  and  am  proud  of 
you,  one  and  all.  In  recognition  of  all  of  this  the 
Board  of  Managers  of  the  Presbyterian  Hospital 
has  made  out  for  each  of  you  a  diploma  making 
you  a  full-fledged  graduate  nurse  and  it  is  my 
distinct  honor  to  present  these  diplomas  to  you, 
which  I  now  gladly  do. 

Now  as  you  turn  your  faces  about  and  look  into 
the  future  what  does  it  hold?  I  once  asked  a  nurse 
who  was  graduating  from  the  Good  Samaritan  Hos- 
pital what  she  was  going  to  do,  private  duty,  school 
nursing,  public  health?  Her  reply  was  "No,  sir, 
Ise  tired  working,  Ise  goin'  to  get  married."  In 
that  case  I  said  you  are  merely  changing  from  12- 
hour  duty  to  24-hour  duty. 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


If  you  follow  the  example  of  your  predecessors 
in  the  nursing  profession  half  of  you  will  be  mar- 
ried in  five  years.  But  whatever  your  matrimonial 
inclinations  you  are  now  equipped  to  support  your- 
selves in  the  world  and  at  the  same  time  to  render 
an  efficient  service  to  mankind.  The  nature  of  your 
training  has  given  you  a  sympathetic  understand- 
ing of  your  fellow-men  and  has  equipped  you  to 
be  a  leader  and  a  worker  in  public  health,  school 
health  and  social  service,  as  well  as  to  minister 
to  those  sick  in  body  and  mind.  To  assure  you 
success  in  your  profession  I  would  advise  you  to 
continue  to  apply  yourselves  as  diligently  and  as 
conscientiously  as  you  have  in  your  undergraduate 
work  and  I  am  sure  you  need  have  no  fear  of  the 
future.  I  predict  for  you  one  and  all  a  life  full  of 
love,  joy  and  helpful  service. 


Ratmond  Lull  was  bom  in  a  high  station  at  Majorca  in 
1235.  As  early  as  the  age  of  30  he  received  visions,  entered 
the  order  of  Minorites,  learned  Arabic,  and  then  went  on 
a  journey  to  northern  Africa  to  convert  the  Saracens.  The 
Saracens,  however,  declined  to  learn  anything  from  him, 
so  he  returned  again  to  Italy,  only,  however,  to  go  back 
to  Africa.  Once  more,  persecuted  and  harassed,  he  jour- 
neyed bac  kto  Italy,  but,  in  spite  of  his  earlier  and  double 
unfortunate  experience,  ventured  once  again  to  Africa  and 
was  there  stoned  to  death  in  1315  as  an  importunate  mis- 
sionary by  the  Saracens,  whose  patience  was  finally  ex- 
hausted. Beside  alchemistic  and  philosophico-theological 
works  among  which  is  his  "Ars  magna,"  he  wrote  also  on 
medical  subjects. — Baas. 


GENERAL  PRACTICE 

WiNGATE  M.  Johnson,  M.D.,  Editor,  Winston-Salem,  N.  C. 


"The  Physician  and  the  Pharisees" 
The  Illinois  Medical  Journal,  as  I  have  said 
before,  is  one  of  the  best  medical  magazines  pub- 
lished. It  was  my  great  pleasure  while  in  Kansas 
City  to  meet  its  brilliant  editor.  Dr.  Charles  J. 
Whalen.  Dr.  Whalen  is  one  of  the  most  militant 
foes  of  socialized  medicine  in  the  country.  In  his 
gallant  fight  against  this  menace  he  has  some  able 
backers,  notably  Dr.  Charles  B.  Reed,  who  has 
just  retired  as  president  of  the  Illinois  Medical 
Society.  Dr.  Reed's  presidential  address,  "The 
Physician  and  the  Pharisees,"  is  published  in  full 
in  the  June  number  of  the  Illinois  Medical  Journal, 
and  is  so  full  of  pithy  and  powerful  epigrams  that 
I  am  devoting  the  rest  of  my  space  to  quoting  some 
of  the  most  striking  of  them.  My  interest  in  read- 
ing this  address  was  increased  by  the  fact  that  I 
saw  a  good  deal  of  Dr.  Reed  during  the  A.  M.  A. 
meeting  in  Kansas  City,  and  had  breakfast  with 
him  one  morning.  He  is  a  delightful  gentleman,  a 
cultured  doctor  of  the  old  school,  yet  as  progres- 
sive as  any  of  last  year's  graduates. 

"The  problem  of  'Socialized  Medicine'  is  lying 


heavily  on  our  professional  doorstep  and  we  are 
doomed  apparently  to  continue  the  discussion  of 
this  anomaly  until  we  have  convinced  the  world, 
the  flesh  and  the  devil  of  the  reasonableness  and 
sincerity  of  our  disbelief  in  that  socialistic  fetich." 

"If  the  Foundations  were  not  lacking  in  civic 
sense  and  gratitude  they  would  support  the  ideals 
of  that  government  which  brought  them  into  ex- 
istence and  if  they  were  not  deficient  in  moral  sense 
they  would  not  weaken  that  State  through  a  sub- 
versive paternalism  which  destroys  the  virility  of 
its  citizens.  We  cannot  act  like  children  and  be 
respected  as  men." 

"This  socialistic  attack  upon  American  ideals, 
morals  and  basic  laws  has  been  long  in  preparation 
and  is  recruited  from  an  active  organized  minority 
of  less  than  5  ]3er  cent,  of  the  inhabitants.  .  .  The 
group  is  led  and  conducted  by  high-salaried  social- 
ists who  exemplify  and  reproduce  the  Pharisees  so 
perfectly  described  by  Christ  in  the  23d  chapter 
of  Matthew.  'For  they  bind  heavy  burdens,  griev- 
ous to  be  borne,  on  men's  shoulders:  but  they 
themselves  will  not  move  them  with  one  of  their 
fingers.  But  all  their  works  they  do  to  be  seen  of 
men:  they  make  broad  their  phylacteries  and  en- 
large the  borders  of  their  garments,  and  love  the 
upper  rooms  at  feasts,  and  the  chief  seats  in  the 
synagogue,  and  greetings  in  the  markets,  and  to  be 
called  of  men.  Rabbi,  Rabbi.'  " 

"Paternalism  is  a  tutelary  device  intended  osten- 
sibly to  secure  welfare  but  if  once  recognized  as  a 
cure  for  political  evils  it  will  only  be  by  accident 
that  it  does  not  end  in  despotism  or  a  reign  of 
terror." 

"Bureaucracy  creeps  over  the  country  like  some 
foul  skin  disease — a  leprosy  which  slowly  eats  away 
the  Nation's  life." 

".  .  it  has  been  estimated  that  in  twenty  years 
approximately  $50,000,000,000  would  have  to  be 
held  in  reserve  for  protection  against  illness  alone. 
The  reserves  for  old  age  pensions  and  for  unem- 
ployment insurance  are  estimated  at  similar  sums, 
so  that  the  completion  of  this  new  legislation  will 
compel  the  laying  aside  of  $150,000,000,000  with 
a  regular  charger  for  interest  (4,500,000,000  at  3 
per  cent.)  .  .  ." 

"All  the  gold  in  the  world  amounts  to  $42,000,- 
000,000  and  only  half  of  it  is  monetary  and  only  a 
quarter  of  it  belongs  to  America  and  even  if  such 
a  reserve  as  $11,000,000,000  could  be  accumulated 
in  place  of  the  present  deficit  of  that  sum,  how 
long  could  the  treasure  be  maintained?  How  long 
before  this  idle  opulence  would  be  Sweitzered  by 
needy  socialists,  political  profligates  or  a  shame- 
fully subservient  Congress  which  has  neither  vis- 
cera, vertebra,  nor  cerebral  vitality?" 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


389 


".  .  .  the  agents  of  Government  with  besotted 
vanity  continue  to  pour  the  financial  life  blood  of 
the  nation  into  bottomless  barrels." 

"The  general  public  is  the  offering  about  to  be 
burnt  on  the  flimsy  altar  of  an  irrational  and  un- 
sound social  experiment." 

"A  people  who  look  habitually  to  their  Govern- 
ment to  prompt  or  command  them  in  all  matters 
of  private  concern  have  their  faculties  only  parti- 
ally developed.  .  .  The  worst  lesson  a  man  can 
learn  is  that  he  can  depend  on  others  and  whine 
over  his  sufferings." 

"The  State  owes  nothing  to  any  man  except  the 
chance  to  work  for  life,  liberty  and  pursuit  of  hap- 
piness. .  .  .  Men  are  not  equal  except  in  oppor- 
tunity, but  socialism  demands  that  they  should  be 
equal  also  in  stupidity." 

"The  world  would  be  spared  much  trouble  and 
suffering  if  amateur  philanthropists  had  not  inher- 
ited from  their  anthropoid  ancestors  a  wild  passion 
for  action  first  and  thought  at  long  last — if  at 
all." 

"The  doctors,  wedded  to  their  duties,  have  rarely 
been  political  partisans;  but  the  time  has  come 
when  they  must  act  definitely  in  politics  or  they 
have  no  duties  to  attend.  The  medical  man  knows 
humanity  intimately  as  child  and  adult  and  he  is 
able  to  judge,  work  and  vote  for  those  candidates 
most  competent  to  conduct  local.  State  and  Na- 
tional affairs." 

"The  emergency  must  be  met  and  surmounted 
for  this  'Social  Security'  scheme  means  security, 
undoubtedly,  for  the  politician  and  bureaucrat;  but 
only  poverty,  degeneration  and  slavery  for  the  peo- 
ple they  exploit." 


Shakespeare  did  not  die  until  April,  1616,  the  margin  of 
probability  in  the  reported  epitaph  is  small,  though  of 
course  its  truth  is  possible. — Baas. 


Rome,  especially  under  the  first  emperors,  had  become  a 
magnificent  city.  It  began  to  suffer  in  repair  severely 
during  its  occupation  by  Alaric  (410),  and  again  under  the 
Vandals  (455),  who  plundered  it  particularly  of  its  treas- 
ures in  metal,  though  they  still  left  more  than  3,000  statues 
in  bronze.  The  city,  however,  suffered  most  severely  at 
the  hands  of  Totila  (546).  At  one  time  it  sunk  to  the 
position  of  a  Uttle  city  with  not  more  than  500  inhabitants. 
Thenceforth  it  remained  impoverished  and  decaying,  so 
that  from  the  8th  century  onward  the  most  expensive  mar- 
ble fragments  were  burned  for  lime,  and  the  remnants  of 
masterpieces  in  architecture  and  sculpture  were  employed 
in  the  construction  of  ordinary  walls.  In  this  way  much 
has  been  preserved  to  us.  It  was  not  until  the  13th  and 
14th  centuries  that  a  beginning  was  made  in  the  removal 
of  the  rubbish  which  had  become  an  unendurable  nuisance. 
— Baas. 


The  followtn^c  epitaph  is  said  by  the  N.  Y.  Medical 
Record  to  appear  upon  a  stone  in  the  cemetery  at  Freder- 
icksburg, Va.:  "Here  lies  the  body  of  Edward  Heldon, 
Practitioner  in  Physics  and  Chirurgery.  Born  in  Bedford- 
shire, England,  in  the  year  of  our  Lord  1542.  Was  con- 
temporary with,  and  one  of  the  pall-bearers  of,  William 
Shakespeare,  of  the  Avon.  After  a  brief  illness  his  spirit 
ascended   in   the   year   of   our   Lord    1618 — aged   76."     As 


In  the  16th  Century  Linacre  and  John  Kaye  emanci- 
pated English  medicine  from  the  control  of  the  clergy,  and 
laid  the  foundation  of  the  self-government  of  English  phy- 
sicians. Heretofore  licenses  to  practice  had  been  granted 
by  the  bishops.  Linacre  founded  the  College  of  Physicians 
in  London;  Kaye  established  Caius  College  in  Cambridge. — 
Baas. 


RADIOLOGY 


Wricht  Claekson,  M.D.,  and  Allen  Barker,  M.D., 
Editors,  Petersburg,  Va. 


Pituitary  Irradiation  for  the  Menopausal 
Syndrome 

The  series  of  unpleasant  constitutional  disturb- 
ances so  frequently  accompanying  the  natural  or 
artificial  climacteric  in  women  can  be  relieved  in  a 
large  percentage  of  the  cases  by  properly  irradiating 
the  pituitary  gland.  In  the  past,  these  nervous 
manifestations  have  been  attributed  directly  to  a 
lack  of  ovarian  secretion,  but  more  recent  investi- 
gations indicate  that  they  are  due  to  an  over-activ- 
ity of  the  anterior  lobe  of  the  hypophysis. 

The  work  in  this  field  by  Collins,  Menville  and 
Thomas'  deserves  special  mention.  They  report 
the  following  conclusions  after  a  study  of  47  cases: 

"(I)  The  menopausal  syndrome  is  primarily 
the  result  of  an  excess  of  prolan  secreted  by  the 
anterior  hypophysis  initiated  by  the  withdrawal  of 
the  ovarian  hormone. 

(2)  Irradiation  of  the  hypophysis  for  climac- 
teric symptoms  produces  excellent  results  in  the 
majority  of  cases. 

(3)  Irradiation  of  the  pituitary  in  the  dosage 
given  will  not  produce  any  harmful  results." 

The  authors  quoted  above  call  attention  to  the 
work  of  Tandler  and  Grosz^  who  showed  an  in- 
crease in  the  size  and  function  of  the  anterior  por- 
tion of  the  hypophysis  following  castration,  and  to 
the  work  of  Rossle^  who  found  typical  "castration 
cells"  in  the  pituitary  following  castration. 

The  natural  answer  to  this  problem  is  that  the 
female  sex  hormone  produces  an  inhibitory  effect 
on  the  anterior  pituitary  and  thus  when  the  sex 
hormone  disappears  from  the  circulating  blood  the 
anterior  pituitary  becomes  over-active. 

Borak  of  Vienna  in  1929  reported  favorable  re- 
sults in  a  series  of  274  patients  with  menopausal 
disturbances  treated  by  pituitary  irradiation.  A 
few  of  Borak's  patients  who  received  little  or  no 
benefit  following  the  pituitary  irradiation  responded 
well  to  thyroid  irradiation. 

In  this  connection  it  is  interesting  to  note  the  work 
of  Loeb  in  America  and  Aron  in  France.  These  men 
injected  extracts  of  the  anterior  lobe  of  the  pitui- 


390 


SOUTHERN  MEDICINE  AND  SURGERY 


July,   1936 


tary  into  guinea  pigs  and  were  thereby  able  to  pro- 
duce a  rapid  enlargement  of  the  thyroid  gland. 

If  injecting  anterior  pituitary  extract  will  enlarge 
the  thyroid  gland  it  seems  logical  to  believe  that 
reducing  the  activity  of  the  anterior  pituitary  may 
prove  beneficial  in  cases  of  hyperthyroidism,  and 
this  has  proven  to  be  true  in  certain  cases. 

Anderson  and  Collip  have  isolated  a  hormone 
from  the  anterior  pituitary  which  acts  directly  as  a 
stimulant  to  the  thyroid.  Borak''  and  others  have 
successfully  treated  numerous  cases  of  hyperthy- 
roidism by  irradiating  the  pituitary  gland.  This 
type  of  treatment,  however,  is  usually  beneficial 
only  in  those  cases  of  hyperthyroidism  occurring 
in  women  after  the  menopause  and  in  elderly  men. 

Borak  says  that  the  pituitary  should  not  be  ir- 
radiated in  those  cases  of  hyperthyroidism  where 
the  causative  agent  arises  in  the  thyroid  gland.  In 
these  cases  the  excessive  thyroid  secretion  produces 
a  decrease  in  the  activity  of  the  pituitary  gland 
and  here  roentgen  irradiation  of  the  pituitary  is 
contraindicated. 

Newell  and  Pettit"  report  an  amelioration  of 
dysmenorrheas  in  more  than  two-thirds  of  a  select- 
ed group  of  patients  receiving  small  doses  of  roent- 
gen irradiation  to  the  pituitary,  and  in  the  same 
article  they  report  a  favorable  influence  upon  men- 
opausal symptoms  in  patients  so  treated. 

The  roentgen  technique  used  by  Collins,  Menville 
and  Thomas  in  treating  their  menopausal  cases  is 
as  follows:  120  kvp.,  5  ma.,  0.25  mm.  cu.,  and  I 
mm.  al.,  30  cm.  distance  and  148  r  measured  with 
back-scattering.  This  was  delivered  through  a  cone 
to  one  temporal  area  and  the  same  was  given  to 
the  opposite  temporal  area  the  following  day.  This 
procedure  was  repeated  at  the  end  of  three  weeks, 
making  a  total  of  296  r.  This  dose  is  surprisingly 
small  and  serves  to  emphasize  the  radiosensitivity 
of  the  "castration  cells"  of  the  anterior  hypophysis. 

The  true  story  of  the  sundry  interrelated  func- 
tions of  our  ductless  glands  is  gradually  being  told 
by  the  many  research  workers  in  this  field,  and  no 
chapter  in  modern  medicine  is  more  interesting  or 
more  important.  As  our  knowledge  of  the  endo- 
crines  becomes  more  complete  new  indications  and 
contraindications  tor  irradiation  therapy  of  certain 
glands  must  necessarily  develop,  for  one  of  the  most 
positive  and  uniform  results  of  irradiation  therapy 
is  the  diminution  of  the  secretion  of  a  gland  that  is 
properly  irradiated. 

Bibliography 

1.  Collins,  C.  G.,  Menville,  L.  J.,  and  Thomas,  E.  P.: 
A  Study  of  a  Series  of  Menopausal  Cases  after  Irradia- 
tion of  the  Pituitary  Gland.     Radiology,  June,  1936. 

2.  Tandler,  J.,  and  Grosz,  S.;  Wien  Klin.  Wchnschr., 
1908,  21,  266. 

3.  RossLE,  R.:  Virchow's  Arch.  f.  path.  Anat.,  1914,  216, 
248. 


4.  Borak,  J.:  The  Treatment  of  Hyperthyroidism  by 
Roentgen  Irradiation  of  the  Pituitary  Gland.  Radi- 
ology, May,  193S. 

5.  Newell,  R.  R.,  and  Pettit,  A.  V.:  Effect  of  Irradia- 
tion of  the  Pituitary  in  Dysmenorrhea.  Radiology, 
Oct.,  1935. 


Wilhelm  Fabriz  (1S60-1634,  Fabricius  Hildanus),  of 
Hilden  near  Cologne,  was  the  first  to  amputate  the  thigh, 
an  operation  which  even  Pare  had  not  ventured.  He  was 
also  distinguished  as  an  oculist  and  aurist  (ear-speculum, 
1S80).  He,  or  his  wife,  removed  a  particle  of  iron  from 
the  superficial  layers  of  the  cornea  by  means  of  a  magnet. — 
Baas. 


CARDIOLOGY 

Clyde  M.  Gilmore,  A.B.,  M.D.,  Editor,  Greensboro,  N.  C. 


Recent  Cardiovascular  Literature 

Fineberg  and  Wiggers^  present  a  study  of  com- 
pensation and  failure  of  the  right  ventricle,  of  im- 
portance in  pulmonary  embolism  and  infarction, 
emphysema  and  lobar  pneumonia.  They  conclude 
that  the  lumen  of  the  main  pulmonary  artery  may 
be  compressed  up  to  60%  without  appreciable  in- 
terference with  the  function  of  the  right  ventricle, 
and  that  the  eventual  failure  of  this  chamber  under 
prolonged  strain  is  a  result  of  the  attendant  low- 
ered aortic  pressure  and  the  resulting  decrease  in 
coronary  circulation.  They  positively  conclude  that 
venesection  is  of  no  value  for  right  ventricular 
failure. 

Boas  and  Levy-  pertinently  call  attention  to  the 
fact  that  extrasystoles  occurring  for  the  first  time 
during  an  acute  infection  indicate  that  the  heart 
mucle  has  been  damaged  by  the  toxin  or  the  virus 
of  the  disease;  occurring  during  or  after  a  coronary 
attack  they  are  of  serious  import.  "Extrasystoles 
at  heart  rates  above  110  are  usually  indicative  of 
myocardial  disease  ...  in  patients  with  active 
Graves'  disease  usually  point  to  an  accompanying 
cardiac  lesion.  Extrasystoles  ....  without  the 
above  associations  are  without  clinical  significance." 

Shipley  and  Halloran^  found  in  a  series  of  200 
normal  adults  T-3  inverted  in  15%  and  slurring 
and  notching  of  Q-R-S  3  and  4  of  common  occur- 
rence in  this  healthy  group.  It  is  a  great  relief  to 
have  the  significance  of  these  heretofore  question- 
able findings  definitely  settled. 

Cushing^  reports  a  case  of  trichinosis  with  elec- 
trographic  findings  identical  with  those  seen  in  cor- 
onary occlusion — a  possibility  to  be  remembered. 

"Acute  fatal  coronary  insufficiency  without 
thrombosis"  is  the  diagnosis  of  Levy  and  Bruem" 
in  24  cases  reported  from  their  study  of  376  cases 
of  coronary  disease.  The  symptoms  suggested 
coronary  occlusion  but  at  autopsy  only  coronary 
sclerosis  was  found.  "There  is  a  group  of  patients 
with   atherosclerosis  of  the    coronary    arteries    to 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


whom  death  comes  suddenly  and  in  whose  coronary 
vessels,  at  necropsy,  no  fresh  thrombus  is  found. 
.  .  .  Nonfatal  attacks  of  various  sorts  in  patients 
with  coronary  sclerosis  may  be  regarded  clinically 
as  intermediate  between  the  ordinary  bout  of  an- 
ginal pain  or  its  equivalent  and  a  fatal  seizure." 

In  the  surgical  treatment  for  Pick's  syndrome 
(constricting  mediastino-percarditis)  and  after  su- 
turing heart  wounds,  Griswold''  strongly  advocates 
a  novel  indirect  route  of  postoperative  pericardial 
drainage:  a  tear  of  3  to  S  cm.  is  made  in  the 
mediastinal  pleura  and  the  fluid  aspirated  from  the 
pleural  cavity  when  indicated. 

Willius^  summarized  the  life  expectancy  in  cor- 
onary thrombosis  from  a  careful  follow-up  study 
of  370  patients  who  lived  from  a  few  minutes  to 
17  years.  One  hundred  and  sixty-nine  (45.7%) 
of  the  patients  survived  to  date,  2.7%  died  from 
intercurrent  disease  while  51.6%  died  cardiac 
deaths.  There  was  a  7-to-l  predominance  of  males 
in  this  series  and  the  women  were  affected  at  a 
later  f>eriod  of  life  than  men.  Seventeen  per  cent, 
of  his  patients  had  a  second  occlusion;  the  cardiac 
mortality  progressively  increases  with  recurrent  cor- 
onary thrombosis.  There  was  no  relation  between 
the  duration  and  severity  of  the  attack  and  the 
mortality.  All  his  patients  under  40  survive  and 
the  mortality  rate  increases  progressively  with  each 
decade  of  life.  Contrary  to  some  opinions  he  finds 
the  location  of  the  infarct  has  little  influence  on 
death  or  survival.  (It  is  generally  thought  that 
the  prognosis  is  much  better  in  posterior  occlu- 
sions.) Of  the  patients  living,  42.6%  reported 
themselves  to  be  in  good  health,  23.1%  were  well 
while  living  a  restricted  life,  28.9%  had  recurrent 
anginal  attacks,  while  5.4%  were  totally  disabled. 
In  Willius'  opinion:  "There  is  no  doubt  that  the 
strict  maintenance  of  a,  carefully  individualized 
regimen  plays  an  important  part  in  the  life  ex- 
pectancy of  the  patients  who  survive  the  immediate 
perils  of  sudden  coronary  occlusion." 

Mercurial  diuretics  have  to  a  great  extent  re- 
placed the  mechanical  methods  for  the  relief  of 
obstinate  edemas.  Yet  there  are  occasional  cases 
of  persistent  ascites  and  edema  in  which,  when  all 
other  measures  fail,  the  patient  may  be  made 
more  comfortable  by  the  use  of  Southey's  tubes. 
Leech'*  reports  an  improvement  on  these  small  tro- 
cars which  he  intimates  will  drain  six  times  the 
volume  of  fluid  from  edematous  tissues  compared 
with  the  original  Southey  tubes. 

It  is  dangerous  to  give  calcium  intravenously  to 
a  patient  who  has  been  digitalized.  Bower  and 
Mengle"  report  two  sudden  deaths  from  such  a 
combination  and  prove  by  animal  experiments  that 
the  two  drugs  have  a  strange  affinity.  Digitalis 
may  be  given  after  the  calcium  with  little  danger 


of  toxicity  but  in  reverse  order  the  results  may  be 
disastrous.  We  would  never  dare  to  give  calcium 
intravenously  anyway  but  it  is  assumed  that  the 
same  rule  would  apply  to  oral  administration:  the 
administration  of  calcium  appears  to  greatly  in- 
tensify the  action  of  digitalis. 

References 

1.  FiNEBERG,  M.  H.,  &  WiGGERs,  C.  J. I  Compensation  and 
Failure  of  the  Right  Venticle.  Am.  Heart  Jour.,  March, 
1936. 

2.  Boas,  E.  P.,  &  Levy,  H.:  Extrasystoles  of  Clinical 
Significance.     Idem. 

3.  Shipley,  R.  A.,  &  Hali-aran,  W.  R.:  The  Four-Lead 
Electrocardiogram  in  200  Normal  Men  and  Women. 
Idem. 

CusHBTG,  E.  H.:  Electrocardiographic  Changes  in 
Trichinosis.     Idem,  April,  1936. 

Le\"^,  R.  L.,  &  Bruenn,  H.  G.:     Acute,  Fatal  Coronary 
Insufficiency.    Jour.  A.  M.  A.,  March  2Sth,  1936. 
Griswold,  R.  a.:     Chronic  Cardiac  Compression  Due 
to  Constricting  Pericarditis.     Idem. 
Willius,  F.  A.:     Life  E.xpectancy  in  Coronary  Throm- 
bosis.   Idem,  May  30th,  1936. 

Leech,  C.  B.:  Improvement  of  Southey's  Tubes.  Idem. 
BoKver,  J.  0.,  &  Mengle,  H.  A.  K.:  The  Additive 
Effect  of  Calcium  and  Digitalis:  A  Warning,  with  a 
Report  of  two  Deaths.    Idem,  April  4th,  1936. 


Passages  in  the  autobiography  of  Felix  Platter 
(about  1557):  There  was  an  old  woman  in  Gerbergasslein, 
who  had  a  throng  of  patients  as  did  the  two  e.xecutioners, 
the  brothers  Kase,  Wolf  and  George,  of  whom  the  elder 
was  famous  in  medicine  at  Schaffhausen,  as  was  his  father 
Wolfe  also,  executioner  at  Tubingen. — Baas. 


Roger  Lopez,  a  Portuguese  Jew  captured  in  the  defeat 
of  the  Spanish  Armada  (1588),  became  ordinary  physician 
of  Queen  Elizabeth,  but  was  convicted  of  conspiring  against 
the  life  of  the  queen,  and  hanged  at  Tyburn,  June  7th, 
1594.— BfMj. 


Linacre,  the  founder  of  the  College  of  Physicians,  formed 
a  statute  to  restrain  apothecaries  from  carrying  the  water 
of  their  patients  to  a  doctor,  and  afterwards  giving  medi- 
cines in  consequence  of  the  opinions  they  received  concern- 
ing it.  This  statute  was  soon  after  followed  by  another, 
which  forbade  the  doctors  themselves  to  pronounce  on  any 
disorder  from  such  an  uncertain  diagnostic. — Baas. 


Thomas  Jordan  (1539-1585),  city-phycician  of  Brunn, 
in  Moravia,  famous  for  his  description  of  the  "Lues  Pan- 
nonica"  and  for  an  account  of  more  than  200  cases  of 
syphilis  contracted  in  Brunn  from  the  employment  of 
infected  cupping-glasses  in  the  hands  of  a  certain  bath- 
keeper. — Baas. 


PEDIATRICS 

G.  W.  KuTSCHER,  M.D.,  F.A.A.P.,  Editor,  Ashcville,  N.  C. 


Allergy  Simplified 
Warren  T.  Vaughan,  Richmond  allergist,  writing 
in  the  March  issue  of  The  Journal  of  Laboratory 
and  Clinical  Medicine,  removes  much  of  the  cloud 
that  befogs  the  picture  of  asthma  to  most  of  us. 
Despite  the  fact  that  this  title,  "The  Theory  Con- 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


cerning  the  Mechanism  and  the  Significance  of 
the  Allergic  Response,"  suggests  uncertainty,  his 
masterly  explanation  of  many  phases  of  the  prob- 
lem brings  a  practical  understanding  of  allergy  a 
great  deal  closer  to  those  of  us  who  are  not  aller- 
gists. Abstracting,  unless  it  can  be  done  exactly, 
had  better  not  be  done.  The  following  abstract  is 
offered,  without  recourse  to  quotation  marks. 

All  persons  are  potentially  allergic.  The  allergic 
response  may  be  made  to  a  large  variety  of  things, 
e.g.,  cold,  heat,  light,  effort,  drugs  and  many  known 
non-nitrogenous  contact  agencies.  Carbohydrates 
may  sensitize  but  do  not  shock  unless  united  with 
specific  proteins.  Allergy  is  not  a  pathologic  state. 
It  is  a  pathologic  exaggeration  of  a  physiologic  re- 
ponse.  Thus  he  explains  the  statement  that  there 
is  no  fundamental  difference  between  the  allergic 
and  the  nonallergic  individual.  If,  as  he  believes, 
over  60%  of  the  population  have  or  have  had  some 
form  of  allergy,  then  allergy  becomes  the  rule  and 
if  we  lived  long  enough  lOO^o  of  the  population 
would  develop  allergy.  An  elaborate  contention 
that  human  beings  are  difficult  to  sensitize  to  aller- 
gens, leads  up  to  a  discussion  of  the  belief  that 
anaphylaxis  in  animals  and  allergy  in  man  are  fun- 
damentally identical  phenomena. 

The  allergic  response  is  based  on  an  integrated 
purposeful  phenomenon.  A  dominant  requirement 
of  all  life  is  that  it  maintain  adequate  adjustment 
to  its  environment.  There  is  in  all  life  a  protective 
covering  or  mechanism  against  injury.  In  man 
there  are  several  correlated  mechanisms  including 
the  skin  and  mucous  membranes  and  ciliated  epi- 
thelium; hairs  on  the  body,  in  the  nostrils,  and  in 
the  ears;  the  turbinates,  uvula  and  epiglottis,  the 
digestive  juices,  leucocytes,  opsonins  and  antibodies. 
In  addition  there  are  the  reflexes — blinking,  pupil- 
lary reaction  to  light,  sneezing,  coughing,  the  gag 
reflex,  vomiting,  diarrhea,  smooth  muscle  spasm  and 
the  coordinated  protective  reflexes  of  the  voluntary 
muscles.  There  are  certain  deleterious  influences 
against  which  the  body  must  protect  itself  includ- 
ing trauma,  extreme  changes  of  temperature,  in- 
tense light,  electricity,  ultraviolet  rays,  radium, 
x-ray,  acids  and  alkalis,  drugs,  infections,  toxins 
and  foreign  proteins.  The  acclimatization  to  many 
factors  must  be  kept  in  mind.  This  refers  espe- 
cially to  heat  and  cold. 

Man  has  built  up  a  complicated  system  of  pro- 
tective agencies  and  the  allergic  response  is  pri- 
marily a  protective  reaction.  The  cough,  smooth 
muscle  spasm  and  increase  in  bronchial  secretion 
of  asthma  may  be  looked  upon  as  an  attempt  to 
remove  a  supposed  foreign  body.  The  prompt 
vomiting  that  follows  the  ingestion  of  an  allergenic 
food  is  again  a  protective  response,  as  is  the  hy- 
perperistalsis  and  diarrhea  associated  with  mucous 


colitis  following  the  ingestion  of  an  allergenic  food 
which  the  stomach  has  not  expelled.  Urticaria 
and  angioneurotic  edema  involve  internal  structures 
probably  to  nearly  as  great  as  extent  as  they  do 
the  visible  integument,  and  are  manifestations  of 
an  effort  to  dilute  the  allergenic  substances  ni  the 
tissues. 

All  allergic  manifestations  are  correlated.  They 
are  purposeful  reactions.  They  are  pathologic  ex- 
aggerations or  perversions  of  a  normal  physiological 
function,  that  of  protecting  the  body  against  dele- 
terious environmental  factors.  The  allergen  may 
come  in  contact  with  the  skin  and  cause  asthma,  it 
may  be  injected  into  the  skin  (pollen  extract)  and 
cause  diarrhea,  it  may  be  inhaled  (house  dust)  and 
produce  asthma,  or  it  may  be  ingested  (wheat 
bread)  and  cause  asthma  or  some  other  allergic 
response.  The  reactions  are  not  always  coordinat- 
ed. The  allergic  response  to  irritability  of  the 
central  nervous  system,  as  well  as  of  the  sympa- 
thetic, is  now  better  recognized  than  it  was  a  few 
years  ago.  The  part  played  by  the  adrenals  Mn 
preventing  anaphylactic  shock  is  not  entirely  clear 
but  it  does  perform  an  important  function  in  this 
mechanism. 

Allergic  individuals  often  lose  their  allergic  man- 
ifestations following  an  acute  illness  or  simple  an- 
esthesia. The  same  improvement  sometimes  follows 
foreign-protein  therapy.  It  is  probable  that  all  of 
these  stimulate  the  immunity  mechanism,  the  same 
mechanism  which  is  responsible  for  the  allergic  re- 
sponse, in  such  a  way  as  to  make  it  more  effectively 
responsive,  at  least  for  a  time.  Eventually,  how- 
ever, it  again  loses  its  acquired  effectiveness  and 
allergic  symptoms  return. 


Smallpox  in  the  United  States  in  1935 
(Bui.  Met.  Lite  Ins.  Co.) 

A  serious  setback  was  encountered  in  the  fight  against 
smallpox  in  the  United  States  during  193S;  reported  last 
year  8,021  cases  as  against  5,366  in  1934. 

Only  37  cases  of  smallpox  were  reported  in  1935  by  the 
nine  Provinces  constituting  the  registration  area  of  Can- 
ada. This  means  that  only  three  persons  in  ever)-  1,000,000 
inhabitants  of  Canada  contracted  smallpox  during  the  year, 
whereas  in  the  United  States  there  were  63  cases  per  1,000,- 
000  of  population. 


Remissions  in  Progressive  Muscular  Dystrophy 
(D.  V.  Conwell,  Halstead,  in  Jl.  Kan.  Med.  Soc.  Jl.,  June) 
Remissions  have  occurred  in  progressive  muscular  dys- 
trophy after  persistent  use  of  viosterol  and  of  haliver  oil 
with  visosterol  with  regularity.  There  was  return  of  function, 
from  improved  motor  power  to  complete  return  to  normal. 
The  amount  of  improvement  was  governed  by  the  duration 
of  the  disease  and  the  extent  of  muscle  loss  before  treatment 
was  instituted. 


The  physician  should  not  only  cure  safely,  speedily  and 
pleasantly,  but  also  with  few  and  cheap  drugs. — Ludwig, 
quoted  by  Baas. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


HUMAN  BEHAVIOR 

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


On  Invisible  Goldfish 

I  had  not  thought  for  two  or  three  years  of  the 
story  of  the  imported  invisible  Argentine  goldfish. 
But  the  radiations  from  the  Hamiltonian  assem- 
blage in  Cleveland  and  the  vocal  output  from  the 
Delanoed  gathering  in  Philadelphia  lately  fetched 
up  into  the  upper  strata  of  my  psyche  the  alluring 
account  of  the  successful  get-rich-quick  scheme  of 
the  young  grocery  clerk. 

Within  the  month  that  the  little  new  grocery 
store  had  been  open  for  business  few  customers  had 
exchanged  their  substance  for  its  edibles.  A  receiv- 
ership was  impending. 

The  young  clerk  sought  permission  of  the  owner 
for  a  brief  absence.  In  a  few  minutes  the  young 
man  returned,  carrying  a  large  glass  bowl.  He 
placed  the  bowl,  all  but  filled  with  clear  water,  in 
one  of  the  small  display  windows.  Again  the  young 
man  disappeared.  After  an  hour  he  returned,  carry- 
ing a  large  piece  of  card-board  on  which  he  had 
attractively  lettered  the  following:  Imported  In- 
visible Argentine  Goldfish — twenty-five  cents  each. 
Above  the  glass  bowl  he  placed  the  placard.  Within 
a  few  minutes  a  man  stepped  out  of  the  assembled 
crowd,  entered  the  store  and  questioned  the  digni- 
fied and  assured  young  man  about  the  fish  in  the 
bowl.  Certainly  the  bowl  is  filled  with  fish,  im- 
ported Argentine  fish,  but  you  cannot  see  them  be- 
cause they  are  invisible.  The  prospective  customer 
again  scrutinized  the  bowl  almost  filled  with  clear, 
quiet  water.  And  what  are  the  fish  worth?  Twenty- 
five  cents  each.  The  customer  in  a  little  wooden 
bucket  carried  away  six  little  fish  that  he  could  not 
see — for  one  dollar  and  fifty  cents.  The  demand 
became  so  heavy  and  remained  so  persistent  that 
the  merchant  and  his  young  clerk  within  three 
months  had  retired  with  a  competency. 


On  Laymanized  Psychiatry 
I  think  of  psychology  as  concerned  about  be- 
havior and  what  lies  causatively  beneath  the  be- 
haviour. And  I  think  of  psychiatry  as  concerned 
about  unwell  behaviour,  the  manifestations  of  it 
and  the  causes  of  it.  I  think  of  those  set  apart  by 
society  and  by  law  to  deal  with  disease  as  physi- 
cians. I  think,  therefore,  that  psychiatric  problems 
should  be  dealt  with  by  those  trained  to  deal  with 
them — especially  nurses  and  physicians.  The  world 
is  becoming  filled  with  pseudoids — those  who  sorter 
seem  to  know  but  do  not  know. 

Psychiatry  remains  largely  outside  the  domain 
of  modern  medicine  because  so  many  pseudo-physi- 
cians tinker  with  it.  Reputable  physicians  do  not 
like  to  have  to  do  with  a  professional  activity  that 


is  dominated  by  lay  people  who  know  no  medicine. 

About  a  month  ago  press  dispatches  told  of  the 
organization  at  Charlotte,  North  Carolina,  of  a 
State  Mental  Hygiene  Society.  I  was  entertained 
by  the  statement  that  both  the  president  of  the 
Society  and  the  secretary  are  non-medical  men. 
What  does  a  Doctor  of  Philosophy  know  about 
medicine,  or  a  Doctor  of  Laws  know  about  psychia- 
try? When  will  the  head  of  the  Department  of 
English  in  the  University  at  Chapel  Hill  be  assign- 
ed to  Doctor  MacNider's  Chair  of  Pharmacology, 
and  when  will  the  Professor  of  Archaeology  take 
over  Doctor  Mangum's  Department  of  Anatomy? 
Yet  a  Doctor  of  Philosophy  in  the  University  is 
spoken  of  as  State  Commissioner  of  Mental  Hy- 
giene! 

Are  there  no  physicians  in  North  Carolina  who 
are  interested  in  sickness  unless  it  be  of  the  palpa- 
bles  and  the  ponderables?  At  the  meeting  of  the 
American  Psychiatric  Association  in  St.  Louis  a 
month  or  more  ago  I  looked  in  pain  and  humilia- 
tion upon  a  display  of  statistical  figures.  At  the 
bottom  of  the  list  of  all  the  states  in  the  Union 
stands  or  lies  North  Carolina  in  her  annual  per 
capita  expenditure  upon  her  mentally  sick  folks — 
$130.00.  What  private  person  would  undertake  to 
furnish  all  needful  things  to  a  psychiatric  patient 
for  a  whole  year  for  one  hundred  and  thirty  dol- 
lars? Virginia,  God  bless  her  improvident  old  soul! 
spends  three  or  four  or  five  dollars  more.  But  the 
philosophical  mental  hygienists  in  North  Carolina 
may  take  hold  of  those  figures  and  hist  them  or 
lower  them.  Who  can  tell  what  a  group  of  profes- 
sorial radicals  may  not  do? 


Why  Publicize  Psychotics? 

We  may  be  much  farther  from  civilization  than 
we  realize.  Why  do  the  irrational  or  the  unre- 
strained speech,  and  the  bizarre  movements,  of  the 
mentally  sick  person  attract  and  hold  the  attention 
of  those  who  think  themselves  mentally  normal? 
All  who  are  not  afraid  of  an  insane  person  will  help 
to  form  a  circle  for  the  delectation  of  their  eyes  and 
ears.  And  the  press  usually  spreads  before  the 
public  all  the  distressing  details  of  a  suicide. 

For  several  weeks  the  behaviour  of  a  member  of 
the  national  legislative  body  has  afforded  live  copy 
for  those  who  spread  the  news  before  us  each  day 
at  the  rising  of  the  sun  and  the  going  down  of  the 
same.  Those  who  give  any  thought  to  the  qualis 
and  the  quantum  of  conduct  surmise  that  the  law- 
maker may  not  be  a  well  man,  and  that  instead  of 
having  publicity  he  should  have  psychotherapy. 
Why  should  the  behaviour  of  a  psychotic  be  placed 
before  the  people  by  radio,  by  photography,  and 
through  the  medium  of  many  newspaper  words 
many  times  each  week? 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  19.^6 


The  immaterial  attributes  of  mortals  may  fall  ill, 
even  as  the  physical  organs,  and  such  mental  sick- 
ness may  make  itself  manifest  through  behaviour 
unusual  in  quality  or  in  quantity.  But  why  should 
the  public  be  given  by  the  press  daily  accounts  of 
the  soul  in  such  a  predicament?  The  outcries  of 
the  woman  in  bringing  forth  her  kind  are  no  more 
sacred.    Are  our  reticences  all  to  disappear? 

Nicoto  Massa  (1499-1S69),  of  Venice,  is  the  first  writer 
to  point  out  syphilis  as  the  cause  of  mental  diseases. — 
Baas. 


ORTHOPEDIC  SURGERY 

John  Stuart  Gaul,  M.D.,  Editor,  Charlotte,  N.  C. 


The  Metastatic  Type  of  Osteomyelitis 

A  Rational   Method   of   Treatment 

Following  an  attack  of  osteomyelitis  in  which 
operation  has  been  done  and  the  patient  apparently 
on  the  way  to  a  cure,  the  physician  and  patient 
frequently  are  discouraged  with  the  appearance  of 
a  lesion  in  some  other  extremity,  or  over  the  ribs, 
clavicle  or  mandible.  This  lesion  is  characterized 
by  pain,  swelling,  redness,  fever  and  increase  of 
white  cells,  and,  later,  abscess  formation  and  fluc- 
tuation. 

The  physician  incises  and  drains  this  lesion.  A 
small  ilake  of  bone  may  or  may  not  be  extruded 
through  the  wound.  Everybody  is  happy  at  the 
prospect  of  healing  of  this  last  lesion,  when  dis- 
couragement again  ensues  with  the  appearance  of 
a  new  lesion.  This  may  continue  until  the  patient 
has  had  20  or  more  such  experiences. 

The  organism  most  frequently  found  is  a  staphy- 
lococcus, and  less  frequently  a  streptococcus.  The 
organism  is  transferred  by  the  blood  stream,  but 
one  rarely  obtains  a  positive  blood  culture. 

The  metastasizing  lesion  is  located  near  the 
epiphysis  of  the  involved  bone  in  nearly  all  cases. 
This  fact,  I  believe,  is  due  to  the  greater  number 
of  vessels  near  the  epiphysis,  thus  providing  greater 
opportunity  for  the  circulating  organism  to  lodge 
there. 

Why  should  metastasis  occur  and  continue  to 
recur  in  certain  cases  when,  as  far  as  we  are  able 
to  determine,  there  is  nothing  unusual  about  the 
organism  producing  the  condition?  I  believe  it  to 
be  due  to  the  manner  in  which  the  case  is  treated 
in  the  acute  phase. 

Abundant  experience  of  many  men  points  to  this 
fact:  in  the  acute  type  operation  should  not  be 
done  in  the  first  week  of  the  infection — and  not 
in  the  second  unless  one  is  sure  Nature  has  walled 
off  the  infection.  The  recurrent  lesion  should  not 
be  operated  on  but  permitted  to  open  spontane- 


ously, hot  boric-acid  dressings  being  used  in  the 
meantime.  Here  again  nature  will  wall  off  the 
infection  and  protect  the  surrounding  tissues,  par- 
ticularly the  blood  spaces,  from  contamination  with 
the  organism  in  the  pus. 

When  the  abscess  has  pointed  and  is  about  to 
rupture,  paint  the  surface  with  iodine  and,  using 
a  sterilized  needle  and  syringe,  aspirate  the  pus, 
send  it  to  a  laboratory  and  have  a  vaccine  made. 

Match  the  blood  of  the  patient  with  a  suitable 
and  willing  donor,  usually  a  parent,  for  the  purpose 
of  blood  transfusion. 

Administer  the  vaccine  to  the  donor>  using  such 
doses  as  are  recommended  by  the  laboratory,  until 
you  have  obtained  three  good  reactions  at  three- 
day  intervals.  The  day  following  the  third  reaction 
transfuse  the  donor's  blood  containing  the  anti- 
bodies into  the  blood  stream  of  the  patient. 

I  have  used  this  procedure  in  six  children  with 
most  gratifying  results.  One  child  who  had  had 
lesions  involving  both  arms,  both  thighs  and  both 
legs,  and  with  an  associated  kidney  involvement 
with  albumin,  waxy  and  granular  casts,  completely 
recovered,  gained  26  pounds  and  has  remained  well 
for  more  than  one  year. 


NicoL.\s  Andry,  of  Lyons  (1658-1742),  professor  at  Paris, 
wrote  on  orthopedic  surgery  '  and  originated  the  name 
"orthopedie." — Baat. 


INTERNAL  MEDICINE 

Paul  H.  Ringer,  A.B.,  M.D.,  F.A.C.P.,  Editor 
Asheville,  N.  C. 


PSYCHONEUEOSES 

The  editor  does  not  wish  in  any  way  to  infringe 
upon  the  territory  so  ably  covered  by  Dr.  James 
K.  Hall,  but  an  article  in  the  June  number  of  the 
Annals  of  Internal  Medicine  so  attracted  his  atten- 
tion that  he  could  not  refrain  from  reproducing 
its  salient  points  in  this  column.  The  article,  en- 
titled Some  Factors  in  the  Etiology  of  the  Psycho- 
neuroses,  by  Dr.  Louis  Casamajor,  of  New  York, 
who  begins  his  most  interesting  paper  by  stressing 
the  point  that  the  psychoneuroses  are  not  clinical 
states  in  the  sense  of  disease  but  rather  they  are 
states  of  mind;  and  the  symptoms  referable  to  them 
represent,  not  something  which  has  happened  inside 
the  patient,  but  something  which  has  happened  to 
the  relationship  of  the  patient  to  the  world  in 
which  he  has  to  live. 

Dr.  Casamajor  states  that,  paradoxical  as  it  may 
seem,  sickness  may  be  an  asset  to  the  patient.  To 
be  sure,  sickness  is  incapacitating;  but  it  also  serves 
as  an  excuse  that  permits  one  to  neglect  to  do  things 
that  would  be  required  of  one  who  is  well.  The 
fundamental  reason  of  the  psychoneurosis  is  the 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


39S 


fact   that    it   permits  the   patient   to  escape   from 
complete  responsibility  for  himself. 

All  of  us  here  below  play  a  dual  role  in  many 
of  our  activities,  and  the  two  ends  of  this  duality 
are  mutually  incompatible. 

"The  more  incompatible  the  components  of  this  conflict 
the  greater  is  the  possibility  of  the  conflict  eventuating  in 
a  neurosis.  Such  a  conflict  as  that  between  man  as  a 
decent  member  of  a  civilized  society  and  man  as  a  mam- 
mal, or  between  man  as  an  idealistic  social  being  and 
man  as  a  greedy  individualist,  requires  considerable  mental 
adjustment  and  adaptation  to  reach  a  level  of  solution. 
This  solution  may  be  one  compatible  with  mental  health — 
an  adequate  one  such  as  most  of  us  succeed  in  attaining 
and  maintaining  most  of  the  time — or  an  inadequate  one 
in  which  the  need  for  sickness  plays  a  part  of  varying 
importance.  Such  inadequate  solutions  may  be  benign  or 
maUgnant.  The  benign  reactions  are  those  which  permit 
the  individual  to  lead  something  approximating  a  normal 
life  even  though  a  sick  one,  which  is  the  psychoneurosis ; 
while  in  the  malignant  reactions  the  patient  has  cast  aside 
all  pretense  of  a  normal  life  to  live  in  a  world  of  his  own 
fantasy,  which  is  psychosis  of  the  schizophrenic  sort." 

Our  instincts  are  divided  into  two  groups:  1) 
instincts  of  self-preservation;  and  2)  instincts  of 
preservation  of  the  species.  The  former  may  be 
called  the  ego  instincts  and  the  latter  the  sexual 
instincts.  The  instinct  of  self-preservation  is  essen- 
tially egocentric  and  is  in  itself  not  a  pretty  thing. 
Underlying  it  are  two  major  factors,  fear  and  greed. 
Fear  of  injury,  fear  of  exposure  and  of  shame,  fear 
of  loss  of  position  and  respect,  fear  of  the  future 
here  and  hereafter,  and  fear  of  the  loss  of  the  feel- 
ing of  personal  security,  are  quite  as  competent 
causes  of  the  psychoneurosis  as  is  anything  in  the 
sexual  life. 

Self-respect  which  is  often  onlj'  another  name  for 
conceit,  justice  which  is  often  indistinguishable 
from  revenge,  and  the  desire  for  security  which 
may  be  but  a  form  of  indolence,  may,  any  or  all, 
enter  into  the  causation  of  the  ego  neurosis. 

The  so-called  traumatic  neuroses  are  very  defi- 
nitely eccentric  things  which  have,  in  the  main,  to 
do  with  the  matter  of  greed,  because  they  are  com- 
pensable. Dr.  Casamajor  very  sanely  points  out 
that  the  nature  and  severity  of  the  injury  have 
nothing  to  do  with  the  make-up  of  the  neuroses. 
The  one  point  that  they  all  have  in  common  is 
that  the  injury  is  compensable,  and  he  states;  "I 
have  yet  to  see  a  patient  with  a  traumatic  neurosis 
which  resulted  from  an  injury  sustained  while  work- 
ing for  himself.'' 

It  is  interesting  to  note  that  the  depression  has 
not  materially  increased  the  number  of  psychoneu- 
rotics. 

"This  is  especially  true  of  those  people  who  are  on  relief. 
They  have  hit  the  bottom  and  have  nothing  left  to  fear. 
Life  ran  become  nothing  but  better  for  them,  and  on  the 
groundwork  of  such  a  psychology,  psychoneurosis  cannot 
Imri  soil  to  grow.  They  may  become  dulled  and  discour- 
aged or  they  may  become  social  radicals,  but  the  psycho- 


neurosis is  not  a  part  of  their  reactions.  It  is  usually 
those  who  still  have  hopes  of  surmounting  their  difficulties 
and  eventually  triumphing  who  hold  in  their  make-up  the 
capacity  for  psychoneurosis.  This  is  especially  true  when 
compensating  factors  occupy  a  place  in  the  general  life 
picture." 

This  very  interesting  comment  on  the  psycho- 
neuroses  ends  with  detailed  reports  of  two  exceed- 
ingly instructive  cases,  which  illustrate  in  a  strik- 
ing way  the  points  that  Dr.  Casamajor  is  making. 
His  analysis  of  the  whole  subject  has  impressed  the 
editor,  who  is  in  no  sense  a  trained  neurologist  or 
psychiatrist,  as  being  practical  for  the  understand- 
ing of  many  of  the  mental  vagaries  that  we  see  in 
our  patients.  It  gives  an  insight  into  a  complex 
and  nebulous  subject  and  opens  our  eyes  to  the 
mental  quips  which  all  of  us  have  to  some  degree 
and  which  some  of  us  have  to  a  marked  degree. 
The  paper  will  bear  reading  in  full,  and  also  will  be 
further  appreciated  if  perused  a  second  and  a  third 
time. 

Suggestion. — Write  the  author,  Dr.  Louis  Casamajor,  706 
W.  lesth  St.,  New  York  City,  requesting  that  he  mail  you 
reprint. — J.  M.  N. 


Sir  Christopher  Wren,  a  savant  as  well  as  an  architect, 
in  the  year  16S7  was  the  first  to  devote  attention  to  the 
injection  of  medicines  into  the  veins.  His  example  was 
followed  by  Timothy  Clarke  (1664),  Richard  Lower  (1631- 
1691)  and  others,  and  their  experiments  resulted  in  demon- 
strating that  the  same  effects  followed  the  administration 
of  drugs  by  this  method  as  when  they  were  given  per  os. — 
Baas. 


SURGERY 

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


The  Air-conditioned  Operating  Room 

In  the  Hall  of  Fame  in  the  national  capitol  at 
Washington  each  State  is  invited  to  place  statues 
of  its  two  most  distinguished  sons.  It  is  of  interest 
to  know  that  the  State  of  Florida  has,  as  one  of 
its  representatives,  a  physician.  Dr.  John  Gorrie, 
the  discoverer  of  artificial  refrigeration.  The  origi- 
nal machine  by  which  artificial  ice  was  first  made 
about  a  hundred  years  ago  is  on  exhibition  at  the 
Smithsonian  Institution  in  Washington.  It  was  for 
a  long  while  an  object  of  ridicule  and  he  was  un- 
able to  get  funds  for  its  commercial  development. 
It  was  not  until  thirty  years  after  his  death  that 
one  of  the  first  artificial  ice  factories  in  the  world 
was  built  in  Apalachicola,  his  home.  As  a  prac- 
ticing physician  he  had  to  treat  many  cases  of 
fever  including  malarial,  which  made  him  seek  a 
way  to  procure  ice  for  the  control  of  the  fever  and 
for  the  comfort  of  his  patients.  It  is  of  especial 
interest  to  know  that  unselfishly  seeking  a  ther- 
apeutic aid  for  his  patients  and  not  the  desire  to 
make  money  led  him  to  the  discovery  whose  im- 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


portance  to  humanity  in  the  economic  and  indus- 
trial world  is  just  being  fully  appreciated.  He 
understood  the  necessity  for  proper  ventilation  of 
the  sick  room  and  attempted  air-conditioning  in 
a  crude  way. 

In  midsummer  of  last  year  air-conditioning  was 
installed  in  the  operating  rooms  of  the  Columbia 
Hospital.  After  a  year's  experience  one  should 
have  a  definite  impression  of  its  benefits  and  of 
its  malefits,  if  any.  The  sterilizing  room  is  imme- 
diately between  the  two  major  operating  rooms  on 
the  top  floor  and  is  without  a  hood  or  overhead 
vent  for  the  hot  air  and  escaping  steam,  although 
there  is  an  outside  window.  The  operating  rooms 
have  large  skylights  through  which  the  hot  summer 
sun  shines.  Neither  the  sterilizing  room  nor  the 
operating  rooms  have  adequate  through-and-through 
ventilation,  so  the  humidity  is  even  more  of  a 
problem  than  the  heat.  So  it  comes  to  pass  that, 
with  an  outside  temperature  of  100°,  the  working 
conditions  in  the  operating  room  are  almost  unbear- 
able. 

Air-conditioning,  as  here  used,  shall  be  consid- 
ered as  it  affects  the  patient,  the  surgeon  and  the 
operating-room  nurses.  With  the  temperature  of 
the  operating  room  uniformly  kept  at  80°  the 
patient  experiences  an  exhiliration  on  entering, 
sweating  stops,  respirations  are  deeper  and  slower. 
The  skin  through  which  the  incision  is  made  is 
dry  so  that  the  antiseptic  preparation  is  more  ef- 
fective, it  stays  dry  during  the  operation  so  that 
aseptic  technic  can  be  better  preserved.  A  local 
internist  at  first  thought  that  pneumonia  might  be 
caused  by  the  sudden  entrance  of  a  lightly  clad 
patient  already  ill  and  with  poor  resistance  into 
an  atmosphere  20°  less  than  that  to  which  he  had 
been  accustomed.  He  thought  that  shock  might  be 
greater  because  of  the  lowered  temperature.  Ex- 
perience has  proved  both  fears  groundless.  On  the 
contrary,  the  patient  seems  to  get  increased  vitality 
from  the  lowered  room  temperature. 

In  hot  weather  the  comfort  of  the  surgeon  work- 
ing in  an  air-conditioned  room  is  infinitely  greater. 
His  body  is  no  longer  drenched  in  sweat.  His 
face  and  neck  are  dry  and  do  not  have  to  be  con- 
stantly mopped  to  keep  the  sweat  from  dripping 
upon  the  dressings  or  the  wound.  He  does  his 
work  with  greater  safety,  with  more  facility  and 
with  less  fatigue.  The  greatest  benefit  of  air- 
conditioning  is  experienced  in  operations  at  -night. 
Heretofore  gnats  and  bugs,  attracted  by  the  light, 
have  come  through  the  window  screens  almost  with 
impunity,  so  that  the  windows  had  to  be  kept 
closed  while  the  lights  were  on.  Now  the  room 
may  be  kept  comfortable  even  with  the  windows 
closed. 


It  is  a  biologic  fact  that  white  women  do  not 
stand  the  heat  and  humidity  of  the  tropics  well. 
Both  of  these  are  more  severe  in  summer  in  the 
unconditioned  operating  room  in  this  climate  than 
in  the  tropics.  The  nurses  when  on  operating-room 
duty  in  summer  in  Columbia,  almost  without  ex- 
ception, lose  weight  and  color.  They  have  to  be 
shifted  often.  The  surgeon  spends  a  comparatively 
short  time  in  the  operating  room  but  the  nurses 
spend  their  working  hours  there.  To  them  air- 
conditioning  is  indeed  a  godsend. 


Surgery  of  old  could  do  things  (The  Jl.  of  Ayurveda, 
Calcutta,  April)  that  it  cannot  do  today.  For  is  there  not 
a  Greek  inscription  about  the  wise  servant  of  Aesculapius 
who  cured  a  dropsy  by  cutting  off  the  sufferer's  head,  hold- 
ing him  upside  down  to  drain,  and  sewing  it  on  again? 


Cesare  Maoati  (1579-1647),  of  Scandiano,  insisted  upon 
simplification  of  the  treatment  of  wounds  and  the  infre- 
quent change  of  dressings.  Instead  of  changing  the  latter 
several  times  a  day,  as  was  the  custom,  he  would  have  thera 
renewed  once  in  4  days. — Baas. 


Bebe  mentions  a  Saxon  leech,  Cynifrid,  whose  practice 
was: 

"For  hare-lip,  pound  mastic  very  small,  add  the  white 
of  an  egg,  and  mingle  as  thou  doest  vermilion:  cut  with  a 
knife  the  false  edges  of  the  lip,  sew  fast  with  silk,  then 
smear  without  and  within  with  the  salve,  ere  the  silk  rot. 
If  it  draw  together,  arrange  it  with  the  hand. — Anoint 
again  soon." — Baas. 


PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 
Pitt  County  Health  Officer 


The  Physician  and  the  Sanitary  Inspector 

The  writer  has  done  public  health  work  over  a 
period  of  years.  During  this  time,  he  has  dis- 
cussed with  many  physicians  the  work  of  the  sani- 
tary inspector.  As  a  result  he  has  come  to  the 
conclusion  that  the  average  physician  does  not  fully 
appreciate  the  important  role  the  sanitary  inspector 
plays  in  preserving  the  health  of  the  community. 

It  has  been  the  writer's  experience  that  in  the 
case  of  the  average  physician,  when  reference  is 
made  to  the  work  of  the  health  department,  the 
physician  thinks  in  terms  of  the  work  of  the  health 
officer  and  the  public  health  nurse.  In  short,  the 
average  health  department  is  better  known  among 
physicians  for  its  quarantine  work,  inoculations 
against  typhoid  fever,  diphtheria,  etc.,  than  for 
its  sanitary  inspection  work;  while  the  truth  of 
the  matter  is,  a  health  department  without  a  sani- 
tary inspector  (a  more  modern  title,  sanitary  engi- 
neer) could  hardly  be  more  than  SO-per  cent,  effi- 
cient. (And  we  suspect  that  the  State  Health  Of- 
ficer regards  the  value  of  his  Division  of  Sanitary 
Engineering  in  pretty  much  the  same  light.) 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


We  have  found  that  the  average  physician  who 
gives  any  thought  at  all  to  the  role  of  the  sanitary 
inspector,  usually  associates  his  work  almost  solely 
with  privies  and  proper  sewer  connections.  Of 
course,  these  things  are  an  essential  part  of  his 
work,  but  in  addition  to  privy  and  sewer  sanitation, 
the  sanitary  inspector  must  keep  constant  watch 
over  the  water  supply,  the  milk  supply,  the  food 
supply  (hotels,  restaurants  and  cafes),  proper 
drainage,  etc. 

The  chief  diseases  which  may  be  prevented  by 
the  work  of  the  sanitary  inspector  are,  of  course, 
known  to  every  physician;  but  it  will  probably  not 
be  amiss  to  here  mention  typhoid  fever,  tuberculo- 
sis, undulant  fever,  diarrhea  and  enteritis,  malaria 
and  hookworm  disease. 

It  is  well  known  that  infected  milk,  infected 
water,  or  infected  food  may  be  responsible  for  the 
spread  of  typhoid  fever,  tuberculosis,  diarrhea  and 
enteritis  and  undulant  fever;  that  improper  excreta 
disposal  is  responsible  for  typhoid  fever,  diarrhea 
and  enteritis  and  hookworm;  and  that  lack  of 
drainage  is  indirectly  responsible  for  the  spread  of 
malaria. 

Not  only  does  the  sanitary  inspector  make  the 
milk  supply  safe  by  enforcing  the  ordinance  requir- 
ing that  the  herds  be  tested  against  tuberculosis 
and  Bang's  disease  and  seeing  to  it  that  the  milk 
is  produced  under  sanitary  conditions;  he  also 
checks  on  the  quality  of  the  milk,  i.e.,  as  to  the 
amount  of  solids  and  fats  present.  To  know  the 
purity  of  milk  is  essential;  it  is  also  essential  that 
it  be  up  to  the  proper  nutritional  standard. 

Of  course,  in  large  health  departments,  milk  an- 
alyses and  dairy  inspection  are  under  a  special 
milk-and-dairy  inspector;  but  in  the  smaller  health 
departments  this  work  must  be  done  by  the  regular 
sanitary  inspector. 

In  conclusion,  I  would  like  to  say  that  this  article 
was  written  not  so  much  to  acquaint  the  private 
physician  with  the  importance  per  se  of  the  work 
of  the  sanitary  inspector,  as  it  was  to  arouse  an 
interest  on  the  part  of  the  physician  in  this  im- 
portant phase  of  public  health  work. 

I  regard  a  good  sanitary  inspector  as  the  health 
officers'  most  important  lieutenant  in  the  fight 
against  preventable  disease.  The  sanitary  inspector 
needs  the  cordial  support  of  the  private  practitioner 
and  he  is  entitled  to  it. 

Just  as  a  health  officer  in  quarantine  work,  tu- 
berculosis control,  maternal  and  infant  welfare 
[  work,  etc.,  is  dependent  upon  the  support  of  the 
,  private  practitioner  for  success,  so  is  the  sanitary 
inspector  dependent  upon  the  sympathetic  support 
of  the  private  practitioner  for  success  in  his  own 
work,  which  is  so  vital  to  the  health  of  the  com- 
munity. 


To  express  the  same  idea  a  little  differently,  no 
other  group  of  citizens  can  further  the  cause  of 
public  health  in  North  Carolina  like  the  private 
physicians  can  and,  in  our  opinion,  in  no  other 
way  can  this  group  more  effectively  further  the 
cause  of  public  health  than  in  championing  the 
cause  of  the  sanitary  inspector. 


The  brothels  of  London  were  privileged  and  regulated 
by  statute  from  1162  to  1547.    Among  the  regulations: 

"No  maiden  shall  receive  pay  from  a  man  unless  she  has 
passed  the  whole  night  until  morning  with  him. 

No  host  shall  keep  a  maiden  who  has  the  dangerous 
burning  disease,  nor  shall  he  sell  either  bread,  beer,  meat 
or  other  victuals." — Baas. 


Numerous  and  frightful  epidemics  in  the  Middle  Ages 
left  to  succeeding  times  only  one-half  fhe  population  which 
they  had  themselves  received  at  their  beginning. — Baas. 


EYE,  EAR,  NOSE  AND  THROAT 

Frank  C.  Smith,  M.D.,  Charlotte,  N.  C,  Editor 
Charlotte  Ey«,  Ear  and  Throat  Hospital 


Look  for  General  Conditions  as  Explanations 
OF  Eye  Symptoms 

The  longer  one  does  an  active  practice  in  oph- 
thalmology, the  more  he  realizes  the  need  of  a 
general  knowledge  of  medicine.  Because  of  the 
eyes  taking  part  subjectively  and  objectively  in 
so  many  medical  and  neurological  conditions,  pa- 
tients have  a  general  idea  that  the  wearing  of 
glasses  will  relieve  the  symptoms  referred  to  the 
eyes,  and  not  a  few  think  glasses  are  needed  when 
the  condition  is  obviously  an  acute  infection;  con- 
sequently, the  fitter  of  glasses  must  have  a  knowl- 
edge of  general  medicine  if  the  case  is  to  be  han- 
dled properly.  In  fact,  the  ophthalmologist  should 
always  attempt  to  rule  out  some  general  condition, 
first,  in  all  cases  in  which  the  history  does  not 
clearly  indicate  eye-strain.  A  brief  summary  of 
some  of  the  patients  seen  in  the  last  seven  days 
who  thought  that  glasses  would  relieve  their  symp- 
toms will  indicate  the  need  of  medical  information. 

Case  1 — .\  child  5  years  of  age  had  sensitiveness 
to  light  and  tearing  for  over  a  week.  There  was 
one  small  phlyctenule  at  the  upper  margin  of  the 
cornea,  otherwise  the  eyes  were  practically  quiet. 

Case  2 — A  young  woman  30  years  of  age  had 
noticed  the  print  had  been  blurred  for  several  days. 
She  had  a  5'  central  scotoma  with  normal  fundi. 

Case  ,5 — .\  woman  25  years  of  age  suddenly  de- 
veloped a  nystagmus. 

Case  4 — A  woman  26  years  of  age  had  pain 
around  her  eyes  and  some  photophobia  following 
headache  and  scintillating  scotomata  which  had 
come  on  after  two  weeks  of  strenuous  eye  work. 
Her  glasses  were  correctly  fitted.  (A  very  common 
cause  for  changing  glasses  unnecessarily.) 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


Case  5— A  woman  32  years  of  age  with  nervous- 
ness, pain  and  pressure  in  the  top  of  her  head  and  a 
variety  of  eye  symptoms  which  had  been  present 
since  an  oophorectomy  two  years  previously.  (Such 
cases  frequently  have  glasses  changed  unnecessari- 
ly.) 

Case  6 — A  woman  42  years  of  age  complained 
of  blurred  vision  when  reading.  During  the  past 
two  weeks,  the  symptoms  came  on  two  or  three 
days  after  she  began  taking  atropine  for  relief  of 
some  intestinal  symptoms.  She  had  only  a  small 
amount  of  far-sightedness  which  will  be  taken  care 
of  without  glasses  when  the  atropine  is  stopped. 

Case  7 — A  man  60  years  of  age,  who  had  no- 
ticed one  eye  failing  for  several  months,  had  an 
optic  atrophy,  a  4-plus  Wassermann  reaction. 

Case  8 — A  man  59  years  of  age,  who  had  been 
dizzy  and  nauseated  for  three  days,  especially  when 
he  tried  to  read,  had  beginning  3rd-nerve  paralysis 
and  an  arteriosclerosis  with  a  hypertension. 

Case  9 — A  woman  72  years  of  age  whose  vision 
had  been  blurred  for  several  weeks.  It  was  im- 
possible by  any  known  means  to  make  her  see 
more  than  she  could  with  the  glasses  she  was  wear- 
ing. Her  pupils  were  dilated  and  a  number  of 
small  hemorrhages  with  edema  of  the  retina  were 
seen.  (It  should  be  remembered  that  a  careful 
study  of  the  fundus  cannot  be  made  through  an 
undilated  pupil  and  only  a  physician  is  permitted 
to  use  drops  which  dilate.) 


Georg  Baetisch  (1535  to  about  1606)  of  Konigsbruck 
near  Dresden,  subsequently  court  oculist  of  the  Elector  of 
Saxony,  was  an  independent  spirit  and  a  man  of  character 
and  heart,  inspired  by  a  love  of  his  profession  and  of 
mankind,  whom  he  saw  outrageously  maltreated  in  his 
own  department.  We  find  in  his  work  a  great  number  of 
preparations  necessary  before  operations,  on  the  part  of 
both  the  patient  and  the  physician  specified  very  carefully 
and  circumspectly,  the  patient  should  continue  fasting  the 
whole  day;  the  operating  room  should  be  light,  and  the 
bed  well  prepared,  etc.:  the  physician  too  should  have 
drunk  nothing  for  a  few  days  previous  to  the  operation, 
and  should  not  have  set  up  long  by  candle  light;  curiously 
enough  too  he  was  "to  abstain  entirely  from  conjugal  duty 
with  his  wife  for  2  days  and  nights  before  the  operation," 
so  that  the  possession  of  an  ordinary  practice  in  operating 
for  cataracts  must  have  furnished  by  itself  a  very  good 
legal  ground  for  divorce. — Baas. 


Very  few  young  men  are  gieted  towards  research 
(C.  H.  Fagge,  In  Australian  &  New  Zealand  Jl.  of  Surg., 
April),  and  even  so  most  of  the  research  done  is  sterile  in 
its  application  to  the  alleviation  of  disease.  It  is  important 
that  research  should  be  undertaken  as  soon  as  possible, 
provided  the  right  type  of  worker  is  available. 


Do  You  Know  About  the  Volta  Bureau.'' 

"We  consulted  several  specialists,  and  all  of  them  con- 
firmed our  fears,  but  none  offered  any  solution  of  our 
problem."  Thus  the  mother  of  a  small  deaf  child  wrote 
to  the  Volta  Bureau.  The  sentence  might  be  quoted 
verbatim  from  many  letters  written  by  parents  of  deaf 
or  hard-of-hearing  children,  or  by  hard-of-hearing  adults. 

The  knowledge  that  deafness  is  present  and  that  it  is 
incurable  comes  wtih  the  force  of  a  major  calamity.  It 
is  so  crushing  in  its  effect  that  something  positive  in  the 
way  of  help  must  be  offered  immediately,  if  the  individual 
is  not  to  spend  desperate  years  in  a  bewildered  effort  to 
adjust  himself.  The  parents  of  a  deaf  child  must  be  told 
that  the  child  can  be  taught  to  speak  and  can  be  success- 
fully educated,  and  that  this  education  may  be  begun  at 
home  immediately,  even  if  the  child  is  not  more  than  two 
years  old.  The  parents  of  a  child  whose  hearing  is  only 
slightly  impaired  must  be  given  advice  as  to  his  adjustment. 
The  hard-of-hearing  adult  must  be  told  about  Up  reading, 
about  hearing  aids,  about  social  efforts  in  his  behalf. 

The  Volta  Bureau  was  established  for  the  purpose  of 
furnishing  all  this  information  to  all  who  ask  for  it.  Its 
services  are  free.  Alexander  Graham  Bell,  the  son  of  a 
hard-of-hearing  mother,  the  husband  of  a  deaf  wife,  the 
lifelong  friend  of  everyone  handicapped  by  deafness,  used 
the  money  received  as  a  prize  for  inventing  the  telephone 
to  found  the  Volta  Bureau  so  that  anyone  confronting  tlie 
problems  of  deafness  might  be  assured  of  help.  Advice  is 
given  as  to  schools  and  preschool  training,  lip  reading 
instruction,  hearing  aids,  social  contacts,  psychological  dif- 
ficulties. While  the  Volta  Bureau  is  not  equipped  to  do 
employment  service,  it  gives  information  in  regard  to  the 
fields  of  activity  that  are  open  to  the  deaf  and  the  hard- 
of-hearing. 

The  Volta  Review,  a  magazine  for  parents  and  teachers 
of  the  deaf  and  for  the  hard-of-hearing.  is  on  the  reading 
table  of  many  physicians.  Pamphlets  dealing  with  all 
phases  of  deafness  except  medical  problems  are  available 
to  all  who  ask  for  them.  Lists  of  such  pamphlets  and 
sample  copies  of  the  magazine  will  gladly  be  sent  free  of 
charge  by  request  directed  to  The  Volta  Bureau,  1537  35th 
St.,  N.W.,  Washington,  D.  C. 


The  Choice  of  Bismuth  or  Mercury  With 
Arsphenamine 

(A  B.  Cannon  cS.  J.  Robertson,  New  York,  in  Jl.  A.  M.  A., 
June  20th) 

Mercurv  give;  more  brilliant  but  less  uniform  results 
than  bismuth,  so  that  in  robust  patients  with  a  healthy  ex- 
cretory mechanism  the  body's  natural  defenses  are  perhaps 
more  effectively  stimulated  by  the  mercurials.  For  patients 
less  vigorous  and  for  those  who  do  not  respond  well  to 
mercury  preparations,  bismuth  offers  a  valuable  substitute. 

.■Arsphenamine  can  be  counted  on  to  dehver  the  strongest 
initial  attack  against  Spirochaeta  pallida  and  acts  to  best 
advantage  when  reinforced  by  one  of  the  heavy  metals;  but 
if  for  any  reason  an  arsphenamine  is  contraindicated,  bis- 
muth will  probably  give  the  better  performance  alone. 

For  those  who  would  minimize  the  chances  of  ill  effects 
and  for  those  who  hold  that  the  parasite  may  become  drug- 
fast,  alternating  the  two  metals  offers  an  obvious  advan- 
tage. 


"Drawers  of  blood  and  hewers  of  members,"  was  the 
paraphrase  with  which  Dr.  Oliver  Wendell  Holmes  aptly 
describe  the  operators  rather  than  surgeorts  among  his  con- 
temporaries. 


ANTtHTRiN-S,  2  c.c.  cvcry  other  day  in  30  cases  of  acne 
vulgaris  (C.  H.  Lawrence,  Boston,  //.  .4.  M.  A.,  Mch. 
21st)  gave  improvement  in  the  majority  in  2  to  4  wks., 
maximum  benefit  in  12  to  16  wks.  Ten  patients  are  re- 
garded as  cured.  There  appeared  to  be  no  difference  in 
response  between  the  two  sexes. 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


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 
jAiiES  K.  Hall,  M.D    Richmond,  Va. 

Dentistry 
W.  M.  RoBEY,  D.D.S _ Charlotte,  N.C 

Eye,    Ear,    Nose   and   Throat 

Eye,  Ear  and  Throat  Hospital  Group —Charlotte,  N.  C. 

Ortliopedrc   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. 


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 
Chas.  R.  Robins,  M.D Richmond,  Va. 

Pediatrics 
G.  W.  Kutscher,  jr.,  M.D Asheville,  N.  C. 

General   Practice 
Wingate  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.  Gilmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Ennett,  M.D.  .- .        Greenville,  N.  C. 

Radiology 

Allen  Barker,  M.D.        |  Petersburg,  Va. 

Wright  Clarkson,  M.D. ) 


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. 


What  to  Tell  the  Patient  With  Heart 
Disease 

This  is  to  be  a  by-request  editorial.  A  confrere 
asks  that  the  editor  deliver  himself  on  this  sub- 
ject. What  is  to  follow  is  not  offered  as  the  last 
word.  It  is  by  way  of  suggestion  rather  than 
proclamation. 

Right  here  comes  to  mind  the  direction  for  mak- 
ing squirrel  stew,  which  direction  begins  with, 
"First  get  your  squirrels."  Many  an  individual 
with  a  heart  as  sound  as  anybody's  goes  through 
the  greater  part  of  a  long  life,  haltingly,  because 
some  doctor  has  told  him  he  has  heart  disease,  a 
leaky  heart  valve,  or  a  heart  murmur;  or  perhaps 
the  doctor  has  only  snatched  his  stethoscope  away, 
wiped  the  ear-pieces  and  sprung  to  ree.xamine — 
and  then  turned  on  the  thoroughly  alarmed  patient 
a  look  full  of  dole,  in  which  there  was  no  ray  of 
hope.  It  behooves  us  to  bear  it  ever  in  mind  that 
we  tell  our  patients  in  many  ways  besides  by 
spoken  or  written  word,  and  that  our  words,  many 
times,  convey  meanings  far  different  from  our  in- 
tent. Dr.  George  Ben  Johnston  used  to  tell  of  the 
distress  he  once  caused  by  inadvertently  bidding 
a  patient  "Farewell,  Mrs.  Sullivan,"  when  his  in- 
tent was  only  to  wish  her  a  good  morning  as  he 
left  the  room. 

It  is  a  fixed  idea  of  mine  that  the  instances  in 
which  a  remediable  disease  condition  develops, 
without  giving  timely  and  repeated  plain  warnings, 
are  too  few  to  justify  having  people  who  feel  well 
go  to  doctors  for  examination  and  thus  put  it 
into  their  minds  to  search  themselves  daily  for 
evidences  of  disease.  Birthdays  should  be  joyous 
occasions  for  wishing  one  many  happy  returns  of 
the  day,  not  days  for  going  to  a  doctor's  office  in 
fear  and  trembling  and  coming  to  the  dinner  table 
with  dismal  forebodings  over  a  lot  of  facts  that 
are  not  true.  Many  a  doctor  has  made  merry  over 
the  caution  against  self-medication,  "You  might 
die  of  a  misprint?,  who,  himself,  regularly  neglects 
to  inform  himself  as  to  the  significance,  or  lack 
of  significance,  of  what  may  be  signs  of  cardiac 
incompetency.  We  see  so  much  stuff  about  "the 
alarming  increase  in  the  number  of  deaths  from 
heart  disease,"  that,  unless  we  happen  to  be  dis- 
posed to  reason  about  things,  we  may  be  impressed, 
even  stampeded.  It  is  well  to  remember  that  those 
who  died  of  summer  diarrhea  at  fifteen  months  or 
of  diphtheria  at  six  years  never  lived  to  die  of 
heart  disease  at  fifty  or  sixty  or  seventy;  that, 
since  mankind  has  not  yet  put  on  immortality,  we 
must  die  of  something;  that  an  organ  which  beats 
incessantly  from  the  first  few  weeks  of  intrauterine 
life  must  wear  out;  and  that  heart  failure  is  a 
mighty  convenient  diagnosis. 


400 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  lyit 


Our  erring  is  not  so  much  for  lack  of  light  as 
from  failure  to  seek  the  light — even  closing  our 
eyes  to  the  light.  On  the  subject,  heart  disease, 
the  two  names  which  have  carried  the  most  weight 
in  the  past  three-quarters  of  a  century  are  Austin 
Flint  and  William  Osier.  By  lectures  and  text- 
books, Flint  taught  his  students: 

"Valvular  lesions  not  involving  either  obstruction  or 
regurgitation  may  remain  innocuous  for  an  indefinite  pe- 
riod. Tiie  physician  should  be  careful  not  to  attach  undue 
importance  to  the  presence  of  one  or  more  of  the  organic 
murmurs.  These  are  frequently  discovered  in  examinations 
of  the  chest  when  patients  complain  of  no  symptoms  re- 
ferable to  the  heart,  and  in  persons  who  suppose  themselves 
to  be  in  perfect  health.  If  the  lesions  be  accompanied  by 
enlargement  of  the  heart,  obstruction  or  regurgitation,  or 
both,  may  be  inferred,  and  the  lesions  are  not  innocuous; 
yet  so  long  as  the  enlargement  is  exclusively  or  mainly 
hypertrophic,  serious  evils  directly  attributable  to  the 
cardiac  lesions  rarely  occur.  The  patient  under  these  cir- 
cumstances, as  a  rule,  simply  suffers  more  or  less  inconveni- 
ence. The  suffering  and  danger,  as  already  stated,  depend 
chiefly  on  the  weakness  arising  from  predominant  dilatation 
of  one  or  more  of  the  cavities  of  the  heart.  The  progress 
of  enlargement  is  generally  slow,  and  it  is  not  uncommon 
for  patients  affected  with  valvular  lesions,  together  with 
more  or  less  hypertrophy,  to  hve  many  years,  and  even  to 
old  age." 

Osier  followed  with: 

"The  question  is  entirely  one  of  efficient  compensation. 
So  long  as  this  is  maintained  the  patient  may  suffer  no 
inconvenience,  and  even  with  the  most  serious  forms  of 
valve  lesion  the  functions  of  the  heart  may  be  little,  if  at 
aU,  disturbed. 

Practitioners  who  are  not  adepts  in  auscultation  and 
feel  unable  to  estimate  the  value  of  the  various  heart  mur- 
murs should  remember  that  the  best  judgment  of  the  con- 
ditions may  be  gathered  from  inspection  and  palpation. 
With  an  apex  beat  in  the  normal  situation  and  regular  in 
rhythm  the  auscultatory  phenomena  may  be  practically 
disregarded. 

A  murmur  per  se  is  of  little  or  no  moment  in  determining 
the  prognosis  in  any  given  case.  There  is  a  large  group  of 
patients  who  present  no  other  symptoms  than  a  systolic 
murmur  heard  over  the  body  of  the  heart,  or  over  the 
apex,  in  whom  the  left  ventricle  is  not  hypertrophied,  the 
heart  rhythm  is  normal  and  who  may  not  have  had  rheu- 
matism. Indeed,  the  condition  is  accidentally  discovered, 
often  during  examination  for  life  insurance." 

Flint  never  heard  of  an  electrocardiograph  and 
Osier  died  before  this  useful  piece  of  diagnostic 
apparatus  had  come  into  its  own;  still  the  state- 
ments of  these  two  wise  doctors  stand  as  reliable 
guides  for  those  who  have  the  care  of  patients 
who  have  heart  abnormalities.  Today,  advice, 
counsel  and  comfort  based  on  the  principles  they 
laid  down  is  sound. 

Finally  (and  this  may  have  been  what  was  in 
the  minds  of  the  doctor  responsible  for  this  ex- 
pression), there  is  the  problem  of  how  much  we  are 
to  tell  patients  we  know  to  have  heart  disease. 
My  own  opinion  is  that  it  is  best  to  tell  any  pa- 
tient of  average  sense,  afflicted  with  a  chronic  dis- 


ease, the  full  facts  so  far  as  we  know  them.  The 
attempt  to  withhold  anything  of  consequence  will 
almost  certainly  fail  of  its  object,  and  the  main 
result  will  be  loss  of  confidence  in  his  doctor — 
maybe  all  doctors.  History  goes  to  show  that  ap- 
prehension of  disaster  weighs  heavier  on  the  mind 
than  does  it  certainty.  Jailers  say  prisoners  sleep 
much  better  the  night  before  they  are  to  be  hanged 
than  they  do  the  night  before  they  are  to  be  tried. 
The  German  submarine  crews  mutinied  after  a 
few  months  during  which  no  report  came  back  of 
the  ships  that  went  out  and  were  swallowed  up  in 
silence.  The  British  Admiralty  knew  its  psych- 
ology. 

On  the  other  hand,  the  ninety-and-nine  can  bear 
with  astonishing  equanimity  the  most  appalling 
news,  when  it  is  broken  by  a  doctor  in  whose  head 
and  heart  they  have  confidence,  and  when,  with 
the  news,  goes  the  assurance  that  the  doctor  will 
stand  by.  And  every  doctor  should  be  saturated 
with  the  conviction  that  a  good  doctor  can  do 
something  valuable  for  a  patient  as  long  as  breath 
remains,  and  every  doctor  who  gives  his  orders  on 
the  principle  that  everything  a  patient  enjoys  is 
bad  for  him  and  everything  he  detests  is  good  for 
him  should  quite  the  practice  of  medicine.  If  your 
patient  enjoys  fishing,  let  him  go  fishing.  You 
don't  know  when  he  is  going  to  die  and  if  he  should 
die  on  the  trip  one  place  is  as  good  as  another  as  a 
starting-point  for  Heaven.  There  is  no  sense  in 
the  prescription: 

All  those  things  that  you  don't  do,   do. 
And  the  things  that  you  do  do,  don't. 


Publicity  for  Every  County  Medical  Society 
The  people  of  any  county  are  seldom  conscious 
of  the  existence  of  the  organization  which  is  of 
most  importance  to  them.  Now  and  then  they  see, 
perhaps,  a  note  that  the County  Medi- 
cal Society  has  held  a  meeting,  and  that  is  about 
all.  Each  of  our  county  medical  societies  should 
concern  itself  actively  with  every  problem  which 
has  a  bearing  on  health — and  this  classification 
includes  nearly  all  problems;  and  it  should  keep 
the  general  public  informed  as  to  what  it  is  doing 
toward  solving  these  problems  and  handling  the 
situations  growing  out  of  them. 

There  is  one  county  medical  society  in  North 
Carolina  that  keeps  itself  before  the  public  in  the 
right  way,  i.e.,  by  its  energetic  activities  in  protec- 
tion of  the  health  of  the  people.  There  may  be 
other  county  societies  as  alert  and  energetic,  but 
if  so  they  escape  our  notice.  Note  report  of  a 
recent  meeting  of  the  Buncombe  society  in  the  news 
section  of  this  issue.  While  health  officers  should 
take  the  lead  and  bear  the  brunt  in  such  work,  if 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


they  will  not,  the  burden  falls  on  the  county  medi- 
cal societies;  and  the  Buncombe  ^Medical  Society 
believes  in  protecting  the  people's  health  and  their 
member's  rights. 

Always  we  have  with  us  the  problems  of  cancer, 
of  diabetes,  of  nephritis,  of  heart  disease,  of  blind- 
ness, of  nervous  instability,  of  mental  insufficiency 
or  perversion,  of  preventive  inoculations.  In  recent 
years  another  important  problem  is  on  our  hands — 
that  of  reducing  the  highway  fatalities. 

In  a  certain  county  one  problem  is  most  insist- 
ently demanding  solution;  in  another  county,  an- 
other problem;  in  every  county  the  problem  of 
reducing  the  speed  at  which  cars  are  being  oper- 
ated on  the  highways  is  an  acute  one. 

Every  county  society  can  interest  itself  1)  that 
every  car  be  equipped  with  a  governor  set  at  the 
legal  speed  limit,  and  2)  that  two  lines  be  drawn 
on  roads  instead  of  one — each  12  inches  from  the 
middle — so  road-hogs  can  run  on  the  line  without 
menacing  the  lives  of  decent  folks. 

This  is  only  one  of  the  many  ways  in  which 
county  medical  societies  can  prolong  the  lives  of 
their  own  members,  regain  the  leadership  they  once 
held  and  make  their  position  so  strong  that  the 
Foundations  et  al  will  discharge  their  high-salaried 
agitators  and  cease  their  warring  on  Medicine. 


\  Obituary 

Doctor  John   T.   Burrus 

Dr.  John  Tilden  Burrus,  president  in  1928  of  the 
Medical  Society  of  the  State  of  North  Carolina, 
died  June  9th  at  his  own  hospital  at  High  Point, 
from  an  illness  of  twenty-four  hours  duration. 

Born  in  Surry  County  fifty-nine  years  ago,  he 
was  schooled  at  Yadkin  Valley  Institute,  later  be- 
ing graduated  from  Davidson  College  and  taking 
his  degree  in  medicine  in  Chattanooga.  In  1899 
he  entered  on  practice  at  Jonesville,  removing  to 
High  Point  in  1904.  In  1909  Dr.  Burrus  took  over 
the  conduct  of  the  Junior  Order  Hospital  at  High 
Point,  which  later  became  High  Point  Hospital  and 
still  later — in  1932 — The  Burrus  Memorial. 

Dr.  Burrus  devoted  himself  with  diligence  and 
enthusiasm  to  his  professional  work  and  this  devo- 
tion was  rewarded  with  a  large  surgical  practice 
and  abundant  recognition  in  the  profession.  He 
interested  himself  in  civic  and  political  affairs  and 
so  attained  to  political  office  and  influence.  He 
lent  his  services  in  the  World  War  and  won  to  the 
high  pwsition  of  Commanding  Officer  of  a  Base 
Hospital.  His  were  a  large  and  devoted  clientele, 
financial  success,  the  presidency  of  the  Medical 
Society  of  the  State  of  North  Carolina  and  of  the 
North  Carolina  State  Board  of  Health  and  the  vice 


presidency  of  the  Tri-State  Medical  Association  of 
the  Carolinas  and  Virginia,  a  Lieutenant  Colonelcy 
in  the  Army,  a  State  Senatorship  twice  and  promi- 
nent mention  for  the  Governorship.  Though  less 
than  three-score,  he  died  full  of  honors.  He  lay 
in  State  at  the  residence  for  the  five  hours — ten  to 
three — preceding  the  funeral.  All  past  command- 
ers of  Andrew  Jackson  Post  No.  87  of  the  Ameri- 
can Legion  gathered  with  other  Legionnaires  at  the 
Burrus  home  at  three  o'clock  to  pay  final  tribute. 
All  stores  in  his  city  were  closed  for  the  hour  of 
his  funeral. 

Trustees  of  Burrus  Memorial  Hospital  and  all 
members  of  the  medical  profession  who  attended  the 
services  were  honorary  pallbearers.  His  medical 
associates  at  the  hospital,  Drs.  H.  L.  Brockmann, 
P.  W.  Flagge,  Emmett  A.  Sumner,  O.  B.  Bonner, 
E.  F.  Long,*  S.  S.  Saunders  and  Kenneth  Geddie 
and  another  member  of  the  hospital  staff,  Mr.  John 
Long,  were  active  pallbearers. 


writing    came    news   of   the 


Co-ordination   of  Private  Practice  and  Preventive 

MEmCINE 

(W.  W.  Bauer,  C^hicago.  in  Jl.  Fla.  Med.  Assn.,  June) 
The  doctor  has  been  a  health  educator  ever  since  there 
were  doctors.  The  family  doctor  encouraged  his  patients 
to  keep  in  constant  and  friendly  touch  with  him  and  to 
confide  in  him  matters  touching  on  their  health.  His  re- 
lationship was  informal  but  effective.  Even  in  the  face  of 
official  endorsement  of  the  periodic  health  examination  by 
a  number  of  organizations,  including  the  A.  M.  A.,  there 
are  many  who  hold  that  the  more  intimate  relations  be- 
tween the  family  doctor  and  his  patients  were  more  desir- 
able and  effective  than  are  the  practices  that  are  advocated 
today. 

The  physician  as  a  health  educator  discharges  his  func- 
tions for  the  most  part  satisfactorily.  There  are  physicians 
who  hold  that  the  less  the  patient  knows  the  better  off  the 
patient  will  be.  There  are  some  patients  concerning  whom 
this  is  a  fact  beyond  dispute.  Some  individuals  seize  on 
every  bit  of  health  information  and  convert  it  into  mate- 
rial for  controversy  with  the  doctor  or  for  a  state  of 
neurasthenia. 

The  person  with  a  noncommunicable  disease  must  be 
handled  as  an  individual  patient.  The  mass  methods  often 
adopted  in  clinics  for  physical  examinations  and  immuniza- 
tions are  contrary  to  the  training  of  the  physician  and  to 
his  proved  practice.  He  knows  that  the  best  work  for  the 
patient  cannot  be  done  that  way.  In  spite  of  that  convic- 
tion, physicians  have  been  hberal  in  their  co-operation  with 
projects  of  this  character,  giving  their  services  often  as 
individuals  and  as  county  societies,  because  they  have  con- 
ceded that  some  good  might  come  ^f  the  educational  effects 
of  mass  movements,  which  have  their  peculiar  stimulatmg 
effect  on  the  public  mind.  The  physicians,  however,  have 
been  disappointed  because  they  have  seen  undesired  though 
not  unexpected  results  come  out  of  mass  methods.  Parents 
of  children  examined  in  a  group  clinic  are  often  misled  as 
to  what  constitutes  a  real  examination.  Certificates  of 
good  health  have  been  issued  to  children  who  were  later 
discovered  to  have  more  or  less  serious  disease  conditions 
discoverable  by  more  careful  examination.  Such  experi- 
ences tend  to  discredit  public  health  work,  create  distrust 


402  SOUTHERN  MEDICINE  AND  SURGERY 


July, 


of  medical  science  m  the  mmds  of  the  pubUc,  drive  the  things  have  been  done  in  the  wrong  way.  For  example, 
people  to  quadis  and  fakers,  and  are  detrimental  to  the  there  is  grave  doubt  in  the  minds  of  many  experienced 
pubhc  health.  Witliout  denymg  that  something  has  been  pubUc  health  workers,  as  well  as  practicing  physicians 
accomphihed  by  mass  methods,  especiaUy  in  calling  atten-  whether  or  elaborate  systems  of  getting  corrections  of 
tion  to  opportunities  for  better  health,  the  medical  profes-  physical  defects  in  school  children  are  effective  and  ecn- 
sion  holds  that  better  results  could  have  been  accomplished  nomical,  and  what  the  true  values  are  in  a  number  of 
by  methods  more  sound,  if  less  rapid.  other  health  activities.  We  were  rushed,  not  too  many 
There  has  been  too  much  haste  in  public  health  work  at  \-ear5  ago  into  a  frantic  hurry-  to  stimulate  toothbrush 
certain  times  and  in  certam  places.  The  entirely  commend-  drills  m  our  schools,  and  we  went  so  far  as  to  furnish 
able  urge  to  meet  a  need  which  appears  to  be  urgent,  or  toothbrushes  on  the  theory  that  a  clean  tooth  never  decays. 
the  desire  to  emulate  another  community  in  which  certain  But  they  did  decay,  and  we  had  our  attention  called  to 
activities  are  being  carried  on,  or  pressure  from  intJuential  persons  who  never  used  a  toothbrush  except  to  clean  the 
lay  groups,  or  the  occasional  ambition  to  make  a  personal  silvenvare  and  had  perfect  teeth.  If  we  had  waited  a  little, 
record,  have  hurried  communities  into  activities  which  they  we  would  have  emphasized  the  toothbrush  in  a  sane  man- 
could  not  afford,  and  which  in  due  course  collapsed.  Some-  ner  as  we  do  now,  and  put  more  emphasis  on  diet,  and 
times  the  building  up  of  activities  for  which  no  real  need  above  all,  we  would  have  acknowledged  that  we  do  not 
existed  has  been  encouraged;  necessary  and  commendable  (Continued  on  page  410) 

WHQ^S  WHO 

4,  _  ■ 

*  in  Central-  and  East-Europe 

*  Edited  by  STEPHEN  TA\T.OR,  R.  P.  D. 
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*  It  contains  about   10,000  authentic  biographies  of   prominent   people   from  seventeen   countries: 

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*  Regular  edition  (clotli  binding)  $20. 
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t                                              I 

t                  I 


July,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Eli  Lilly  and  Company 

FOUNDED     1876 

^Makers  of  ^Medicinal  Products 


THE    TIME    ELEMENT 

in  the  Jreatment  of  Burns 

'Amertan'CTannic  Acid  Jelly,  Lilly)  frequently  provides 
the  saving  of  time  which  saves  life  in  the  treatment  of 
extensive  bums.  When  promptly  applied,  Amertan 
seals  off  the  damaged  tissues  with  a  dense  protective 
eschar  and  conserves  the  body  fluids  which  are  so  vital 
to  the  recovery  of  the  patient.  » When  bums  are  minor, 

'Amertan' saves  time  in  a  different  sense,  because  of  its 
ease  of  application  and  the  facility  with  which  the  pa- 
tient is  subsequently  cared  for.  »'Amertan  is  ready  for 
use  at  all  times  and  should  be  kept  on  hand  in  either  the 
5-ounce  tubes  or  the  pound  jars  in  which  it  is  supplied. 


Prompt  Attention  Qiven  to  Projessional  Jncfuiries 

PRINCIPAL    OFFICES    AND    LABORATORIES,    INDIANAPOLIS,    INDIANA,    U.S.A. 


Please  Mention  THIS  JOURNAL  When  Writing  to  Advertisers 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


BOOK  REVIEWS 


THE  EYE  AND  ITS  DISEASES,  by  82  International 
Authorities.  Edited  by  Conrad  Berens,  M.D.,  Ophthalmic 
Surgeon,  Pathologist  and  Director  of  Research,  New  York 
Eye  and  Ear  Iniirmary;  Special  Consulting  Ophthalmolo- 
gist, Woman's  Hospital;  Consulting  Ophthalmologist,  Vet- 
erans Administration  Facility,  New  Yorlc;  Lecturer  in  Oph- 
thalmology, New  York  Eye  and  Ear  Infirmary;  Member 
of  American  Board  of  Ophthalmology;  Member  of  the  So- 
ciety of  Surgeons  of  Paris;  Lieut.-Col.,  M.  R.  C,  U.  S. 
Army.  1254  pages  with  436  illustrations,  some  in  colors. 
Philadelphia  and  London:  W.  B.  Saunders  Company,  1936. 
Cloth,  $12.00  net. 

Giving  only  a  few  of  the  divisions  of  the  subject 
will  indicate  the  general  usefulness  of  the  book. 
Take,  for  example:  Physiology  and  Physiologic 
Optics;  Examination  of  the  Eye — by  the  various 
methods,  all  plainly  and  minutely  described;  Re- 
fraction and  Accommodation — made  plain;  Hered- 
ity— as  an  etiologic  factor;  Glaucoma,  and  Sympa- 
thetic Ophthalmitis — subjects  for  which  all  of  us 
need  to  be  kept  informed;  Toxic  Amblyopia  and 
Medical  Ophthalmology  and  Ocular  Syphilis — all 
important  to  all  doctors;  Injuries  to  the  Eye — that 
all  doctors  have  to  treat;  and  Preventive  Ophthal- 
mology. The  specialist  will  find  the  successive 
steps  of  operations  on  the  various  eye  structures 
clearly  described. 

The  four-score  and  two  eminent  men  who  have 
put  out  this  work  for  undergraduate  and  postgrad- 
uate students  of  medicine  have  succeeded  remark- 
ably in  presenting  the  things  needful  to  be  known 
about  the  eye  and  its  diseases  without  wandering 
into  the  bypaths.  The  temptation  to  say  too  much, 
to  which  so  many  investigators  in  special  fields 
yield,  has  been  firmly  withstood,  and  the  result  is 
an  excellent  volume  of  valuable  instruction  for  the 
student  in  college  and  the  practitioner  of  general 
medicine,  and  a  handy  help  in  difficult  cases  for 
the  specialist,  including  the  ophthalmologist. 


MINOR  SURGERY,  by  Frederick  Christopher,  S.B., 
M.D.,  F.A.C.S.,  Associate  Profesor  of  Surgery  at  the  North- 
western University  Medical  School,  Chicago;  Chief  Surgeon 
at  the  Evanston  (lU.)  Hospital.  With  a  foreword  by 
Allen  B.  Kanavel,  M.D.,  F.A.C.S.,  Professor  of  Surgery 
at  the  Northwestern  University  Medical  School.  Third 
Edition,  Reset.  1030  pages  with  709  illustrations.  Phila- 
delphia and  London:  W.  B.  Saunders  Company,  1936. 
Cloth,  $10.00  net. 

The  great  increase  in  the  number  and  variety  of 
accidents  in  the  past  few  years  has  made  surgery — 
minor  and  major — of  more  and  more  importance 
ing  the  practice  of  medicine.  While  the  dividing  line 
between  minor  and  major  surgery  can  not  be 
drawn  sharply,  all  of  us  have  a  good  working  idea 
as  to  what  falls  within  the  realm  of  minor  surgery, 
and  all  these  subjects  will  be  found  adequately  dealt 
with  in  this  treatise. 


EXOPHTHALMIC  GOITER  AND  ITS  MEDICAL 
TREATMENT,  by  Israel  Bram,  M.D.,  Medical  Director, 
Bram  Institute  for  the  Treatment  of  Goiter  and  other  Dis- 
eases of  the  Ductless  Glands,  Upland,  Pa.;  Formerly  In- 
structor in  Clinical  Medicine,  Jefferson  Medical  College, 
Philadelphia;  Member  of  the  Association  for  the  Study  of 
Internal  Secretions,  The  American  Association  for  the  Study 
of  Goiter,  etc.;  Foreword  by  R.  G.  Hoskins,  Ph.D.,  M.D., 
Director  of  Research,  Memorial  Foundation  for  Neuro- 
endocrine Research,  Harvard  Medical  School,  Boston.  2nd 
edition  completely  revised  and  enlarged;  with  79  illustra- 
tions.    C.  V.  Mosby  Co.,  St.  Louis.     1936.     $6.00. 

The  foreword  says  that  the  book  is  written  from 
the  point  of  view  of  one  who  believes  that  Graves' 
disease  is  a  malady  that  can  most  successfully  be 
treated  by  medical,  psychotherapeutic  and  hygienic 
measures,  and  that  this  belief  is  founded  on  a  large 
experience  of  more  than  20  years  of  specialized  at- 
tention to  the  disease. 

In  a  series  of  5,000  cases  of  exophthalmic  goiter 
observed  by  the  author  90%  presented  a  clear  his- 
tory of  psychic  trauma  which  appeared  to  bear  a 
significant  relationship  to  development  of  the  dis- 
ease. In  many  cases  the  thyroid  is  not  enlarged 
and  in  some  there  is  no  exophthalmos.  There  is  no 
active  Graves'  syndrome  without  heart  symptoms. 
Behavior  changes  may  approach  a  psychotic  state. 
We  are  told  that  almost  invariably  patients  who 
faithfully  cooperate  with  a  properly  equipped  in- 
ternist get  well.  Under  prevention,  the  author 
quotes  a  magnificent  passage  from  the  p)en  of  James 
K.  Hall  on  the  ascription  to  environment  of  causa- 
tive influence,  with  only  the  vaguest  idea  of  what 
the  word  connotes. 

All  that  goes  to  make  up  proper  child  rearing, 
correction  of  faulty  habits  that  crop  out,  instruction 
and  exercise  in  mental  hygiene — all  these  with  spe- 
cial care  toward  those  predisposed — constitute  the 
ground-work  of  prevention;  and  curative  medical 
treatment  is  much  more  than  prescribing  rest  and 
iodine. 

Whether  or  not  you  can  go  all  the  way  with  the 
author,  whatever  may  be  your  division  of  the  field 
of  Medicine,  you  will  do  well  to  purchase  and  study 
this  book. 


FRIGIDITY  IN  WOMEN:  Its  Characteristics  and 
Treatment,  by  Dr.  Eduard  Hitschmann  and  Dr.  EDMtniD 
Bercler,  Director  and  Assistant  Director,  respectively,  of 
the  Psychoanalytic  Clinic  in  Vienna.  Authorized  Transla- 
tion by  Polly  Leeds  Weil  of  New  York.  Nervous  and 
Mental  Disease  Publishing  Co.,  Washington  and  New  York. 
1936. 

This  booklet  treats  of  the  development  and  char- 
acteristics of  female  sexuality  and  then  leads  up  to 
the  main  subject.  Female  ligidity  is  regarded  as 
psychical  and  the  authors  are  optimistic  as  to 
cure.  Two  cases  are  presented  as  cured  by  psycho- 
analysis. The  final  chapter  is  on  prevention  and 
treatment. 


July,  19o6 


SOUTHERN  MEDICINE  AND  SURGERY 


SYNOPSIS  OF  DISEASES  OF  THE  HEART  AND 
ARTERIES,  by  George  R.  HERRiiANN,  M.D.,  Ph.D.,  Pro- 
fessor of  Clinical  Medicine.  University  of  Texas;  member 
Association  of  American  Physicians,  American  Climatologi- 
cal  and  Clinical  Association,  American  Society  for  Clinical 
Investigation,  American  Society  for  E.xperimental  Pathology 
and  the  Society  for  Experimental  Biology  and  Medicine 
Fellow  American  Association  for  the  Advancement  of 
Science,  American  College  of  Physicians  and  the  American 
Heart  Association;  Membro  Correspondiente  Extrajero  De 
La  Sociedad  Mexicana  De  Cardiologia.  With  SS  text  illus- 
trations and  3  color  plates.  C.  V.  Mosby  Co.,  St.  Louis. 
1936.     S-t.OO. 

A  book  which  contains  the  essential  facts  about 
diseases  of  the  heart  and  arteries  that  a  doctor 
needs  to  have  in  his  head  as  he  goes  about  his  daily 
practice.  Methods  applicable  in  the  home  and  office 
without  elaborate  equipment  are  emphasized  and 
represented  to  be  adequate  in  the  great  majority  of 
cases. 


NEWS  ITEMS 


THE  1035  YEAR  BOOK  OF  NEUROLOGY,  PSYCH- 
IATRY ANT)  ENTDOCRINOLOGY. 

NEUROLOGY,  edited  by  Hans  H.  Reese,  M.D.,  Pro- 
fessor of  Neurology  and  Psychiatry,  University  of  Wiscon- 
sin Medical  School. 

PSYCHI.\TRY,  edited  by  Harry  A.  Pasking,  M.D.,  As- 
sistant Professor  of  Nervous  and  Mental  Diseases,  North- 
western University  Medical  School;  Attending  Neurologist, 
Evanston  Hospital ;  Associate  .\ttending  Neurologist,  Mich- 
ael Reese  Hospital. 

ENDOCRINOLOGY,  edited  by  Euvier  L.  Serejghaus, 
M.D.,  Associate  Professor  of  Medicine,  University  of  Wis- 
consin Medical  School.  Tlie  Year  Book  Publishers,  Inc., 
304  S.  Dearborn  St.,  Chicago.    1936.    $3.00. 

Developments  of  consequence  in  these  fields  in 
the  year  1935  are  quite  well  presented.  Samples 
arresting  the  attention  are:  treatment  of  cerebral 
hemorrhage  by  withdrawing  blood  from  a  vein  of 
the  patient  and  injecting  it  in  his  opposite  gluteal 
region;  pneumocranium  for  headache;  satisfactory 
treatment  of  chorea  with  typhoid-paratyphoid  vac- 
cine; epilepsy  following  roentgen  irradiation  of  the 
head  in  childhood;  luminal  as  the  most  useful  drug 
in  all  tv'pes  of  migraine;  continuous  gastric  aspira- 
tion in  cases  of  bromide  intoxication;  carbon-diox- 
ide-oxygen mixture  in  acute  alcoholism;  ulcerative 
colitis  is  said  to  be  incurable;  a  review  of  the  cases 
of  28  patients  who  died  within  eight  days  after  the 
onset  of  psychosis;  dinitrophenol  for  dementia  prae- 
cox;  no  correlation  between  amounts  of  alcohol  in 
blood  and  spinal  fluid  and  the  clinical  picture. 

London  investigators  studied  the  width  of  the 
convolutions  of  54  brains  of  mental  defectives  and 
of  eight  normals,  and  found  no  significant  differ- 
ences. Myerson  (Boston)  says  there  is  no  science 
of  eugenics  worth  considering  as  to  prognostication 
of  any  person's  qualities. 

A  useful  section  on  endocrine  therapy  is  included. 
The  pituitary  groups  are  given  the  space  their  im- 
portance demands. 


Buncombe  County  (N.  C.)  Medicu.  Society,  Asheville, 
regular  meeting  held  the  evening  of  June  15th  at  the  City 
Hall  Bldg.,  President  Parker  in  the  chair,  3i  members  pres- 
ent, \Tsitor,  Dr.  E.  P.  Mallette,  Hendersonville. 

Address  by  Dr.  Robert  C.  Scott  on  Important  Diagnostic 
Laboratory  Procedures  in  Anemia,  discussion  by  Dr.  C.  H. 
Cocke. 

Dr.  Crump  asked  about  the  status  of  goats'  milk  offered 
for  sale  in  our  city.  He  made  a  motion  asking  the  society 
to  query  the  City  Health  Officer  in  this  regard  and  report 
back  to  the  society.    Seconded  by  Johnson  and  carried. 

The  matter  of  Helen  Gertrude  Randle  was  brought  up 
by  Dr.  Elias.  After  much  debate  Dr.  Huston  moved  the 
matter  be  referred  to  the  committee  on  public  health  and 
legislation  to  investigate  and  report  back  to  the  society  at 
the  next  meeting.    Seconded  and  carried. 

Dr.  Huston  announced  the  opening  of  the  Asheville  Pre- 
ventorium. The  president  announced  the  next  meeting 
would  be  a  clinical  evening  and  would  be  at  the  Asheville 
Mission  Hospital. 

Buncombe  County'  Medical  Society,  regular  meeting 
at  the  Asheville  Mission  Hospital  the  evening  of  July  6th, 
President  Parker  in  the  chair,  55  members  present. 

Committee  on  Public  Health  and  Legislation,  Dr.  P.  H. 
Ringer,  Chr.,  submitted  a  written  report  on  the  activities 
of  one  Helen  Gertrude  Randle,  who  is  operating  the  so- 
called  Mountain  Health  School  on  Sunset  Mountain.  She 
is  practicing  medicine  without  a  hcense.  The  committee 
urged  our  members  to  get  sworn  affidavits  to  this  effect 
from  patients  under  treatment  there  and  confer  with  the 
committee.  Dr.  Johnson  moved  the  report  as  presented  be 
adopted  and  the  committee  proceed  further.  Seconded  and 
carried. 


Anal-Sed 


Analgesic,   Sedative   and   Antipyretic 

.Affords  relief  in  migraine,  headache,  sciatica  and 
neuralgia.  Rheumatic  symptoms  are  frequently  re- 
lieved by  a  few  doses. 

Description 
Contains   3J/^    grains   of    Amidopyrine,    '/i    grain    of 
Caffeine  Hydrobromide  and  15  grains  of  Potassium 
Bromide  to  the  teaspoonful. 

Dosage 
The  usual  dose  ranges  from  one  to  two  teaspoonfuls 
in  a  httle  water. 

How  Supplied 
In  pints  and  gallons  to  physicians  and  druggists. 


Burwell  &  Dunn  Company 


Manufacturing 
Established 


Pharmacists 
in    1887 


CHARLOTTE,  N.  C. 

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


406 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


AS  AC 

ELIXIR    ASPIRIN    COMPOUND 


Contains  five  grains  of  Aspirin,  two  and  a  half 
grains  of  Sodium  Bromide  and  one-half  grain  Caf- 
feine Hydrobromide  to  the  teaspoonful  in  stable 
Elixir.  ASAC  is  used  for  relief  in  Rheumatism,  Neu- 
ralgia, Tonsillitis,  Headache  and  minor  pre-  and  post- 
operative cases,  especially  the  removal  of  Tonsils. 

Average  Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water  as  prescribed  by  the  physician. 

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


Burwell  &  Dunn  Company 

Manufacturing    ^=^^  Pharmacists 

JJslnhli'ihpil     M^SxM     in     1  RUT 


CHARLOTTE,  N.  C. 

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


Publicity  Committee,  Dr.  K.  E.  Brown,  Chr.,  submitted 
a  written  report  offering  three  recommendations.  After 
much  debate  on  the  recommendations  a  motion  by  Dr. 
Ringer  was  made  to  postpone  the  consideration  of  the  rec- 
ommendations to  the  next  society  meeting  on  July  20th. 
Seconded  and  carried.  Dr.  J.  W.  Williams  made  a  verbal 
report  on  the  status  of  goat  milk  production  in  the  city. 
Matter  received  as  information. 

Under  the  head  of  the  paper  of  the  evening,  the  meeting 
was  turned  over  to  Dr.  W.  P.  Herbert,  Chief-of-Staff  of 
the  Mission  Hospital.  The  program  was;  Tuberculous 
Peritonitis  in  Young  Adult,  Dr.  G.  F.  Parker;  Tuberculosis 

FOR 

PAIN 

The  majority  of  the  phy- 
Blclans  In  the  Carollnaa 
are  preacTibing  our  new 


tablets 


^ANDg 


751 


A„.l,..l.  .nd  8.d.t.v.    7,nar^  pS^PJ^*,,  J^^n 


We  will  mail  professional  samples  regularly 
with  our  compliments  if  you  desire  them. 
Carolina  Pharmaceutical   Co.,   Clinton,  S.  C. 


in  Child  age  2  yrs.,  Dr.  J.  L.  Ward;  Total  Alopecia  in 
Young  Adult,  Dr.  S.  L.  Whitehead;  Chronic  Alcoholism 
with  Pellagra  in  Negro  Boy,  Dr.  W.  R.  Johnson;  Permanent 
Nephrostomy  Drainage,  Dr.  T.  R.  Huffines;  Agranulocyto- 
sis in  Young  Adult  with  recover>',  Dr.  Wilson  Pendleton. 
(Signed)     M.  S.  Broun,  M.D.,  Sec. 


The  American  Board  of  Ophthalmology  announces  the 
removal  of  its  executive  offices  to  Room  1002,  Beaumont 
Medical  Building,  3720  Washington  Boulevard,  St.  Louis, 
Missouri,  John  Green,  M.D.,  Secretary-Treasurer.  All  ap- 
phcations  and  communications  should  be  sent  to  the  above 
address.  All  candidates  expecting  to  appear  for  examina- 
tion in  New  York  City  on  September  26th  must  file  their 
applications  and  ten  case  reports  before  July  2Sth. 


The  Roaring  Gap  Children's  Hospital,  Roaring  Gap, 
North  Carolina,  opened  June  ISth  for  the  1936  season. 
Mothers  may  occupy  room  with  baby  and  may  obtain 
board  in  hospital  at  reasonable  rates.  The  hospital  con- 
tinues under  the  direction  of  Dr.  Leroy  J.  Butler,  Winston- 
Salem.  Dr.  Howard  M.  Starling  is  resident  physician  and 
Mrs.  Etta  Blakley  Bowen,  R.N.,  superintendent. 


Dr.  Alexander  W.  Terrell,  for  SO  years  a  beloved 
practitioner  of  medicine  in  Lynchburg,  Va.,  was  given  a 
testimonial  dinner  by  several  hundred  residents  of  his  "city 
the  evening  of  June  30th.  The  gathering  was  in  the  main 
hall  of  the  Randolph  Macon  Woman's  College,  of  which 
Dr.  Terrell  has  been  resident  physician  for  a  great  many 
vears. 


Dr.  John  J.  Bender  has  completed  his  intemeship  in  a 
Boston'  hospital  and  joined  the  staff  of  the  State  Hospital 
for  the  Negro  Insane  at  Goldsboro  to  fill  the  vacancy  cre- 
ated by  the  resignation  of  Dr.  A.  L.  Allen,  who  has  gone 
to  Chapel  Hill  to  take  a  special  course  in  pubUc  health 
work. 


Dr.  John  A.  Hawkins,  Danville  radiologist,  underwent 
amputation  of  both  feet  in  a  Baltimore  hospital  recently. 
The  operation  was  necessitated  because  of  injuries  suffered 
when  he  burned  his  feet  accidentally  three  months  ago 
with  unslaked  lime  in  the  basement  of  his  home. 


Dr.  Douglas  VanderHoof  and  Dr.  T.  Dewey  Davis,  of 
Richmond,  announce  the  retirement  of  Dr.  VanderHoof  on 
July  1st  from  the  association  of  the  two  in  the  practice  of 
Internal  Medicine  for  the  past  fourteen  years.  Dr.  Davis 
will  continue  practice  in  the  same  offices  with  the  complete 
equipment  and  all  of  the  case  records. 


Dr.  Dougl.\s  V.'UjderHoof  has  been  chosen  Chairman  of 
the  Executive  Committee  of  the  Board  of  Visitors  of  the 
Medical  College  of  Virginia,  it  was  announced  at  that 
institution  recently.  Other  members  of  the  committee  are 
Julien  H.  Hill,  Dr.  Stuart  McGuire,  H.  W.  Ellerson, 
William  R.  Miller,  Eppa  Hunton  4th,  W.  W.  Schwarz- 
schild  and  Dr.  W.  T.  Sanger. 


Dr.    Malcolm    Greer   Stutz   has    opened   an    office   in 
Southern  Pines,  North  Carolina. 


W. ANT ED: 
facilities, 
qualified. 


E.  E.  N.  &  T.  man.  Town  10,000.  Hospital 
Must  have  North  Carolina  license,  and  well 
Good  opening.    Answer  care  this  Journal. 


SOUTHERN  MEDICINE  AND  SURGERY  407 

PRACTUREf 

SPRAINS 

STRAINS 

u  HYSICAL  treatment  is  an  essential  procedure  in  the 
treatment  of  injured  tissues  following  fractures,  sprains 
and  strains. 

Foremost  on  the  list  of  topical  thermic  agents  is 
Antiphlogistine.  Its  use  aids  in  the  disappearance  of 
swelling,  in  the  relief  of  pain  and  muscular  spasm 
and  it  helps  to  improve  the  range  of  movement. 

ANKYLOflS 

Its  use,  also,  is  indicated  preceding  and  following 
manipulation  of  a  joint,  as  it  aids  considerably  in 
relaxing  the  tissues  and  in  overcoming  any  inflam- 
matory reaction.  It  is  a  valuable  adjunct  following 
physiotherapy. 


ANTIPHLOGISTINE 

Sample  on  request 


The  Denver  Chemical 
Man'f'g  Company 

163  Varick  Street 
New  York,  N.  Y. 


408 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


Announcement  of  three  changes  on  the  medical  staff  of 
the  South  Carolina  tate  Hospital,  to  be  effected  in  the  near 
future  or  already  brought  about,  was  made  by  Dr.  C.  Fred 
Williams,  superintendent. 

Three  new  men,  Drs.  William  M.  Fox  of  Wagener,  G.  B. 
Frey  of  Spartanburg  and  R.  S.  Matthews,  who  recently 
completed  an  intemeship  at  Roper  Hospital,  Charleston, 
will  join  the  staff,  filling  vacancies  made  by  the  death  of 
Dr.  J.  M.  Austin  and  the  resignations  of  Dr.  James  E. 
Boone  and  Dr.  G.  R.  Westrobe.  The  three  new  men  are 
graduates  of  the  State  Medical  College  in  Charleston, 
having  had  var\'ing  degrees  of  experience  and  come  to 
the  institution  highly  recommended.  Doctor  Boone,  who 
has  been  on  the  medical  staff  at  the  hospital  since  June, 
1917,  resigns  his  position  as  senior  physician  and  urologist 
to  enter  the  practice  of  urology  in  Columbia,  and  will 
open  private  offices  this  week.  Doctor  Westrobe  has  gone 
to  Gaffney  as  director  of  pubUc  health  work. 

Radium  is  not  a  very  rare  element.  Dr.  Robert  B.  Taft, 
faculty  member  of  the  Medical  College,  told  members  of 
the  Kiwanis  Club  in  Charleston  during  the  weekly  lunch- 
eon at  the  Fort  Sumter  Hotel.  Speaking  on  a  few  salient 
points  of  radium.  Dr.  Taft  said  it  is  probably  one  of  the 
least  known  materials  in  everyday  life  and  explained  how 
its  penetrating  rays  are  being  employed  to  battle  cancer, 
pointing  out  that  the  rays  destroy  undesirable  cells  and 
tissues. 

Dr.  Louis  Mazzotti,  of  Mexico  City,  was  a  recent  visitor 
in  Charleston  inspecting  the  local  health  department.  Dr. 
Mazzotti,  who  has  just  completed  a  year's  study  at  Johns 
Hopkins,  visited  the  rural  white  well  baby  clinic,  the 
rural  negro  midwife  class,  the  city  negro  toxoid  clinic,  the 
city  white  well  baby  clinic  and  the  Pasteur  treatment  clinic. 
Dr.  Mazzotti  praised  the  department  after  the  inspection 
and  commended  the  city  for  having  Dr.  Banov  as  its  health 
director. 

The  Coastal  Medical  Society  of  S.  C.  met  at  Walterboro 
June  18th;  the  program — Ringworm  Infections,  Dr.  John 
van  de  Erve;  The  Maternal-Child-Health  Program  in  South 
Carolina,  Dr.  Wilson  Ball;  Traumatic  Surgerj'  of  the  Ex- 
tremities, motion  pictures.  Dr.  G.  Carroll  Brown;  election 
of  officers. 


MARRIED 

Dr.  Claude  A.  Nunnally,  of  Richmond,  and  Mrs.  Emma 
Lawless  Smith,  of  Fredericksburg,  were  married  on  July 
1st  at  Fredericksburg. 

Miss  Mildred  Field  King,  of  Jackson  Heights,  Long  Is- 
land, and  Dr.  Franklin  Stafford  Wearn,  son  of  William  R. 
Wearn  and  the  late  Mrs.  Wearn  of  Charlotte,  June  27th. 
Dr.  Wearn  is  a  graduate  of  Davidson  College  and  the 
Harvard  Medical  School.  On  their  return  the  young  cou- 
ple will  be  at  Point  o'Woods,  Long  Island,  for  the  summer 
months  where  Dr.  Wearn  will  be  the  resident  physician. 
In  the  fall  they  will  make  their  home  at  35-41  76th  Street, 
Jackson  Heights. 

Miss  Marguerite  Mason,  of  Durham,  North  Carolina, 
and  Dr.  Robert  Wilkins  were  married  on  June  27th  at 
Durham. 

Dr.  Alexander  Lewis  Bassin,  of  Baltimore,  was  married 
on  June  9th  to  Miss  Mildred  Emma  Zinn,  of  Myerstown, 
Pennsylvania.  Dr.  Bassin  practices  his  profession  in  Myers- 
town. 

Dr.  Vernard  August  Benn,  Medford,  Wisconsin,  and 
Miss  Mar>'  Bryan  Vaughan,  Rocky  Mount,  North  Caro- 
lina, were  married  in  Richmond  on  June  30th. 

Dr.  Roger  Irving  Wall,  Raleigh,  North  Carolina,  and 
Miss  Olsen  Stier,  New  Orleans,  Louisiana,  were  married  on 
June  17th  at  the  home  of  the  latter. 


Dr.  James  Hampton  Byerly,  of  Sanford,  North  Carolina, 
and  Alameda,  California,  and  Miss  Aileen  Marie  AUridge, 
of  Oakland,  California,  were  married  in  the  latter  city.  May 
30th. 

Dr.  Douglas  Nathaniel  West,  Ann  .Arbor,  Michigan,  and 
Miss  Sarah  Male  Clark,  Elizabethtown,  North  Carolina, 
were  married  in  the  home  of  the  bride  on  June  6th. 

Dr.  Guy  Winston  Horsley,  of  Richmond,  and  Miss  May 
Clare  Wright,  of  Petersburg,  were  married  on  June  10th. 

Dr.  Herman  Keith  Herrin,  of  Cerro  Gordo,  and  Miss 
Helen  Thelma  Cherry,  of  Greenville,  North  Carolina,  were 
married  on  .April  29th,  in  Dillon,  South  Carolina. 

Deaths 

Dr.  H.  O.  Averitt,  of  Cumberland  County,  dropped  dead 
in  his  home  at  Cedar  Creek,  June  29th.  Quietly  stating 
that  he  felt  ill.  Dr.  Averitt  excused  himself  from  several 
patients  and  went  to  the  back  of  the  house.  When  he 
failed  to  return  after  a  reasonable  time,  his  mother  was 
summoned,  and  she  found  him  dead.  Dr.  Averitt  last 
September  succeeded  to  the  practice  of  his  father.  Dr. 
K.  G.  Averitt,  who  was  one  of  the  foremost  country  doctors 
of  North  Carolina. 


Dr.   Thomas   P.   Darracott,   M.    C.   V.    '85,   died   at   his 
home,  Tunstall,  Virginia,  on  June  26th. 


Dr.  Richard  Gregory  Rozier  died  at  Lumberton,  North 
Carolina,  at  the  age  of  67  years,  on  July  1st. 


Oiir  Medical  Schools 


Wake  Forest 


.At  the  meeting  of  the  Board  of  Trustees  on  June  1st, 
enlargement  of  the  Library  was  authorized  and  Mrs.  Mar- 
garet R.  Cardwell,  jr.,  elected  Librarian.  Mrs.  Cardwell 
received  the  A.B.  degree  from  Smith  College  and  the  A.B. 
degree  in  Library  Science  from  the  University  of  North 
Carolina.  She  has  had  six  years'  experience  in  Library 
work. 

Herbert  C.  Tidwell,  Ph.D.,  was  elected  Grier  Research 
Professor  of  Biochemi5tr\'.  This  professorship  is  supported 
by  a  grant  from  Dr.  G.  Layton  Grier  of  Milford,  Delaware. 
Dr.  Tidwell  received  the  A.B.  and  M..A.  degrees  from  Bay- 
lor University  in  1919;  Ph.D.  Johns  Hopkins  1930;  Instruc- 
tor in  Pediatrics  Johns  Hopkins  University  1930-35;  In- 
structor in  Biochemistry  Duke  University  1935-36.  He  has 
contributed  the  following  publications  to  the  Medical  Lit- 
erature: 

Vapor  Phase  Esterification  in  the  Presence  of  SiUca  Gel. 
With  Reid.    /.  Amer.  Chem.  Soc,  Si,  4353.     (1931). 

Studies  on  Fat  Metabolism  in  Infants.  With  Holt  et  al. 
Acta  Paediatrica,  16,  165.     (1933). 

A  Simple  Method  for  Production  of  Vitamin-D  Milk  of 
Known  and  Controllable  Potency.  With  Shelling.  Proc. 
of  Soc.  for  Exptl.  Biol,  and  Med.,  31,  605.     (1934). 

Studies  in  Fat  Metabolism.  1.  Fat  Absorption  in  Infanta. 
With  Holt  ct  al.    J.  of  Pediatrics,  6,  427.     (1935). 

Studies  in  Fat  Metabolism.  2.  Fat  Absorption  in  Pre- 
matures and  Twins.  With  Holt  et  al.  J.  of  Pediatrics,  6, 
481.     (1935). 

Intravenous  .Administration  of  Fat.  With  Holt  et  al. 
J.  of  Pediatrics,  b,\S\.     (1936). 

Liver  Function  as  Tested  by  the  Lipemic  Curve  after 
Intravenous  Administration  of  Fat.  With  Nachlas  et  al. 
.1.  C'in.  Invest.,  15,  143. 

The  Estimation  of  the  Total  Lipids  and  the  Lipid  Par- 


July,  1036 


SOUTHERN  MEDICINE  AND  SURGERY 


409 


tition  in  Feces.  With  Holt.  J.  Biol.  Ctieni.,  112,  60S. 
(1936). 

Robert  Page  Morehead,  B.A.,  M.A.,  M.D.,  was  elected 
Instructor  in  Pathology.  Dr.  Morehead  received  his  M.D. 
degree  from  Jefferson  Medical  College  and  is  at  present 
connected  with  the  Department  of  Pathology  of  the  Phila- 
delphia General  Hospital. 

Dr.  E.  S.  King,  Professor  of  Bacteriology,  was  granted  a 
leave  of  absence.  In  September  he  will  go  to  Harvard 
Medical  School  where  he  will  serve  as  a  volunteer  teacher 
in  Bacteriology. 

Dr.  George  C.  Mackie,  Professor  of  Physiology,  will  take 
post-graduate  work  in  Edinburgh  University  during  the 
summer. 

Dr.  C.  C.  Carpenter,  Professor  of  Pathology  since  1926, 
was  elected  Dean  of  the  School. 


University  of  North  Carolina 


The  University  has  graduated  its  first  regular  class  of 
public  health  officers — 43  of  the  SI  who  enrolled  last  spring 
after  the  University's  newly  created  division  of  Public 
Health  Service  as  the  center  for  the  training  of  health  offi- 
cers for  Interstate  Sanitary  District  No.  2,  extending  from 
Delaware  to  Florida. 

These  graduates — 36  of  whom  already  had  degrees  in 
medicine  or  engineering — represent  Delaware,  Maryland, 
Virginia,  North  Carolina,  South  Carolina,  Georgia,  Florida 
and  the  District  of  Columbia. 

These  first  diplomas  bear  the  names  of  President  Frank 
P.  Graham,  Dr.  Milton  J.  Roseman,  director  of  the  Public 
Health  Division;  Dr.  Carl  V.  Reynolds,  secretary  of  the 
State  Board  of  Health,  and  Dean  Charles  S.  Mangum  of 
the  University  Medical  School. 

For  the  next  month  the  graduates  will  get  practical  ex- 
perience in  field  work  under  the  direction  of  Dr.  W.  P. 
Richardson  of  the  Orange-Person  Health  Department. 


Paranoid  Deviation 


The  paranoid  state  of  mind  in  adults  may  be  defined  as 
"of  himself,  excusatory;  of  others,  accusatory,"  when  things 
go  wrong. 

When  normally  evolving  children  reach  the  mental  age 
of  9J/2  years,  they  usually  show  a  paranoid  attitude.  They 
do  not  want  their  mistakes,  especially  their  errors  of  omis- 
sion, noted  or  commented  upon.  They  are  approaching 
the  age  when  they  want  recognition  or  merit  badges  for 
the  things  they  do  well. 

The  paranoid  person  cannot  see  his  personality  defect 
even  when  it  is  pointed  out  to  him  by  others.  That  is 
why  paranoid  deviation  is  not  self-correctable. 

When  one  finds  a  person  who  spends  a  lifetime  "perfect- 
ing an  invention,"  or  who  by  type  and  the  code  "proves" 
Bacon  wrote  Shakespeare,  or  that  God  said  ...  or  who 
painstakingly  engraves  the  Lord's  prayer  on  the  head  of 
a  pin,  then  one  finds  a  self-disclosed  paranoid  personality. 
Some  of  these  do  a  wonderful  amount  of  good  in  the 
world,  and  some,  especially  the  anti-this  or  the  anti-that 
reformers,  do  a  tragic  amount  of  harm,  starting  wars  or 
schisms. 

Some  become  addicted  to  drugs  or  other  hurtful  prac- 
tices. Some  start  borderline  crazy  schools  of  thought  in 
religion  or  in  economics  and  convince  less  paranoid  but 
equally  psychopathic  followers  who  are  chronically  dissat- 
isfied. 

Insane  paranoids  have  graduated  from  ideas  that  other 


persons  are  jealous  of  them  into  the  delusional  belief  that 
other  persons  persecute  them. 

Paranoids'  actions,  if  socially  valuable,  are  good;  bad  if 
the  paranoid  individual  is  bitter  and  anti-social  in  his  pro- 
gram, for  under  such  circumstances  he  is  implacable. 

They  are  sanctimonious  quarrelers  who  cannot  change. 
They  talk  plausibly,  and  much  of  what  they  say  is  true. 

If  a  paranoid  is  bothersome,  it  is  advisable  that  he  be 
diagnosed  as  paranoid  psychopathic  or  psychotic,  and  after 
the  diagnosis  has  been  publicized,  he  should  be  allowed  to 
drift.  Paranoids  who  are  held  in  a  fixed  environment 
become  more  and  more  bitter  and  thus  become  dangerous 
to  those  whom  they  accuse  of  persecution.  Let  them  drift. 
If  a  paranoid  becomes  menacing,  then  he  must  be  institu- 
tionalized until  in  senility  his  paranoid  ideas  lose  their 
"voltage." 

Ordinary  people,  lonesome,  seclusive  and  relatively  non- 
successful,  may,  if  sickened  with  some  toxic  or  poisonous 
condition  when  33,  34  or  35,  or  so  years  old  have  a  para- 
noid state  lasting  a  few  months  or  years  recover  mentally 
after  ^physical  recovery. 

Paranoids  who  are  more  than  a  menace  are  assassins, 
character  assassins  or  reputation  assassins.  They  should  not 
be  allowed  freedom  to  travel,  to  be  in  public,  or  to  use 
the  mails.  Probation  or  later  parole  are  not  to  be  consid- 
ered; either  would  be  misconstrued  as  a  mixture  of  ap- 
proval and  license. 

In  repeating  their  crimes,  each  paranoid  always  follows 
the  pattern  of  his  preceding  crime,  bizarre  as  that  pattern 
may  be. 

Paranoid  variety  of  senile  dementia,  of  course,  occurs 
late  in  life;  there  may  or  may  not  have  been  a  lifetime  of 
antecedent  eccentricities. 

Paranoid  deviation  is  associated  with  an  insufficiency  of 
brain  cells,  which  although  usually  hereditary,  may  be 
from  congenital  hypoplasia,  or  it  may  be  from  destruction 
of  brain  tissue. 

A  few  of  them  become  character  assassins  or  reputation 
assassins;  only  a  very  few  become  insane,  and  of  these  a 
very,  very  few  become  criminal  in  action.  The  tendency  is 
to  get  worse;  they  cannot  improve. 

Paranoid  criminals  and  paranoid  insane  should  be  per- 
manently institutionalized,  and  not  be  paroled  until  they 
have  become  so  senile  that  they  have  no  vigor  to  execute 
their  ideas. 


A  GROUP  OF  100  white  women  patients  with  pulmon- 
ary tuberculosis  is  studied  (C.  J.  Stringer,  Detroit,  in 
Med.  Times  &  L.  I.  Med.  Jl.,  June). 

The  percentages  at  the  time  of  admission  to  the  sanato- 
rium were  53%  far  advanced,  43%  moderately  advanced, 
and  4%  minimal;  50%  were  not  diagnosed  by  the  physician 
who  first  treated  them. 

The  early  symptoms  in  the  order  of  their  frequency  of 
occurrence  as  an  initial  symptom  were:  Cough,  25%; 
fatigue,  23;  head  colds,  21;  dry  pleurisy,  IS;  hemoptysis, 
5;  weight  loss,  3;  pleurisy  with  effusion,  2;  expectoration, 
1;  hoarseness,  1;  night  sweats,  1. 


The  Use  of  Oxidizing  Agents  in  the  Treatment  of 

Vincent's  Infection 

(D.  C.  Lyons,  Jackson.  Mich.,  in  Clin.  Med.  &  Surg.,  June) 

The  mouth  is  thoroughly  cleansed,  without  vigorous  in- 
strumentation; removal  of  all  tartar;  removal  or  correc- 
tion of  overhanging  fillings  and  faulty  dental  restorations; 
elimination  of  all  local  irritations;  application  of  the  medi- 
cament— cerous-ceric  chromate  5-7%  solution — to  the 
depths  of  the  pockets,  undiluted  by  mouth  secretions;  it  is 
very  important  that  sloughs  be  first  removed. 


410 


SOUTHERN  MEDICINE  AND  SURGERY 


July,  1936 


(Continued  from  page  402) 
know  all  about  it  yet.  Doctors  who  pointed  out  these 
possibilities  some  years  ago  were  pilloried  as  obstructionists. 
Today  we  face  a  great  potential  expansion  in  public  health 
work  under  Social  Security  legislation.  Doctors  are  ready 
to  co-operate  in  all  wise  measures  under  the  Act,  but  would 
undoubtedly  be  found  opposing  were  expansion  for  its  own 
sake. 

We  must  recognize  that  many  communities  are  not  ready 
for  full-time  health  service,  and  that  they  could  not  be 
supplied  with  competent  personnel  if  they  were. 

The  public  health  movement  largely  emanating  from  the 
medical  profession.  And,  in  the  larger  sense,  it  has  de- 
pended upon  the  physicians  for  its  application. 

"The  program  that  has  been  inaugurated  in  Detroit," 
Geib  and  Vaughan  emphasize,  "has  1)  secured  the  protec- 
tion of  70%  of  preschool  children  and  80%  of  school  chil- 
dren against  diphtheria,  without  the  use  of  free  clinics;  2) 
reduced  the  diphtheria  death  rate  to  }i  of  the  level  existing 
prior  to  the  beginning  of  the  campaign ;  3 )  provided  for 
postgraduate  conferences  on  communicable  disease  control ; 
4)  completely  changed  the  attitude  of  the  medical  profes- 
sion toward  the  work  of  the  health  department  and,  more 
especially,  eliminated  the  antagonistic  feeling  that  has  fre- 


quently existed  toward  the  work  of  the  public  health  nurse ; 
5)  stimulated  parental  responsibility  for  the  care  of  the 
child;  6)  provided  compensation  to  physicians  for  service 
rendered  to  the  indigent;  7)  actually  served  as  a  beginning 
to  make  a  health  center  of  the  offices  of  each  physician, 
and  8)  offered  an  opportunity  to  expand  the  program  of 
health  conservation  with  medical  co-operation  into  other 
lields,  such  as  tuberculosis  and  cancer  control,  periodic 
physical  examinations,  and  the  health  of  mothers  and  in- 
fants." 

Doctors  have  always  consistently  protected  constructive 
legislation,  and  have  as  consistently  opposed  unwise  legis- 
lation affecting  the  public  health.  It  is  important  that  the 
tried  and  tested  ethical  principles  of  the  profession  shall 
not  be  sacrificed  for  the  sake  of  spurious  advantages  in 
health  education.  It  is  important  that  the  personal  rela- 
tionship between  doctor  and  patient  be  emphasized  and 
maintained.  All  this  requires  the  sober  group  judgment  of 
the  medical  profession  and  it  requires,  in  my  opinion,  the 
organization  in  even."  county  and  state  medical  society  of  a 
committee  on  public  relations  and  the  consistent  function- 
ing of  such  a  committee  with  the  full  support  and  under- 
standing of  the  membership  in  the  society  which  that  com- 
mittee represents. 


HE  advertisers 
in  this,  YOUR 
A  Journal,  merit 
*     consideration. 

If  you  are  in  the  market 
for  anything  tliey  sell, 
give  them  preference 
when  you  can,  to  your 
own  and  your  patients' 
advantage. 

Remember  to  mention  SOUTHERN  MEDICINE 
&  SURGERY  when  writing  to  advertisers. 


Journal 

of 

SOUTHERN  MEDICINE   &  SURGERY 


Vol.  XCVIII 


AUGUST,  1936 


No.  8 


Sacrococcygeal  Cysts* 

J.  Rolling  Jones,  M.D.,  Petersburg,  Virginia 


ALTHOUGH  recently  two  observers, ^  in  re- 
porting a  case  of  double  sacro-coccyxgeal 
teratomata,  make  the  statement  that  tu- 
mors in  this  region  are  not  uncommon,  after  a 
careful  review  of  the  literature  and  a  discussion 
of  the  matter  with  several  of  my  surgeon  friends, 
I  feel  convinced  that  they  are  so  uncommon  and 
so  baffling  as  to  justify  my  handling  the  subject 
in  a  general  way  with  you  and  putting  on  record 
two  cases  I  have  recently  encountered  and  operated 
on.  Both  cases  were  distinctly  of  the  ventral  type. 
Neither  the  histories  nor  the  physical  or  operative 
findings  indicated  any  destructive  changes  in  the 
sacrum  or  coccyx  to  which  they  were  gently  ad- 
herent; but  both  were  densely  adherent  to  the 
lower  posterior  rectal  wall  and  the  perineal  mus- 
cles, contrary  to  the  usual  findings. 

As  to  frequency,-  Hundling  quotes  J.  Colbert  as 
stating  that  the  sacral  tumors  of  some  type  occur 
once  in  34,582  births. 

Briefly,  as  to  origin:  It  is  generally  accepted 
that  all  tumors  of  this  type  are  congenital.  Accept- 
ing Copling's  statement:^  "Perfect  evolution  of 
the  tissues  embraced  in  this  part  of  the  body  is 
beset  by  many  narrow  escapes,  the  marvel  is  that 
we  do  not  encounter  more  evidences  of  develop- 
mental errors  in  this  region.  In  normal  develop- 
ment, we  have  tissues  representing  the  mesoderm, 
the  ectoderm  and  the  endoderm;  consequently,  tu- 
mors arising  here  may  show  the  histological  char- 
acteristics of  either,  or  of  some  modification.  For 
this  reason,  Rindfleish  has  named  them  histologic 
potpourri.  Their  complex  histology  readily  ex- 
plains their  complex  pathology  and  emphasizes  the 
statement  of  Pearse^  that  "the  confusion  of  the 
amateur  pathologist  in  studying  these  tumors  is 
equalled  only  by  the  embarrassment  of  the  amateur 
operator  in  operating  on  them." 

^Fultiple  varieties  of  tumors  are  reported.  Hund- 
ling, reporting  and  discussing  nineteen  cases  of  the 
ventral  type  seen  at  the  ^Nlayo  Clinic  up  to  1924, 

•Presented  to  the  Tri-State  Medical  Asso^ 
lina.  February  17th  and  18th. 


found  seven  varieties,  gliomas  and  dermoids  pre- 
dominating. It  is  interesting  that  with  the  excep- 
tion of  one  case,  age  3,  the  majority  were  between 
the  ages  30  and  60,  one  age  68.  In  1932,"  Haus- 
mann  and  Berne  report  a  case,  consider  the  sub- 
ject fully  and  tabulate  20  additional  cases  since 
Hundling's  report.  The  vast  majority  of  these  were 
in  extreme  infancy  or  early  childhood,  only  three 
had  reached  maturity — one  age  20,  one  43  and 
one  50.  However,  in  viewing  this  report,  the  line 
seems  not  distinctly  drawn  as  in  Hundling's  report 
as  to  location.  Most  of  these  cases  in  infancy  and 
childhood  were  what  I  would  style  the  external 
variety.  In  other  words,  it  would  appear  that, 
with  the  same  basic  congenital  origin,  those  of  the 
external  variety  manifest  themselves  definitely  at 
birth  or  in  very  early  childhood,  and  that  those  of 
the  ventral  type  show  themselves  after  maturity 
on  to  old  age.  Renner  and  Goodsitt  report  their 
case  as  one  of  double  tumor,  one  internal  and  one 
external,  apparently  separate  and  distinct.  In 
making  this  report  they  find  three  other  recorded, 
one  by  Weintraub  and  Young,  one  by  .Alter  and 
Bates,  and  one  by  Stewart,  Alter  and  Craig. 

It  seems  pretty  generally  accepted  that  tumors  of 
this  region  rarely  metastasise,  spreading  only  by 
invasion  of  tissue;  that  their  symptomatology  will, 
in  the  main,  depend  on  what  structures  they  dam- 
age most.  Those  of  the  external  or  mixed  type 
have  as  their  chief  symptom  pain  in  the  back  or 
thighs  similar  to  ordinary  sciatica;  whereas  those 
of  the  ventral  variety,  by  pressure  on  the  rectum, 
cause  alarming  constipation  and,  in  one  rase  re- 
ported, absolute  obstruction.  In  the  female,  pres- 
sure on  the  pelvic  organs  may  become  alarming. 
In  practically  all  instances  these  tumors  are  en- 
capsulated. This  applies  particularly  to  those  of 
the  ventral  type. 

To  revert  to  their  origin:  I  cannot  find  any 
reference  to  heredity  playing  any  role  in  develop- 
ment.    From  this  standpoint,  my  cases  seem  to  be 

of  the  Carolinas  and   Virginia,   meeting  at   Columbia,    South  Caro- 


SACROCOCCYGEAL  CYSTS— Jones 


August,  1936 


unique.  The  first  was  discovered  by  accident  when 
operating  on  a  multipara  on  a  preoperative  diag- 
nosis of  intraligamental  cyst.  During  this  lady's 
convalescence  she  was  continually  insisting  that  I 
must  see  her  oldest  son,  age  30,  who  had,  since 
birth,  had  trouble  with  his  rectum  associated  with 
constipation. 

The  young  man  presented  himself  at  my  office 
a  few  days  after  his  mother's  return  from  the  hos- 
pital. He  brought  with  him  a  letter  written  26 
years  before  by  his  mother,  setting  forth  in  a  mar- 
vellously intelligent  and  natural  way  the  difficul- 
ties and  trials  she  had  experienced  with  this  boy 
since  birth.  He  was  then  aged  four.  As  a  result 
Oi  this  early  history,  the  boy's  own  history  of  him- 
self, the  physical  findings,  but  more  particularly 
remembering  the  physical  and  operative  findings 
observed  in  the  mother,  I  was  enabled  to  correctly 
diagnose  a  ventral  sacrococcygeal  cyst.  A  com- 
plete x-ray  study  of  his  large  bowel  was  later 
made.  A  conference  with  Drs.  Peple  and  Williams, 
of  the  McGuire  Clinic,  confirmed  the  diagnosis, 
and  operation  was  advised.  Previous  to  this  time, 
in  1935,  I  had  operated  on  two  other  sons  of  this 
mother:  one  for  aggravated  hemorrhoids  with  his- 
tory of  prolapse  of  rectum  in  early  childhood  and 
exhibiting  marked  congenital  defects  in  the  form 
of  muscular  dystrophies,  club  feet,  and  marked 
mental  precosity  in  some  ways;  the  other  for  a 
fistula-in-ano,  possibly  congenital,  the  usual  his- 
tory of  acute  ischiorectal  abscess  absent.  There 
is  distinct  hereditary  tendency  to  trouble  in  this 
region  in  this  family. 

Case    Reports 

Case  1.— Para  X,  aged  57,  entered  hospital  August  13th, 
193S.  The  mother  died  of  old  age,  father  of  malaria,  two 
sisters  and  one  brother  1.  &  w.,  grandfather  died  of 
cancer. 

Has  had  chronic  constipation  and  bearing  down  with 
full  sensation  in  lower  abdomen.  Deliveries  normal,  men- 
opause two  years  ago,  hot  flushes  since.  The  bearing-down 
sensations  and  difficulties  in  bowel  movements  have  in- 
creased, requiring  enemas  for  relief.  Feels  worse  on  stand- 
ing. No  vaginal  discharge  or  renal  disturbance,  no  pain 
in  back,  thighs  or  lower  limbs. 

The  patient  was  obese,  did  not  look  sick,  color  and 
expression  were  good.  No  pathology  was  found  in  upper 
respiratory  or  upper  gastrointestinal  tract.  The  lungs  were 
normal.  No  evidence  of  cardio-vascular-renal  pathology 
was  detected.  Organs  of  upper  abdomen  normal.  On 
inspection,  the  lower  abdomen  presented  a  growth  extending 
well  above  the  pelvic  brim.  On  palpation  it  seemed  smooth 
and  fixed,  occupying  the  middle  Une,  extending  uniformly 
from  side  to  side,  and  was  somewhat  painful.  No  path- 
ology was  noted  in  the  region  of  the  sacrum  or  coccyx. 

On  vaginal  examination,  an  old  perineal  tear  was  found, 
also  a  large  rectocele  and  small  cystocele.  Just  back  of 
the  rectocele  was  a  mass  bulging  the  posterior  wall  of 
vagina  forward,  almost  obliterating  the  vaginal  tube.  On 
bimanual  examination  this  mass  below  gave  evidence  of 
being  continuous  with  the  growth  above.  The  uterus  was 
pushed  so  far  upward  and  forward  that  it  could  scarcely 


be  reached.  The  tumor  so  completely  filled  the  pelvic 
cavity  that  the  adnexa  could  not  be  palpated.  On  rectal 
examination  this  organ  was  found  forward  and  to  the 
left. 

It  was  felt  wise  to  operate  first  for  the  pelvic  tumor 
and  to  leave  the  deformity  until  a  later  sitting. 

0/ifra(rott.— August  14th,  1935,  assistant,  Dr.  W.  D.  Wil- 
son. Trendelenberg  position.  Midline  incision,  higher  than 
usual  in  order  to  be  sure  of  not  injuring  the  bladder.  The 
findings  were  a  retroperitoneal  mass,  with  overlying  struc- 
tures, namely,  an  enlarged,  thickened,  collapsed  colon,  and 
a  perfectly  normal  involuted  uterus,  its  appendages  and 
urinary  bladder.  The  growth  filled  the  pelvis  from  side 
to  side  and  extended  well  above  the  sacral  promontory. 

Its  removal  was  accomp  ished  by  first  splitting  the  pos- 
terior peritoneum  from  the  summit  above,  downwards, 
close  to  the  distorted  rectum  and  other  pelvic  organs.  A 
clear  cyst  immediately  came  into  view.  Starting  above,  it 
was  dissected  manually  from  the  posterior  peritoneum  in 
front,  the  sides  of  the  pelvis,  the  sacrum  and  coccyx  be- 
hind. Fortunately,  there  were  few  adhesions  until  the 
junction  of  the  sacrum  and  coccyx  was  reached.  Here  it 
was  attached  by  a  dense  band  which  required  division 
with  scissors.  In  doing  this,  on  account  of  lack  of  space, 
the  cyst  ruptured  near  its  lower  pole,  and  its  contents, 
distinctly  giving  evidence  of  a  sebaceous  character,  flooded 
the  operative  field.  The  most  intimate  attachment  was 
to  the  lower  posterior  surface  of  rectum  and  perinei  mus- 
cles. Its  complete  dissection  was  made  safe  by  passing 
a  large  rectal  tube  well  up  in  the  bowel  as  a  guide.  Hem- 
orrhage was  negligible,  but  in  order  to  assure  against  any 
postoperative  oozing  a  small  rubber-dam  drain  was  placed 
deep  in  pelvis,  bringing  it  out  at  the  lower  angle  of  the 
incision  in  the  posterior  peritoneum  at  the  lower  angle  of 
incision  in  abdominal  wall.  It  was  left  in  24  hours.  The 
posterior  peritoneal  wound  was  closed  with  continuous 
catgut  suture  and  the  abdominal  wound  closed  in  layers 
in  the  usual  manner. 

The  patient's  condition  was  excellent  during  and  imme- 
diately following  operation.  Convalescence  was  entirely 
satisfactory.  She  left  the  hospital  at  the  end  of  two 
weeks. 

Pathological  report:  Dermoid  cyst.  No  evidence  of 
malignancy. 

In  January  of  this  year,  this  lady  re-entered  the  hospital 
to  be  relieved  of  her  rectocele  and  cystocele.  Prior  to 
doing  an  anterior  colporrhaphy  and  an  Emmet  perineorha- 
phy  it  was,  for  the  first  time,  noted  that  instead  of  an 
old  perineal  tear  as  the  basis  for  the  pathology,  there 
was  distinct  evidence  of  congenital  deformity  of  the  outer 
structures  of  the  vulva.  Also  at  this  time,  no  evidence 
could  be  found  of  any  remnant  of  the  previous  growth. 
Uterus  and  appendages  occupied  their  normal  level  and 
were  freely  movable.  The  rectum  seemed  normal  except 
a  slight  relaxation  of  its  sphincter. 

Case  2. — White  man,  aged  30,  son  of  the  patient  whose 
case  was  just  described  and  referred  to  heretofore  when 
discussing  the  matter  of  heredity,  entered  Petersburg  Hos- 
pital November  9th,  1935,  complaining  of  constipation  and 
"a  feeling  that  he  had  a  tumor  of  some  sort  in  his  lower 
abdomen."  This  feeling  has  increased  in  the  last  two 
years.  He  stated  his  father  was  living  and  well.  (Mother 
case  just  described.)  Four  brothers  and  two  sisters  living 
and  well.     One  sister  died  in  infancy. 

The  story  from  his  birth  is  gotten  from  a  description 
written  by  his  mother  26  years  ago.  In  the  main,  it  is  a 
history  of  obstinate  constipation,  particles  of  undigested 
food  at  times  remaining  in  his  rectum  for  weeks  and 
having  to  be  removed  manually  or  with  some  household 


August,   1036 


SACROCOCCYGEAL  CYSTS—Jones 


instrument.  He  has  had  to  lead  an  enema  life.  Other 
than  this  he  developed  normally  and  has  had  no  serious 
illness.  He  has  been  hospitalized  three  times,  chief  com- 
plaint in  each  instance  being  chronic  constipation.  The 
first,  at  age  6,  when  the  final  diagnosis  was:  congenital 
stricture  of  rectum;  treatment,  dilatation  of  rectum,  which 
was  repeated  in  two  weeks.  Second,  at  age  24,  with  final 
diagnosis  congenital  absence  of  the  external  rectal  sphinc- 
ter. Only  general  measures,  with  continual  use  of  enemas, 
advised.  Third,  at  age  28,  two  years  ago.  At  this  time, 
after  a  careful  study  and,  I  believe,  being  influenced  largely 
by  the  striking  x-ray  findings,  a  final  diagnosis  of  Hirsh- 
sprung's  disease  was  made.  He  gave  no  histor,-  of  ever 
having  pains  in  his  back,  lower  spine  or  lower  limbs. 

He  was  well  nourished  and  symmetrically  developed, 
color  and  e.xpression  good,  no  enlarged  glands.  No  evidence 
of  pathology  was  detected  in  the  upper  respiratory,  upper 
gastrointestinal  tract,  lungs,  heart,  blood  vessels  or  kid- 
neys. The  organs  of  upper  abdomen  were  apparently  nor- 
mal. There  was  a  mass  in  lower  abdomen  extending  con- 
siderably above  the  pelvic  brim  and  somewhat  to  the 
right  side,  recognized  on  inspection  and  confirmed  by  pal- 
pation and  percussion.  There  was  no  tenderness.  The 
presence  of  a  distended  thickened  colon  was  somewhat 
confusing  but  the  position  of  this  organ  could  be  changed 
by  manipulation. 

The  anus  was  funnel-shaped,  probably  due  to  former 
treatments,  the  rectal  canal  longer  and  narrower  than  nor- 
rjal,  admitting  with  difficulty  the  gloved  finger.  The  tip 
/f  the  coccyx  could  not  be  felt  per  rectum.  The  most 
convincing  evidence  of  a  tumor  formation  between  the 
rectum  and  bony  structures  was  gotten  by  a  bimanual 
examination  in  Sims'  position.  In  this  way,  a  distinct 
continuity,  with  slight  fluctuation,  between  the  growth 
above,  and  the  retrorectal  growth  below  could  be  posi- 
tively demonstrated. 

On  account  of  the  similarity  to  Case  1,  in  every  respect, 
it  was  decided  to  follow  the  same  anterior  operative  pro- 
cedure. This  may  or  may  not  have  been  wise,  as  future 
results  alone  will  prove.  Primarily,  the  operation  was 
successful  and  beneficial.  Secondarily,  it  was  incomplete 
and  therefore  unsatisfactorj-. 

Operation. — November  12th,  1935.  Preoperative  diagno- 
sis, sacrococcygeal  cyst,  ventral.  Thorough  preoperative 
preparation.  Assistants:  Dr.  H.  C.  Jones  and  Dr.  W.  D. 
Wilson.  Trendelenberg  position.  Median  line  incision. 
The  bladder  was  found  to  have  a  high  attachment,  and 
care  was  exercised  to  protect  it.  The  findings  were  exactly 
the  same  as  in  Case  1,  namely,  a  large  retroperitoneal 
growth,  filling  the  pelvis  from  side  to  side  and  extending 
well  above  the  sacral  prominence.  The  colon,  in  this  in- 
stance, was  larger  and  offered  difficulty  in  keeping  it  out 
of  the  way.  After  dividing  the  posterior  peritoneum,  the 
same  manual  dissection  of  the  cystic  growth  from  the 
surrounding  structures  was  followed.  The  left  ureter  was 
lying  across  the  anterior  surface  of  the  tumor,  requiring 
protection.  Few  adhesions  were  encountered  before  the 
sacrococcygeal  junction  was  reached.  At  this  point  dis- 
section with  scissors  was  necessary.  At  this  time,  just  as 
in  the  former  case,  this  cyst  ruptured  near  its  lower  pole 
and  at  least  two  quarts  of  fluid  escaped,  flooding  the 
operative  field.  Its  gross  appearance  indicated  sebaceous 
characteristics.  At  this  point,  there  was  noted  through 
the  empty  sac,  far  down  in  the  pelvis,  a  soft  irregular 
mass,  densely  involving  the  rectal  wall,  which  it  seemed 
almost  to  encircle.  While  complete  removal  appeared 
doubtful,  this  was  nevertheless  attempted.  In  doing  so, 
extreme  hemorrhage  occurred,  uncontrollable  by  ligatures, 
jeopardizing  the  patient's  life.  However,  by  carrying  out 
the   principle    of    marsupilation,    packing    the    sac    with    a 


three-yard  roll  of  gauze,  the  hemorrhage  was  controlled. 
We  also  hope  that  this  procedure  may  be  of  some  perma- 
nent advantage.  At  least  we  were  leaving  the  relationship 
of  the  remaining  pathology  such  as  to  offer  a  safer  pos- 
terior operation  later,  should  developments  make  this  nec- 
essary. 

The  posterior  peritoneum  was  closed  by  continuous  su- 
tures of  No.  1  catgut,  except  at  lower  angle  where  the  cyst 
wall  containing  the  gauze  pacliing  was  brought  out.  The 
latter  was  then  stitched  to  the  anterior  peritoneum  at  the 
lower  angle  of  the  abdominal  wound,  leading  the  gauze 
out  at  this  point.  The  abdominal  wound  was  then  closed 
in  layers  in  the  usual  way. 

The  patient  left  the  table  in  quite  severe  hemorrhagic 
shock.  However,  by  the  judicious  use  of  intravenous  fluids 
and  stimulants  this  was  promptly  overcome.  Transfusion 
was  not  necessary.  Other  than  quite  marked  abdominal 
discomfort  the  first  few  days,  convalescence  was  satisfac- 
tory. Gauze  packing  was  removed  on  the  fifth  postopera- 
tive day.  This  was  followed  by  no  hemorrhage.  Skin 
sutures  were  removed  on  the  eighth  postoperative  day; 
when  the  wound  was  entirely  healed  except  at  drainage 
tract  and  there  was  little  or  no  drainage.  On  the  tenth 
postoperative  day  this  area  was  closed.  However,  about 
the  twelfth  day,  the  drainage  area  was  pouting  and  on 
opening  it,  quite  a  large  amount  of  clear  fluid  escaped. 
From  then  on,  about  every  two  days  of  the  remaining  time 
in  the  hospital,  quite  a  large  amount  of  clear  fluid  would 
be  discharged. 

The  patient  left  the  hospital  on  the  24th  postoperative 
day,  feeling  fine — better  than  he  had  felt  in  years.  What 
pleased  him  most  was  the  fact  that  he  was  now  having 
bowel  movements  daily  without  the  aid  of  purgatives  or 
enemas.  He  seemed  little  disturbed  by  the  intermittent 
drainage  that  was  still  occurring.  A  supply  of  dressings 
was  ordered,  and  the  mother  taught  how  to  dress  the 
drainage  tract.  It  was  explained,  that  how  long  this 
drainage  would  keep  up  we  were  unable  to  say. 

Soon  after  the  operation  a  frank  statement  had  been 
made  to  the  parents  as  to  findings  at  operation:  that  we 
were  unable  to  completely  remove  the  tumor;  that  a 
future  operation  might  become  necessary,  but  if  so,  as  a 
result  of  this  operation  it  could  now  be  safely  and  com- 
pletely done  by  a  different  route;  that  at  least  he  would 
be  benefited. 

To  my  surprise  and  gratification  about  four  weeks  later 
he  walked  into  my  office  and  stated  that  he  was  feeling 
fine  and  that  the  drainage  had  completely  stopped  about 
ten  days  previously.    He  looked  well. 

He  was  seen  again  just  before  I  left  home.  He  was 
feeling  well  and  had  gained  six  pounds  in  weight.  How- 
ever, he  said  his  movements  were  not  quite  so  satisfactory 
as  soon  after  his  operation.  He  was  advised  to  take  min- 
eral oil  at  night  should  it  become  absolutely  necessary; 
but  to  make  every  effort  possible  to  have  a  natural  move- 
ment daily.  We  examined  his  abdomen  and  rectum.  The 
former  was  normal.  The  latter  seemed  by  no  means  as 
narrow  as  before  operation.  Some  thickening  of  the  pos- 
terior wall  is  still  present,  but  no  definite  tumor  mass  in 
the  retrorectal  space  could  be  recognized. 
Summary 

Two  cases  of  definitely  proven  sacrococcygeal 
cysts  of  the  ventral  type  are  reported. 

The  first,  discovered  by  accident  when  operating 
for  what  was  thought  to  be  an  intraligamentous 
cyst  in  a  woman  57  years  old,  who,  it  turned  out 
later,  was  the  mother  of  patient  2. 

Patient  2,  son  of  patient  1,  diagnosed  correctly 


SACROCOCCYGEAL  CYSTS— Jones 


August,  1936 


preoperatively,  by  virtue  of  similarity  of  history, 
physical  findings,  but  particularly  influenced  by  the 
recent  operative  findings  observed  in  the  mother. 

Both  cases  were  operated  on  by  the  anterior 
route;  the  first,  successfully  and  completely;  the 
second,  successfully  and  beneficially,  but  incom- 
pletely. 

However,  due  to  the  carrying  out  of  the  princi- 
ple of  marsupilation,  exercised  primarily  to  control 
hemorrhage,  the  anatomy  of  the  region  and  re- 
maining pathology  were  left  in  such  circumstance 
as  to  make  a  secondary  posterior  operation  much 
safer,  and  with  better  end-results  in  view,  than  if 
this  method  had  been  followed  in  the  first  instance. 

As  to  end-results,  I  believe  patient  1  is  cured. 
The  second  is  at  least  benefited.  A  possible  future 
operation  will  be  decided  by  his  future  behavior. 

Pathologically,  the  growth  removed  from  patient 
1  showed  definite  dermoid  characteristics;  that  from 
patient  2  is  undetermined  definitely. 

Supporting  the  influence  of  heredity,  two  other 
sons  of  this  mother  are  referred  to;  one  showing 
multiple  evidence  of  congenital  anomalies.  Among 
these,  as  a  child,  he  suffered  for  a  long  while  with 
prolapse  of  the  rectum,  indicating  definite  weakness 
in  this  region.  The  other  son  had  a  lesion  near  the 
rectum,  requiring  operation,  which  possibly  may 
have  had  a  congenital  basis. 

Given  any  case  of  suspected  pathology  in  the 
post-rectal  area,  a  combined  bimanual  rectal  exam- 
ination, in  Sims'  position  will,  in  my  judgment,  dis- 
close the  most  accurate  findings. 

X-ray  pictures  of  the  colon  are  presented  showing 
how  naturally  one  might  conclude  the  presence  of 
Hirschsprung's  disease,  when  dealing  with  a  true 
ventral  sacrococcygeal  cyst. 

Bibliography 

1.  Renner,  R.  R.,  and  Goodsitt,  E.:  Sacrococcyxgeal 
Teratoma.     Am.  J.  Cancer,  24:617-625,  July,  1935. 

2.  HT.rNDi,iNG,  H.  W.:  Ventral  Tumors  of  the  Sacrum. 
Surg.,  Gynec.  &  Obst.,  1924,  38,  518-533. 

3.  CoPLiNC,  \.:  Pub.  jrom  Library  of  Jefferson  Medical 
College  Hospital,  1906,  vol.  m. 

4.  Peaese,  H.  E.;  Removal  of  Ventral  Tumors  of  the 
Sacrum  by  Posterior  Route.  Surg.,  Gynec.  &  Obst., 
33:164-167,   1921. 

5.  Hausmann,  G.  H.,  &  Berne,  C.  J.:  Sacrococcygeal 
Teratomas.    Arch.  Surg.,  1932,  25,  1090-1097. 

Discussion 
Dr.  Allen  Barker,  Petersburg: 

I  wish  to  congratulate  Dr.  Jones  on  his  very  excellent 
diagnosis  in  this  case.  Through  his  kindness  I  had  the 
good  fortune  to  see  this  patient  and  also  of  making  a 
complete  roentgen  examination  of  the  colon.  I  have  only 
one  lantern  slide  of  the  colon  itself. 

The  rectum  is  very  much  dilated  (shows  slide),  and 
there  is  a  large  filling  defect,  from  pressure.  We  made  a 
diagnosis  of  megacolon,  secondary  to  obstruction  from  a 
tumor.  We  knew  the  patient  had  a  tumor,  which  we 
could  see  and  feel,  and  therefore  we  did  not  think  the 
dilated    colon    was    a    true    Hirschsprung's    disease.      This 


condition  is  congenital,  as  you  all  know,  and  is  a  true 
megacolon,  .\nother  type  is  the  pseudomegacolon,  of 
which  this  is  an  example.  There  are  certain  other  types 
of  pseudomegacolon  which  are  neuropathic  in  origin,  there 
being  paralysis  of  a  section  of  the  colon. 

I  don't  know  exactly  the  amount  of  barium  that  was 
administered  in  this  case,  but  as  I  remember  it  was  around 
five  quarts,  and  even  then  we  did  not  completely  fill  the 
colon. 

Dr.  Jones  mentioned  that  the  pathological  diagnosis  in 
this  case  was  indefinite.  But  Dr.  Jones  left  Petersburg 
about  a  week  ago,  and  since  then  we  have  had  Dr.  Broders, 
of  the  Medical  College  of  Virginia,  to  examine  it,  and  he 
called  it  an  epithelial  cyst,  which  might  be  termed,  I  sup- 
pose, a  dermoid  cyst,  as  Dr.  Jones  suggested,  although  no 
hair  was  present. 

In  discussing  these  cases  it  is  interesting  to  consider  their 
origin  from  an  embryological  standpoint.  It  is  recognized 
by  most  people  that  these  cysts  arise  from  remnants  of  the 
post-anal  gut.  If  we  remember  our  embryology,  the  cen- 
tral canal  of  the  spinal  cord  and  the  alimentary  canal  arc 
continuous  around  the  caudal  end  of  the  notochord.  When 
the  proctodeum  invaginates  to  form  the  anus,  it  meets  the 
gut  anterior  to  where  the  neurenteric  canal  opens  into  it. 
.\s  a  result,  we  have  left  in  the  embryo  a  portion  of  the 
hind  gut  which  is  behind  the  anus,  and  which  normally 
disappears.  But  in  some  cases  it  does  not,  and  we  have 
a  remnant  left  which  may  continue  to  grow,  though  en- 
closed by  neighboring  structures.  In  this  particular  case. 
Dr.  Broders  believes  that  this  cyst  was  derived  from  the 
ectoderm  rather  than  the  entoderm,  although  one  can 
readily  understand  why  cysts  arising  in  this  region  may 
be  lined  with  either  entoderm  or  ectoderm  depending  on 
slight  developmental  anomalies. 

Dr.  R.  B.  McKnight,  Charlotte; 

.\ny  association  of  physicians,  whether  it  be  a  society  of 
doctors  in  general  or  of  specialists,  should  be  grateful  to 
Dr.  Jones  for  bringing  these  cases  to  its  attention. 

I  wonder  just  what  the  similarity  between  these  cases 
and  those  wc  ordinarily  refer  to  as  sacrococcygeal  dermoid 
cysts,  or  pilonidal  sinuses,  really  is.  The  latter  are  also  of 
ectodermal  origin  and  point  posteriorly.  I  have  never  seen, 
nor  have  I  heard  of  before,  an  anterior-growing  sacrococcy- 
geal cyst. 

The  pathological  pictures  of  Dr.  Jones'  cases  are  practi- 
cally identical  with  those  of  the  ordinan,-  pilonidal  sinuses. 
The  chief  gross  evidence  of  the  ectodermal  origin  of  the 
latter  is  the  presence  of  hair,  which  may  vary  in  amount 
from  a  few  small  strands  to  a  ball  of  considerable  size. 
Was  there  any  hair  present  in  either  of  these  cases? 

I  think  without  a  doubt  these  are  two  of  the  most  in- 
teresting case  reports  I  have  ever  heard. 

Dr.  Jones,  closing: 

Gentlemen,  I  certainly  want  to  thank  you  all  for  your 
patience  in  listening  to  this  paper,  and  I  particularly  thank 
Dr.  McKnight  for  his  discussion. 

I  regard  these  two  cases  as  among  the  unique  experiences 
in  my  professional  life.  When  I  encountered  the  first  case 
by  accident,  expecting  to  have  an  easy  operation,  or  at  least 
one  I  was  accustomed  to  doing,  and  instead  encountered 
this  enormous  retroperitoneal  growth,  I  did  not  feel  very 
good.  I  felt  that  I  was  going  to  get  into  all  kinds  of 
difficulties.  And  yet  the  operation  was  completed  with 
ease  and  readiness.  The  passage  of  the  rectal  tube  into  the 
anus,  as  mentioned,  facilitated  its  removal.  It  was  a  lot  of 
help  to  do  that. 

If  I  had  not  seen  the  first  case  I  doubt  very  much 
whether  I  would  have  made  a  correct  diagnosis  preopera- 


I 


August,    103h 


SACROCOCCYGEAL  CYSTS— Jones 


415 


lively  in  the  second  case.  This  patient  had  been  studied 
two  years  by  a  keen  surgical  specialist  and  a  keen  internist. 
If  they  had  had  the  information  which  I  had,  and  had 
had  it  just  previously,  I  am  sure  they  would  have  consid- 
ered it  a  true  surgical  condition  rather  than  Hirschsprung's 
disease. 

One  thing  I  should  like  to  emphasize  is  that,  given  a 
case  with  chronic  constipation  since  birth  (that  was  a 
distinctive  feature  in  both  these  cases,  especially  the  boy), 
it  is  well  for  us  to  look  out  for  such  a  picture;  and  I  am 
convinced,  gentlemen,  there  is  no  method  which  wiU  tell 
you  as  much  in  the  examination  of  these  cases  as  the  old 
Sims  position  and  making  a  bimanual  examination,  with 
one  finger  in  the  rectum.  In  that  way  you  can  certainly 
make  out  any  mass  in  the  perirectal  space. 


Prec.-vncerous  Lesions  of  the  Skin- 
id.    G.    Duncan,   Oklahoma  City,    in   Jl.    Okla.    State    Med. 
Assn.,   July) 

Chronic  ulcerations  of  all  kinds  and  especially  syphilitic 
are  prone  to  degenerate  into  malignancy.  This  is  partic- 
ularly true  in  the  case  of  gumma  of  the  tongue  and 
chronic  ulcerations  in  the  buccal  cavity.  It  is  well  there- 
fore to  continue  to  suspect  malignancy  in  many  of  these 
lesions  even  though  the  Wassermann  reaction  is  positive. 
Frequently  a  malignant  lesion  in  the  mouth  is  aggravated 
by  antisyphilitic  therapy. 

Leukoplakia  must  always  be  considered  as  a  premalig- 
nant  lesion.  In  many  cases  of  persistent  leukoplakia  the 
Wassermann  reaction  is  positive,  but  they  do  not  improve 
under  treatment. 

The  probability  of  cancer  deceloping  from  a  single  mole 
is  very  small.  If  a  mole  is  black,  blue-black  or  slate  col- 
ored it  should  be  considered  as  a  melanoma  and  should  be 
handled  with  care.  It  is  occasionally  better  to  leave  a 
lesion  of  this  kind  entirely  alone  unless  the  lesion  grows, 
has  peculiar  sensations,  or  is  frequently  irritated. 

Keratoses  are  probably  the  most  common  forerunners 
of  skin  cancer. 


Looking  to  the  Solution  of  Some  of  Society's 

Problems 

(Wm.  A.   White,  Washington,  in   Med.   An.   D.  C,  July) 

It  is  largely  the  job  of  the  men  who  make  up  your 
medical  societies  to  translate  to  the  public  discoveries 
which  are  of  value,  to  warn  the  public  against  those 
alleged  cures  which  are  of  no  value  or  are  really  harmful, 
to  develop  leadership  in  this  whole  field  which  will  support 
adequate  programs  of  public  health,  to  be  enforced  by 
the  pub'ic  health  authorities  [Italics  ours. — S.  M.  &  S.] 
and  which  will  properly  translate  all  of  these  things  into 
necessary  educational  procedures,  legislation,  and  in  general 
their  application  in  the  actual  care  and  prevention  of  dis- 
ease. 

The  results  of  war  manifest  themselves  in  innumerable 
directions,  building  up  hates,  antagonisms,  jealousies  which 
masquerade  under  the  names  of  patriotism,  nationalism, 
self-protection,  race  superiority,  justice,  and  a  thousand 
and  one  disguises  which  are  used  for  all  sorts  of  purposes. 
It  is  a  part  of  the  strategy  of  hiding  that  the  place  of 
concealment  should  be  chosen  with  a  view  to  its  incon- 
spicuousness,  that  it  should  be  the  last  place  where  anyone 
would  expect  to  find  that  which  is  hidden.  So,  just  as  the 
malarial  Plasmodium  seeks  out  the  mosquito,  as  an  appro- 
priate hiding  place,  so  do  these  aggressive  and  destructive 
tendencies  of  man  hide  behind  such  symbols  as  I  have 
named,  which  it  would  appear  to  be  a  sacrilege  to  suspect 
of  harbonng  such  guests.  Can  we  not  vision  a  Gorgas 
of  the  future  in  some  new  Geneva  unmasking  the  motives 
of  some  international  demagogue,  and  having  history  re- 


cord that  this  is  the  first  time  that  nations  have  been  free 
from  the  danger  of  the  unknown  disguises  of  the  cruel 
and  selfish  motives  of  their  representatives,  for  thousands 
of  years? 

The  aggressive  and  the  destructive  instincts  of  man  are 
held  in  abeyance  by  the  customs,  the  traditions,  the  social, 
moral  and  religious  standards  of  civilization,  and,  like  the 
disease-producing  organisms,  they  are  held  in  abeyance  so 
long  as  we  are  eternally  vigilant  in  the  care  of  our  de- 
fenses. We  have  the  ways  and  means  within  our  knowl- 
edge and  control  to  protect  ourselves  from  great  epidemic 
scourges,  but  we  have  never  yet  consciously,  intelligently 
and  scientifically  undertaken  to  protect  ourselves  from 
the  disasters  that  may  emanate  from  these  other  sources. 
You  may  have  thought  as  I  have  spoken  in  these  last  few 
sentences  that  I  look  to  psychology  for  the  future  solution 
of  these  more  immediate  problems.  It  may  be  from  the 
psychologist ;  but,  up  to  the  present  writing,  such  material 
and  information  as  we  have  gained  along  these  lines  have 
come  primarily  from  the  physician. 


Therapeutics  of  Drug  Habits 
(A.  Lambert,  New  York,  in  N.  E.  Jour,  of  Med.,  July  9th) 

In  1928  the  Mayor's  Committee  on  Drug  Addictions  in 
New  York  City  was  appointed.  This  committee  studied 
under  carefully  controlled  conditions  the  action  of  the 
various  recognized  drugs  believed  to  relieve  the  withdrawal 
symptoms  of  morphine.  Atropin  diminished  the  gastro- 
intestinal symptoms;  hyoscin  increased  these  symptoms 
and  produced  an  active  delirium  with  severe  prostration 
and  weakness.  Slow  withdrawal  was  a  disagreeable  nag- 
ging misery,  much  resented  by  the  patients.  The  7-  and 
14-day  withdrawals  delayed  the  certain  occurrence  of  the 
withdrawal  symptoms  and  slightly  reduced  their  intensity. 
Codein  was  the  only  drug  used  which  decidedly  diminished 
the  symptoms.  The  codein  was  increased  up  to  5  grains 
every  four  hours.  After  the  morphine  had  not  been  given 
for  four  days,  the  codein  was  rapidly  cut  down  in  a  four- 
day  period.  This  was  the  most  successful  and  the  least 
painful  of  the  methods  I  have  used;  but  it  requires  a 
month  to  six  weeks  of  hospitalization  and  sometimes  ends 
with  a  codein  habit  to  be  reduced. 

I  have  used  rossium  in  some  seventy-five  patients  for 
treatment  of  addiction  to  various  opium  alkaloids.  I  have 
also  used  it  in  many  alcoholics.  I  have  found  that  the 
treatment  by  rossium  successfully  reduces  the  withdrawal 
symptoms  and  the  period  of  hospitalization  more  than  any 
other. 

The  gastrointestinal  symptoms  are  reduced  to  a  mini- 
mum. The  muscular  aches,  joint  pains  and'  abdominal 
cramps  can  be  controlled  by  glucose;  the  nervous  restless- 
ness and  terrors  can  be  controlled  by  small  doses  of 
codein. 

Multiply  the  body  weight  of  the  patient  by  .05  and  one 
obtains  the  number  of  grams  of  rossium  to  be  used  in  the 
24  hrs. — ave.  two  0.5  gram  capsules  every  four  hours.  This 
accompanied  during  the  first  48  hours  by  a  sufficient  dose 
of  morphine  to  make  the'  patient  comfortable. 

Codein  is  particularly  valuable  in  getting  a  patient  off  of 
morphine,  dilaudid  or  heroin.  In  the  withdrawal  of  codein 
dilaudid  is  particularly  useful.  If  codein  has  to  be  given 
in  large  doses  in  the  withdrawal  of  morphine,  dilaudid  will 
control  the  symptoms  and  can  be  used  without  fear  of  its 
own  habit  in  the  four  or  five  days  that  are  necessary  to 
help  the  patients  in  control  of  their  discomfort. 


It  takes  V/2  tons  of  hog  ovaries  to  yield  lyi  mgms.  (less 
than  l/40th  grain)  of  hormones.— M.  Casper,  in  A'y.  Med. 
JL,  July. 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  l°it} 


Medicine's  Need  of  Eugenics* 

William  Allan,  M.D.,  Charlotte,  North  CaroHna 


WE  should  be  more  interested  in  being 
well  born  in  the  South  than  elsewhere  in 
this  country,  for  the  South  with  one 
quarter  of  the  nation's  population  is  furnishing 
one-half  the  nation's  children.  We  spend  an  in- 
finite amount  of  time  and  patience  rearing  these 
children  with  very  little  concern  for  the  raw  prod- 
uct we  start  with.  While  we  all  inherit  handicaps 
of  some  sort,  along  with  our  desirable  traits,  yet 
some  of  the  children  we  produce  generation  after 
generation,  without  thought  of  the  future,  are  so 
badly  handicapped  that  the  wisdom  of  producing 
them  seems  more  than  doubtful. 

In  the  days  when  Sparta  flourished,  defective 
children  were  exposed  on  the  mountainside  to  die 
In  this  Christian  era  defectives  are  carefully  nur-  ■    I 

tured,  and  if  their  defects  are  hereditary  allowed  -v-^r— J-p-p-, -,7- 
to  pass  them  do^vn  to  future  generations.     Would  u    n    ^  ^  si  ■ 
it  not  be  more  sensible  in  the  case  of  hereditary 
defects  that  are  predictable  to  avoid  the  production 
of  such  children? 

As  an  illustration,  Consider  the  following  pedi- 
gree of  a  family  of  deaf  mutes  scattered  over  upper 
South  Carolina. 


The  two  deaf  children  in  G  "V  will,  of  course, 
pass  the  trait  to  their  children  and  the  27  hearing 
children  of  the  deaf  in  G  V  all  carry  this  recessive 
trait  and  will  pass  it  on  to  half  their  children. 

These  known  and  potential  recessives  should  be 
listed  by  the  public  health  authorities  and  either 
education  or  legislation  invoked  to  meet  this  men- 


»T^ 


% 


SHAKi/iG  PALSr 


sr»ii)#« 


I 


Pedigree  No.  I. — This  pedigree  shows  the  re- 
cessive trait,  hereditary  congenital  deafness,  appear- 
ing une.xpectedly  in  two  families  in  G  III.  Two 
of  these  deaf  persons  married  each  a  deaf  partner; 
the  first  couple  had  six  children,  all  deaf,  and  the 
second  couple  had  nine  children,  all  deaf.  Eleven 
of  the  deaf  mutes  in  G  IV  married  deaf  partners: 
three  of  these  marriages  were  without  issue,  on? 
resulted  in  two  deaf  children,  and  seven  of  thes- 
unions  produced  27  hearing  children. 

In  G  III  the  8  hearing  sibs  had  2  out  of  >i 
chances  of  passing  deafness  along  to  their  42  chil- 
dren: these  42  children  in  G  IV  had  1  chance  in» 
3  of  passing  deafness  on  to  their  71  children  in 
G  V  each  of  whom  has  one  chance  in  six  of  carry- 
ing the  trait. 


Pedigree  U. — Recently  the  daily  press  carried 
news  of  the  capture  of  Tommy  Touhy,  the  noto- 
rious Chicago  gangster,  helpless  from  the  shaking 
palsy.  This  illustrates  the  type  of  trait  that  devel- 
ops in  middle  or  later  life  and  interferes  with  our 
occupations  as  well  as  comfort. 

Palsy  is  apparently  a  unit  dominant  trait,  an 
affected  parent  passing  it  on  to  half  the  children. 
The  moral  is  if  one  of  your  parents  has  hereditary 
shaking  palsy,  you  stand  an  even  chance  of  having 
your  career  brought  to  a  close  in  middle  life  should 
you  be  a  gangster,  a  watch-maker,  or  a  surgeon. 

Pedigree  III. — :Many  hereditary  deformities  such 
as  six  fingers  or  birth  marks  are  simply  annoying, 
but  in  North  Carolina  a  combination  of  lobster-claw 
hands  with  one  withered  leg  is  traveling  unseen 
through  successive  generations  as  a  recessive  trait, 
cropping  out  at  intervals  to  make  economic  adjust- 


e 

0CP 

3(^ 

B                e1^    .0^1           4      ^ 

r                          v      ]  \  "         \ 

ment  hard  for  men  and  social  success  all  but  impos- 
sible for  women.  In  a  marriage  of  first  cousins  once 


•Presented  by  Title  to  the  Tri-State  Medical  Association    of    the 
outh  Carolina,  February  17th  and  18th. 


Carolinas    and    Virginia,    meeting   at    Columbia, 


August,   1036 


EUGENICS— Allan 


417 


removed,  the  trait  proved  lethal  for  two  children  in 
a  family  of  four,  and  the  marriage  of  second  cous- 
ins once  removed  produced  two  deformed  children 
in  a  fraternity  of  seven. 

A  careful  study  of  the  ramifications  of  this  dis- 
astrous recessive  trait  would  probably  prevent  a 
good  deal  of  future  misery. 


COROAARY  Occlusio.v 


cj-wwM  m  m  o  uo^  ©T^ 

7-„^/,..J    CO         '         -  '      -  -  


M 


Pedigree  IV. — Our  most  serious  problems  in  med- 
icine and  public  health  have  to  do  with  those  so- 
called  constitutional  diseases  that  are  now  the  lead- 
ing causes  of  death.  In  North  Carolina  the  three 
leading  causes  of  death  after  infancy  are  chronic 
heart  disease,  nephritis  and  apoplexy — the  cardio- 
vascular diseases  usually  associated  with  high  blood 
pressure.  These  cardiovascular  diseases  are  doubt- 
less inherited,  but  no  one  as  yet  has  taken  the  trou- 
ble to  prove  this,  nor  to  investigate  the  mechanism 
of  their  inheritance. 

In  North  Carolina  the  State  Vital  Statistics 
Bureau  reports  that  1  death  in  50  was  due 
to  coronary  disease  in  1933.  Using  this  figure,  by 
the  law  of  chance,  6  out  of  13  children  will  die  of 
coronary  disease  in  only  one  in  every  11  million 
families  of  that  size. 

.'\pparently  then  this  pedigree  is  significant  evi- 
dence of  the  inheritance  of  cardiovascular  disease. 

We  will  never  be  able  to  prevent  our  serious  con- 
stitutional diseases  until  we  know  whence  they  come 
and  how. 

To  meet  this  situation  we  need  a  Family  Record 
Office  in  every  Health  Department  to  survey  our 
population,  county  by  county,  for  these  morbid  he- 
reditary traits.  Such  surveys  are  as  feasible  in  our 
stationary  rural  population  as  are  surveys  for 
hookworm  or  malaria.  If  the  morbid  hereditary 
traits  in  all  our  county  families  were  as  carefully 
recorded  as  are  the  infectious  diseases,  then  a  young 
couple  applying  for  a  marriage  license  could  ask, 
what  will  our  children  inherit?,  and  get  a  depend- 
able answer.  Sometimes  the  answer  will  have  to 
be  deafness,  blindness,  crippling,  etc.  While  every- 
body want  schildren,  nobody  wants  defective  chil- 
dren. The  certain  knowledge  or  strong  probability 
of  producing  defective  children,  is  a  strong  enough 
motive  to  curb  the  supply  of  defectives. 


Discussion 

Dr.  J.^s.  M.  Northington,  Charlotte: 

Mr.  President  and  gentlemen:  It  was  said  a  long  time 
ago.  and  it  is  still  true,  that  men  do  not  gather  figs  from 
thistles  nor  grapes  from  thorns.  Over  many  years,  many 
decades,  the  problem  of  prevention  of  disease  and  decay 
among  the  population  was  largely  that  of  seeing  that  the 
larger  number  of  those  children  that  were  born  grew  up, 
and  a  problem  that  is  intermingled  with  that,  they  did  not 
die  of  communicable  diseases.  We  have  got  along  to  the 
point  that  almost  all  those  things  that  can  be  controlled 
from  that  viewpoint  have  been  largely  controlled.  Now 
we  get  back  to  the  matter  of  what  one  might  call  the 
essential  vitality  of  the  stock.  Therefore  we  must  consider 
from  what  stock  these  human  roots  come.  A  long  time 
ago  it  was  laid  down — and  I  ask  you  to  look  critically  over 
the  specimens  of  the  human  race  that  come  under  your 
observation,  and  that  those  you  have  seen  you  review  in 
retrospect,  and  see  if  it  is  not  as  true  now  as  it  was  two 
thousand  years  ago  when  it  was  said,  "The  days  of  a 
man's  years  are  three  score  and  ten;  and  if  by  reason  of 
strength  they  be  fourscore,  yet  is  their  strength  but  labour 
and  sorrow."  Look  over  it;  look  over  it  from  now  on, 
and  look  over  it  from  now  back,  and  see  if  that  is  not  at 
least  ninety-five  per  cent.  true.  Man  was  born  to  die,  and 
so  is  every  other  of  the  animal  race,  every  other  of  the 
vegetable  race.  There  is  no  reason  to  believe  that  in  any 
of  the  projects  of  nature,  there  is  any,  if  I  may  say  without 
irreverence,  Divine  intention,  that  anything  should  live 
and  continue.  There  is  a  stadium  incrementi,  then  a 
fastigiom,  then  a  stadium  decrements  What  Dr.  Allan 
has  said  suggests  a  declaration  of  fundamental  principles, 
but  something  that  has  been  neglected.  From  this  time 
on,  if  we  shall  e.xpect  that  the  average  span  of  man's  ex- 
istence which  in  my  brief  memory  has  been  carried  forward 
from  thirty  years  to  sixty  years — if  it  shall  be  continued, 
and  if  it  shall  come  to  the  time  when  the  days  of  our 
years  are  fourscore  (which  seems  to  be  the  Ultima  Thule, 
the  most  we  can  hope  for) ;  if  we  are  to  come  to  that,  the 
way  is  by  the  study  of  heredity ;  and  a  great  many,  partic- 
ularly among  English  people,  are  now  advocating,  and 
advocating  seriously  and  intelligently,  a  chair  of  heredity 
in  every  medical  school,  even  if  we  must  abolish  at  least 
one  chair  from  our  schools  in  order  to  make  a  place  for 
this  chair  of  heredity.  And  I  hope  to  see  Dr.  Allan  adorn- 
ing one  of  those  chairs. 

Dr.  a.  M.  Bratlsford,  Camden,  S.  C: 

Eugenics  covers  a  wide  scope,  and  although  the  essay 
itself  and  its  discussion  by  Dr.  Northington  covers  most 
phases  of  it,  still  there  is  another  phase  to  eugenics  which 
we  must  not  neglect.  From  the  moral  and  intellectual 
viewpoint,  we  must  earnestly  consider  the  provision  of 
good  citizens  by  controlling  our  births  in  this  country. 
This  will  mean  something  to  the  building  up  and  carr>ing 
on  of  the  traditions  and  history  of  our  country  by  the 
coming  generations  of  natives  and  will  influence  for  good 
those  w'ho  have  recently  arrived  upon  our  shores.  Those 
are  the  ones  that  we  must  try  to  regulate,  so  they  will 
have  a  reverence  and  a  regard  for  the  traditions  and  his- 
tory of  these  United  States. 


Recovery  from  PNEirMOCOccus  meningitis  is  reported 
by  F.  G.  Norberry,  Jacksonville,  111.,  in  the  Medico!  Rec- 
ord of  July  1st. 

Spinach  is  not  entitled  to  any  high  rating  as  a  food, 
according  to  Yale  investigators.  A  lot  of  us  have  held  all 
along  that  its  touting  was  based  on  the  idea  that  anything 
with  so  vile  a  taste  must  be  "good  for  you." 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


Are  Transfusions  Beneficial  in  Poliomyelitis* 

Chakles  H.  Gay,  M.D.,  Durham,  North  CaroHna 

MANY  believe  that  the  intravenous  admin-  or  extent  of  paralysis  in  thirteen  patients  who  were 

istration   of  serum  or  whole  blood   from  transfused  and  in  eleven  who  were  not  transfused, 

patients    convalescent    from   poliomyelitis  Table  1 

or   from   normal   adults   has   therapeutic   value   in  ,                           ;Age  of  Patients 

,.           ,.  .    ,      _                     „    ,      1             ,•           1  •'Ig'"                            Transfused                   Not  Transfused 

pohomyelitis.i     Few  controlled  observations,  how-  j    .,   ^.^,            .  ^^^^^^^^  ^g^^^,,         3  ^^^.^^^^  ^33^^, 

ever,  have  been  recorded.'    In  this  series  of  twenty-  31,^.9  yrs.            6  patients  (17%)           8  patients  (50%) 

four    patients,     thirteen    were    given     two    or    three  'Figures    in    brackets    indicate    the    percentage    of    the 

^                '                                       f  patients  who  were  paralyzed. 

large    transfusions    (100-250    c.c.)    from    different  ^  ^,    „ 

"                                                                                     .  Table  2 

normal  adults  at   twelve-  to  eighteen-hour   intervals  Time  Between  onset  and  Admission  to  the  Hospital 

and  the  remaining  eleven  were  given  no  transfu-  ^""^                     Transfused                Not  Transfused 

sions.     Although   the   number   of    the   patients   in  l'  "^^^^            I  P^'!^"f  ['."JjI*         t  P^|i^"f  ^'H"] 

"                                                /  3-33   davs              S  patients  (oO%)             3  patients  (60%) 

these   two    groups      (those     given     transfusions     and  "Figures    in    brackets    indicate    the    percentage    of    the 

those  not  given  transfusions)    is  too  small   to  be  "^"^"'^  ^'^^  '''^'^  paralysed. 

conclusive,  it  is  interesting  that  the  incidence  and  ^       ^  Table  3 

'                                  ^  Symptoms  and   Signs 

extent   of  paralysis,   the  symptoms   and  signs,   and  Symptoms                         Transfused    Not  Transfused 

the  duration  of  disease  as  determined  by  fever  were  (13  patients)    (u  patients) 

similar  in  the  two  groups  (tables  1,  2,  3  and  4).  Fever -.. -„    92%*  90% 

Two  patients  who  were  given  transfusions  had  pro-  Headache       61%  72% 

t  ,      ■       c,       ^  f      ■  J  *  u  VomitinK   ...__ _ ____.     46%  54% 

gression  of  paralysis  after  transfusion  and  two  who  Paralvsi-                                 54%               45% 

were  not  given  transfusion  had  progression  of  pa-  Anorexia                                 46%               36% 

ralysis  while  in  the  hospital.     Two  patients  had  Stiff  Neck  30%  54% 

severe  reactions  following  transfusion.  Drowsiness  30%               18% 

.  Upper  respiratory  infection..       7%                    9% 

Iwenty-one  of  these  twenty-four  patients  were  \bdominal                              15%                 0% 

white  and  three  were  colored.    Thirteen  were  boys  Diarrhea  7%  0% 

and  eleven  girls.    There  were  two  instances  of  two  Irritability    _. 7%  0% 

cases  in  one  family,  in  each  pair  was  a  boy  and  a  Convulsion  „ 0%  9% 

.  1        e    u                i    i      lU-        ^    J        i                i-      i          -ii.  'The  figures  indicate  the  percentage  of  the  patients  in 

girl.      Subsequent    to   this   study,    two  patients   with  each   group  who   had   the   symptom   indicated,    e.g.,    11   of 

Bell's  palsy  were  seen  in  the  dispensary,  who  gave  'p'rtient.sT^"K.f"^4?e'noi"™^ll\''.us/c?  ^^           (90%),'et'c." 

a  history  characteristic   of   poliomyelitis   followed  Table  4 

by  unilateral   paralysis   of   the    face.      Both   patients  Duration  of  Disease   (as  determined  by  fever) 

have  regained  some  use  of  the  facial  muscles  fol-  -Davs                       Transfused                    Not  Transfused 

lowing  exercise  and  electrical  stimulation.  "                              ffi6^)                           5  (40^) 

The  average  spinal-fluid  cell  count  in  the  twenty-  »Figures    in    brackets    indicate    percentage    of    patients 

three  cases  in  which  a  lumbar  puncture  was  dons  "                                                                ' 

was    75    cells.      The   non-paralyzed   patients   showed  m^.j^ence  ot  Paralysis   Acco^rding   to   Number   of  Cells   in  \ 

an  average  of  77  cells  as  compared  with  73  cells  ^  „                          _  spinai  Fimd              ,,  ,  ^      ,,  ,„ . 

o                                            '^  Cells                             Transfused                      Not  Transfused 

for  the  paralyzed.     The  lowest  cell  count  was  4  jjq                           j  ^  o%)*                       i  (ioo%) 

and  the  highest  175.     The  percentage  of  paralysis  ii-ioo                        9  (55%)                         4  (50%) 

according  to  the  number  of  cells  is  shown  in  table  101-175                      3  (66%)                         5  (20%) 

5.     Of  the  twelve  patients  whose  blood  was  grouped,  ..-hfl^'f^'^rf  paraly™?'''''    indicate    percentage    of    patients 

all  of  whom  had  transfusions,  three  were  group  A,  References 

one   of  whom  was   paralyzed;    one  was   group   B  1.   Henry,  J,  N.,  &  Johnson,  G.  E.:    J.  A.  M.  A.,  1934, 

and  had  no  paralysis;  one  was  group  AB  and  had  103,  94.                                                                         1 

paralysis;   seven  were  group  O,  four  of  whom  were  Special  Committee  on  Poliomyelitis:     Practical  Sugges- 

•^        ,         ;         ^r     ,,           •   ,  ,                 ,.      ,          ,  lions  on  Poliomvelitis.     A.  M.  A.,  1934. 

paralyzed.      Of    the   eighteen    patients    who    were  schultz,  E.  W.;    /.  Fed.,  1932,  1,  35S. 

given  the  Schick  test,  there  were  two  positive,  both  t.aillens,  M.:     Bidl.  Sac.  de  Pediat.  de  Paris,  1933, 

of  whom  were  paralyzed,  and  sixteen  negative,  of  31,  304.                                                                        ] 

whom  seven  were  paralyzed.  London,  a.  H.,  &  Roberts,  B.  W.  (in  press). 

Committee  on  Poliomvelitis,  and  Christensen,  R.  E.:  , 

StXMMARY  Ugeskrift  for  Laeger,  1935,  97,  837,  855.                               ' 

There  was  no  apparent  difference  in  the  incidence  Brown,  E.  G.:  Pub.  Health  Rep.,  1932,  47,  1899.           ■; 

•From  the  Department  of  Pediatrice,   Duke  University  School   of   Medicine   and  Duke  Hospital,    Durham,   N.   C. 


August,   1936 


TRANSFUSIONS  IN  POLIOMYELITIS— Gay 


419 


Nettee,  a.,  Gexdron  &  Tovr.uxe:   Compt.  rend.  Soc. 
de  biol.,  1911,  70,  625,  707,  739. 

Levinson,   S.   0.,   McDouGAL,   C,   &   Thalhimer,   W.: 
J.  A.  M.  .4.,  1932,  99,  105S. 

Gerstlev,  J.  R.:     M.  Clinks  North  America,  1932,  16, 
517. 

Richardson,  D.  L.,  &  West,  E.  J.:     Rhode  Island  M. 
J.,  1932,  15,  100. 

ScHOTTMULLER,   E.:      Deutsche   Med.   Wchnschr.,   1933, 
59,  43. 

Daneri:     Rev.  Chilena  de  pediat.,  1933,  4,  449. 
Sherman,  I.:     Am.  J.  Dis.  Child.,  1934,  47,  532. 
S.^NDS,  J.  J.:     /.  Nerv.  &  Ment.  Dis.,   1932,  75,  601; 
N.  Y.  State  J.  Med.,  1934,  34,  587. 
SiEGL,  J.:    Wien.  klin.  Wchnschr.,  1934,  47,  237. 
TOROK,  G.:     Med.  Klinik,  1934,  30,  1093. 
2.   Landon-,  J.  F.,  &  Smith,  L.  W.:     Poliomyelitis.     N.  Y., 
The  Macmillan  Co.,  1934. 
Editorial,  /.  .4.  M.  A.,  1934,  104,  262. 
Kramer,  B.:     New  York  State  J.  Med.,  1932,  32,  855. 
Landox,  J.  F.:     /.  Ped.,  1934,  5,  1,  9,  16,  29  &  33. 
Baastrup,  S.:     Ugeskrift  f.  Laeger,  1934,  96,  759. 
Round    Table    Discussion    on    Poliomyelitis.      J.    Fed., 
1935,  7,  277. 

Kramer,   S.   D.,   Aycock,   W.    L.,   Solomon,   E.   I.,   & 
Thenebe.  C.  L.:     New  England  J.  Med.,  1932,  206,  432. 
Kramer,  S.  D.:     Am.  J.  Pbl.  Health,  1932,  22,  380. 
New   York    .■\cademy    of    Medicine    Committee:      Bull. 
New  York  Acad.  Med.,  1932,  8,  613. 
Park,  W.  H.:     /.  ,4.  M.  A.,  1932,  99,  1050. 
Hudson,  N.   P.,  &  Lennette,  E.  H.:     /.  Prev.  Med., 
1932,  6,  335. 

Pregitali,  G.:     Arch.  Ped.,  1932,  49,  540. 
Wesselhoeft,  C:     J.  Ped.,  1933,  3,  330. 
HoEFFLER,    M.:      Munchen    Med.    Wchnschr.,    1933,   80, 
1367. 

Harmon,   P.   H.:      .4m.   /.   Dis.   Child.,   1934,   47,    1179- 
12SS. 

Fischer,  A.  E.:     Am.  J.  Dis.  Child.,  1934,  48,  481. 
ScHULTz.  E.  \V.,  &  Gebhardt,  L.  p.:     /.  Ped.,  1935,  6, 
615. 

Brodie,  M.:     /.  Immunol,  1935,  28,  353. 
Park,  W.  H.,  &  Brodie,  M.:     Am.  J.  Dis.  Child.,  1935, 
50,  1077. 


The  Role  of  Lumbar  Puncture  in  the  Causation  of 

Meningitis 

(D.    B.    Remsen,   Cincinnati,    in   Jl.    of    Med.,    May) 

There  are  many  reports  of  meningitis  occurring  after 
normal  spinal  fluid  has  been  obtained  by  lumbar  puncture. 
Unfortunately  the  records  are  lacking  in  reports  of  simul- 
taneous blood  cultures,  but  the  clinical  descriptions  fre- 
quently allow  for  the  assumption  of  a  septicemia. 

The  tendency  has  long  been  to  multiply  the  indications 
for  performing  the  lumbar  puncture  on  patients  suspected 
of  having  meningitis.  In  fact,  in  any  general  hospital  as 
many  spinal  taps  are  done  for  the  experience  in  technique 
alone,  as  for  any  clinical  purpose.  This  can  only  mean 
that  it  is  regarded  as  almost  free  from  danger,  but  there  is 
a  hazard  in  the  presence  of  a  bacteremia.  The  e.xperimental 
work  as  well  as  isolated  clinical  cases  indicate  that  both 
the  virulence  of  the  organism  for  the  meninges  and  the 
number  of  organisms  in  the  blood  stream  must  be  above 
a  certain  level  before  meningitis  results  from  spinal  punc- 
ture, but  even  with  this  added  margin  of  safety  I  am 
convinced  that  it  is  the  policy  of  wisdom  to  reduce  spinal 
taps  to  a  minimum  in  patients  with  possible  septicemia. 
In  the  presence  of  even  a  suspicion  of  blood-stream  infec- 
tion one  feels  justified  in  urging  the  physician  to  exercise 


cautious  judgment  before  ordering  a  lumbar  puncture. 

I  do  not  wish  to  appear  an  alarmist,  crying  against 
lumbar  punctures,  but  only  to  speak  emphatically  enough 
to  stimulate  the  exercise  of  judgment.  Brief  thought  may 
show  that  very  little  in  the  way  of  neglected  therapy  will 
be  lost  by  this.  Meningococcus  meningitis  appears  fre- 
quently if  not  always  to  be  ushered  in  by  a  septicemia. 
The  diagnosis  of  the  septicemia  is  commonly  made  by 
clinical  observations  and  the  variations  in  the  intensity 
of  the  infection  from  a  fulminating  one  with  death  in  a 
few  hours  to  the  transitory  illness,  over  in  a  day  or  two, 
are  well  known.  There  is  still  the  too-easy  assumption 
that  lumbar  puncture  can  do  no  harm  since  the  menin- 
gococcus septicemia  is  all  too  frequently  regarded  as  a 
certain  forerunner  of  meningitis.  The  logical  way  to  handle 
such  cases,  it  seems,  would  be  to  treat  the  blood  injection 
by  intravenous  antiserum,  and  avoid  lumbar  puncture  until 
signs  of  meningeal  involvement  are  present.  As  for  sep- 
ticemia with  any  one  of  the  pyogenic  organisms,  it  might 
even  be  questioned  whether  lumbar  puncture  should  be 
performed  at  all  even  though  signs  of  meningitis  are  present. 
The  incidence  of  recovery  from  a  meningitis  due  to  these 
organisms  is  tragically  small.  Until  some  satisfactory  ther- 
apeutic measures  are  found,  or  some  adequate  means  for 
ameliorating  symptoms  appear,  the  obtaining  of  spinal 
fluid  does  no  more  than  establish  the  suspected  diagnosis. 


Children's  Teeth  tn  Relation  to  Pediatric  Practice 

(J.    B.   stone,   Richmond,   Va.,   in   Sou.    Med.   Jl.,  July) 

Dental  hypoplasia  and  caries  can  be  definitely  influenced 
by  diet,  and  liberal  amounts  of  dairy  products,  eggs,  bulky 
vegetables,  fruits  and  codliver  oil  are  effective  in  the  pre- 
vention and  arrest  of  both  hypoplasia  and  caries. 

The  present  report  on  a  study  of  a  small  group  of  cases 
in  private  practice  is  to  be  regarded  as  suggestive  rather 
than  conclusive. 

Children  breast-fed  for  6  to  12  months  showed  as  much 
caries  as  did  those  breast-fed  for  only  1  month. 

Children  under  supervision  from  early  infancy  whose 
prescribed  diet  included  the  so-called  essential  foods  and 
codliver  oil  or  its  equivalent  showed  about  as  high  inci- 
dence of  caries  as  those  first  observed  after  4  years  of  age 
and  whose  feeding  histories  suggested  a  less  adequate  diet. 
However,  in  the  former  group  it  was  noted  that  the  caries 
was  usually  less  extensive  and  restorative  work  was  done 
before  advanced  destruction  of  the  teeth  occurred. 

In  those  children  of  good  general  nutrition  the  incidence 
and  the  extent  of  the  caries  was  less  than  in  those  with 
poor  nutrition. 

Even  when  all  available  knowledge  of  this  subject  is 
utilized  it  seems  that  caries  inevitably  occurs  in  the  decidu- 
ous teeth  of  a  large  number  of  children.  The  physician 
should  be  constantly  on  the  lookout  for  such  conditions 
md  with  the  co-operation  of  a  competent  dentist,  and  by 
inclusion  in  the  diet  of  those  things  known  to  have  a 
favorable  influence  on  the  arrest  of  caries,  and  by  other 
measures  that  will  make  for  the  child's  best  general  health, 
much  can  be  done  to  prevent  further  progress  of  the  de- 
structive process. 


The  signs  and  symptoms  of  alcoholic  pellagra  (T.  D. 
Spies,  Cincinnari,  in  //.  of  Med.,  May)  and  endemic  pel- 
lagra appear  similar.  Alcohol  alone  does  not  cause  the 
development  of  pellagra  provided  an  adequate  diet  is  taken. 
If  pellagra  is  treated  adequately,  alcohol  does  not  prevent 
the  healing  of  lesions.  Fifty  per  cent,  alcohol  does  not 
directly  inactivate  all  the  protecting  substances  in  food. 


Many  a  dermatitis  is  caused  by  a  drug. 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


The  Apportionment  of  Insulin  Throughout  the  Day  in  the 
Treatment  of  Diabetes 

William  R.  Jordan,  M.D.,  Richmond,  Virginia 


THE  daily  use  of  insulin  in  the  treatment  of 
a  diabetic  gives  best  results  when  doses  of 
the  proper  size  are  given  at  the  prop>er 
hours.  It  is  not  sufficient  to  know  merely  the  ap- 
proximate total  daily  requirement.  We  must  know 
what  proportion  of  the  dosage  should  be  given  at 
different  hours  of  the  day  and  at  what  time  each 
dose  is  indicated.  This  varies  in  different  patients 
and  even  in  the  same  patient  with  varying  exercise, 
etc.  To  a  diabetic  whose  carbohydrate  tolerance 
and  insulin  requirements  are  unknown,  it  is  well 
to  give  a  small  dose  of  insulin  and  determine  its 
effect  before  subsequent  doses  are  given.  Except 
in  emergencies,  which  we  will  not  consider  here, 
it  is  usually  safer  and  better  to  give  small  doses 
and  to  increase  these  doses  slowly  and  gradually 
and  thus  gradually  reduce  the  blood  sugar  level 
than  it  is  to  try  to  bring  the  blood  sugar  to  normal 
within  a  few  hours.  Especially  is  this  true  of  the 
older  patient  who  is  particularly  liable  to  anginal 
or  cerebral  attacks. 

The  proper  insulin  dosage  cannot  be  foretold 
accurately  in  any  case,  although  knowledge  of  the 
patient's  age  and  previous  diet  and  of  the  duration 
of  the  disease  is  helpful.  One  determines  the  dose 
by  trial.  A  dose  of  5  units  can  be  given  and  its 
effect  determined  by  urine  examination.  If  the  gly- 
cosuria has  not  decreased  markedly  before  the  next 
meal  is  given,  this  dose  may  be  repeated  and  a 
subsequent  test  for  urinary  sugar  made.  If  the  gly- 
cosuria remains  high,  6  or  8  units  of  insulin  may 
be  given  before  breakfast  the  following  morning. 
Urine  examinations  are  then  made  before  lunch 
and  before  supper,  and  3  to  6  units  of  insulin  are 
given  at  these  times  in  accordance  with  the  tests. 
We  may  even  give  2  to  4  units  of  insulin  at  bed- 
time if  the  glycosuria  has  not  decreased  satisfac- 
torily. Daily  quantitative  determinations  of  the 
sugar  in  the  24-hour  specimens  of  urine  should  be 
made  and  the  subsequent  insulin  dosage  regulated 
accordingly.  An  increase  in  each  dose  of  2  to  3 
units  each  day  is  often  adequate.  When  the  urine 
has  become  sugar-free,  we  can  look  back  at 
his  record  and  see  the  total  amount  of  insulin  used 
in  each  24-hour  period.  This  tells  us,  not  how 
much  insulin  was  required  for  the  diet  which  the 
patient  was  eating  during  that  period,  but  the 
amount  of  insulin  the  patient  needed  to  utilize 
that  diet  and  the  excess  sugar  which  was  in  his  sys- 
tem. Therefore  it  is  often  necessary  either  to 
increase  the  diet  or  to  reduce  the  insulin. 


Now  that  we  know  the  approximate  24-hour  re- 
quirement of  this  patient,  we  can  more  easily  esti- 
mate at  what  hours  he  is  apt  to  need  the  insulin 
and  how  much  should  be  given  each  time.  To 
determine  these  factors  we  make  use  of  our  knowl- 
edge of  the  action  of  insulin.  Usually  insulin  given 
subcutaneously  begins  to  take  effect  within  15  to 
20  minutes  and  its  maximum  action  is  reached  in 
about  an  hour.  The  food  ingested  undergoes  rapid 
absorption  within  30  minutes,  so  that  the  maxi- 
mum blood  sugar  level  is  reached  about  an  hour 
after  the  meal  is  eaten.  Therefore  we  give  insulin 
20  minutes  before  the  meal  so  that  its  greatest 
activity  will  coincide  with  the  period  of  the  fastest 
absorption  of  food,  and  thus  prevent  the  usual 
elevation  of  the  blood  sugar.  Three  to  4  hours 
after  insulin  is  given  or  3)4  hours  after  the  food 
is  eaten,  the  effect  of  insulin  is  most  noticeable, 
yet  the  action  of  insulin  persists  for  8  hours.  Even 
after  this  8-hour  period,  there  is  an  indirect  effect 
of  insulin  because  it  enables  the  patient  to  enter 
the  second  8-hour  period  with  blood  sugar  consid- 
erably below  the  level  it  would  have  been  had 
insulin  not  been  given.  Assuming  that  the  24-hour 
insulin  requirement  is  10  units  or  less,  this  entire 
amount  may  be  given  20  minutes  before  breakfast. 
In  this  way  the  insulin  enables  the  patient  to  utilize 
his  breakfast  and  his  lunch,  and  it  gives  him  a 
relatively  low  blood  sugar  at  supper  time  so  that 
the  blood  sugar  rise  following  supper  may  not 
exceed  the  normal  level.  Often  a  person  requiring 
only  10  units  of  insulin  each  day  has  so  mild  a 
diabetes  that  his  blood  sugar  exceeds  normal  at 
no  time  other  than  shortly  after  meals.  When  we 
give  merely  one  dose  a  day,  we  should  determine 
the  blood  sugar  level  3)^  hours  after  breakfast. 
If  the  blood  sugar  is  too  low,  the  insulin  dosage 
should  be  divided,  giving  a  slightly  larger  portion 
before  breakfast  and  the  remainder  20  minutes  be- 
fore supper.  For  example,  for  the  requirement  of 
10  units,  6  units  may  be  given  before  breakfast 
and  4  before  supper.  The  reason  for  this  distribu- 
tion is  that  the  breakfast  insulin  must  care  for 
breakfast  and  for  lunch,  whereas  the  supper  dose 
is  given  for  that  one  meal. 

In  somewhat  more  severe  diabetes  cases,  requir- 
ing more  than  10  units  daily,  it  is  usually  necessary 
to  divide  the  dosage  into  two  parts,  the  morning 
dose  being  somewhat  greater  than  the  evening  dose. 
For  example,  a  requirement  of  20  units  would  ne- 
cessitate a  morning  dose  of  12  units  and  an  evening 


August,   1936 


APPORTIONMENT  OF  INSULIN— Jordan 


dose  of  8  units.  If  with  this  amount  the  diabetes 
is  not  sufficiently  controlled,  each  dose  may  be 
increased  gradually  day  after  day  until  the  blood 
sugar  reaches  the  proper  level,  or  until  hypoglyce- 
mia occurs.  Some  patients  can  take  a  dosage  of 
24  units  before  breakfast  and  20  before  supper 
without  glycosuria  and  without  insulin  reactions. 
This  is  not  usually  the  case. 

Diabetes  severe  enough  to  require  more  than  30 
units  daily  usually  requires  at  least  three  doses 
each  day — a  breakfast  dose,  a  supper  dose  and  a 
dose  at  bedtime  or  at  noon.  Usually  in  such  severe 
diabetes  the  fasting  blood  sugar  is  considerably 
elevated,  and  this  necessitates  the  giving  of  insulin 
at  bedtime  even  though  the  patient  shows  no  gly- 
cosuria before  breakfast.  JNIore  rarely  one  encoun- 
ters a  diabetic  who  requires  considerable  insulin  to 
enable  him  to  utilize  his  meals,  and  yet  the  fasting 
blood  sugar  remains  essentially  normal.  In  the 
former  instance  an  insulin  dosage  of  36  units  would 
be  divided  as  follows — 18  units  before  breakfast, 
14  units  before  supper  and  4  units  at  bedtime. 
The  bedtime  dose  need  not  be  large.  Two  to  6 
units  of  insulin  at  that  hour  is  often  adequate. 
Occasionally  in  the  diabetes  of  young  subjects  the 
bedtime  dose  is  as  much  as  10  or  even  12  units. 
In  the  second-type  patient  whose  fasting  blood  su- 
gar remains  satisfactory  and  the  breakfast  dose  of 
a  size  which  will  not  produce  insulin  reactions  at 
noon  fails  to  care  for  the  noon  meal,  we  must  give 
some  insulin  about  20  minutes  before  lunch.  The 
insulin  dosage  in  this  latter  case  would  be  approx- 
imately 17  units  before  breakfast,  6  units  before 
lunch  and  13  units  before  supper.  In  general  we 
try  to  avoid  the  noon  dose  of  insulin.  It  is  apt  to 
be  inconvenient,  for  children  are  at  school  and 
adults  very  often  are  away  from  home  for  the 
noonday  meal.  The  reason  the  breakfast  dose  is 
made  so  large  is  that  the  blood  sugar  rises  to  a 
greater  extent  after  this  meal  in  many  cases  than 
after  the  other  two  meals  of  the  day.  Occasionally 
we  can  obviate  the  necessity  for  a  noon  dose  by 
increasing  the  insulin  before  breakfast  and  then 
giving  a  light  lunch  of  carbohydrate  food  three 
hours  after  breakfast  to  prevent  the  otherwise  in- 
evitable insulin  reaction,  or  by  shifting  food  from 
lunch  to  supper  or  increasing  the  afternoon  exercise 
we  may  dispense  with  a  noon  dose.  Intervals  of 
less  than  five  hours  between  meals  may  contribute 
to  glycosuria  and  this  should  be  corrected. 

Unfortunately  many  young  diabetics  suffer  from 
insulin  reactions  if  the  size  of  the  insulin  dose  is 
increased  sufficiently  to  carry  through  from  break- 
fast to  supper;  furthermore,  the  fasting  blood  sugar 
in  these  patients  is  too  high.  This  necessitates  the 
giving  of  four  doses  daily — breakfast,  lunch,  supper 
and  bedtime.    The  amount  of  insulin  given  at  any 


particular  time  will  depend  on  the  blood  sugar 
level  and  the  glycosuria  during  this  period.  When 
the  blood  sugar  is  high  despite  fasting,  the  dose 
at  bedtime  must  be  increased.  Glycosuria  occur- 
ring after  supper  usually  means  that  the  insulin 
before  supper  should  be  increased  and  similarly  at 
other  times  of  the  day.  In  general  about  40  per 
cent,  of  the  insulin  is  given  before  breakfast,  20 
per  cent,  before  lunch,  30  per  cent,  before  supper 
and  10  per  cent,  at  bedtime;  e.g.,  if  a  dosage  of  SO 
units  of  insulin  is  required  daily,  20  units  would 
be  given  before  breakfast,  10  units  before  lunch, 
15  units  before  supper  and  5  units  at  bedtime.  If 
we  find  that  the  blood  sugar  during  fasting  is  not 
then  satisfactory  and  an  increase  of  the  bedtime 
dose  produces  an  insulin  reaction  during  the  night, 
we  can  advance  the  breakfast  dose  to  one  hour 
before  that  meal.  Occasionally  if  the  reaction 
occurs  within  two  hours  after  the  bedtime  dose  is 
given,  it  is  of  advantage  to  give  10  gm.  of  carbo- 
hydrate at  the  time  the  insulin  is  taken. 

One  sometimes  gives  insulin  every  eight  hours, 
at  7  a.  m.,  3  and  11  p.  m.  In  general  this  is  less 
effective  because  meals  are  not  served  at  such  times 
and  therefore  maximum  action  of  insulin  is  not 
obtained  during  the  most  rapid  rise  of  the  blood 
sugar.  Here  again  the  proportion  of  insulin  to  be 
given  at  each  time  must  be  determined  by  the  gly- 
cemia  and  glycosuria.  One  such  patient  found  that 
the  best  distribution  for  her  was  20  units  at  7 
a.  m.,  14  units  at  3  p.  m.  and  9  units  at  11  p.  m. 
To  prevent  reactions  daily  at  11;30  a.  m.,  she 
takes  three  ounces  of  milk  and  one  Uneeda  biscuit 
just  prior  to  this  time. 

We  have  found  the  so-called  4-period  test  of 
great  advantage  in  helping  us  determine  the  proper 
distribution  of  insulin.  This  test  involves  quanti- 
tative sugar  determinations  of  the  24-hour  urine 
collected  in  four  specimens.  The  first  specimen 
includes  all  the  urine  formed  between  breakfast 
and  lunch,  the  second  includes  that  between  lunch 
and  supper,  the  third  is  that  from  supper  to  bed- 
time, the  fourth  includes  the  urine  formed  from 
bedtime  to  breakfast.  In  this  way  we  determine 
how  much  sugar  is  spilled  in  the  urine  after  each 
meal  and  during  the  night,  and  we  regulate  the 
insulin  dosage  accordingly.  Occasionally  this  test 
is  somewhat  misleading  because  the  glycosuria  fol- 
lows to  a  certain  extent  the  rise  in  blood  sugar, 
and  because  the  indirect  action  of  insulin  may  be 
overlooked.  This  is  well  illustrated  in  a  patient 
whose  4-period  test  showed  much  sugar  after  break- 
fast and  none  in  the  other  three  specimens.  She 
had  an  insulin  reaction  at  10:40  p.  m.  One  might 
conclude  from  this  that  the  patient  needed  more 
insulin  in  the  morning  and  less  at  night,  yet  her 
dosage  was  25  units  before  breakfast  and  10  units 


APPORTIONMENT  OF  INSULIN— Jordan 


August,  1936 


before  supper.  We  suspected  that  the  glycosuria 
following  breakfast  was  due  to  an  abnormally  high 
blood  sugar  before  breakfast,  and  this  was  con- 
firmed by  examination  of  the  blood.  We  concluded 
that  the  large  dose  of  insulin  at  breakfast  main- 
tained the  blood  sugar  at  such  a  low  level  in  the 
late  afternoon  that  the  10  units  at  supper  was  suf- 
ficient to  produce  hypoglycemia.  Furthermore,  the 
small  dose  of  insulin  at  supper  was  insufficient  to 
maintain  the  blood  sugar  at  a  normal  level  through- 
out the  night.  We  therefore  reduced  the  morning 
dose  to  18  units,  raised  the  supper  dose  to  14  units 
to  compensate  for  the  reduction  in  the  breakfast 
dose  and  gave  4  units  of  insulin  at  bedtime  to 
lower  the  blood  sugar  during  fasting.  These  changes 
reduced  the  blood  sugar  of  fasting  from  360  mg. 
to  120  mg.,  eliminated  the  insulin  reaction  after 
supper,  and  kept  the  urine  sugar-free  throughout 
the  24  hours.  It  is  not  infrequent  that  one  obtains 
a  negative  test  on  the  urine  voided  before  break- 
fast, and  yet  the  blood  sugar  during  fasting  is  very 
high. 

Patients  receiving  insulin  in  equal  doses  before 
each  meal  show  one  of  two  things  in  most  cases: 
either  the  blood  sugar  remains  too  high  in  the 
early  part  of  the  day,  else  it  goes  too  low  in  the 
late  afternoon  or  in  the  early  part  of  the  night.  If 
15  units  of  insulin  is  given  before  each  meal,  a 
part  of  the  dose  given  at  breakfast  is  still  effective 
in  handling  the  lunch,  and  this  effect  is  augmented 
by  the  15  units  given  at  lunch.  Similarly,  the 
effect  of  the  supper  insulin  is  added  to  the  action 
of  the  noon  insulin  on  the  evening  meal.  The  re- 
sult of  this  process  is  either  glycosuria  in  the  morn- 
ing or  hypoglycemia  in  the  late  afternoon  or  during 
the  early  part  of  the  night.  In  the  latter  instance 
much  of  the  insulin  given  at  noon  is  wasted. 

In  closing,  I  would  emphasize  that  insulin  does 
not  have  its  maximum  action  for  some  time  after 
it  is  given,  and  that  it  therefore  should  be  given 
before  meals.  Its  action  persists  for  about  eight 
hours,  and  this  should  be  considered  in  the  distri- 
bution of  the  insulin  throughout  the  24-hour  period. 
Finally,  to  determine  the  proper  dosage  and  distri- 
bution, we  must  make  full  use  of  frequent  exam- 
inations of  the  blood  and  the  urine  for  sugar. 


The   Gexerai   Practitioner   .\nd   Allergy 

(T.   D.   Cunningham  &.  J.   C.    Mendenhall,   Denver,  In  Col. 

Med.,  July) 

The  number  of  people  who  are  allergic  has  been  under- 
estimated. The  following  list  will  give  some  idea  as  to 
how  many  conditions  have  been  overlooked  or  classed  as 
neurosis  which  are  usually  allergic. 

On  the  skin  we  have  acne,  acute  and  chronic  eczema, 
acute  dermatitis,  urticaria,  and  pruritis  ani.  The  mucous 
membrane  manifestations  are  many:  hayfever,  asthma, 
chronic  nasal  catarrh,  chronic  colds,  winter  coughs,  vas- 
omotor rhinitis,  canker  sores  in  the  mouth,  edema  of  the 
lips,   vomiting,   gallbladder  pain,   indigestion   and   mucous 


colitis. 

Vaughan  states  that  70%  of  migraine  cases  are  allergic, 
a  few  epileptics  will  have  attacks  after  ingesting  foods  to 
whic  hthey  are  sensitive. 

Waldbott  states  that  the  so-called  thymic  death  is  an 
allergic  phenomenon  similar  to,  or  identical  with,  anaphy- 
lactic shock. 

Ever\-  good  case  history  should  contain  a  record  of 
whether  allerg\'  is  or  is  not  in  the  family.  There  is  hardly 
a  system  in  the  body  free  from  allergic  manifestations. 
The  general  practitioner  cannot  ignore  the  importance  of 
allergy  in  his  practice. 

Excellent  results  are  obtainable  with  co-operation  be- 
tween the  allergic  patient  and  the  family  doctor. 


Low  Back  Pain 
(R.  A.  Milliken,  Little  Rock,  in  Jl.  Ark.  Med.  Soc,  July) 
Of  recent  years  Albee  has  been  preaching  that  most  so- 
called  lumbago  is  a  myofibrositis.  I  had  occasion  to  lunch 
beside  him  a  few  years  ago  and  heard  it  all  expounded 
with  mallet-stroke  diction,  but  I  was  left  a  bit  vague  as 
to  whether  this  myofibrositis  is  due  to  focal  infection,  the 
phases  of  the  moon,  or  the  Hoover  administration.  This 
is  but  a  revivification  of  an  old  concept  and  rests  on  a 
solid  foundation  of  cases  miraculously  cured  by  tonsillec- 
tomy, by  prostatic  massage,  or  by  tooth  extraction.  "The 
cause  of  backache,"  say  these  people,  "is  anywhere  but  in 
the  back."  The  mechanical  concept  of  backache  is,  I  think, 
attributable  to  Goldthwait  who  about  1903  published  an 
article  about  the  sacroiliac  joint.  He  has  had  occasion  to 
repent  very  deeply  for  since  then  sacroiliac  subluxation  or 
strain  has  been  the  diagnosis  put  on  thousands  of  cases 
which  show  tenderness  to  pressure  over  the  posterior  spine, 
or  show  limitation  of  straight  leg-raising  on  one  side.  .\nd 
yet  I  believe  he  was  right  in  his  fundamental  unspoken 
conviction  that  the  cause  of  backache  is  in  the  back  and 
that  it  is  there  that  the  cause  must  first  be  sought,  though 
of  later  years  he  and  his  followers  have  paid  less  attention 
to  the  sacroihac  and  more  to  the  lubbosacral  articulation. 


The   Endocrine   Relationship  to   the   Etiology   of 

Cancer 

(N.     K.    Forster,    Hammond,    In    J  I.    Indiana    State    Med. 
Assn.,  July) 

Certain  endocrine  secretions,  especially  those  of  the 
pituitary  anterior  lobe  and  its  dependencies,  are  concerned 
in  the  production  of  cancer  and  other  malignant  disease 
on  the  basis  that  these  hormones  accelerate  growth.  The 
pancreatic  and  thyroid  secretions,  and  possibly  those  of 
the  liver,  are  concerned  possibly  in  the  metabolism  of 
malignant  growths.  Certain  unsaturated  hydrocarbons 
favor  malignancy  because  they  are  growth-stimulating  sub- 
stances. They  may  produce  carcinoma  or  sarcoma  accord- 
ing to  the  tissue  affected  by  them.  Some  of  these  carci- 
nogenetic  hydrocarbons  can  produce  the  phenomena  of 
estrus.  Certain  body  substances  and  secretions,  including 
the  estrin  hormone,  contain  in  their  chemical  structures 
substances  equivalent  to,  if  not  actually  identical  with,  the 
carcinogenetic  hydrocarbons.  Carcinogenesis  and  estrogene- 
sis  are  associated  and  estrin  may  be  the  carcinogenetic 
agent  in  the  production  of  cancer  of  the  female  genitalia. 


Ordinarily,  in  the  16th  century,  midwtves  only 
were  ADinxTED  to  the  delivery  room  {\.  C.  Hansen,  in 
Mil-ivaukee  Med.  Times,  July),  a  custom  which  was  rigidly 
adhered  to  in  Europe.  In  the  year  1521,  a  Hamburg  phy- 
sician named  Veithes  dressed  himself  as  a  midwife  and 
brought  to  a  happy  conclusion  a  labor  which  the  midwives 
could  not  complete.  For  this  trouble  he  was  burned  at  the 
Etake. 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Acute  Laryngeal  Stenosis  in  Children 

E.  W.  Carpenter,  M.D.,  Greenville,  South  Carolina 

MV  PURPOSE  in  presenting  this  topic  is             Average  in  months  3.164 
three-fold:  first,  because  it  is  one  in  which            Intubations  22 
.                                  ji        i                 Tracheotomies  Jl 
we    are    greatly    interested,    secondly,    to             ^^^^  tracheotomies  and  intubations -    10 

compare  our  records  of  2i  years  ago  with  the  pres-  Mortality  18  (29%) 

ent-day  results  and  procedures  and,  third,  to  ana-  Eight  tracheotomy  cases  had  peanut  broncho- 

lyze  records  at  the  General  Hospital  during  the  last  pneumonia 

four  years  Deaths   in   intubation   cases  13% 

„',,  T  xj  •         c  1  c  in  tracheotomy  cases  _„ . 26 

Twenty-three  years  ago  I  reported  a  series  of  15  .^  intubation  and  tracheotomy  cases 70 

cases  of  intubation  performed  during  the  two  pre-  Laboratory  reports  positive  for  diphtheria 33 

ceding  winters  with  a   mortality   of    13   per  cent.  Respiratory  type  infection     — 14 

covering  a  territory  extending  from  Westminster  to  Negative    * 

Union  and  from  the  upper  part  of  this  county  into  None  on  record 4 

Laurens  County.     Some  of  these  cases  were   100  Cause  of  death 

.,  ^        r  _  a-         Tu  A  Bronchopneumonia   o 

miles  apart  and  30  miles  from  my  office.     1  he  roads  ^^^j^, 2 

were  firm  hard  clay  in  dry  weather  and  the  most  Cardiac 4 

lu.xurious  deep,  slippery  ruts    and    holes    in    wet  Pulmonary  edema 2 

weather.    There  were  very  few  phone  lines  through  Emphyema 1 

the  country  and  only  those  doctors  whose  wives  '^     ^"* 

could  endorse  for  them  owned  an  automobile.  Folks  -pgiui 18 

came  for  the  doctor  on  or  behind  a  mule  or  horse  you  will  note  the  mortality  in  intubation  cases 
and  usually  arrived  in  the  afternoon  or  night.  23  years  ago  was  the  same  as  in  these  recent  cases. 
Most  of  my  visitations  were  done  at  night,  driving  ^j^^^  ^^le  mortality  after  tracheotomy  is  twice  as 
as  far  as  the  roads  went  and  then  getting  a  neigh-  g^g^^^  ^^  ^f^^^.  intubation.  You  may  immediately 
bor  to  take  me  the  rest  of  the  way  in  a  wagon  or  ^^^^  ^^  ^^^  conclusion  that  intubation  is  twice  as 
some  other  horse-drawn  rig.  Thus  when  the  doctor  ^^f^  ^^  tracheotomy.  This  is  not  the  fact.  There 
arrived  precious  time  had  been  lost.  i^  ^^^^^^  ^  distinct  field  of  usefulness  for  each  pro- 
Few  of  these  patients  were  seen  in  the  interval  cedure.  Tracheotomy  is  done  when  our  judgment 
between  intubation  and  extubation  unless  they  dictates  that  intubation  will  not  suffice  and  some- 
coughed  up  the  tube  and  there  was  time  to  arrive  times  we  find  that  having  done  intubation  our  judg- 
before  death.  Several  did  extubate  themselves  but  nient  was  erroneous.  x'Vs  a  rule  the  younger  the 
only  one  died.  This  may  suggest  to  you  that  they  patient  the  greater  is  the  indication  for  tracheo- 
were  mild  cases;  the  contrary  is  true.     People  did  tomy. 

not  go  for  a  specialist  in  those  days  unless  the  pa-  Modern   direct   methods   permit   us   to   make   a 

tient  was  in  extremis  and  when  he  arrived  the  baby  much  more  correct  diagnosis  and  to  use  better  dis- 

was  usually  blue,  with  swollen  face  and  neck  and  crimination    in    choosing    between    intubation   and 

great  suprasternal  tugging  and  protruding  eyeballs,  tracheotomy,  and  then  produce  less  trauma. 

In  none  of  these  cases  was  tracheotomy  done:  in  past  years  we  seldom  saw  a  case  until  the 

the  parents  would  not  permit  it  because  there  was  patient  was  in  extremis,  had  been  laboring  for  days 

no  one  to  properly  nurse  the  case  and  the  tech-  for   breath   and   was  exhausted.     Today   they  are 

nique  was  not  so  highly  developed  as  now.  brought   into,  the  hospital   earlier   in   their   illness. 

Hospitals   tabooed   such  cases.     Most   of   them  Any   child   who   has   suffered    several    hours   with 

were  called  membranous  croup  by  the  family  doctor  obstructive  dyspnea  and  the  symptoms  increasing 

and  the  first  case  I  succeeded  in  having  admitted  in  severity  should  be  relieved. 

to  the  hospital  was  on  this  distinction.     My  con-  When  dyspnea  begins  a  vicious  circle  is  estab- 

science  was  not  serene  and  I  advised  isolation.  This  lished.     Congestion   and   edema   may  be  the  first 

was  done  by  caring  for  the  baby  in  a  lavatory.  cause  and  as  a  child  struggles  for  breath  there  is 

I  now  wish  to  report  a  series  of  62  cases  occur-  more  and  more  stasis  and  greater  and  greater  dysp- 

ring  in  the  years  1931-32-33  and  34  at  the  General  nea.     The  first  examination  usually  frightens  the 

Hospital.    This  does  not  include  private  cases  at-  child,  which  also  increases  the  distress.     At  times 

tended  outside  this  institution.  oxygen  will  soothe  and  quiet  and  if  it  can  be  kept 

Total  cases  at  the  General  Hospital  1930-1934    62  Quiet,  fed  oxygen  as  required  and  given  cool  air 

Total  of  ages  in  months    ,_ 1962  perhaps  it  will  cough  up  a  chunk  of  membrane 


LARYNGEAL  STENOSIS— Carpenter 


and  a  quantity  of  thick  mucous  which  will  obviate 
the  necessity  of  interference. 

A  child  with  slight  dyspnea  if  taken  into  a 
warm  crowded  room  where  the  oxygen  is  dimin- 
ished will  have  to  pump  much  harder  than  if  taken 
out  of  doors.  I  have  kept  them  outside  and  warm 
in  the  dead  of  winter  and  tided  them  over  a  tight 
place. 

Sedatives  must  not  be  given,  as  this  reduces  the 
ability  of  the  voluntary  muscles  of  respiration  to 
function. 

If  you  wish  to  sympathize  with  these  little  suf- 
ferers just  obstruct  your  breathing  to  the  point 
where  supra-  and  infra-sternal  and  epigastric  re- 
cession occur  on  inspiration  and  you  will  appre- 
ciate their  suffering. 

Indikect  Intubation 

Hippocrates  mentions  the  passage  of  the  sounds 
through  the  larynx  for  obstructed  respiration,  so 
you  see  the  effort  to  relieve  laryngeal  dyspnea  is 
ancient. 

Bauchut  (1858)  produced  silver  tubes  introduced 
on  a  sound  and  attached  to  a  thread  for  relief  of 
laryngeal  obstruction.  Numerous  changes  and  im- 
provements were  added  until  O'Dwyer,  of  New 
York,  perfected  his  tubes  and  technique  which 
have  not  been  surpassed  for  the  indirect  method. 

Not  every  one  who  has  tried  has  been  able  to 
master  this  procedure.  In  order  to  perform  it  cor- 
rectly the  patient  must  be  held  in  correct  position 
and  the  doctor  must  visualize  the  anatomy  of  the 
parts  clearly  in  order  to  cause  the  tube  to  traverse 
the  normal  deviations  of  the  mouth,  pharynx  and 
larynx.  His  manipulations  must  be  of  the  gen- 
tlest. I  have  seen  it  done  as  if  by  magic  and  I 
have  seen  doctors  bloody  almost  up  to  their  elbows 
before  succeeding  in  introducing  a  tube.  All  forms 
of  trauma  must  be  avoided  so  far  as  possible. 
Numerous  sizes  and  patterns  of  tubes  have  been 
devised  for  stenotic  complications — some  very  thin 
at  the  neck,  some  with  bulbous  end,  some  with  a 
swell  in  the  middle,  some  cut  out  behind  the  head, 
etc.  Great  things  were  accomplished  with  these 
tubes  but  many  chronic  conditions  followed.  Our 
impression  since  the  perfection  of  the  technique 
for  tracheotomy  and  improvement  of  the  tubes  is 
that  there  are  also  fewer  chronic  cases  following 
tracheotomy. 

If  the  patient's  condition  permits,  a  general  phy- 
sical examination  and  history  should  be  procured 
and  direct  inspection  of  its  hypopharynx  and 
larynx  should  be  done.  This  will  guide  us  on 
our  way.  The  indirect  method  of  inspection  is 
impractical  in  children. 

Direct  Intubation 
This   may   reveal  a   negative   hypopharynx   and 
larynx  and  lead  us  to  discover  an  enlarged  thymus, 


atelectasis,  pneumonia,  emphysema,  recurrent  pa- 
ralysis— double  or  single — or  foreign  body.  On 
the  other  hand  we  may  observe  edema  of  the  glot- 
tis, purulent  accretions,  membranous  obstruction, 
abscess  in  pyriform  sinus,  retropharyngeal  abscess, 
edema  of  the  epiglottis,  subglottic  swelling,  acute 
tonsillitis  with  large  pendulous  tonsils  blocking  in- 
spiration, papilloma,  catarrhal  laryngitis  with 
croup,  or  laryngismus  stridulus. 

The  last-named  affection  is  seldom  seen  and  it 
is  generally  observed  in  neurotic  children  who  have 
rickets.  A  few  drops  of  chloroform  usually  suffices 
but  occasionally  intubation  or  tracheotomy  has  to 
be  performed. 

The  findings  lead  us  to  select  our  procedure. 
Tracheotomy  in  itself  carries  a  mortality  of  scarce- 
ly one  per  cent.,  but  the  occasions  for  this  operation 
are  serious  and  this  is  the  reason  for  a  high  mor- 
tality. The  causes  of  death  as  shown  in  the  sketch 
will  convince  that  most  of  the  cases  were  doomed 
from  the  beginning.  Some  excellent  laryngologists 
believe  that  all  of  these  inflammatory  membranous 
cases  are  diphtheritic  and  that  the  mixed  infections 
represent  complications.  Our  experience  does  not 
sustain  this  point  of  view.  We  are  convinced  that 
there  are  primary  streptococcic  and  other  respira- 
tory types  of  infections.  We  believe  that  all  of 
these  cases  should  be  treated  as  diphtheria  and 
given  antitoxin  after  testing  for  allergy.  If  the 
laboratory  reports  show  the  absence  of  diphtheria 
organisms  and  the  presence  of  a  mixed  infection 
we  have  not  lost  anything.  The  foreign  protein  will 
do  good  in  these  cases. 

Technique  of  Tracheotomy 
The  patient  should  be  flat  on  the  table  with  a 
slight  pad  under  the  shoulders,  one  assistant  at  the 
head  and  one  to  hold  arms,  body  and  knees  steady 
on  the  table.  The  chin  is  raised  and  three  lines 
visualized  on  the  neck  forming  a  triangle  with  its 
base  on  a  level  with  the  Adam's  apple  and  the  apex 
of  the  sternal  notch,  the  outside  lines  being  near 
and  parallel  with  the  sternomastoid  muscle.  (Jack- 
son) 

The  operator  tucks  his  fingers  under  the  patient's 
chin,  putting  the  tissues  in  the  front  of  the  neck 
on  the  stretch  and  with  one  sweep  cuts  down  to 
the  trachea  in  the  midline,  where  there  are  no 
important  vessels.  Occasionally  a  transverse  thy- 
roid vein  is  cut.  If  lateral  traction  is  made  the 
normal  relations  are  disturbed  and  disaster  may 
follow.  The  first  ring  of  the  trachea  should  be 
identified  and  the  incision  should  be  through  the 
second  and  third  rings,  always  keeping  in  the  mid- 
line. If  there  is  great  dyspnea  and  bulging  upward 
of  the  mediasternal  contents  it  is  safer  to  make  the 
incision  from  below.  Try  to  have  a  dry  field  be- 
fore incising  the  trachea  but  in  an  emergency  incise 


August,  1936 


LARYNGEAL  STENOSIS— Carpenter 


42S 


the  trachea  and  turn  the  patient  on  its  side.  This 
sounds  simple  but  in  an  infant  dying  from  an 
obstructed  larynx  the  venous  system  is  enormously 
distended,  minute  veins  are  dilated  and  the  back 
pressure  causes  tremendous  bleeding. 

It  is  seldom  justifiable  to  cut  the  cricoid  or  the 
thyroid  but  it  is  better  for  an  untrained  physician 
to  commit  almost  any  error  than  not  to  get  air 
to  the  patient  promply.  INIost  mistakes  can  be 
rectified.  Dr.  Ellis  Gray  once  helped  me  do  a 
tracheotomy  on  a  cabin  porch  with  the  baby  on  an 
old  trunk  and  only  the  grandfather  to  help.  Our 
sponge  consisted  of  a  soiled  towel.  The  baby  re- 
covered. Dr.  Chevalier  Jackson  says  a  tracheo- 
tomy can  be  done  in  the  dark  with  a  pocket  knife. 

Do  not  be  alarmed  if  breathing  ceases  after 
opening  the  trachea,  there  is  often  a  period  of 
apnea.  Gently  open  the  incision  and  wait  a  rea- 
sonable time  for  breathing  to  be  resumed.  Do 
not  insert  hooks  in  the  trachea;  the  ends  of  the 
cartilaginous  rings  may  be  fractured  and  dislocat- 
ed, thus  causing  future  complications.  A  cannula 
should  reach  well  into  the  trachea,  should  not 
impinge  on  anterior  or  posterior  wall  and  should 
have  a  small  air  space  all  around. 

Do  not  give  sedatives;  encourage  the  cough  re- 
fle.x,  the  patients  who  do  not  cough  are  the  sickest. 
Force  fluids;  do  not  hesitate  to  keep  the  abdomen 
generously  supplied  with  fluids  through  a  needle. 

Often  the  intubation  or  tracheotomy  is  only  the 
beginning  of  the  treatment.  Accumulation  of  fluid 
in  the  trachea  may  require  extubation  or  bron- 
choscopic  aspiration;  this  can  not  be  repeated  indefi- 
nitely and  a  tracheotomy  must  follow.  At  times  a 
patient  threatens  to  drown  in  his  own  secretions 
and  aspirations  must  be  done.  At  times  bron- 
choscopy must  be  repeatedly  performed  to  remove 
dried  secretions,  scabs  and  plugs  of  mucus.  We 
did  this  eight  times  on  an  infant  and  it  recovered. 

We  have  found  no  remedy  which  effectively  pre- 
vents the  formation  of  tough  bronchial  and  tracheal 
secretions.  Equal  parts  of  salt  and  soda  in  strength 
of  normal  salt  solution,  weak  silver  solutions,  dilute 
ephedrine  oils  have  been  used  with  varying  success. 
Food  is  the  main  prop  in  these  cases  and  glucose 
solution  may  be  used  freely  in  the  vein  and  ab- 
domen to  tide  these  babies  over  a  crisis. 


Hydrochloric  Acid  in  Surgery 

(M.    A.    Long,    Rosita,    Coah.,    Mexico,    &    Burr    Ferguson, 

Eirmingham.  Ala.,  in  Clin.   Med.  &  Surg.,  July) 

Dr.  Long's  Report: 

A  doctor  brought  his  son  to  be  treated  for  a  granulat- 
ing wound  on  the  outer  surface,  middle  third  of  his  right 
thigh  following  a  prophylactic  dose  of  tetanus  antitoxin 
and  was  22  x  13  cm.,  the  edges  indurated  and  the  whole 
area  nfected.  The  father  wanted  me  to  make  a  skin  graft, 
but  I  suggested  that  we  wait  and  try  to  clean  out  the 
wound  with  a  1:250  solution  of  hydrochloric  as  a  dressing. 


This  doctor,  22  days  later,  brought  another  son  with 
acute  appendicitis.  He  showed  me  the  former  patient,  and, 
to  my  surprise,  the  lesion  was  completely  healed.  Nothing 
else  was  used  but  the  HCl  solution. 

In  a  clinic,  where  we  have  3,200  workmen  and  their 
families  (which  usually  average  about  4  to  each  family) 
to  take  care  of,  not  long  ago  we  had  an  epidemic  of  sore 
throats,  and  our  laboratory  reported  that  it  was  due  to 
staphylococci.  We  ordered  the  patients  to  use  gargles  of 
plain  salt  water,  and  gave  every  patient  we  saw  10  c.c. 
of  a  1:1,500  solution  of  hydrochloric  acid  intravenously, 
giving  3  injections  of  the  drug  (one  each  day)  to  each 
patient  and  sending  him  back  to  work  on  the  third  day. 
We  noted  first,  in  these  cases,  the  fact  that  the  pain  dis- 
appeared the  same  day  we  gave  the  acid.  We  did  not 
have  a  single  failure  in  these  more  than  135  cases. 

The  head  of  one  of  our  departments  has  been  suffering 
with  a  maxillary  sinus  infection  for  10  years,  several  opera- 
tions, no  nasal  irrigation  had  done  any  good;  the  man  was 
desperate.  We  started  giving  him  hydrochloric  acid  intra- 
venously, and  he  took  24  injections.  His  headache  dis- 
appeared after  the  fifth  injection,  and  his  nose  is  now 
clear.  We  are  going  to  give  this  man  another  series  of 
injections,  and,  as  he  feels  so  much  better,  he  has  great 
faith  in  the  treatment. 

Between  March  and  October,  1935,  I  operated  in  12 
cases  of  suppurative  appendicitis,  and  each  of  these  patients 
received  from  10  to  30  intravenous  injections  of  10  c.c.  of 
a  1:1,500  solution  of  HCl.  All  of  these  patients  recovered 
in  from  10  to  30  days  (in  the  hospital).  In  1934,  in 
similar  cases,  when  we  were  not  using  the  acid,  the  mor- 
tality rate  was  25%. 

A  woman  from  a  nearby  ranch  came  to  see  me,  with 
an  inoperable  cancer  of  the  breast  and  with  metastases  in 
all  of  the  contiguous  glands.  The  cancer  had  broken  down 
and  a  horrible  odor  was  present.  We  used  a  1:250  solution 
of  hydrochloric  acid  as  a  local  dressing  for  18  days,  and 
gave  one  intravenous  injection  of  a  1:1,500  solution  of  the 
acid  daily.  At  the  end  of  this  time  the  lesion  was  clean; 
there  was  no  odor;  and  the  woman  was  3  kilos  heavier. 

Comments  by  Dr.  Ferguson: 

I  maintain  that  leukocyte  counts,  before  and  after  major 
operations,  will  show  a  great  increase  in  the  white  cells; 
that  this  mobilization  of  the  reserves  is  done  by  Nature  for 
the  purpose  of  repairing  wounds;  that  the  injection  of 
hydrochloric  acid  after  the  operation  merely  hastens  this 
purely  natural  process;  and  that  any  germs  left  by  the 
surgeon,  after  the  removal  of  the  evident  foci  of  infection, 
are  eliminated  much  more  quickly  by  this  artificial  stim- 
ulation. As  an  evidence  of  the  truth  of  this  the  report  of 
the  12  cases  of  appendicitis  operated  on  by  Dr.  Long  is 
cited. 

With  the  great  increase  in  the  oxygen  content  of  the 
red  cells  after  the  intravenous  injections  of  hydrochloric 
acid,  and  the  stimulation  of  the  leukocytes,  in  numbers 
and  activity,  my  conclusions,  after  reading  Dr.  Long's  re- 
ports, are  that  HCl  is  a  most  useful  agent  for  rh^nolaryn- 
gologists,  and  for  surgeons  also. 


Out  of  6  million  persons  on  relief  in  this  country  there 
are  only  SO  physicians  and  surgeons,  according  to  a  sur- 
vey made  recently  by  the  Kny-Scheerer  Corporation,  Long 
Island  City,  New  York.  The  survey  disclosed  that  there 
are  1,000  law\-ers,  3,000  ministers  and  religious  work- 
ers and  more  than  20,000  teachers  on  relief  rolls. 


Rabies  appears  to  be  on  the  increase  throughout  the 
world,  and  especially  in  the  Southern  part  of  the  United 
States. 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


Mortality  in    1786   Cases  of  Acute  Appendicitis 

Critical  Analysis  of  920  Cases 

FuRMAN  Angel,  M.D.,  and  Edgar  Angel,  M.D.,  Franklin,  N.  C. 
Angel  Hospital 


IN  October,  1932,  the  authors  reported  on  1291 
cases  of  acute  appendicitis  operated  on  in  the 
Angel  Hospital  in  the  six  preceding  years.  A 
critical  analysis  of  424  of  these  cases  as  to  the  fac- 
tors influencing  mortality — age,  time  elapsing  be- 
tween onset  of  symptoms  and  operation,  the  use  of 
cathartics,  the  association  with  intestinal  parasites 
and  pregnancy,  and  the  surgical  management — 
was  gone  into.  Since  that  time  496  cases  have 
been  operated  on  and  these,  plus  the  424  in  the 
previous  series,  form  the  basis  of  this  report.  They 
have  been  studied  with  the  same  idea  in  mind, 
namely,  to  determine  if  the  mortality  of  acute  ap- 
pendicitis is  increasing  or  decreasing  and  what  fac- 
tors are  influential  in  its  production.  The  following 
table  sets  forth  these  factors  in  the  two  series: 

10-30  10-32  10-30 

10-32  1-36  1-36 

No.       %         No.      %         No.       % 

Purgatives    20       4.7         143     28.7         163     16.0 

Perforations  — 56     13.2  82     16.5         138     15.0 

Drained    82     19.3         117     23.5         199     21.0 

Ascariasis   4         .8  2         .4  6         .65 

Pregnancy    — 11       2.6  8       1.6  19       2.0 

Mortality   12       2.8  5       1.0  17       1.8 

Mort.  Perf.  cases.-.     9     16.0  3       3.6  12       8.0 

Age — oldest  70,  youngest  3,  average  24 
Time  elapsing  before  operation — 1,  58  hours;  2,  39  hours 
Age:  The  ages  are  approximately  the  same  in 
the  two  series,  the  oldest  being  70,  the  youngest  3, 
and  the  average  24.  The  majority  occurred  be- 
tween 10  and  20.  It  was  much  more  frequent  in 
children  up  to  15  years  of  age  than  in  adults  past 
40. 

Time  elapsed  before  operation:  There  has  been 
a  marked  reduction  in  the  time  elapsing  between 
the  onset  of  symptoms  and  operation  during  the 
past  few  years,  which  is  due  no  doubt  to  the  fact 
that  hospitals  are  more  accessible.  This  has  de- 
creased from  58  to  39  hours. 

Cathartics:  There  has  been  a  tremendous  in- 
crease in  the  number  receiving  cathartics  before  ad- 
mission in  spite  of  the  fact  that  there  has  been  an 
attempt  by  most  physicians  to  advise  against  their 
indiscriminate  use  in  the  presence  of  abdominal 
pain.  For  instance,  in  the  first  series  of  424  only 
20  gave  a  history  of  having  received  a  cathartic, 
whereas  in  the  last  series  of  496,  as  many  as  143 
had  received  some  cathartic.  Obviously  the  first 
figures  are  incorrect,  because  this  point  was  not 
gone  into  thoroughly  enough  as  was  done  in  the 
second  series  when  not  only  the  interne  taking  the 


history  but  the  anesthetist  as  well  inquired  of  the 
patient  the  amount  and  type  of  cathartic  taken, 
whether  opiates  had  been  administered,  the  time 
of  onset  and  if  there  had  been  a  previous  attack. 

Perforations:  The  percentage  of  perforations  has 
remained  practically  the  same,  the  decreased  time 
elapsing  before  operation  probably  counterbalanc- 
ing the  increased  cartharsis. 

Drainage:  The  percentage  drained  also  remain- 
ed practically  the  same.  All  perforated  and  ab- 
scessed cases,  and  practically  all  with  an  unrup- 
tured gangrenous  appendix  were  drained,  using  soft- 
rubber  tubing,  a  cigarette  drain,  or  a  combination 
of  the  two;  or  when  there  was  an  unruptured  gan- 
grenous appendix,  a  rubber  dam. 

Intestinal  Parasites:  In  the  previous  series  there 
was  one  death  when  there  was  an  associated  intes- 
tinal obstruction  produced  by  roundworms  in  the 
terminal  ileum.  Out  of  the  entire  series  of  920, 
six  were  found  associated  with  ascariasis.  In  one 
when  the  diagnosis  of  acute  appendicitis  with  ab- 
scess formation  was  erroneously  made,  the  patient 
was  found  to  have  volvulus  of  the  ileum  produced 
by  roundworms.  The  ileum  was  opened,  60  round- 
worms removed,  the  intestine  closed,  and  the  pa- 
tient made  an  uneventful  recovery. 

Pregnancy:  In  spite  of  the  small  number  of 
cases  of  pregnancy  associated  with  acute  appendi- 
citis reported  here — 19  in  920  without  a  death — we 
do  not  believe  that  it  affects  the  mortality  to  any 
marked  degree. 

Mortality:  There  has  been  a  reduction  in  the 
mortality  both  in  the  non-perforated  and  the  per- 
forated types  from  16  per  cent,  for  the  perforated 
cases  in  the  first  series  to  3.6  per  cent,  in  the  last. 
This  is  attributable  to  the  decrease  in  time  elapsing 
before  operation  and  the  use  of  more  fluids  sub- 
cutaneously,  and  to  the  fact  that  during  the  oper- 
ation the  small  intestine  is  not  brought  into  the 
wound  unless  absolutely  necessary  and  the  entire 
operation  is  carried  out  as  expeditiously  as  possible 
with  the  minimum  of  trauma  and  handling  of  the 
intestine. 

Operative  Management:  1)  The  McBurney  in- 
cision is  always  used.  2)  The  stump  is  never 
buried,  it  is  simply  treated  with  carbolic  acid  and 
alcohol.  3)  Doubtful  cases  are  always  drained — 
especially  if  the  peritoneal  fluid  is  cloudy.  4) 
Non-ruptured  gangrenous  cases  are  usually  drain- 
ed.    5)  Wounds  in  which  drains  are  inserted  are 


August,   1936 


APPENDICITIS— Angel  &  Angel 


427 


dosed  loosely.  6)  The  treatment  of  perforated 
cases  is  augmented  post-of)eratively  by  small  blood 
transfusions. 

CONCLI'SION 

Seventeen  hundred  and  eighty-si.x  cases  of  acute 
appendicitis  operated  on  in  a  ten-year  period  are 
reported  with  a  mortality  of  1.8%.  Nine  hundred 
and  twenty  of  these  (1.8%  mortality)  covering  a 
six-year  period  have  been  studied  regarding  the 
factors  influencing  mortality.  In  the  first  424  of 
these  there  was  a  mortality  of  2.8%;  in  the  last 
490  the  mortality  was  1%,  showing  a  reduction  in 
both  the  perforated  and  non-perforated  types. 


Value  of  Proctology  in  General  Medicine 
(R.  J.   Boesel,  Cheyenne,  in  Col.   Med.,  July) 

The  majority  of  pathologic  conditions  about  the  rectum 
respond  well  to  treatment,  and  there  is  nothing  very  com- 
plicated about  them.  Few  are  proiicient  in  the  use  of  the 
proctoscope,  .'\bout  20%  of  patients  with  carcinoma  of 
the  rectum  have  been  operated  on  for  hemorrhoids,  or 
treated  without  a  diagnosis  having  been  made;  90%  of 
carcinomas  of  the  rectum  can  be  palpated  by  digital  ex- 
amination. 

Many  rectal  diseases  manifest  themselves  by  backache, 
sciatica,  arthralgia,  anemia,  frequency  or  urgency  of  uri- 
nation, restlessness,  loss  of  weight,  and  nervousness. 

Ordinarily  a  proctoscopic  examination  can  be  made  satis- 
factorily within  an  hour  after  a  normal  bowel  movement. 
It  is  often  necessary  to  give  a  warm  enema  until  the  water 
returns  clear  an  hour  before  the  examination.  If  there 
is  extreme  tenderness  with  spasm  of  the  anal  sphincter  and 
ulceration,  swabbing  with  10%  cocaine  solution  may  re- 
lieve the  spasm;  3  grs.  of  sodium  amytal  may  be  given  2 
hrs.  before  examination,  and  30  c.c.  of  2%  novocaine  in- 
jected into  the  sacral  hiatus.  .Anesthesia  should  be  complete 
in  10  min.  It  may  be  necessary  to  inject  2  c.c.  more 
into  each  of  the  2nd,  3rd  and  4th  sacral  foramina.  Sacral 
or  parasacral  anesthesia  is  satisfactory  in  all  rectal  opera- 
tions, as  it  produces  relaxation  of  the  anal  sphincter. 

The  patient  upon  a  protoscopic  table  if  one  is  available, 
if  not.  the  knee  chest  position  is  used,  or  the  patient  is 
placed  in  an  inverted  position  by  lowering  him  over  the 
edge  of  the  bed  with  his  elbows  resting  on  pillows  on  the 
floor.  First  the  tissues  about  the  anal  margin  are  inspected, 
then  with  a  finger  cot  and  a  water-soluble  jelly  a  digital 
examination  is  made.  Next  the  proctoscope  with  the 
obturator  in  place  is  inserted  until  it  passes  the  internal 
sphincter,  following  the  anterior  wall.  The  obturator  i; 
then  removed,  and  the  remainder  of  the  examination  i; 
made  under  the  direction  of  the  eye.  It  is  generally  not 
neccssar\'  to  use  the  inflation  bulb,  but  if  used,  the  head 
should  be  removed  as  soon  as  possible  to  allow  the  air  to 
escape.  The  patient  is  asked  not  to  strain  but  to  breathe 
easily  through  the  mouth.  Most  of  the  examination  is 
made  while  removing  the  proctoscope  through  the  12  in. 
of  the  large  bowel  visible  through  the  proctoscope. 

Uncomplicated  internal  hemorrhoids  of  moderate  degree 
respond  best  to  non-surgical  treatment.  The  patient  is 
given  a  sodium  amytal,  2  hrs,  before  the  treatment  and 
is  asked  to  take  a  tap  water  enema  Yi  hr.  before.  The 
anoscope  is  inserted  and  the  internal  hemorrhoidal  tissue 
posteriorly  brought  into  view;  5%  quinine  and  urea  hydro- 
chloride solution  with  2%  procain  is  injected  1  cm.  be- 
neath the  surface  in  the  middle  of  the  hemorrhoidal  tissue 
with  a  special  needle  and  syringe  until  swelling  is  visible. 
The  mucosa  should  not  become  tight  and  glistening.    The 


left  half  of  the  anal  canal  is  injected,  using  2  to  4  c.c.  of 
the  solution.  The  patient  is  instructed  to  take  hot  sitz 
baths  for  discomfort  and  to  report  daily  to  the  office,  at 
which  time  an  inspection  is  made  with  the  anoscope  and 
the  anal  canal  irrigated  with  warm  witch  hazel.  .After  3 
to  5  days  the  right  side  is  similarly  injected.  The  treatment 
is  ambulatory  and  very  satisfactory.  Occasionally  there 
is  a  recurrence  which  may  be  treated  in  the  same  manner. 

Fistula:  The  internal  opening  should  be  located  by  prob- 
ing with  a  blunt  probe,  the  probe  should  be  passed  through 
the  tract  and  this  tunnel  converted  into  a  groove  by 
opening  the  roof  its  entire  length.  The  overhanging  edges 
should  be  removed  and  the  wound  allowed  to  granulate 
in  from  the  sides  over  a  flat  surface.  Daily  dressings  and 
inspection  are  essential. 

A  fissure  is  generally  at  the  posterior  commissure,  a 
linear  ulcer  occupying  a  narrow  surface  of  the  anal  mucosa. 
Edema  of  an  adjoining  papilla  often  causes  it  to  enlarge, 
and  this  enlarged  papilla  is  called  a  sentinel  pile.  The 
fissure  is  excised  with  an  oval  area  of  skin  external  to  it 
for  about  3  or  4  cm.  and  of  a  depth  to  the  external  sphinc- 
ter. The  mucous  membrane  should  be  restored  to  the 
line  of  the  dentate  margin.  The  wound  should  granulate 
in  from  the  sides  over  a  flat  surface  leaving  a  scar  which 
will  not  become  inflamed  when  traumatized. 

Pruritis  ani:  After  all  ordinary  methods  of  treatment 
have  failed,  subcutaneous  injections  of  40%  ethyl  alcohol 
gives  complete  relief  in  a  large  percentage  of  cases;  20  to 
30  c.c.  of  alcohol  is  generally  sufficient.  It  should  be 
injected  superficially  to  the  external  sphincter;  in  about 
half  the  cases  sloughing  takes  place.  The  wounds  require 
daily  dressing  untU  healed. 


Afebrile  Exhaustive  Psychosis  Following  Sickness 

(J.    C.    Hill,   KnoxviUe,    in    Jl.    Tenn.    State    Med.    Assn., 

July) 

The  condition  we  see  many  of  these  patients  in  makes 
one  feel  there  is  no  use  trying  to  do  anything,  or  they 
should  be  put  in  the  state  hospital,  but  I  say  nay. 

Some  authorities  put  mortality  as  high  as  50%,  but  the 
writer  believes  their  figures  are  high.  The  treatment  is 
very  simple.  A  nurse  should  be  with  patient  day  and 
night.  If  relatives  cannot  afford  graduate  nurses,  obtain 
practical  ones  or  instruct  members  of  the  family  as  to 
what  must  be  done.  Necessary  fluids  by  mouth,  rectum, 
hypodermoclysis,  or  in  a  vein.  I  have  seen  wonderful 
results,  when  apparently  everything  failed,  from  glucose 
intravenously  and  blood  transfusions. 

The  majority  of  these  patients  must  be  fed  by  spoon  or 
tube  and  guarded  very  carefully.  Give  regular  diet.  I 
am  a  prohibitionist,  but  whiskey,  2  to  4  oz.  daily,  will 
help  things  along.     I  do  not  mean  doctor,  I  mean  patient. 

When  very  restless  and  bromides  will  not  control  give  3 
grs.  sodium  amytal  intravenously  and  when  necessary  re- 
peat in  6  hrs.  Saline  laxatives  as  needed.  Give  intramus- 
cularly or  intravenously  iron  cacodylate  and  sodium  gly- 
cerophosphate. 

Examine  the  urine  at  least  once  every  2  weeks. 

Two  general  massages  daily,  with  force  behind  the  rub- 
bing. 

.Afebrile  exhaustive  psychosis  following  sickness  is  a 
condition  frequently  erroneously  diagnosed. 


The  most  famous  northern  physician,  surgeon  and 
lithotomist,  Rfn  Sveinbjornsen  (died  1289),  according  to 
the  detailed  account  of  Ludw.  Faye  of  Christiania,  was  an 
Icelander.  He  had  travelled  extensively  in  France,  Italy 
and  Spain,  and  had  also  visited  England,  but  died  in  Den- 
mark. He  practiced  the  bimanual  manipulation  of  Celsus 
in  the  diagnosis  of  vesical  calculus. — Baas. 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1Q36 


Case  Report 

A  Sudden  Death  Not  Caused  by  Heart  Disease 
J.  F.  Nash,  M.D.,  Saint  Pauls,  N.  C. 

A  manufacturer,  aged  75,  had  had  no  serious 
illnesses.  His  wife  died  at  80  of  chronic  bronchitis 
of  40-yrs.  standing  {sic!):  one  son,  married,  aged 
30,  living  and  well;  two  mature  sons  died  of  pul- 
monary tuberculosis;  one  daughter  died,  aged  2, 
of  colitis.  His  health  had  been  perfect  except  for 
one  attack  of  erysipelas  in  foot  and  leg  45  yrs. 
ago.  Has  been  executive  of  textile  manufacturing 
company  for  30  years,  during  which  time  he  at- 
tended to  all  duties  of  his  position  with  ease.  He 
had  never  been  vaccinated  against  anything!  He 
was  virile  and  active  until  one  week  before  death. 

Three  weeks  before  death  while  attending  a 
meeting  of  cotton  mill  e.xecutives  in  a  town  20 
miles  away,  he  was  taken  with  a  pain  in  right 
epigastrium,  and  called  to  see  a  professional  friend 
at  a  hospital.  This  doctor  friend  strapped  his  side, 
and  he  returned  home  in  comparative  comfort  and 
so  remained  for  one  week.  At  the  end  of  a  week 
his  local  physician  was  called  at  2  a.  m.  and  found 
him  with  a  temp,  of  102',  general  malaise  and  a 
slight  cough.  The  physician  suggested  rest  in  hos- 
pital for  two  or  three  weeks,  which  was  readily 
agreed  to,  and  at  that  early  hour  the  patient  was 
taken  to  his  friend's  hospital. 

He  improved  quickly — temperature  returned  to 
normal  within  48  hours,  and  he  was  able  to  walk 
about  the  hospital;  pain  diminished  and  he  was 
about  ready  to  return  home.  Suddenly  he  died 
within  a  space  of  two  minutes  (at  11  p.  m.)  while 
nurses  and  doctors  were  present.  What  caused  this 
death? 

Laboratory  findings  were  essentially  negative — 
urine  normal,  b.  p.  110/80  (the  same  for  past  20 
yrs.) ;  x-rays  showed  a  slight  haziness  in  right  hy- 
pochondrium.  There  were  minor  varicosities  of 
both  extremities.  A  tentative  diagnosis  of  cancer 
of  the  liver  was  made. 

An  autopsy  was  requested  and  promptly  granted 
by  the  family. 

Post-mortem  examination  showed  a  slit  of  3 
inches  in  the  abdominal  aorta — spontaneous. 


A  Critical  An.\lysis  of  the  Diagnosis  .^nd  Surgical 
Treatment  of  Thyroid  Conditions 

(N.  W.  Gillette,  Toledo,   in  Ohio  State   Med.  Jl.,  July) 

The  injection  of  adrenalin  will  produce  every  symptom 
of  hyperthyroidism  does,  and  the  same  is  true  of  hyper- 
adrenalism.  Overstimulation  of  the  ovaries  may  brinj 
about  the  same  result. 

McGregor  of  Hamilton,  Ontario,  maintains  that  persist- 
ence of  the  symptoms  following  thyroidectomy  is  due  to 
an  enlarged  thymus  and  has  submitted  some  convincing 
cases.     The  anterior  lobe  of  the  pituitary  body  produces  a 


secretion  which  apparently  directly  stimulates  the  thyroid 
to  the  extent  that  hyperthyroidism  has  been  diagnosed, 
whereas  it  was  only  functionally  at  fault  and  the  pituitary 
body  was  the  primars-  cause  of  the  trouble.  With  all  of 
these  other  factors  entering  into  the  diagnosis  of  hyper- 
thyroidism the  difficulty  of  determining  whether  a  goitre 
should  be  treated  or  removed,  or  left  untreated  and  allowed 
to  improve  by  itself  and  some  other  gland  cared  for,  is  of 
the  utmost  importance. 

The  basal  metabolism  machine  has  been  and  still  is  val- 
uable. It  has  its  faults.  This  rate  varies  extremely,  enough 
at  times  to  make  the  diagnosis  by  the  machine  unreliable. 

The  determination  of  blood  iodine,  by  McCullough's 
lest,  is  perhaps  the  best  method  for  the  determination  of 
the  activity  of  the  thyroid  gland.  It  is  not  necessary  to 
do  this  test  in  those  cases  which  are  frankly  suffering  from 
toxic  goitre.  The  frank  case  of  toxic  goitre  needs  no  test. 
The  diagnosis  can  be  made  as  the  patient  walks  into  the 
consulting  room. 

I  have  operated  upon  patients  for  Graves'  disease  with 
the  heart  beat  not  over  80  per  minute  and  obtained  a 
good  result  with  complete  elimination  of  the  psychosis. 
The  two  associated  symptoms  of  nervousness  and  a  pound- 
ing heart  should  be  enough  to  make  a  careful  diagnosti- 
cian suspect  and  either  rule  out  or  diagnose  thyrotoxicosis. 
The  longer  the  patient  has  a  toxic  goitre  the  longer  will 
be  the  convalescence  and  the  poorer  the  postoperative  re- 
sult. Also,  there  is  a  direct  relationship  between  the  length 
of  time  of  the  toxicity  and  the  probability  of  postoperative 
storm. 


Dry  Labor  Not  Slow 


(A.  G.  King,  Cincinnati,  in  Jl.  of  Med..  July) 
In  this  study  of  1,001  consecutive  uncomphcated  full- 
term  vertex  deliveries  the  incidence  of  dry  labor  was  31%, 
with  some  11%  more  cases  rupturing  the  membranes  spon- 
taneously during  the  first  stage.  Primiparity  seemed  to 
predispose,  but  occipitoposterior  position  played  no  signifi- 
cant part. 

The  average  duration  of  dry  labor  was  shorter  than 
that  of  the  controls  by  2.0  hours  in  primiparae  and  2.4 
hours  in  multiparae.  The  percentage  of  prolonged  labors 
was  low-er  in  the  dr>-  labor  group  and  the  cumulative 
distribution  curve  was  more  favorable. 

The  incidence  of  operative  interventions  in  the  dn,-  labor 
group  was  10.6%  against  16.3%  in  the  controls.  The 
morbidity  was  shghtly  lower  in  the  dry  labor  group.  There 
Kns  no  evidence  of  increased  damage  to  the  cervLx  as  a 
result  of  the  rupture  of  the  membranes.  There  was  no 
demonstrable  effect  on  the  fetal  mortality.  The  findings 
concurred  with  those  of  the  majority  of  writers  on  dry 
labor. 


Gonorrheal  Vaginitis  in  Children 
(S.  F.  Abrams,  St.  Louis,  in  Jl.  Mo.  Med.  Assn.,  July) 
About  2  years  ago  I  began  the  use  of  theelol  by  mouth. 
Nine  patients  from  3  to  5  years  with  one  child  aged  9, 
all  were  given  4  capsules  daily  in  divided  doses  or  a  total 
of  200  rat  units  daily.  At  the  end  of  the  second  week 
there  was  very  little  discharge  in  7  of  the  cases  and  at 
this  time  definite  hypertrophy  of  the  labia  with  a  fine 
growth  of  hair  at  the  vulva  could  be  seen.  One  case  also 
showed  hypertrophy  of  one  breast.  Negative  smears  were 
obtained  on  all  in  8  to  12  weeks  and  they  have  remained 
consistently  negative.  One  child  had  negative  smears  but 
the  discharge  continued,  probably  due  to  a  secondary  in- 
vader. This  series  is  small  and  conclusions  cannot  be 
drawn. 


August,   1036 


SOUTHERN  MEDICINE  AND  SURGERY 


Surgical    Observations 

A  Column  Conducted  by 

The  Staff  of  the  Davis  Hospital 
Statesville,  N.  C. 


The  Prostate 

The  most  common  symptom  of  prostate  disease 
is  increased  frequency  of  urination.  In  all  sus- 
pected cases  of  prostate  disease  the  patient  should 
have  a  thorough  examination,  including  a  cystos- 
copic  examination.  A  careful  consideration  of  the 
heart  and  circulatory  system  generally,  also  the 
kidneys  and  liver,  is  essential. 

The  treatment  must  be  based  not  only  on  the 
condition  of  the  prostate,  but  also  on  the  condition 
of  the  patient  generally.  No  surgical  procedure 
should  be  attempted  until  the  patient's  general  con- 
dition is  carefully  investigated. 

Many  patients  come  in  with  a  history  of  pros- 
tate disease  of  long  standing  with  gradually  in- 
creasing difficulty  in  urination,  until  at  some  time 
catheterization  has  been  necessary.  Then  the  pa- 
tient usually  seeks  medical  aid  if  not  before.  Some 
of  these  patients  on  careful  investigation  will  be 
found  to  have  a  high  blood  urea,  impairment  of 
the  heart  muscle,  impairment  of  the  kidney  and 
liver  function.  A  patient  of  this  type  may  be  able 
to  go  about  and  attend  to  his  business  and  yet  he 
may  be  in  a  critical  condition.  Such  a  patient  is 
a  poor  surgical  risk  and  slight  shock  or  a  simple 
operative  procedure  may  carry  him  off. 

Fortunately  many  of  these  patients  can  be  pre- 
pared so  that  they  can  stand  a  transurethral  oper- 
ation, but  some  of  them  cannot  and  it  is  this  type 
of  patient  that  presents  a  real  problem. 

Unfortunately  many  people  expect  relief  no  mat- 
ter how  serious  the  condition,  and  owing  to  the 
fact  that  the  public  has  been  led  to  expect  miracles 
of  the  transurethral  operations,  there  will  natur- 
ally be  some  disappointment. 

While  it  is  true  that  the  transurethral  operation 
has  made  it  possible  to  operate  upon  many  of  these 
patients  who  could  not  stand  a  prostatectomy,  yet 
it  must  be  remembered  that  this  operation  has  its 
limits. 

The  Preparation  for  Operation 

Many  are  in  good  condition  for  prostatic  opera- 
tion immediately  after  admission.  Others  may  re- 
quire days  or  even  weeks  of  careful,  painstaking 
preparation.  .After  a  careful  study  of  the  patient 
has  been  made,  every  possible  preliminary  treat- 
ment and  preparation  for  operation  should  be  given 
so  far  as  it  will  aid  in  the  return  toward  normal  of 
the  body  functions. 

One  of  the  most  important  things  is  to  see  that 
the  kidneys  have  reached  the  maximum  improve- 


ment. The  heart  and  circulatory  system  should 
be  carefully  reexamined  and  appropriate  treatment 
given.  The  patient  should  be  in  the  proper  frame 
of  mind.  Without  a  careful  preparation  for  opera- 
tion, the  mortality  will  be  extremely  high;  with 
careful  preparation  it  is  extremely  low. 
The   Choice   of   Operation 

While  approximately  90  per  cent,  of  patients 
can  have  a  transurethral  prostatic  resection  without 
any  great  difficulty  and  with  uniformly  good  re- 
sults, there  are  about  10  per  cent,  of  patients  who 
have  prostatic  hj^pertrophy  which  is  not  suitable 
for  transurethral  operation.  In  such  cases  a  supra- 
pubic or  perineal  prostatectomy  may  be  advisable. 
We  have  many  objections  to  this  on  the  part  of 
the  laity  because  they  have  come  to  regard  trans- 
urethral resection  as  a  sort  of  cure-all  and  without 
danger.    Many  think  it  only  a  minor  procedure. 

Before  anything  is  done,  the  patient  and  his 
friends  should  be  carefully  told  about  the  operation 
and  what  to  e.xpect. 

In  the  vast  majority  of  cases  where  there  has 
been  no  marked  kidney  damage,  where  the  ureters 
are  in  good  condition  and  bladder  inflammation 
has  been  cleared  up,  patients  get  excellent  results 
from  transurethral  prostatic  resection.  The  results 
in  these  cases  are  extremely  gratifying  to  patient 
and  surgeon. 

Cases  Which  Do  Not  Get  a  Good  Result 

There  are  certain  types  of  cases  in  which  it  is 
almost  impossible  to  get  a  good  result. 

A  patient  with  a  badly  impaired  general  condi- 
tion together  with  damage  to  the  kidneys,  ureters 
and  bladder  and  of  the  body  generally,  that  may 
come  from  prolonged  prostatic  obstruction,  is  nat- 
urally a  bad  risk  for  any  surgical  procedure.  In  a 
patient  of  this  type  a  transurethral  prostatic  re- 
section may  relieve  the  obstruction;  but  with  a 
chronically  inflamed,  greatly  thickened  bladder 
wall,  dilated  ureters  and  chronically  infected 
kidney  with  imuaired  function,  one  cannot  expect 
very  much.  Unfortunately  patients  of  this  type, 
kidneys  with  impaired  function,  one  cannot  expect 
this  operation  to  work  miracles.  With  so  great 
damage  to  the  kidneys  it  may  be  too  late  for  any 
surgical  procedure  to  do  any  good.  Sometimes  in 
these  cases  where  there  is  doubt  as  to  the  outcome, 
it  may  be  advisable  to  do  a  resection,  since 
sometimes  patients  of  this  type  react  very  favor- 
ably and  come  out  much  better  than  one  would 
expect.  On  a  whole,  however,  such  patients  do 
not  do  well,  as  one  would  naturally  expect  after 
considering  the  pathological  condition  present. 
After-treatment 

The  after-treatment  of  a  patient  with  prostatic 
resection  is  of  great  importance.  Catheter  drainage 
after  operation  is  necessary  and  should  be  kept  up 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1036 


for  a  proper  length  of  time,  which  varies  with  the 
case — the  average  being  four  days.  After  the  pa- 
tien  treturns  home  it  is  important  that  a  careful 
watch  be  kept  on  his  progress.  Sometimes  it  re- 
quires several  weeks  to  get  the  bladder  condition 
cleared  up.  If  one  will  just  remember  that  a  con- 
siderable amount  of  prostatic  tissue  has  been  re- 
moved and  that  there  is  a  large  area  which  must 
heal  over,  it  can  easily  be  seen  that  a  considerable 
period  of  convalescence  is  inevitable.  Straining, 
lifting,  or  any  undue  exercise  may  start  up  hem- 
orrhage. Sometimes  a  little  hemorrhage  will  occur 
anyway.  Any  little  complication  that  may  develop 
should  always  be  attended  to  promptly  and  in  this 
way  most  of  the  patients  who  have  a  little  after- 
trouble  will  come  on  through  to  a  safe  and  satis- 
factory recovery. 

Early  Operation 

The  medical  profession  can  do  much  to  improve 
the  results  by  advising  operation  when  prostatic 
obstruction  first  appears.  A  patient  who  is  in  good 
health  otherwise  and  has  good  resistance  and  no 
impairment  of  the  kidney  function  can  have  a 
prostatic  resection  with  very  little  disturbance  and 
with  such  rapid  recovery  that  very  little  time  is 
lost  from  work. 

Patients  who  delay  this  operation  until  long- 
continued  back  pressure  causes  renal  impairment, 
infection,  dilatation  of  the  ureters,  chronic  hyper- 
trophy of  the  bladder  walls  and  chronic  cystitis 
cannot  hope  for  the  good  results  that  are  obtained 
in  the  early  cases. 

It  must  be  remembered  that  a  rectal  examination 
may  disclose  a  large  prostate,  yet  many  cases  of 
prostatic  obstruction  do  not  show  a  great  deal  of 
prostatic  enlargement  when  examined  by  the  rec- 
tum. Only  a  cystoscopic  examination  can  reveal 
the  true  condition  of  the  prostate  gland. 

In  all  cases  of  suspected  prostatic  disease,  a 
thorough,  careful  and  painstaking  examination  is 
always  advisable. 


The  Treatment  of  Hypothyroidism 
(C.  M.  Guion,  New  York  City,  in  Med.  Woman's  Jl.,  July) 

The  supply  of  iodine  to  the  thyroid  becomes  insufficient 
very  frequently  during  adolescence,  menstruation,  preg- 
nancy, lactation  and  the  menopause.  We  must  protect  our 
patients  by  the  early  administration  of  iodine  as  a  preven- 
tive measure. 

I  prescribe  10  mg.  of  iodine,  IS  minims  of  the  syrup  of 
hydriodic  acid,  once  a  week  for  the  entire  duration  of 
pregnancy  and  lactation. 

The  results  obtained  in  these  cases  is  very  gratifying 
when  we  compare  the  course  of  the  same  woman  through 
two  pregnancies  in  one  of  which  she  does  not  have  the 
iodine. 

Young  girls  and  boys  should  be  given  iodine  at  the  first 
signs  of  puberty.  I  use  10  mg.  once  a  week  until  they  are 
16  or  17.  This  routine  usually  prevents  the  development 
of  the  simple  goitre  so  common  in  this  age  group.    If  the 


dosage  is  discontinued  too  early,  young  girls  may  show  a 
diffuse  enlargement  of  the  thyroid  at  each  menstruation. 
If  this  occurs,  the  iodine  must  be  continued  as  before,  or 
10  mg.  given  daily  for  several  days  before  the  swelling 
begins  and  continued  through  the  menstrual  period  for 
another  year.  The  dosage  can  then  be  reduced  to  10  mg. 
daily,  for  two  weeks  ever>-  three  months,  until  the  girl 
has  passed  through  the  strain  of  her  first  year  in  business, 
in  college,  or  married  life.  How  can  we  recognize  and 
what  can  we  do  to  relieve  the  condition  after  it  has  devel- 
oped? 

Many  cases  will  be  missed  if  we  look  only  for  typical 
my.xedema  and  cretinism,  mild  cases  of  insufficiency  of 
the  thyroid  are  common. 

The  children  are  often  nervous,  irritable,  poor  scholars, 
subject  to  infections  that  heal  slowly.  They  may  be  obese, 
but  usually  they  have  poor  appetites  and  are  poorly  devel- 
oped and  nourished.  The  pulse  and  b.  p.  may  be  low,  the 
skin  dry,  the  thyroid  diffusely  enlarged  and  the  basal  metab- 
olic rate  low.  The  picture  may  not  be  clear-cut,  and  our 
diagnosis  may  depend  upon  the  therapeutic  test  of  the 
administration  of  the  desiccated  thyroid  gland.  Most  of 
the  cases  respond  promptly  by  developing  a  good  appetite, 
gaining  in  weight  and  height,  and  showing  a  marked  in- 
crease in  physical  and  mental  alertness  and  stability. 

The  adult  patient  is  usually  a  woman  approaching  'the 
late  forties,  and  we  are  prone  to  be  satisfied  with  the 
diagnosis,  menopause,  and  prescribe  a  sedative.  She  has 
many  varied  complaints,  most  of  which  can  be  summed 
up  in  her  feeling  of  inadequacy  to  meet  the  demands  of 
her  ordinary  life.  She  may  explain  this  on  the  basis  of 
vague  joint  pains,  or  urinary  symptoms,  headaches,  irri- 
tability, nervousness;  she  is  puffy  under  the  eyes  and  the 
skin  of  her  face  shows  fine  lines  and  an  abnormal  thick- 
ness; the  hair  may  be  thin,  brittle  and  fine.  The  b.  m. 
is  usually  below  normal.  The  accuracy  of  our  diagnosis 
may  be  proven  by  the  therapeutic  test. 

The  effect  of  the  thyroid  usually  takes  6  to  7  days  to 
become  manifest  and  is  at  a  maximum  in  10  to  14  days; 
therefore,  patients  should  be  followed  at  weekly  intervals 
until  the  effect  can  be  determined  in  terms  of  pulse  rate! 
and  general  condition.  The  b.  m.  test  should  be  repeated 
at  the  end  of  2  or  3  weeks.  //  this  can  not  be  done  the- 
pulse,  weight,  general  conditions  and  symptoms  can  be, 
safely  depended  on  as  a  guide  to  the  size  of  the  dose. 

I  usually  start  with  desiccated  thyroid,  gr.  ^  to  J^J 
daily  for  children  and  gr.  ^^  to  lyi  for  adults.  This" 
amount  will  usually  suffice  to  maintain  a  balance.  Large 
doses  are  not  necessary.  If  the  patient  does  not  respond 
to  gr.  IJ^  to  3  daily  after  a  period  of  3  or  4  weeks,  the 
condition  is  probably  not  due  to  an  inadequate  thyroid, 
and  it  is  useless  to  increase  the  dosage  or  to  continue  the 
medication. 


A  STUDY  OF  1,000  CASES  (L.  W.  Gaker,  in  Jl.  of  Med., 
June)  showed  that  women  gaining  more  than  30  pounds 
during  pregnancy  had  nearly  50%  more  operative  deliveries 
and  signs  of  toxemia  than  women  gaining  24  pounds  or 
less. 


Gilbert  of  England  (1290):  "In  cases  of  stone  he  ad- 
ministers the  blood  of  he-goat  which  has  eaten  diuretics; 
lethargy,  however,  he  treats  by  tying  a  lusty  sow  to  the 
bedstead,  that  the  healing  influence  of  a  vigorous  grunt, 
close  at  hand,  may  be  felt  by  the  patient." — Baas. 


Collect  promptly. — Credit  men  estimate  that  a  doctor's 
account  depreciates  20%  if  it  is  not  paid  in  60  days,  50% 
in  6  mos. 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


DEPARTMENTS 

THERAPEUTICS 

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


Some  Useful  Prescriptions  in  Some  Common 
Ailments 

The  Joint  Pharmaceutical  &  Medical  Commit- 
tee of  the  Medical  Society  of  New  Jersey  is  pub- 
lishing in  the  Journal  of  that  Society  a  number  of 
prescriptions  of  unusual  usefulness.  Some  of  these 
are  herewith  passed  on  to  the  readers  of  this  jour- 
nal. 

Three   prescriptiotis   suggested   jor   local    applications    in 
poisanoak  dermatitis. 
R 

Plumbi  Acetatb gr.  xxx 

Tr.  Opii m.  Lxiii 

Aquae  Dest.  q.s.  ad. oz.  iv 

M.    Sig:  Shake  well.    Sop  on  skin  with  cotton  or  gauze 

and  let  dry. 
Note:     This   may   be   prescribed   as    "Lotio   Plumbi   Et 
Opii  N.  F.  Vi,"  If  you  do  not  care  to  write  out 
the  prescription  in  full. 


Calaminae  Praeparatae 

Zinci  Oxidi 

Glycerini 


dr.  V 

dr.  V 

m.  Lxxx 

Liq.  Caici  Hydroxidi  q.s.  ad. oz.  viii 

M.     Sig:     Shake  well.    Sop  on  skin  with  cotton  or  gauze 

and  let  dry. 
Note:     This    may   be    prescribed    as    "Lotio    Calaminae 
X.  F.  VI."     If  you  do  not  care  to  write  out  the 
prescription  in  full. 
R 

Sodii  Thiosulphatis oz.  iii 

Fid.  Ext.  Grindeliae  Robustae dr.  iii 

Aq.  Dest.  q.s.  ad. oz.  iv 

M.    Sig:     Shake  w.rJI.    Sop  on  skin  with  cotton  or  gauze 

and  let  dry. 
Three  prescriptions  suitable  for  local  application  in  sun- 
hum  or  burns  due  to  other  causes. 
R 

Aethylis  Aminobenzoatis 

Zinci  Oxidi  

Phenolis 


Antacid,  laxative  and  carminative. 
R 

Pulv.  Rhei  Co.  U.  S.  P.  IX  or  N.  F.  VI 

Sig:     One-half  teaspoonful  in  water  as  required. 
Note:     Laxative  and  antacid. 

Each  30-graln  dose  contains: 

0.4864  Gm.  or  7%  gr.  Rhubarb 

1.264  Gm.  or  19%  gr.  Magnesium  Oxide 

0.194  Gm.  or  3  gr.  Ginger 


R 

Mistura  Rhei  Alkalina  N.  F.  V oz.  iv 

Sig:     One  teaspoonful  after  meals. 
Note:     Antacid,   laxative,   and  carminative. 
Each  dose  contains: 
0.062  c.c.  or  1  minim  Flext.  Rhubarb 
0.031  c.c.  or  "^  minim  Flext.  Hydrastis 
0.065  Gm.  or  1  grain  Pot.  Carbonate 
R 

Mistura  Rhei  Co.  N.  F.  VI oz.  iv 

Sig:     One  teaspoonful  as  required. 
Note:     Antacid,  laxative,  and  carminative. 
Each  dose  contains: 

0.055  c.c.  or  9/10  minim  Flext.  Rhubarb 
0.012  c.c.  or  1/5  minim  Flext.  Ipecac 
0.140  Gm.  or  2  gr.  Sod.  Bicarbonate 
0.140  c.c.   or  2  minims  Sp.   Peppermint 

Tonics  suitable  for  administration  following   exhausting 
illnesses. 


gr.  XI 

— gr.  XLV 
^gr.  iiss 
_gr.  xxiiss 


Cerae  Flavae 

Adeps  Lanae  Hyd. 

Petrolati  aa.  q.s.  ad.  oz.  i 

M.     Sig:     Apply  freely  to  burned  surface. 
Note:     If    ointment    of    softer    consistency    Is    desired, 
leave  out  the  yellow  wax. 
R 

Acidi  Picrici _ gr.  xv 

Alcoholis dr.  iv 

.Aq.  Dest.  q.s.  ad. ... _ oz.  vi 

M.    Sig:     Apply  on  gauze  wet  with  solution. 

Renew  in  three  or  four  days. 
Note:  If  picric  acid  Is  absorbed,  nausea,  headache, 
vertigo  may  appear.  Stain  i.s  difficult  to  remove. 
In  order  to  do  so,  apply  a  paste  of  magnesium 
carbonate  and  permit  to  remain  several  min- 
utes, then  wash  off  with  soap. 
R 

Thymolis  lodidi dr.  i 

Olei  Olivae . dr.  ii 

Petrolati  q.s.  ad.  - oz.  i 

M.     Sig:     Apply  daily  at  first,  then  even.-  two  or  three 

days. 
Note:     Worlcs  well  wheji  surface  Is  blistered. 


Ferric  Pyrophosphate 

Quinine  Sulphate 

Strychnine   Sulphate  _ 
Lactose 


— ^.-gr.  11 

gr.  ss 

-gr.  1/125 
—  gr.  iii 


M.  Ft.  Caps.  No.  I 

Indicate  the  number  desired 
Sig:  One  capsule  with  water  t.i.d. 
Note:     Capsules  represent  a  compact,   convenient  form 

for  administration  of  medication. 

If  a  liquid  form  is  desired,  prescribe  Elixir  Perri 

Pyrophosphatis.   Quininae  et  Strychninae  N.   P. 

Genera!   tonic — Chalybeate. 


R 

Ferri  Reduct. 

Arsen.  Triox. 

Strych.  Sulph. 


gr.  1 

..gr.  1/100 
-gr.  1/60 


M.  Ft.  Caps.  No.  I 
Indicate  the  number  desired 
Sig:     One  Capsule  with  water  t.i.d. 
Note:     General  tonic — Chalybeate. 
R 

Elix.  Glycerophosphatis  Co.  N.  F. oz.  vi 

Sig:     Two  teaspoonfuls  t.i.d. 
Note:     Each   dose   contains: 

0.280  Gm.  or  4  gr.  Sodium  Glycerophosphate 
0.128  Gm.  or  14/5  gr.  Calcium  Glycerophosphate 
0.024   Gm.  or  1/3   gr.   Ferric  Glycerophosphate 
0.0162    Gm.    or    Vi    gr.    Manganese    Glycerophos- 
phate  (soluble) 

0.0064  Gm.  or  1/10  gr.  Quinine  Hydrochloride 
0.0009  Gm.   or  1/80  gr.   Strychnine  Nitrate 
Reconstructive  Tonic. 

Three  prescriptions  for  use  in  the  nose  and  throat. 
Nebula  Ephedrinae  N.  F.  VI 
R 

Ephedrine gr.  v 

Methyl  Salicylate  m  i 

Light  Liquid  Petrolatum  q.  5.  ad.  oz.  i 

M.  Ft.  Solution 
Sig:     One  drop  in  each  nostril  as  necessary. 
Note:     Topical     application     for     shrinking    respiratory 
mucous    membranes    1%    Ephedrine.      Write   out 
ingredients  or  specify  by  title. 

Nebula  Ephedrinae  Composita  N.  F.  VI 


R 

Ephedrine 
Camphor  . 
Menthol  _ 


Oil  of  Thyme 

Light  Liquid  Petrolatum  q.s.  ad. 

M.  Ft.  Solution 
Sig:     Drop  in  each  nostril  as  directed. 


gr.  v 

gr.  iii 

gr.  iii 

-m  iss 

__oz.  i 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


Topical    application    for    shrinking    respiratory 
mucous  membranes. 

1%   Ephedrine.     Write  out  ingredients  or  spec- 
ify by  title. 

Liquor  Ephedrinae  Sulfatis  N.  F.  VI 


Ephedrine  Sulfate 

Chlorbutanol  

Aq.  Dest.  q.s.  ad. 


_gr.  xmss 
__gr.  iiss 
oz.  i 


M.  Ft.  Solution. 
Sig:     One  drop  in  eacli  nostril  as  directed. 

Note:  Topical  application  for  shrinlfing  respiratory 
mucous  membranes.  3%  Ephedrine  Sulfate  or 
3  times  as  strong  as  Nebula  plain  or  compound. 
Average  dilution  is  with  equal  parts  of  distilled 
water.  May  be  used  full  strength.  Solution  is 
used  in  eye,  nose  and  throat.  In  eye  causes 
mydriasis. 
Write  out  ingredients  or  specify  by  title. 

Anodynes  and  sedatives. 

Elixir  Phenobarbitali  N.  F.  VI 


R 

Plienobarbital 

Tr.  Sweet  Orange  Peel 

Tr.  Cudbear  

Alcohol 

Glycerine .. 

Syrup  


_  gr.  vui 
— m.  uv 

m.  xiii 

_dr.  vss 
-dr.  viiss 

dr.  xi 

oz.  iv 


Distilled  Water  q.s.  ad. 

Dose:     dr.  i  equivalent  to  %  gr.  Phenobarbital. 

Note:     Sedative,    hypnotic.      Write    out    ingredients    or 
specify  by  title. 

Tablets    Phenobarbital    and    tablets    of   Pheno- 
barbital   soluble,    each    %    gr.    dose,    official    In 
N.  F.  VI. 
Maximum  dose  12  gr. 

Elixir  Aminopyrinae  N.  F. 
R 
Aminopyrine 


(also  Elixir  Amidopyrine) 


Compound  Spirit  of  Orange 

Alcohol 

Glycerine  

Syrup 


-gr.  Lxxu 
m.  vss 


m  cviu 
-  oz.  iss 

m  ii 

oz.  iv 


Tr.  Cudbear  Co. 

Distilled  Water  q.s.  ad. 

Dose:     dr.  i.  equivalent  to  25^2  gr.  Aminopyrine. 
Note:     Antipyretic,    antineuralgic,    anodyne,    antirheu- 
matic. 

Tablets  Amidopyrine  5  grains  official  N.  F.  VI. 
Maximum  dose  23  grains  over  period  of  a  day. 
Write  out  ingredients  or  specify  by  title. 


Elixir  Barbital  N.  F.  VI 


R 

Barbital 

Caramel 

Spt.  Vanilla  Co 

Alcohol 


— gr.  Ixiv 
_gr.  xxxvi 

m  liv 

dr.  X 


Glycerin  q.s.  ad. oz.  iv 

Dose:     dr.  i  equivalent  to  2  grains  of  barbital. 
Note:     Hypnotic.     Contraindicated  in   insomnia  due  to 
pain,    and   in   renal    disease.      Tablets    Barbital 
and  tablets  Barbital  soluble,   dose  of  each  tab- 
let 8  grains,  official  N.  P.  VI. 
Write  out  ingredients  or  specify  by  title. 


Important  "Don'ts"  Recomm:ended  For  All  Physicians 
(Jl.  Ark.  Med.  Soc,  June) 

Don't  operate  on  a  minor  without  written  consent  of 
the  parent  or  guardian. 

Don't  perform  a  sterilization  operation  on  a  minor  with- 
out a  court  order.  On  those  who  have  attained  their  ma- 
jority, secure  written  consent. 

Don't  operate  on  anyone  without  a  clear  and  full  under- 
standing as  to  the  nature  of  the  operation. 

Don't  report  on  services  rendered  without  patient's  con- 
sent. 

Don't  make  affidavits  until  you  know  their  purpose. 

Don't  fail  to  obtain  consultation  or  advice  when  you  are 


in  doubt. 

Don't  sign  until  you  know  what  you  are  signing. 

Don't  fail  to  consult  your  investment  banker  before  m- 
vesting  in  any  business  or  promotion  scheme. 

Don't  prescribe  narcotics  for  transient  persons  . 

Don't  sign  a  death  certiiicate  if  you  have  not  seen  the 
patient  within  36  hours  before  death.    Call  the  coroner. 


Urticarl^   of   Undetermined   Origin  Treated   With 

Parathyroid 
(A.   M.  Wigser,  Cincinnati,  O.,  in  Jl.  of  Med.,  July) 

In  a  case  of  extreme  urticaria  and  angioneurotic  edema,  ' 
neither  skin  tests  and  elimination  methods  nor  x-rays  gave 
any  explanation,  and  no  form  of  therapy,  including  fever 
therapy,  which  usually  gives  complete  relief  was  of  any 
help.  Typhoid  vaccine,  which  as  a  rule  gives  relief  in  any 
allergic  condition  did  not  accomplish  anything.  Parathy- 
roid gave  complete  relief  and  enabled  her  to  return  to 
her  duties,  cured  her  completely.  Calcium  determination 
was  within  normal  hmits  before  and  after  parathyroid 
injections. 


Benzedrine  Sulfate  in   Gastro-Intestin.al   Sfasm 

(J I.   A.   M.   A.,  Vol.   107,   No.   1) 
Myerson   and   Ritvo   beheve   it   is   of   more   than   usual 
interest  to  internists  and  roentgenologists. 

Benzedrine  sulfate  has  been  found  of  great  value,  in 
gastrointestinal  spasm,  whether  of  reflex,  functional  or  or- 
ganic origin.  Its  use  is  suggested  in  spastic  colitis  and 
pyloric  spasm.  The  effect  is  generally  immediate  and  un- 
attended by  any  side  effects  of  importance. 


Reducing  Heart  Work  in  Coronary  Thrombosis 
(Simon  Dack,  New  York,  in  Jl.  Mt.  Sinai  Hosp.,  July- 
Aug.) 
In  a  patient  who  had  recently  suffered  an  acute  coro- 
nary artery  occlusion,  an  SOO-calorie  diet  lowered  the  basal 
metaboUc  rate  to  — 30  to  — +0%,  slowed  the  pulse  rate, 
lowered  b.  p.  and  pulse  pressure,  and  reduced  cardiac 
output  by  33.5%.  The  work  of  the  heart  was  reduced  49%. 
The  marked  clinical  improvement  observed  in  this  patient 
is  attributed  to  these  beneficial  effects  of  the  low-calorie 
diet  on  the  heart  and  circulation. 


SURGERY 

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


The  Surgeon's  Prayer 

Lord,  I  pray  for  a  fuller  knowledge  of  disease, 
of  its  pathology,  of  its  symptoms,  of  its  causes,  of 
its  complications,  of  its  terminations  so  that  I  may 
better  know  how  to  interpret  its  manifestations.  I 
pray  for  knowledge  of  the  ways  and  means  that 
scientific  men  have,  through  ages  of  trial  and  study, 
found  most  effective  in  the  relief  of  symptoms  and 
in  the  curse  of  disease.  May  I  be  zealous  in  keep- 
ing myself  informed  of  new  discoveries  and  of  new 
methods  of  treatment  that  I  may  give  my  patient 
the  full  benefit  of  what  modern  science  has  to 
offer.  May  I  have  the  power  to  properly  evaluate 
these  so  that  my  patient  shall  not  be  subjected  to 
dangerous  experiment. 

I  pray  for  understanding  of  my  patient.  May  I 
remember  that  he  is  a  man  just  as  I  am  a  man; 
may  I  realize  that  he  may  be  mentally  sick  as  well 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


433 


as  physically  sick;  may  I  resp>ect  his  feelings.  In 
my  study  of  him  and  in  my  treatment  of  him,  may 
he  be  at  all  times  assured  of  my  sympathetic  inter- 
est; may  he  be  made  to  feel  that  to  me  he  is  a  sick 
man,  an  individual,  not  just  a  case. 

I  pray  that  I  may  recognize  my  limitations  and 
not  fail  to  call  consultation  when  I  need  help.  May 
ray  patient's  welfare  always  be  my  first  considera- 
tion; may  it  not  be  jeopardized  by  false  pride  in 
me.  When  called  in  consultation  may  I  have  due 
consideration  for  my  brother  doctor's  reputation 
and  feelings,  may  I  at  all  times  be  ethical  but  not 
at  the  sacrifice  of  the  patient's  proper  treatment 
and  best  chance  for  recovery. 

I  pray  that  I  may  keep  myself  physically,  mor- 
ally and  spiritually  fit  so  that  I  may  give  to  those 
seeking  my  services  the  best  of  which  I  am  capable. 
May  each  operation  be  to  me  a  work  of  art  de- 
manding my  best  effort.  May  I  appreciate  the  fact 
that  every  operation  has  dangers  to  the  patient  that 
must  not  be  forgotten;  may  I  remember  the  basic 
principles  as  laid  down  by  Pasteur  and  of  Lister. 

May  I  remember  that  to  me  the  operation  is 
over  when  the  wound  is  closed,  but  to  the  patient 
the  effects  are  just  beginning.  When  symptoms 
continue  may  I  realize  that  they  are  mute  evidence 
of  an  imperfect  result.  May  I  strive  not  only  to 
save  life  but  to  cure,  to  restore  my  patient  to  health 
and  to  activity.  May  I  think  of  the  human  body 
as  a  temple  not  to  be  defiled  by  careless  or  crude 
work.  May  I  treat  the  tissues  gently  so  that  my 
work  may  entail  a  minimum  of  scars  and  adhe- 
sions, the  results  of  trauma  and  infection. 

I  pray  that  no  worthy  individual  shall  be  denied 
my  services  for  the  lack  of  money.  The  conscious- 
ness of  having  restored  a  child  to  health  and  to 
happiness,  a  mother  to  her  children,  a  father  to  his 
dependent  family,  in  the  poor,  should  be  to  me 
sufficient  recompense  for  my  time  and  effort. 

When  a  patient  dies  may  I  conscientiously  try 
to  get  the  privilege  of  autopsy  so  that  I  may  learn 
the  true  cause  of  death  and  know  how  my  treat- 
ment has  failed. 

I  pray  that  I  may  know  that  opportunity  im- 
plies responsibility.  In  humility  may  I  practice 
surgery  as  I  should  live,  according  to  the  Golden 
Rule.  May  I  at  all  times  treat  my  patient  as  I 
should  wish  myself  treated  under  similar  condi- 
tions, so  that  when  I  go  to  my  reward  it  will  be 
with  the  consciousness  of  having  kept  the  faith,  of 
having  done  my  best  and  with  the  hope  that  per- 
haps the  world  is  a  little  better  off  that  I  have  lived 
in  it. — .'\men. 


social  failures.  The  school  has  only  a  temporary,  fleeting 
hold  on  the  child.  Teachers  should  be  alert  to  discover 
the  child  with  incipient  conduct  disorders.  It  is  a  severe 
mistake  when  our  teachers  encounter  a  problem-child  to 
abandon  the  educative  attitude  and  assume  the  attitude  of 
coercion. 

Naturally,  the  technique  which  the  teacher  uses  on  the 
normal  pupils  (98%)  will  not  prove  satisfactory  to  the 
maladjusted  child.  The  child  is  is  coerced  and  threatened 
making  him  feel  that  he  is  in  a  group  where  he  does  not 
belong.  This  feeling  is  accentuated  when  the  child  is 
transferred  to  a  special  class,  or  to  the  Reform  School. 
Each  step  which  singles  out  the  child  from  the  rest  of  his 
fellows  and  endeavors  through  coercion  or  unwise  disci- 
pline to  make  him  conform  imprints  more  indelibly  on 
the  child's  mind  that  he  is  different.  This  feeling  of 
alienation,  of  not  belonging,  is  at  the  heart  of  almost  all 
delinquency  and  crime. 

Children  do  not  arrive  at  school  at  the  age  of  S  or  6 
fresh  and  unspoiled;  they  have  developed  a  pretty  definite 
set  of  behavior  patterns.  If  a  child  has  diffculty  in  ad- 
justing himself  to  his  new  environment  he  is  immediately 
labelled  as  a  behavior  problem,  and  his  traits  flourish  like 
bacteria  in  warm  soup. 

If  the  teacher  endeavor  through  education  to  make  the 
process  of  conformity  a  voluntary  thing,  the  child  grows 
up,  feeling  a  sense  of  unity  with  the  rest  of  his  fellows. 

Some  of  our  individualists,  those  who  preach  the  doctrine 
of  independence  and  expression  of  personality  mistake  poor 
breeding  for  independence,  boorishness  for  courage  and 
license  for  liberality.  One  does  not  have  to  sacrifice  one's 
personality  to  be  kind,  to  respect  the  person  and  property 
of  another.  If  conformity  and  standardization  means  turn- 
ing out  children  who  are  loyal,  honest,  kind  and  decent, 
then  I  hope  the  mold  is  never  broken. 

Conformity  should  not  lead  us  to  have  our  philosophy 
of  life  handed  to  us  in  tin  cans;  our  concepts  should,  if 
our  mind  is  healthy  and  we  have  been  educated  well,  be 
the  result  of  our  own  appraisal  of  the  value  of  things 
offered  to  us;  but  unintelligent  and  undisciplined  non- 
conformity is  a  blight. 

Child  guidance  clinics  headed  by  competent  psychiatrists 
should  be  as  common  as  dental  clinics  in  our  schools  and 
our  teachers  should  have,  as  a  part  of  their  professional 
training,  sufficient  insight  so  that  they  can  detect  devia- 
tions from  the  normal  and  emotional  conflicts  long  before 
they  have  rooted  themselves  in  the  child's  personality. 

Too  often  we  find  our  "adult  education"  merely  some- 
thing which  excites  the  enthusiasm  of  the  dilettante  It  is 
too  easy  to  gorge  ourselves  with  the  canned  philosophies 
of  the  times;  too  easy  to  have  our  culture  handed  to  us 
in  predigested  pills. 

If  our  children  are  educated  to  have  tabloid  personalities, 
we  will  have  a  tabloid  culture  and  a  tabloid  civilization. 
But  if  our  teachers,  out  of  a  mastery  of  their  own  personal 
problems,  a  development  of  their  own  personalities,  can 
transmit  to  their  youthful  charges  some  of  their  zest  for 
living  fully,  then  our  culture  will  go  on  and  up,  and  the 
tabloid  era  will  pass  into  history  with  none  to  mourn  its 
passing. 


Refining  the  Personality 
(F.  J.  Farnell,  Providence,  R.  I.,  in   Med.   Rec,  July  15th) 
It   is  unfair  to  hold  the  school   entirely  responsible  for 


CuLTisTS  Lose  Court  Battle 
(Lindsay  Hoben,  in  Milwaukee  Med.  Times,  July) 
The  science  of  medicine  won  a  clear-cut  victory  in  Mil- 
waukee County  circuit  court  recently  when  a  jury  found 
that  "the  application  of  light  rays  by  the  use  of  the  Spec- 
tro-Chrome  instrument  has  no  substantial  healing  or  cura- 
tive effect  on  the  diseases  of  the  human  body"  The 
Spectro-Chrome   cultists  are  bitter  and  persistent   enemies 


434 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1' 


of  the  medical  profession.     They  fight  vaccination  and  the 
use  of  antitoxins. 

The  jury  returned  a  unanimous  verdict  on  all  8  questions 
submitted  to  it  in  the  $185,000  libel  suit  of  E.  A.  Ernest  of 
Milwaukee  against  the  Milwaukee  Journal.  The  news- 
paper had  called  Spectro-Chrome  a  "hocuspocus"  healing 
device  in  an  article  published  November  19th,  1935.  Mr. 
Ernest  at  that  time  was  national  distributor  for  the  Spectro- 
Chrome  apparatus. 


UROLOGY 

For  this  issue,  P.  G.  Fox,  M.D.,  and  Haroid  Glascock, 
M.D.,  Raleigh,  N.  C. 


Malignancy  in  an  Undescended  Testis* 
Report  of  a  Case 

In  a  recent  view  of  the  literature,  160  cases  of 
malignancy  in  undescended  testes  have  been  re- 
ported. We  wish  to  add  another  case  and  to  dis- 
cuss briefly  some  of  the  salient  features. 

There  has  been  a  great  deal  of  discussion  about 
whether  or  not  maldescent  of  a  testis  predisposes 
to  malignancy.  MacKenzie  and  Ratner^  are  of  the 
opinion  that  cryptorchidism  does  not  predispose  to 
malignancy  and  they  present  rather  conclusive  evi- 
dence to  support  their  stand: 

"Cunningham  saw  67  cases  of  tumor  of  the  testis  at  the 
Boston  City  Hospital  with  no  case  in  an  undescended 
testicle." 

"Ecclee  reports  859  cases  of  undescended  testicle  without 
malignancy  in  any." 

"Coley  reports  1,357  cases  of  undescended  testicle  with- 
out any  case  of  malignancy." 

"Kocher  found  only  one  case  in  1,000  cases  of  unde- 
scended testicle." 

"Hinman  states  that  one  case  of  malignancy  in  abdomi- 
nal cryptorchidism  is  found  in  every  60,000  admissions  of 
undescended  testicle." 

In  support  of  the  theory  that  maldescent  plays 
a  part  in  malignancy: 

"Deane  found  13.5  per  cent,  of  all  testicular  tumors  occur 
in  undescended  testes." 

"Hinman  reported  12.2  per  cent,  in  a  series  of  649  cases 
that  were  reviewed." 

"Rubaschow  reviewed  cases  reported  by  21  observers 
and  found  that  in  11  per  cent,  of  the  whole  group,  tumors 
were  present." 

Thus  we  see  one  may  easily  prove  either  side  of 
the  argument  by  statistics. 

Rea^  reported  76  cases  of  malignancy  including 
11  in  undescended  testes.  He  stated  that  Coley, 
Cunningham,  Odionne  and  Simmons,  Schischko, 
Lipshuz,  and  Deane,  reported  altogether  1,371  cases 
of  malignancy  in  the  male  sex  gland  with  136  (9.9 
per  cent.)  occurring  in  undescended  testes.  He 
arrived  at  the  following  conclusions: 

"Basing  one's  conclusions  upon  the  figures  one  might  be 
justified  in  the  assertion  that  tumor-formation  occurs  220 
times  as  often  in  the  undescended  testicle  as  in  the  normally 
placed  male  gonad." 

Rea's  theories  for  this  greater  predisposition: 

•Presented  to  the  Wake  County  Medical  Society,  June 
Lltll. 


1.  "Greater  exposure  to  external  trauma." 

2.  "Greater  exposure  to  trauma  caused  by  the  contrac- 

tion of  abdominal  muscles." 

3.  "Inborn  tendency  in  undescended  testicle  to  become 

malignant." 

He  claims  that  prophylactically,  orchidopexy 
should  be  tried  and  if  this  fails,  orchidectomy  f>er- 
formed  if  the  condition  is  unilateral. 

MacKenzie  and  Ratner  disagree  entirely  with 
Rea  on  this  as  they  say: 

"This  procedure  to  our  way  of  thinking,  is  a  most  drastic 
one  and  not  warranted  when  you  consider  that  only  one 
out  of  60,000  cryptorchids  might  develop  maUgnancy  of  an 
abdominal  testis." 

PATHOLOCy 

There  is  no  difference  in  the  pathology  of  the 
growth  in  the  undescended  from  the  pathology  of 
growth  in  normally  placed  testis.  These  growths 
are  practically  all  malignant  and  Ferguson's  classi- 
fication seems  to  cover  the  subject.  Herger  and 
Thibaudeau  report  this  classification:  1)  malig- 
nant teratoma  with  adult  features,  2 )  embryonal 
carcinoma  or  seminoma,  3)  embryonal  carcinoma 
with  lymphoid  stroma,  4)  embryonal  adenocarci- 
noma, and  5)  chorioepithelioma. 

Symptomatology 

Naturally  the  symptoms  of  growth  of  the  cryp- 
torchid  are  different  to  those  of  the  normally  placed 
testis,  and  depend  on  the  site  of  the  undescended 
organ.  If  the  testis  is  located  in  the  inguinal  re- 
gion, the  patient  usually  complains  of  a  mass  and  a 
sense  of  heaviness,  at  times  pain  in  that  region. 
These  symptoms  are  generally  preceded  by  a  his- 
tory of  some  injury  to  the  area.  If  the  testis  is 
in  the  abdomen  there  will  probably  be  no  symp- 
toms until  late  when  a  mass  in  the  abdomen  pre- 
sents itself. 

Diagnosis 

One  must  make  a  differentiation  from  other  con- 
ditions that  affect  the  normally  placed  testis: 
syphilis,  tuberculosis,  hydrocele,  epididymitis,  hem- 
atocele, orchitis  and  chronic  torsion  are  to  be  ruled 
out.  Remember  that  a  positive  Wassermann  reac- 
tion does  not  definitely  rule  out  a  new  growth.  If 
the  mass  is  due  to  syphilis  antisyphilitic  treatment 
will  reduce  its  size. 

In  diagnosing  malignancy  of  the  testicle,  regard- 
less of  site,  all  authors  agree  on  the  value  of  testing 
for  the  presence  of  prolan  A. 

Treatment 

The  consensus  of  opinion  is  that,  first,  a  course 
of  deep  x-ray  therapy  should  be  given.  This  is 
followed  by  orchidectomy  and  several  courses  of 
x-ray  treatment  over  a  long  period  of  time. 

MacKenzie  and  Ratner  also  state  that  in  their 
opinion  no  case  of  cryptorchidism  per  se  is  to  be 
jubjected  to  orchidectomy. 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


43S 


Case    Report 

A  white  farmer,  aged  41,  was  admitted  to  the  Mary 
Elizabeth  Hospital  November  13th,  1935,  complaining  of 
swelling  and  pain  in  the  left  groin.  The  patient  said  that 
the  left  testicle  has  always  been  in  the  left  groin,  but  has 
never  given  any  trouble  until  four  years  ago  when,  after 
heavy  lifting,  he  felt  some  pain  in  the  inguinal  region,  and 
often  since  that  time,  after  lifting  heavy  objects,  he  has 
had  considerable  trouble.  A  year  ago  he  was  struck  in 
the  left  groin  by  a  plow  handle  which  blow  gave  him  a 
great  deal  of  pain,  and  since  then  the  testicle  has  enlarged 
gradually  with  some  pain  and  heaviness  in  the  groin. 

Both  parents,  one  sister  and  two  brothers  are  living  and 
well.    Patient  is  married  and  has  one  living  child. 

The  patient  had  measles,  mumps,  whooping  cough  and 
malarial  fever  when  a  child  and  tonsillectomy  several  years 
ago.    He  denies  venereal  infection. 

The  urine  was  negative  for  albumin,  casts,  blood  and  pus. 
The  red  blood  cells  were  4,200,000,  hemoglobin  85  per  cent., 
white  cells  7,400,  Wasserman  reaction  negative. 

Physical  development  was  good,  weight  130  pounds, 
height  5  feet  4  inches,  temperature  98,  pulse  72,  respiration 
18,  skin  clear,  eyes  negative,  left  ear  contained  hard  mass 
of  cerumen,  teeth  in  very  poor  repair,  gums  badly  dis- 
eased, tonsils  removed,  tongue  moist  and  clean,  thyroid  not 
palpable,  cervical  glands  not  enlarged. 

The  thorax  was  symmetrical,  expansion  good  and  equal, 
percussion  note  clear,  breath  sounds  normal,  area  of  cardiac 
dullness  not  increased,  no  murmurs  heard. 

The  abdomen  was  flat,  stomach  in  position,  liver  not 
enlarged,  neither  kidney  palpable,  spleen  not  felt,  no  areas 
of  tenderness  or  rigidity.  In  the  left  inguinal  region  there 
was  a  rather  firm  and  movable  mass  3x2  inches  just 
above  Poupart's  ligament,  extending  rather  upward  than 
downward  into  the  scrotum.  The  left  external  ring  was 
not  palpable  as  the  mass  came  down  to  the  ring.  The  left 
testicle  was  absent  from  the  scrotum,  the  right  normally 
placed  and  seemed  normal.  The  right  external  ring  was 
normal  and  the  inguinal  lymphatic  glands  not  enlarged. 

The  prostate  was  slightly  enlarged  but  is  movable  and 
not  tender  or  nodular. 

Blood  pressure  120/75,  pulses  regular  and  equal,  knee 
jerks  normal. 

Preoperative  diagnosis:  Growth  of  undescended  testicle 
(left),  probably  malignant. 

Operation:  Left  orchidectomy  was  done  under  one-per 
cent,  novocain  anesthesia,  through  a  left  inguinal  incision. 
As  the  external  fascia  was  opened  a  mass  which  appeared 
to  be  an  enlarged  testicle  was  found.  As  the  tissues  were 
stripped  from  it,  it  shelled  out  without  adhesions  and  it 
was  found  that  it  had  formerly  passed  through  the  external 
ring  and  had  turned  upward  and  lodged  over  the  aponeuro- 
sis of  the  external  oblique  muscle.  The  aponeurosis  was 
split  to  the  external  ring  and  the  cord  severed  at  the 
internal  ring  and  anchored,  the  vas  was  tied  separately 
and  the  end  cauterized  with  carbolic  acid  and  the  wound 
closed. 

Pathological  report  (Dr.  C.  C.  Carpenter,  Wake  Forest 
College):  Specimen  consists  of  a  testicle  that  measures 
11  X  7  X  5  cm.  The  outer  surface  is  reddish  gray  and 
very  smooth,  and  on  one  side  a  large  amount  of  grayish- 
brown  exudate  can  be  stripped  off.  The  outer  surface  has 
a  smooth,  glistening,  semi-transparent  covering  beneath 
which  large  vessels  can  be  seen.  The  cut  surface  is  light 
pink  and  caseous;  small  reddish-brown  areas  are  seen  and 
reddish-brown  fluid  can  be  pressed  out  of  the  tissue.  On 
one  side  the  ti.ssue  is  very  firm,  and  the  cut  surface  is 
light  gray. 

Microscopically  the  section  shows  a  fibrous  connective 
tissue  stroma,  irregular  groups  of  large  round  cells,  of  the 


type  lining  the  seminferous  tubules,  a  good  many  of  which 
show  mitosis.  They  show  marked  anaplasia. 
Diagnosis:  Embryonal  carcinoma  (seminoma). 
Postoperative  treatment:  The  patient  had  a  satisfactory 
convalescence,  the  wound  healing  by  first  intention  and 
the  stitches  were  removed  on  the  seventh  day.  Deep  x-ray 
therapy  was  begun  on  November  17th  and  continued  until 
January  22nd,  a  total  of  48  treatments  through  eight  por- 
tals of  entry: 

1440  R  to  left  lower  abdomen 

1440  R  to  right  lower  abdomen 

1710  R  to  left  lower  back 

1710  R  to  right  lower  back 

1080  R  to  the  middle  of  the  abdomen 

1116  R  to  the  middle  of  the  back 

1080  R  to  the  posterior  chest 

1000  R  to  the  anterior  chest 

A  total  of  10,576  R. 
The  patient  was  last  seen  June  8th,  1936,  at  which  time 
he  stated  that  he  was  feeling  fine — no  loss  of  weight,  is 
following  the  usual  occupation  of  a  farmer.  At  this  time 
there  is  no  evidence  of  any  metastasis  and  we  believe  that 
the  prognosis  is  good.  He  has  been  instructed  to  report 
back  for  observation  every  month.  Another  course  of  x-ray 
therapy  will  be  given  in  the  near  future. 
References 

1.  Mackenzie,  D.  W.,  and  Ratner,  M.:  Malignant  Growth 
in  the  Undescended  Testis.  Journal  of  Urology,  Oct., 
1934. 

2.  Rea,  C.  E.:  Malignancy  of  the  Testis  With  Special 
Reference  to  Undescended  Testicle.  Amer.  Jour,  of 
Cancer,  1931. 

3.     Herger  and  Thibaudeau:     Idem,  Nov.,  1934. 
4.    LiPSHUTz,   H.:     Teratoma    of    Undescended    Testicle. 
The  Urol.  &  Cut.  Rev.,  April,  1936. 


INTERNAL  MEDICINE 

Paul  H.  Ringer,  A.B.,  M.D.,  F.A.C.P.,  Editor 
Asheville,  N.  C. 


The  Treatment  of  Pneumonia 
The  value  of  a  paper  bearing  such  a  title  de- 
pends entirely  upon  the  writer.  Dr.  Rufus  Cole  of 
the  Rockefeller  Institute  surely  is  one  whose  enor- 
mous experience  and  abilities  for  investigation  com- 
pel attention.  His  paf)er  on  the  subject  appears  in 
the  Annals  of  Internal  Medicine  for  July. 

Dr.  Cole  says: 

"For  specific  treatment,  an  etiologic  diagnosis  is  essen- 
tial, but  before  this  is  made  it  must  first  be  determined 
whether  or  not  the  patient  is  really  suffering  from  pneu- 
monia, and  this  should  be  decided  as  early  as  possible.  At 
present  most  physicians  wait  for  the  appearance  of  physi- 
cal signs  of  consolidation  before  making  a  diagnosis.  Pa- 
tient after  patient  has  been  sent  into  our  hospital  with 
the  statement  that  he  has  been  suffering  with  severe  symp- 
toms for  three,  four,  five,  or  even  more  days,  but  that  the 
signs  of  pneumonia  have  just  appeared. 

The  truth  of  the  matter  is  that  evidence  of  consolidation 
is  not  necessary  for  the  diagnosis  of  pneumonia.  To  the 
experienced  observer  the  symptoms  of  the  onset  of  this 
disease  are,  in  most  cases,  definite  and  unmistakable.  In 
almost  all  cases  the  person  who  has  a  chill,  fever  over 
102°,  cough,  pain  in  the  side,  rapid  respirations,  and,  above 
all,  who  is  expectorating  sputum  which  is  bloody  or  even 


436 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


only  slightly  tinged  with  blood,  has  pneumonia.  Even  in 
persons  who  have  suffered  from  cough  or  mild  upper  res- 
piratory infections  before  the  onset,  as  is  the  history  of 
60  per  cent,  of  the  cases,  the  appearance  of  the  more  serious 
pulmonary  infection  is,  in  most  instances,  clearly  indicated 
by  the  more  or  less  sudden  appearance  of  the  symptoms  I 
have  mentioned.  We  physicians  have  made  the  diagnosis 
of  pneumonia  too  difficult,  and  it  is  much  less  harmful  to 
make  an  occasional  mistake  than  to  live  in  fancied  security 
for  days  until  the  time  when  specific  treatment  would  be 
useful  is  passed.  Most  cases  threatened  with  pneumonia 
have  pneumonia." 

Serum  Therapy 

Lobar  pneumonia  has  been  treated  at  the  hos- 
pital of  Rockefeller  Institute  by  means  of  specific 
immune  serum  for  the  past  twenty-two  years,  and 
during  that  time  462  cases  of  Type  I  pneumonia 
were  treated  with  a  mortality  of  48,  or  10.5  per 
cent.  This,  of  course,  is  a  great  improvement  over 
mortality  figures  obtained  from  cases  not  so  treat- 
ed. Dr.  Cole  finds  that  so  far  Type  I  pneumonia  is 
really  the  only  type  in  which  the  serum  is  of  much 
avail.  He  points  out,  however,  that  Type  I  pneu- 
monia probably  causes  25,000  deaths  in  this  coun- 
try every  year  and,  therefore,  should  be  looked 
upon  as  a  specific  infectious  disease— as  specific  as 
typhoid  fever. 

Dr.  Cole  advocates  giving  the  serum  as  early  as 
possible  and  in  large  amounts,  repeating  the  dosage 
every  four  or  five  hours  until  definite  effects  are 
seen  in  the  fall  of  temperature,  decrease  in  pulse 
and  respiratory  rates,  and  improvement  in  the  other 
signs  of  intoxication.  It  is  better  to  give  too  much 
than  too  little. 

Chemotherapy 
Drugs  such  as  optochin  and  other  quinine  deriva- 
tives have  been  used,  but  in  order  to  be  effective 
the  drug  must  be  given  in  such  large  doses  as  to 
develop  toxic  effects  in  the  patient;  therefore,  the 
use  of  such  drugs  is  unjustifiable. 

General  Measures 
Rest  of  body  and  mind  are  most  important.  Ir- 
respective of  how  slightly  ill  the  patient  may  ap- 
pear, he  should  be  kept  absolutely  quiet  and  fear 
and  apprehension  should  be  allayed  in  every  possi- 
ble way. 

Morphine 
Morphine  still  continues  to  be  the  drug  that 
probably  is  most  used  for  bringing  about  a  condi- 
tion of  relative  comfort  in  pneumonia.  Dr.  Cole 
says  that  they  are  now  more  conservative  in  its  use 
at  the  Rockefeller  Hospital  than  used  to  be  the 
case,  because  Dr.  Davis  found  that  in  most  cases 
following  its  administration  there  occurred  a  slow- 
ing in  respiratory  rate,  together  with  a  diminution 
in  pulmonary  ventilation  and  a  decrease  in  oxygen 
saturation  of  the  arterial  blood. 


Oxygen  Therapy 
Dr.  Cole  says: 

"It  is  very  difficult  to  evaluate  the  actual  benefit  derived 
from  the  use  of  ox>-gen.  While,  by  an  occasional  patient, 
much  subjective  relief  is  obtained,  in  most  instances  this 
is  not  evident.  The  immediate  effect  on  the  character  and 
frequency  of  respirations  is  not  so  great  as  certain  of  the 
reports  would  lead  us  to  expect.  What  the  effect  may  be 
on  the  final  outcome  can  not  be  stated  at  present  with  any 
degree  of  accuracy.  Contrary  to  the  statements  of  other 
enthusiastic  observers,  I  can  only  say  that  our  mortality  in 
cases  not  treated  with  serum  has  not  notably  diminished 
since  the  introduction  of  the  oxygen  chamber.  Neverthe- 
less, we  should  feel  greatly  handicapped  if  we  lacked  facili- 
ties for  supplying  oxygen  to  patients  with  cyanosis." 

Dr.  Cole  speaks  briefly  about  the  different  meth- 
ods of  administering  oxygen  and  refers  in  some  de- 
tail to  the  oxygen  tent  of  Dr.  Burgess,  of  Provi- 
dence. 

"Recently  a  very  ingenious  and  simple  method  of  ad- 
ministering oxygen  has  been  devised  by  Dr.  Burgess  of 
Providence.  This  consists  merely  of  a  box,  open  at  the 
top,  lined  on  the  sides  and  bottom  by  a  rubber  bag  at- 
tached by  clamps  to  the  upper  edges  of  the  box.  At  the 
front  is  an  opening  in  the  rubber  bag  through  which  the 
head  is  thrust,  the  edges  of  the  opening  fitting  tightly  about 
the  neck.  In  the  bag  near  the  bottom  are  openings  for 
tubes  through  which  oxygen  is  allowed  to  flow  continu- 
ously. The  oxygen  diffuses  only  slowly  upward,  so  that 
with  a  flow  of  four  to  six  liters  per  minute  the  air  in  the 
bag  at  the  level  of  the  patient's  mouth  and  nose  can  b€ 
kept  constantly  40  to  50  per  cent,  of  oxygen.  With  a 
satisfactory  cooling  system,  the  apparatus  can  be  employed 
continuously  without  discomfort  to  the  patient." 

(The  editor  has  had  some  experience  with  the  Burgess 
tent  and  cannot  share  Dr.  Cole's  enthusiasm  for  it  because 
the  tight  collar  around  the  patient's  neck  is  often  uncom- 
fortable, and  furthermore  the  tent  is  very  difficult  to  ma- 
nipulate unless  the  patient  can  lie  absolutely  recumbent. 
This,  of  course,  many  pneumonia  patients  cannot  do.) 

Dr.  Cole  does  not  believe  that  placing  a  patient 
a  short  period  of  time  in  an  oxygen  tent  is  of  value, 
but  is  of  the  opinion  that  to  obtain  results  he  should 
be  kept  therein  continuously. 

SoDnjM  Chloride 

"Another  physiological  alteration  in  patients  with  pneu- 
monia is  a  decreased  excretion  of  chlorides  in  the  urine  and 
a  diminution  of  the  chloride  content  of  the  blood  plasma. 
From  time  to  time  during  the  past  25  years,  papers  have 
appeared  dealing  with  the  saline  treatment  of  lobar  pneu- 
monia.    *     *     * 

At  the  present  time  the  administration  of  sodium  chloride 
to  pneumonia  patients  should  be  considered  to  be  in  an 
experimental  stage,  and  the  basis  for  this  form  of  therapy 
largely  empiric.  One  must  always  remember  that  modifica- 
tion of  physiological  alterations  present  in  disease  does  not 
necessarily  increase  the  patient's  chances  of  recovery.  Most 
of  us  remember  when  antipyretic  drugs  were  in  their  hey- 
day. Today,  fever  is  being  produced  artificially  in  at- 
tempts to  cure  certain  infectious  diseases." 

Digitalis 
The  question  of  the  employment  of  digitalis  as  a 
routine  measure  is  not  as  yet  settled.    In  1916,  on 
account  of  the  considerable  number  of  pneumonia 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


437 


patients  showing  cardiac  irregularities,  the  routine 
digitalization  of  all  pneumonia  patients  was  begun 
at  Rockefeller  Hospital.  In  1930,  however,  Niles 
and  Wyckoff  reported  that  in  a  large  series  of  cases 
treated  with  digitalis  the  mortality  was  considerably 
higher  than  in  a  corresponding  number  of  cases 
receiving  no  digitalis.  In  the  light  of  this  experi- 
ence, Cohn  and  Lewis  reviewed  all  the  pneumonia 
cases  digitalized  at  the  Rockefeller  Hospital;  and 
their  conclusion  was  that  giving  digitalis  did  not 
seem  to  influence  the  course  of  the  disease. 

Dr.  Cole  is  definitely  opposed  to  the  use  of  qui- 
nine and  alcohol  in  the  treatment  of  lobar  pneumo- 
nia. 

Diathermy 

"Several  years  ago,  influenced  by  the  reported  favorable 
results  from  the  use  of  diathermy,  Binger  and  Christie  in 
our  clinic  carried  on  studies  with  the  idea  of  determining 
its  value.  During  the  passage  of  the  diathermy  current 
they  made  direct  measurements  of  the  temperature  which 
developed  within  the  lungs  in  dogs,  both  in  the  lungs  of 
normal  dog;  and  in  those  which  were  the  seat  of  a  pneu- 
monic consohdation.  It  was  found  that  in  normal  lungs 
in  no  instance  was  it  possible  to  demonstrate  any  consider- 
able amount  of  local  heating,  the  explanation  being  that 
the  lungs  represent  an  excellent  water-cooled  system,  and 
that  the  intact  pulmonary  circulation  prevents  any  consid- 
erable degree  of  local  heating.  In  consolidated  lungs  of 
dogs,  probably  because  of  the  disturbed  circulation,  it  was 
possible  to  increase  the  local  heating  slightly,  but  not 
more  than  one  or  two  degrees.  In  three  pneumonia  pa- 
tients direct  measurements  of  the  lung  temperature  were 
made  by  the  aid  of  thermocouples  enclosed  in  an  ordinary 
Luer  needle,  which  was  inserted  directly  into  the  consoli- 
dated lung.  In  none  of  these  patients  was  there  an  appre- 
ciable rise  in  lung  temperature  during  or  after  exposure  to 
the  diathermy  current. 

In  the  Ught  of  these  studies,  no  further  clinical  use  has 
been  made  by  us  of  this  method  of  treatment.  One  hesi- 
tates to  state  categorically  that  this  method  has  no  value. 
We  grow  cautious  with  experience.  One  can  only  say  that 
it  is  not  based  on  experimental  or  clinical  studies  that 
appear  to  be  sound.  Even  though  it  were  possible  to 
raise  the  temperature  within  the  lung,  it  would  not  neces- 
sarily follow  that  the  results  would  be  beneficial." 

Artificial  Pneumothorax 

Opinions  vary  as  to  the  advantages  of  this  meth- 
od, which  as  yet  has  not  been  tried  in  any  large 
series  of  cases.  That  it  relieves  the  pain  of  dry 
pleurisy  is  unquestionable;  that  it  has  any  effect 
upon  the  course  of  the  disease  lobar  pneumonia  is 
as  yet  sub  judke.  In  two  of  the  cases  at  Rocke- 
feller Hospital  apparent  rupture  of  the  lung  oc- 
curred. 

Dr.  Cole's  conclusions  follow: 

"From  this  brief  review  it  seems  evident  that  the  only 
form  of  specific  therapy  proved  to  be  useful  and  available 
at  present  is  serum  treatment  in  Type  I  pneumonia.  Eti- 
ologic  diagnosis  should  be  made  as  early  as  possible  and 
treatment  started  without  delay.  Care  should  be  taken  to 
have  good  serum  and  it  should  be  administered  in  large 
amounts  and  its  use  continued  until  recovery  is  evident. 


Certain  measures,  such  as  the  administration  of  oxygen 
and  of  sodium  chloride,  may  be  useful  in  overcoming  path- 
ological variations  in  the  body  mechanism. 

The  value  of  artificial  pneumothorax  awaits  further 
study.  At  present  its  usefulness  seems  to  consist  in  the 
relief  of  pain  rather  than  in  any  effect  on  the  infectious 
process.  Finally,  it  should  be  stated  that,  while  the  solution 
of  the  pneumonia  problem  has  not  been  reached,  some 
advance  has  been  made  in  the  past  twenty-five  years.  Not 
the  least  important  part  of  that  advance  has  consisted  in 
the  increase  of  knowledge  concerning  the  nature  of  the  dis- 
ease and  of  the  natural  mode  of  recovery.  The  accrued 
knowledge  should  lead  to  acceleration  of  progress  in  the 
development  of  methods  of  treatment  and  cure." 

This  is  a  panoramic  paper  by  an  individual  who 
has  had  the  opportunity  to  try  out  in  the  most 
scientific  manner  the  various  methods  we  have  with 
which  to  combat  lobar  pneumonia.  He  can  speak 
with  authority,  and  it  is  well  from  time  to  time  to 
have  the  high  spots  in  a  subject  as  important  as 
this  spread  clearly  before  the  eyes  of  our  minds. 


Acute  Aleucemla  Myeloid  Leucemia 
(I.    H.    Marcus,  Brooklyn,   in  Jl.    Lab.  &  Clin.    Med.,  July) 

The  case  demonstrates  the  danger  of  considering  a  pa- 
tient with  leucemia  as  permanently  cured  until  a  very 
long  time  has  elapsed  without  a  recurrence  of  the  dis- 
ease. 

A  case  of  aleucemic  myeloid  leucemia  is  reported,  which 
at  the  outset  appeared  to  be  of  an  acute  type.  The  pa- 
tient, however,  made  a  complete  recovery  for  8  to  10 
months,  with  no  evidence  of  the  disease  either  on  physical 
examination  or  blood  study,  and  then  again  evidenced  the 
findings  of  acute  myeloid  leucemia  and  died. 

The  case  is  of  further  interest  because  of  1)  a  family 
history  of  having  a  brother  suffering  from  Vaquez's  disease 
and  a  sister  with  Hodgkin's  disease,  2)  the  axillary  skin 
infiltration  which  later  disappeared,  3)  the  occurrence  of 
vesicles  on  the  skin  containing  serosanguineous  fluid  with 
induration  about  the  vesicles,  4)  the  onset  of  the  disease 
with  joint  manifestations  strongly  suggesting  rheumatic 
fever,  5)  only  slight  splenic  enlargement  at  any  time,  and 
6)  the  comparatively  large  number  of  lymphocytes  found 
at  various  stages  throughout  the  disease. 


The  first  medical  book  written  in  the  western 
hemisphere  is  about  to  be  published  by  the  Smithsonian 
Institution  after  a  delay  of  almost  four  centuries.  The 
book,  an  Aztec  herbal  or  catalog  of  plants  and  the  healing 
potions  made  from  them,  was  written  in  1552  by  a  Martin 
De  La  Cruz  in  the  Aztec  language  and  translated  into 
Latin  by  another  Aztec,  Juannes  Badianus,  while  they  were 
students  at  the  College  of  Santa  Cruz.  Five  years  ago  it 
was  discovered  in  the  Vatican  Library  at  Rome  by  an 
American,  Dr.  Charies  U.  Clark.  The  book  contains  reme- 
dies for  many  ailments,  among  them  colds,  falling  hair, 
head  fractures,  sore  eyes,  fever,  cataracts,  and  feeble-mind- 
edness. 


Accumulating  experience  with  the  use  of  the  duode- 
nal SUCTION  TUBE  makes  us  (H.  C.  Fang  &  H.  H.  Loucks, 
Peiping,  in  Chinese  Med.  JL,  March)  ready  to  declare 
that  stasis  of  gas  and  fluid  within  the  stomach  and  duode- 
num is  the  chief  cause  of  postoperative  vomiting.  So 
impressed  have  we  been  by  the  promptness  and  certainty 
with  which  duodenal  suction  allays  nausea  and  vomiting, 
prevents  distention  and  decompresses  a  dilated  upper  bowel. 


438 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1930 


that  it  is  now  practically  routine  in  our  clinic,  in  every 
instance  in  which  a  patient  has  suffered  from  vomiting 
and  distention  before  operation  or  is  found  to  have  a 
dilated  intestine  at  the  time  of  operation,  for  a  duodenal 
tube  to  be  inserted  either  before  operation,  in  the  operating 
room  or  immediately  after  the  patient  has  returned  to  the 
ward.  If  difficulty  is  encountered  because  of  the  softness 
of  the  tube  a  flexible  wire  placed  within  its  lumen  will 
facilitate  passage  through  the  esophagus. 


PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 
Pitt  County  Health  Officer 


"The  Relation  of  Physical  Defects  to  Growth 
IN  Children"* 

The  question  of  the  relationship  of  physical 
defects  to  the  growth  in  children  has,  for  a  number 
of  years,  been  a  live  topic.  In  so  far  as  we  know, 
no  conclusions  based  on  a  competent  and  suffi- 
ciently extensive  study  has,  at  any  time,  been  pre- 
sented. 

The  study  here  presented  is,  in  our  opinion,  not 
conclusive;  but  it  is  probabl  ysufficiently  well  done 
and  sufficiently  extensive  to  justify  the  opinion 
that,  heretofore,  we  have  been  too  prone  to  assign 
some  physical  defect  as  a  cause  for  apparent  physi- 
cal retardation. 

The  author  states  that  this  study  is  based  on 
material  furnished  by  records  of  physical  examina- 
tions and  physical  measurements  of  approximately 
30,000  elementary  school  children  of  21  States — 
Maine,  New  Hampshire,  Vermont,  Massachusetts, 
Connecticut,  New  York,  New  Jersey,  Pennsylvania, 
Minnesota,  Wisconsin,  Michigan,  Indiana,  Illinois, 
Texas,  Louisiana,  Arkansas,  Tennessee,  Kentucky, 
Missouri,  Utah  and  Nevada.  The  parents  and 
grandparents  of  the  children  were  all  white  and 
native-born. 

The  summary  of  this  interesting  report  reads  in 
part,  as  follows:  "The  purpose  of  this  paper,  the 
third  of  the  series,  is  the  comparison  of  the  physi- 
cal growth  and  the  rate  of  physical  growth,  re- 
spectively, of  two  groups  of  elementary  school  chil- 
dren, one  group  being  without  and  the  other  with 
physical  defects.  The  comparison  is  made  with 
respect  to,  first,  seven  physical  measurements;  sec- 
ond the  annual  increments  of  the  measurements; 
and,  finally,  four  computed  indexes  of  body  form. 
The  defects  include,  principally,  carious  teeth,  de- 
fective tonsils  and  adenoids,  goiter,  enlarged  cervi- 
cal and  submaxillary  glands,  and  defective  vision. 
The  physical  measurements  are  body  weight,  stand- 
ing and  sitting  heights,  chest  circumference,  trans- 
verse and  anteroposterior  chest  diameters,  and  vital 


capacity.  The  indexes  are  weight  over  height,  sit- 
ting height  over  standing  height,  anteroposterior 
chest  diameter  over  transverse  chest  diameter,  and 
chest  circumference  over  standing  height.  All  of 
the  measurements  are  specific  for  sex  and  age.  *  *  * 
While  the  actual  differences  in  the  mean  physi- 
cal measurements  between  the  two  groups  of  chil- 
dren were  found  generally  to  be  small,  they  are, 
with  one  or  two  exceptions,  in  the  same  direction 
for  both  sexes.  Thus  the  nondefective  group  is,  on 
the  average,  taller  and  heavier  and  has  longer 
trunks  and  greater  vital  capacity.  The  indexes 
showed  the  defective  group  to  be  stockier;  in  re- 
lation to  height,  the  defectives  have  short  trunks 
and  small  chest  girths.  The  two  groups  showed  no 
consistent  differences  between  them  in  their  rate  of 
growth  as  measured  by  mean  annual  increases  in 
each  of  the  seven  physical  measurements." 


Some  Yellow  Fever  Transmitted  by  Means  Other  Than 

Mosquito  Carriage 

(Rockefeller   Commission    Report   1935) 

Ten  years  ago  yellow  fever  in  South  America  was  be- 
lieved to  be  restricted  to  a  district  in  the  northeast  of 
Brazil,  and  to  be  rapidly  disappearing  as  a  result  of  anti- 
mosquito  services  in  a  few  of  the  larger  cities.  It  is  now 
realized  that  yellow  fever  is  widely  disseminated  over  the 
continent  east  of  the  Andes  and  north  of  Paraguay,  and 
the  hope  that  the  disease  might  shortly  be  brought  under 
control  or  disappear  has  been  deferred.  Ten  years  ago 
yellow  fever  was  regarded  as  an  urban  disease  transmitted 
by  Aedes  aegypti,  a  mosquito  living  and  breeding  almost 
entirely  in  houses;  whereas  today  it  is  known  that  yellow 
fever  is  widespread  in  the  interior  and  occurs  as  a  jungle 
disease  hundreds  of  miles  away  from  the  nearest  Aedes 
aegypti  habitat. 

There  were  a  number  of  outbreaks  of  disease  that  looked 
like  yellow  fever  at  unexpected  places  between  1930  and 
1935,  but  its  discovery  in  Goyaz  and  elsewhere  in  south 
central  Brazil  in  1935  was  one  of  the  dramatic  events  in 
epidemiology.  The  area  in  Goyaz  was  one  in  which  yel- 
low fever  had  never  previously  been  reported;  it  was  in- 
vestigated simply  in  order  to  complete  a  survey.  A  local 
practitioner  mentioned  that  from  up  country  there  had 
come  a  fatal  case  of  malaria  with  some  unusual  features. 
On  going  into  the  district  many  other  cases  of  a  disease 
found  to  be  yellow  fever  were  discovered  in  a  stretch  of 
country  extending  over  100,000  sq.  miles.  This  was  coun- 
try which  could  not  be  considered  jungle  or  wild  territory, 
because  it  contained  towns  with  populations  of  over  30,000, 
but  the  strange  thiag  was  that  the  disease  did  not  come 
into  the  towns. 

Jungle  yellow  fever  has  now  been  observed  long  and 
thoroughly  enough  for  its  clinical  identity  with  the  type 
transmitted  by  Aedes  aegypti  to  be  firmly  established. 
Cases  of  every  degree  of  severity  were  seen  in  jungle  yellow 
fever,  just  as  in  urban  yellow  fever. 

Until  more  is  known  of  the  source  of  infection  in  the 
jungle  and  the  mechanism  of  its  transmission  from  such  a 
source  to  man,  a  program  for  control  cannot  be  drawn 
up. 


I 


•Taken  from  Public  Health  Reports,  Vol.  51,  No.  26, 
June  26th.  By  William  M.  Gafater,  Senior  Statistician, 
U.  S..  P.  H..  S. 


Gonorrhea  is  the  medico/  man's  Waterloo  and  the  medi- 
cine  man's  PaTa.dise.—Melicow. 


August,  1936 


SOXJTHERN  MEDICINE  AND  StIRGERY 


439 


PEDIATRICS 

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


r  Mumps  Pancreatitis 

A  twelve-year-old  boy  on  his  way  to  a  summer 
camp  came  down  with  mumps.  Both  parotid 
glands  and  both  submaxillary  glands  were  involved 
when  he  was  first  seen.  He  was  put  to  bed  in 
order  to  keep  his  activities  within  bounds.  On  the 
6th  day  of  the  illness  he  developed  a  high  fever, 
was  chilly  and  complained  of  a  severe  epigastric 
pain.  This  was  indeed  a  surprise  as  the  edema 
associated  with  the  glands  had  almost  completely 
subsided,  the  temperature  was  normal  and.  in  gen- 
eral he  was  feeling  fine.  Marked  nausea  on  motion 
or  when  the  abdomen  was  palpated  completed  the 
onset  picture.  It  was  recalled  that  there  was  such 
a  thing  as  an  involvement  of  the  pancreas  compli- 
cating mumps;  so  to  the  books  for  additional 
knowledge  on  the  subject.  To  my  grief  I  found 
that  no  available  textbook  on  pediatrics  or  general 
medicine  contained  anything  of  value.  They  mere- 
ly said  that  pancreatitis  occurred  "rarely"  or  was 
"not  uncommon."  Without  the  local  medical  li- 
brary, substantial  evidence  of  the  condition  would 
not  have  been  available  until  after  the  boy  had 
recovered. 

Mumps  is  a  condition  seldom  seen  in  hospital 
wards  for  children  except  accidentally.  Because 
of  the  benign  nature  of  the  disease  neither  is  it 
seen  often  in  contagious-disease  hospitals.  There 
are  on  record  a  few  autopsy  reports  on  mumps  pan- 
creatitis and  the  symptoms  are  sufficiently  well 
recognized  to  make  the  condition  a  clinical  en- 
tity. 

In  one  series  studied  there  were  13  cases  of  pan- 
creatitis in  252  cases  of  mumps.  The  onset  is 
usually  on  the  5th,  6th  or  7th  day  of  the  mumps 
illness,  ushered  in  by  sudden  fever  to  103-104, 
epigastric  pain  and  vomiting.  Prostration  is  pro- 
nounced, constipation  exists,  nausea  on  motion  or 
abdominal  palpation  is  a  prominent  feature.  The 
nausea  may  cause  the  anorexia  which  persists  all 
during  the  acute  phase  of  the  complication.  Vom- 
iting also  is  troublesome,  even  sips  of  water  being 
promptly  returned.  The  retching  from  vomiting 
may  cause  the  eyes  to  become  bloodshot.  The 
tenderness  persists  but  rigidity  is  absent.  A  tumor 
mass  over  the  pancreas  area  has  been  felt,  but 
apparently  this  finding  is  rare.  The  pulse  remains 
slow  in  relation  to  the  fever.  Urine  and  stool  ex- 
aminations reveal  nothing  abnormal;  glycosuria 
seems  to  be  extremely  rare.  The  blood  count  re- 
mains within  normal  limits.  The  temperature  falls 
rapidly  to  normal  in  from  one  to  three  days,  or  by 
crisis,  and  the  child  is  well. 


The  AMiioNiACAL  Diaper 
(D.  O.  Rhartie,  Jr.,  Clinton,  in  Jl.  S.  C.  Med.  Assn.,  June) 
The  diagnosis  is  simple — the  odor  of  ammonia.  The 
clinical  significance  of  the  ammoniacal  diaper  lies  in  the 
skin  irritation  which  it  causes.  According  to  statistics  the 
condition  is  severest  between  the  ages  of  1  and  2  years. 
The  lesions  consist  of  inflamed  cutaneous  areas  in  the 
region  in  contact  with  the  diaper.  The  lesions  appear 
when  the  baby  has  lain  wet  for  a  long  period.  The  con- 
dition is  almost  confined  to  artificially-fed  infants,  seen 
especially  at  the  time  of  beginning  solid  food.  The  treat- 
ment would  be,  first  of  all,  strict  attention  to  the  washing 
of  the  diapers  to  be  sure  no  alkali  remains. 


Appropriation  for  Study  of  Care  Mentally  Defective 
inN.  C. 
The  Commission  for  the  Study  of  the  Care  of  the  Insane 
and  Mentally  Defective,  appointed  by  the  State  of  North 
Carolina,  received  $16,300  toward  its  expenses  during  the 
period  from  September  1st,  1935,  to  December  31st,  1936. 
The  program  of  the  commission  includes  a  survey  of  e.xist- 
ing  provisions  in  North  Carolina  for  the  care  and  treat- 
ment of  mental  patients,  a  detailed  study  of  the  needs  for 
psychiatric  service  throughout  the  state,  and  an  investiga- 
tion of  all  means  and  methods,  both  proposed  and  in  use, 
for  the  care  and  treatment  of  the  insane  and  the  mentally 
defective. 


GENERAL  PRACTICE 

Wincaie  M.  JoHNioN,  M.D.,  Editor,  Winston-Salem,  N.  C. 


A  Tribute 

Editor  John  Arch  McMillan    in    Charity    and 
Children  for  June  25th  paid  such  a  beautiful  tribute 
to  the  doctor  that  I  am  reproducing  it  in  full. 
The  Veil  Lifted 

The  family  doctor  is  one  of  the  best  known  and  most 
greatly  beloved  of  the  men  of  the  community.  He  has 
been  paid  many  worthy  tributes  and  richly  deserves  them 
all.  When  he  enters  a  home  where  there  is  sickness  he 
assumes  charge  and  all  await  his  orders  and  put  their  cares 
upon  him.  He  gives  without  stint  the  strength  of  his 
hands,  his  mind  and  his  heart.  He  fights  the  battle  until 
victory  or  defeat.  He  sits  long  hours  at  the  bedside  after 
all  hope  is  gone.  He  waits  until  the  last  breath  leaves 
the  body  and  then  does  not  leave  until  he  is  assured  that 
no  member  of  the  family  will  need  emergency  attention. 
Then,  however,  he  packs  his  bag  and  with  the  stoop  of 
defeat  in  his  shoulders  wearily  goes  on  his  way.  Soon  the 
weariness  is  gone,  the  shoulders  are  erect  and  the  fire  of 
battle  is  again  in  his  eye  as  he  stands  by  the  bedside  of 
another  patient.  That  is  the  everyday  life  of  the  family 
physician;  but  we  do  not  always  think  of  the  city  doctor 
who  works  in  a  hospital  as  anything  more  than  an  effi- 
cient man  of  science.  We  saw  four  of  them  in  another 
light  Thursday  afternoon  at  the  funeral  services  of  little 
Maxine  Richardson  at  the  home  of  her  parents  in  High 
Point.  The  four  doctors  who  had  fought  the  gallant  fight — 
and  lost— did  not  stop  at  death  but  themselves  carried  the 
casket  even  to  the  grave.  We  saw  the  doctors  come  out 
of  the  home  with  bowed  heads  bearing  the  casket.  The 
nurses  who  had  helped  the  doctors  were  there,  alert,  effi- 
cient, all  in  white,  but  with  cheeks  bathed  in  tears.  Then 
the  still  hands  of  little  Maxine  lifted  the  veil  and  let  us  see 
the  great  throbbing  hearts  of  those  men  of  science.  We 
did  not  feel  that  we  were  spying  as  we  looked  upon  the 
very  souls  of  the  doctors  and  the  nurses;   the  sight  was 


440 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


beautiful  to  be  hold.  As  we  raised  our  eyes  we  saw  not 
the  faces  of  defeated  doctors  bearing  the  dead  to  the  grave, 
but  we  saw  the  faces  of  the  Wise  Men  bearing  their  gift 
to  Bethlehem.  Raising  our  eyes  higher,  toward  the  west, 
we  saw  that  the  low-hanging  sun  had  become  a  golden 
crown,  and  the  air  was  filled  with  the  aroma  of  frankin- 
cense and  myrrh.  Instead  of  the  nurses  we  saw  creatures, 
arrayed  in  white,  from  whose  eyes  God  Himself  had 
wiped  every  tear.  We  listened,  expecting  them  to  breali 
forth  in  song:  "Glory  to  God  in  the  highest  and  on  earth 
peace — For  to  you  this  day — is  Christ  the  Lord,"  and  in 
the  stillness  of  our  souls  we  heard  the  Voice:  "Let  not  your 
hearts  be  troubled.  Peace  I  leave  with  you,  my  place  I 
give  unto  you.  Let  not  your  heart  be  troubled,  neither 
let  it  be  afraid.    Arise,  let  us  go  hence." 


THE  MARRIED  WOMAN  (Greenberg,  $2.50) 
is,  as  the  subtitle  implies,  "A  Practical  Guide  to 
Happy  Marriage."  It  is  the  collaboration  of  Mrs. 
Gladys  Hoagland  Groves,  and  Dr.  Robert  A.  Ross. 
Mrs.  Groves  is  the  wife  of  Dr.  Ernest  R.  Groves, 
of  the  University  of  North  Carolina,  and  like  her 
distinguished  husband  has  long  been  interested  in 
marriage  and  parenthood.  Dr.  Ross  is  an  obstetri- 
cian and  gynecologist,  and  is  a  faculty  member  of 
the  Duke  Medical  School. 

This  volume  gives  in  plain,  simple  language  the 
facts  about  married  life  that  the  modern  wife  needs 
to  know.  Every  detail  is  covered,  from  courtship 
on  through  the  early  days  of  married  life,  the 
problems  of  sexual  and  other  adjustments  to  be 
made,  the  problems  of  later  married  life,  the  ques- 
tion of  pregnancy  and  motherhood,  and  finally  of 
the  menopause  and  afterwards. 

As  a  general  criticism,  it  seems  to  me  that  it  is 
a  little  too  wordy,  and  that  sex  is  given  more  im- 
portance than  it  deserves.  But  the  book  is  so  clear 
and  practical  that  it  should  admirably  serve  its 
purpose.  It  would  make  a  very  sensible  gift  for 
the  average  newly  married  woman — or,  for  the  ma- 
ture married  woman.  Indeed,  the  latter  part  of  the 
book,  dealing  with  the  problems  of  middle  age  and 
of  the  menopause  and  afterwards  is,  in  my  judg- 
ment, even  better  than  the  first  part. 

DOCTOR  OF  THE  NORTH  COUNTRY 
(Thomas  Y.  Crowell  Company,  $2.00).  Some  few 
months  ago  some  iconoclastic  magazine  ridiculed 
Professor  William  Lyon  Phelps  because  he  praised 
indiscriminately  thousands  of  books,  and  never 
found  fault  with  one.  I  have  wondered  if  in  a 
much  smaller  way  I  may  be  thought  guilty  of  doing 
the  same  thing,  since  it  happens  that  nearly  all  the 


Quotes  Dakrow's  Opinions  of  Doctors  and  Lawyers 
(Editorial  Milwaukee  Med.  Times,  July,  from  Esquire) 
"The  lawyer's  idea  of  justice  is  a  verdict  for  his  client, 
and  really  this  is  the  sole  end  for  which  he  aims.  .  .  . 
If  the  physician  so  completely  ignored  natural  causes  as 
the  lawyers  and  judges,  the  treatment  of  disease  would  be 
relegated  to  witchcraft  and  magic,  and  the  dungeon  and 
rack  would  once  more  hold  high  carnival  in  driving  devils 


out  of  the  sick  and  afflicted."  Every  human  being,  whether 
parent,  teacher,  physician,  or  prosecutor  should  make  the 
comfort  and  happiness  of  their  dependents  their  first  con- 
cern. Now  and  then  some  learned  courts  take  a  big  view 
of  hfe,  but  scarcely  do  they  make  an  impression  until  some 
public  brainstorm  drives  them  back  in  their  treatment  of 
crime  to  the  methods  of  sorcery  and  conjury. 

"No  scientific  attitude  toward  crime  can  be  adopted 
untU  lawyers,  like  physicians  and  scientists,  recognize  that 
cause  and  effect  determine  the  conduct  of  men." 


Recent  Advances  in  Obstetrics 
(Wm.    B.    Serbin,   Chicago,    in    III.    Med.   Jl.,   July) 

The  Friedman-Schneider  test  requires  an  immature  fe- 
male rabbit  with  or  without  a  control  animal  and  the 
results  are  available  within  24  to  48  hrs.  In  a  series  of 
4,5 IS  cases  collected  from  the  literature  the  gross  error  is 
3.9%.  The  test  should  aid  but  not  supplant  the  usual 
clinical  examination. 

In  hydatidiform  mole  and  chorioepithelioma  the  elim- 
ination of  a  prolan-like  substance  in  the  urine  is  2  to  3 
times  greater  than  in  a  normal  pregnancy. 

In  pregnancy  anemias  diet  and  iron  therapy  improved 
the  general  condition.  For  severer  grade  of  anemiae  some- 
what akin  to  a  percnicious  anemia,  the  treatment  has  been 
unsatisfactory.  , 

Increasing  attention  has  been  paid  to  diet  during  preg- 
nancy with  special  reference  to  the  vitamins  and  calcium 
metabolism.  Calcium  may  be  easily  and  satisfactorily  sup- 
plied by  using  calcium  gluconate  or  calcium  lactate;  it 
may  be  supplied  also  in  milk.  Better  results  are  obtained 
with  calcium  in  organic  combination;  Sherman  recommends 
1  gm.  of  calcium  to  100  gms.  of  protein  in  the  diet.  Vita- 
min D  may  be  given  with  codUver  oil  or  viosterol.  The 
latter  should  not  be  given  without  a  sufficient  quantity  of 
calcium  so  as  to  protect  the  maternal  organism  from  cal- 
cium withdrawal. 

In  organic  heart  disease,  chronic  nephritis,  diabetes  or 
tuberculosis  in  pregnancy  the  patient  is  treated  for  her 
medical  disorder  according  to  established  principles  of  in- 
ternal medicine,  and  the  pregnancy  is  allowed  to  continue 
as  long  as  it  does  not  interfere  with  the  patient's  general 
health,  comfort  or  outlook  on  the  duration  of  her  life. 

Syphilis  should  be  actively  and  energetically  treated  dur- 
ing pregnancy.  In  spite  of  the  difficulty  of  obtaining  neg- 
ative serum  reactions  on  the  mother;  the  outlook  for  the 
fetus  is  excellent. 


The  Diagnosis  of  Carcinoma  of  the  Rectum  and 

Rectosigmoid 
(A.  G.  Schutte,  Milwaukee,  in  Wise.  Med.  Jl.,  July) 
The  great  hazard  in  diagnosis  of  carcinoma  of  the  rectum 
and  rectosigmoid  does  not  lie  in  the  difficulty  of  its  recog- 
nition when  it  is  searched  for,  but  it  lies  in  the  tendency 
to  attribute  the  patient's  symptoms  to  some  minor  rectal 
or  abdominal  aUment  and,  therefore,  to  neglect  to  examine 
the  patient  for  the  presence  of  a  malignant  growth. 


ORTHOPEDIC  SURGERY 

0.  L.  Miller,  M.D.,  Editor,  Charlotte,  N.  C. 


Treatment  of  Giant-Cell  Tumors  of  Long 
Bones 
During  the  lifetime  of  Dr.  Bloodgood,  he  and 
a  few  scholarly  contemporaries  endeavored  to  de- 
velop and  diffuse  more  accurate  knowledge  of  tu- 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


mors  of  bone  and  classify  in  so  far  as  possible  the 
best  methods  of  diagnosis  and  treatment.  These 
surgeons  and  pathologists  taught  with  profit  some 
definite  things  relative  to  malignant  and  benign 
bone  tumor  growths  which  have  been  instrumental 
in  prolonging  life  and  preserving  limbs  where  sur- 
geons have  cooperated  with  experienced  patholo- 
gists and  radiologists  in  the  study  of  their  cases. 

Geschickter  emphasizes  two  possible  methods  of 
treatment  of  giant-cell  tumors  of  bone — surgery  and 
irradiation.  The  choice  of  one  or  the  other  method 
would  depend  upon  the  location  of  the  tumor.  He 
points  out  three  groups  of  giant-cell  tumors  in 
which  irradiation  is  preferable.  The  bone  cyst  on 
the  shaft  side  of  the  epiphyseal  line,  with  a  short 
duration  of  symptoms,  in  young  individuals  may 
contain  a  great  deal  of  giant-cell  tissue.  This  is  a 
so-called  giant-cell  variant  of  the  bone  cyst.  Irra- 
diation is  usually  successful  in  accelerating  healing 
and,  where  properly  given,  does  not  interfere  with 
the  growth  of  the  epiphysis.  The  second  group  of 
tumors  in  which  irradiation  is  preferable  occurs 
usually  in  elderly  adults,  the  tumor  is  seen  rela- 
tively late,  and  there  is  pronounced  destruction  of 
bone.  If  a  weight-bearing  bone  is  involved,  the 
probability  of  restoring  the  functions  of  the  limb 
by  surgery  is  doubtful.  Irradiation  should  be  tried 
first;  surgery  remains  as  a  second  choice.  When 
the  giant-cell  tumor  is  located  in  the  spine,  par- 
ticularly in  the  lumbar  or  cervical  region  or  in 
the  skull  in  the  region  of  the  temporal  fossa,  irra- 
diation is  preferable  to  surgery.  At  such  sites  re- 
currence takes  place  after  surgery  in  over  one- 
third  of  the  cases,  and  such  recurrence  is  difficult 
to  control  and  often  fatal.  For  this  reason,  it  is 
far  better  to  rely  upon  initial  irradiation.  Surgery 
can  be  used  following  irradiation  if  the  irridation  is 
properly  given,  whereas  irradiation  following  un- 
successful surgery  is  usually  without  avail. 

Surgery  is  preferable  to  irradiation  in  giant-cell 
tumors  where  the  bone  is  not  essential  to  the  func- 
tion of  the  limb.  In  such  bones  as  the  ulna  and 
fibula,  and  rarely  the  rib,  resection  is  the  operation 
of  choice  and  is  practically  never  followed  by  re- 
currence. Surgery  is  also  to  be  preferred  in  pa- 
tients who  are  in  middle  life  and  in  whom  the 
function  of  the  limb  is  vital  to  their  occupation 
and  livelihood.  Irradiation  is  too  slow  in  its  effects 
and  disables  these  patients  for  too  long  a  time. 
Finally,  surgery  is  preferable  in  cases  in  which 
the  initial  treatment  has  been  given  elsewhere  and 
where,  because  of  inadequate  excision,  incision  or 
irradiation,  there  is  recurrence.  Irradiation  in  such 
secondary  cases  (particularly  following  a  primary 
unsuccessful  operation)  rarely  gives  good  results. 
Four  important  factors  should  be  considered  by 
the  practitioner  before  proceeding  with  treatment 


in  any  case  of  suspected  giant-cell  tumor: 

First,  there  is  the  question  as  to  the  possibility 
of  making  an  accurate  diagnosis  in  the  absence  of 
biopsy.  If  the  x-ray  picture  is  not  typical  of  giant- 
cell  tumor,  the  chances  are  against  such  a  diagno- 
sis, but  the  reverse  is  not  always  true.  All  bone 
tumors  giving  a  picture  typical  of  giant-cell  tumor 
in  the  roentgenogram  do  not  prove  to  be  benign 
giant-cell  tumors  on  microscopic  examination. 

Second,  before  proceeding  with  surgery,  the  de- 
termination of  the  amount  of  healthy  active  bone 
available  is  important.  It  is  not  advisable  to  pro- 
ceed too  far  with  surgery,  particularly  in  elderly 
adults,  when  there  is  not  enough  uninvolved  bone 
remaining  to  bear  the  weight  on  the  limb. 

Third,  one  must  bear  in  mind  the  importance  of 
the  involved  bone  with  respect  to  the  function  of 
the  limb.  Conservative  surgery  or  irradiation 
should  not  be  persisted  in  to  save  a  bone  such  as  a 
metacarpal,  the  ulna,  or  the  fibula. 

Fourth,  the  possibility  of  performing  a  thorough 
surgical  removal  of  the  lesion,  without  impairment 
of  function,  should  outweigh  all  other  considera- 
tions. 


In  1236  Cordova  fell  before  Ferdinand  III,  the  Saint 
(1139-1252),  of  Castile;  in  1258  Bagdad  succumbed  to  the 
Tartars,  and  with  these  two  chief  seats  of  Arabian  science 
that  science  itself  was  overthrown. — Bcuis. 


HOSPITALS 

R.  B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  Editor,  Greensboro.N.  C. 


Private  Versus  Public  Hospitals 
In  the  last  few  years  there  has  been  a  tendency 
for  federal  authorities,  states,  counties  and  cities 
to  build  hospitals,  assuming  that  these  institutions 
would  render  more  service  to  the  poorer  class  of 
people  than  was  being  rendered  by  private  hos- 
pitals. However,  publicly  owned  institutions  cost 
more  to  operate  than  private  institutions. 

Some  years  ago  when  the  Government  was  con- 
templating building  a  general  hospital  for  the  World 
War  veterans  in  North  Carolina  the  writer  had  an 
opportunity  to  investigate  to  some  extent  the  per- 
capita  cost  of  treating  patients  in  similar  institu- 
tions in  the  other  states.  While  the  Government 
agencies  refused  to  cooperate  with  the  American 
Hospital  Association  to  the  extent  of  giving  definite 
figures,  it  was  conservatively  estimated  that  the 
cost  was  well  over  $7.00  a  day  for  every  patient 
who  entered  the  institutions. 

In  North  and  South  Carolina  the  private  or  semi- 
private  hospitals  are  operated  on  a  much  lower 
per-capita  cost.  By  a  semiprivate  hospital  is  meant 
one  operated  by  a  board  of  trustees  and  without 
taxpayers'  money.    The  figures  for  these  two  States 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1Q36 


will  range  between  $3.25  and  $3.75. 

The  strongest  argument  to  be  used  for  building 
and  operating  hospitals  on  taxpayers'  money  is  that 
enough  money  can  be  had  to  properly  build  and 
equip  modern  institutions.  Yet,  the  author  sub- 
mits the  argument  that  if  it  is  going  to  cost  prac- 
tically twice  as  much  to  treat  the  citizenship  of 
any  community  in  these  institutions  as  it  does  in 
the  already  existing  private  or  semiprivate  institu- 
tions then  the  taxpayers'  dollar  is  purchasing  only 
fifty-cents  worth  of  service. 

There  must  be  some  reason  for  such  a  wide  va- 
riation of  per-capita  cost,  and  it  occurs  to  me  that 
the  important  factor  is  politics.  It  is  easy  to  under- 
stand that  a  good  hospital  administrator  is  exceed- 
ingly busy  looking  after  his  job  and  has  little  time 
for  politics,  therefore  a  poor  political  hospital  ad- 
ministrator can  easily  replace  a  good,  non-political 
administrator.  This  may  take  place  with  all  of  the 
employees  of  the  institution. 

The  county  or  state  jxilitical  boss  has  a  friend, 
or  a  friend  of  a  friend,  who  is  influential  in  a  cer- 
tain precinct  or  territory;  said  influence  has  been 
used  to  promote  the  political  aspirations  and  de- 
sires of  the  boss,  and  political  debts  must  be  paid 
usually  with  taxpayers'  money. 

Then,  again  there  is  the  customary  procedure  for 
federal  employees  to  be  changed  at  frequent  inter- 
vals for  one  reason  or  another  best  known  to  those 
in  authority.  It  frequently  happens  that  the  pro- 
cedure is  simply  a  matter  of  transferring  Mr.  A. 
of  North  Carolina  to  Mr.  B.'s  position  in  Nevada 
and  vice  versa.  These  changes  are  expensive  to  an 
institution. 

In  regard  to  service  rendered,  it  is  unfair  to  say 
that  good  service  is  confined  solely  to  the  one  or 
the  other;  but,  it  is  perfectly  obvious  to  those 
informed  about  hospital  administration  that  chang- 
ing of  personnel  and  depriving  the  personnel  of  all 
initiative  is  conducive  to  a  poorer  type  of  service. 
This  statement  can  easily  be  verified  by  consulting 
World  War  veterans  who  have  been  in  large  Gov- 
ernment hospitals  where  the  names  of  the  doctors 
and  nurses  are  not  even  known  by  the  patients. 

The  service  rendered  in  the  private  and  semi- 
private  institution  is  not  embarrassed  by  such 
handicaps.  For  the  most  part  it  is  customary  for 
the  doctors,  nurses,  business  administrator  and 
other  employees  to  remain  at  one  post  for  a  number 
of  years.  They  absorb  the  atmosphere  of  the  in- 
stitution. They  learn  to  know  the  characteristics 
of  the  patients  and  their  families  as  well  as  the 
general  likes  and  dislikes  of  the  community.  The 
citizens  who  are  served  by  these  institutions  sym- 
pathize with  and  cooperate  with  to  a  much  better 
extent,  and  this  makes  it  easier  for  the  hospital 
employees  to  render  good  service. 


Hospitals    under    lay    administration  certainly    existed, 

e.g.,  at  Lyons  in  542,  and  at  Merida  in  580.    Besides  this 

there   were   also    physicians-in-ordinary  with   the   ancient 
title  of  "Archiater." — Baas. 


Paulus,  bishop  of  Merida  (530-560),  is  said  to  have  per- 
formed the  first  Caesarean  section  upon  a  living  female,  so 
that  this  honor  is  due  to  a  bishop,  and  not  to  a  swine 
gelder. — Baas. 


HUMAN  BEHAVIOR 

Jamis  K.  Hall,  M.D.,  Editor,  Richmond,  Va. 


Professional  Progression 
At  the  meeting  of  the  American  Psychiatric  As- 
sociation in  Richmond  in  1925  I  was  impressed 
and  distressed  by  the  absence  of  my  erudite  friend, 
Dr.  George  Alder  Blumer,  who  had  been  for  many 
years  Superintendent  of  Butler  Hospital  in  Provi- 
dence in  Rhode  Island.  In  the  many  years  of  my 
attendance  I  had  never  known  him  to  be  absent, 
and  I  was  told  that  he  had  missed  no  meeting  for 
at  least  a  quarter  of  a  century.  I  feared  that  ill- 
ness had  immobilized  him.  But  I  was  mistaken. 
Dr.  Blumer  was  kept  from  the  meeting  by  hunger. 
Throughout  the  years  of  his  busy  superintendency 
he  had  browsed  in  Greek  and  Latin  and  French 
and  German,  but  he  could  not  find  the  time  in 
which  to  take  up  the  study  of  the  Italian  language. 
But  just  before  the  Richmond  meeting  he  had  be- 
come Superintendent  Emeritus  of  the  Butler  Hos- 
pital, and  immediately  thereafter  he  had  set  sail 
for  Rome  and  Italy. 

Always  he  had  hoped  some  day  to  be  able  to 
read  in  Dante's  own  tongue  his  immortal  produc- 
tions. The  Secretary  of  the  Psychiatric  Associa- 
tion told  me  that  at  the  moment  of  my  inquiry 
Dr.  Blumer  was  in  Rome  studying  the  Italian 
language,  and  that  soon  he  would  be  able  to  read 
The  Inferno  and  The  Divine  Comedy  in  the  lan- 
guage in  which  they  were  written.  And  the  Psych- 
iatric Association  excused  Dr.  Blumer's  absence 
and  commended  him  for  making  another  addition 
to  his  linguistic  repertoire  at  the  age  when  a  hos- 
pital Superintendent  becomes  Superintendent 
Emeritus.  Dr.  Blumer  had  probably  been  inspired 
by  Marcus  Tullius  Cicero's  study  of  Greek. 

It  is  a  far  piece  from  the  Rhode  Island  Planta- 
tions to  Gastonia  in  Gaston  County  in  North  Car- 
olina, and  there  are  doubtless  many  differences  be- 
twixt Dr.  Blumer,  born  a  Briton,  and  Dr.  Lucius 
Newton  Glenn,  always  a  Tar  Heel.  But  both  Dr. 
Blumer  and  Dr.  Glenn  hungered  and  thirsted — 
not  for  righteousness;  both  perhaps  were  righteous 
enough — but  both  hungered  for  additional  cultural 
acquisitions.  Dr.  Glenn  had  been  called  away 
from  college  in  the  midst  of  his  academic  years, 


August,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


and  when  it  was  possible  for  him  to  reenter,  he 
matriculated  as  a  medical,  not  as  an  academic, 
student.  But  he  continued  to  yearn  for  the  aca- 
demic degree  his  heart  had  once  been  set  upon, 
and  no  amount  of  success  in  medicine,  in  finance, 
and  in  worldlj'  honours,  would  serve  as  substitutes 
for  the  academic  things  he  had  missed.  Although 
he  had  been  for  years  medically  as  busy  as  a  bee 
is  otherwise  busy  in  a  clover  field,  he  continued  to 
long  for  the  degree  he  had  intended  in  his  youth  to 
obtain.  So  he  drove  somewhat  doubtfully  over 
to  his  old  college,  and  talked  the  matter  over  with 
the  Dean  and  the  President.  Prompt  arrangements 
were  made  for  him  to  become  an  irregular  student. 
He  was  surprised  at  the  ease  with  which  his  mind 
grasped  and  mastered  things  that  in  the  years  gone 
by  had  seemed  so  abstruse  and  incomprehensible- 
Latin,  Greek,  German,  Quadratics  and  Hj^erbolas 
and  Physics  and  Philosophy  and  English  Litera- 
ture. He  avoided  football  and  poker,  but  at  Com- 
mencement time  he  assumed  cap  and  gown  and 
walked  away  with  honors  and  with  a  degree — 
earned  by  diligent  study,  and  not  honorary. 

.And  Dr.  Andrew  Henry  Woods,  Fredericksburg- 
born,  director  of  the  Psychopathic  Hospital  of  the 
L'niversity  of  Iowa  at  Iowa  City,  is  as  alert  a  stu- 
dent of  the  drama  as  he  was  when  a  matriculate 
at  Washington  and  Lee  University  in  the  mid- 
nineties.  Two  or  three  years  ago  he  presented  to 
the  .American  Psychiatric  Association  a  detailed 
and  searching  study  of  Shakespeare's  Timon  of 
Athens.  Dr.  Woods  believes  that  Timon  was  of- 
fered by  Shakespeare,  consciously  or  unconsciously, 
as  a  case  of  paresis,  and  that  the  tragedy  contains 
many  other  references  to  syphilis,  although  the 
term  is  not  used.  Timon  exhibited,  to  be  sure,  all 
the  manifestations  of  paretic  overthrow.  In  the 
early  days  of  the  drama  he  was  rich  and  grandiose 
and  profligate,  and  encompassed  'round  about  by 
many  friends  so  long  as  his  substance  lasted;  but 
in  the  end  his  wealth  had  been  squandered,  he  had 
become  depressed  and  wretched  and  friendless, 
and  he  died  miserable.  Dr.  Woods  is  still  the 
student — academic  as  well  as  medical — and  he  reads 
not  with  his  eyes  alone,  but  with  his  acquisitions 
and  with  his  interpretative  experience.  Much  lit- 
erature, ancient  and  modern,  is  filled  with  clinical 
medicine,  waiting  for  interpretation. 

I  think  of  Dr.  Wingate  M.  Johnson,  of  course, 
as  keeping  himself  constantly  under  his  own  aca- 
demic tutelage.  And  in  North  Carolina  and  else- 
where many  busy  physicians  are  still  going  to 
school  to  themselves.  Every  man  who  has  been 
taught  well  has  been  self-taught;  and  going  to 
school  is  in  its  final  analysis  always  a  solitary  per- 
formance. 

Dr.   John   Chalmers   DaCosta,   whom   we   knew 


both  in  affection  and  in  admiration  as  Jack,  illus- 
trated the  possibilities  to  which  education  could 
be  carried  by  constant  effort.  There  was  a  tradition 
about  Jefferson  in  my  student  days  that  Jack's 
mind  embraced  all  knowledge.  His  knowledge  of 
Stonewall  Jackson's  Valley  campaign  was  as  inti- 
mate and  as  accurate,  perhaps,  as  that  of  a  mem- 
ber of  Jackson's  own  staff,  yet  Jack  was  born 
during  that  campaign  and  his  father  was  one  of 
McClellan's  infantrymen.  Not  so  many  years  ago 
Dr.  William  A.  White  was  an  unknown  member 
of  the  medical  staff  of  a  state  hospital  in  upstate 
New  York.  Today,  largely  through  his  own  unre- 
mitting instruction  of  himself,  he  is  one  of  the 
great  psychiatrists  of  the  world,  and  he  is  equally 
as  great,  perhaps,  as  an  executive  and  the  adminis- 
trator of  a  great  Federal  hospital.  Labor  omnia 
vincit. 

\\'hen  I  listened  last  February  in  Columbia  at 
the  meeting  of  the  Tri-State  Medical  Association 
to  the  presentation  of  the  paper  of  Dr.  Page  Oscar 
Xorthington,  of  New  York,  I  remembered  that  I 
had  not  seen  him  for  several  years.  He  spoke 
about  throat,  ear  and  nose  affections  with  such 
simplicity  and  clarity  and  helpfulness  that  I  re- 
marked to  myself  that  he  evidently  knew  what  he 
was  talking  about,  and  that  he  had  that  rare  grace, 
too,  that  enabled  him  to  transmit  to  others  in 
understandable  and  appealing  language  what  he 
knew  himself.  We  scarcely  realize,  in  spite  of  all 
the  use  we  make  of  it,  what  a  mighty  thing  lan- 
guage is. 

I  knew  Page  Northington  when  he  was  a  student 
in  the  Medical  College  of  Virginia,  from  which  he 
was  graduated  about  1917.  I  knew  that  he  en- 
tered the  United  States  Navy  and  served  through- 
out the  World  War.  I  knew  that  I  had  been  re- 
ceiving reprints  from  him  from  time  to  time  that 
indicated  work  of  a  high  order,  both  in  the  realm 
of  practice  and  in  the  field  of  research.  I  found 
out  that  at  the  recent  commencement  of  Columbia 
L'niversity  the  degree  of  Med.  D.Sc.  was  conferred 
upon  him  for  research  work  done  by  him  in  the 
College  of  Physicians  and  Surgeons.  He  was  made 
a  Doctor  of  the  Science  of  Medicine.  The  degree 
was  the  reward  for  investigative  work.  I  think  it 
must  be  most  unusual  for  a  busy  practitioner  of 
medicine  to  be  able  to  find  either  the  time  or  the 
inclination  to  address  himself  to  the  pursuit  of 
academic  work  that  leads  to  the  acquisition  of  a 
degree. 

The  career  of  Dr.  Northington  has  been  charac- 
terized by  a  steady  rise.  Lentil  1926  he  served  in 
the  LTnited  States  Navy.  In  that  year  he  resigned 
with  the  rank  of  Lieutenant  Commander.  In  the 
early  days  of  his  service  he  obtained  a  genera! 
interneship  in  the  Navy's  Hospitals.     Immediately 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


after  the  cessation  of  hostilities  he  was  assigned  as 
Surgeon  to  the  Hospital  Ship  "Panther,"  a 
member  of  the  Mine  Sweeping  Fleet  in  the  North 
Sea.  I  believe  I  can  conceive  of  no  more  hazardous 
engagement.  But  no  assignment  has  distracted  him 
from  his  schooling.  Steadily,  all  along,  without 
interruption,  he  has  kept  himself  in  school  to 
others  but  always  to  himself.  Throughout  the 
years  of  his  service  he  has  been  in  constant  train- 
ing— in  the  Naval  Medical  School;  in  the  Army 
Gas  Defense  School;  in  the  Army  School  for  Flight 
Surgeons;  in  the  New  York  Post-Graduate  School 
and  Hospital;  in  the  New  York  Eye  and  Ear  In- 
firmary; and  in  the  Graduate  School  of  the  Uni- 
versity of  Pennsylvania.  After  his  resignation  as 
an  officer  in  the  Navy  he  spent  two  years  in  Belle- 
vue  Hospital  in  continuing  his  otolaryngological 
studies.  After  having  served  for  some  time  as  a 
member  of  the  House  Staff  of  Bellevue  he  became 
an  associate  of  Dr.  C.  G.  Coakley,  in  his  private 
practice,  which  continued  until  Dr.  Coakley 's  death 
in  1934.  Since  that  time  Dr.  Northington  and  his 
associates  have  cared  for  that  e.xtensive  practice. 
But  he  has  maintained  his  student  activities,  too, 
in  partial  recognition  of  which  is  the  degree  from 
Columbia  University.  The  hunger  for  more  and 
more  knowledge  is  innate  in  him.  He  is  a  North- 
ington. He  is  happy  and  facile  in  using  his  men- 
tality and  in  his  linguistic  activities.  His  initial 
endowment  was  solid,  his  early  schooling  at  old 
Hampden-Sydney  impressed  upon  him  the  belief 
that  the  only  thoroughfare  leading  to  mental  de- 
velopment and  the  acquisition  of  sound  knowledge 
is  steady,  hard  work.  Survival  of  the  rigid  re- 
quirements of  the  Calvinists  at  Hamfxlen-Sydney 
was  enciugh  to  induce  in  him  the  hope  at  least  of 
continuing  survival  even  in  competition  with  the 
Germans  and  later  with  the  Yankees.  By  his  own 
effort,  strengthened  and  sustained  by  the  encour- 
agement of  those  who  knew  him,  Dr.  Northington 
has  become  an  outstanding  specialist  in  the  great 
metropolis.  He  has  even  skill — in  diagnosis,  in 
the  application  of  proper  therapy,  in  didactic  abil- 
ity. He  has  made  distinct  contributions  to  our 
knowledge  of  the  ear,  and  to  a  better  understand- 
ing of  aural  symptomatology.  The  degree  from 
Columbia  was  awarded  for  work  done  in  general 
otolaryngology  and  an  investigation  of  the  ves- 
tibular function,  and  the  title  of  his  thesis  was: 
"The  Hearing  of  Patients  with  Intracranial  Tu- 
mors." He  has  done  much  work  on  the  aural 
equipment  of  aviators.  Although  he  is  an  aviator 
and  his  mind  is  never  in  the  clouds. 

Occasionally  I  have  seen  at  Commencement 
graduates  who  were  better  educated  then  than  at 
any  subsequent  time.  But  the  diploma,  academic 
himself,  his  medical  feet  are  always  on  the  ground. 


or  medical,  should  serve  only  as  the  ticket  of  ad- 
mission to  that  larger  school  of  life,  open  to  all 
intelligent  and  aspiring  mortals.  Dr.  Page  Oscar 
Northington  is  a  matriculate  in  that  University  of 
life.  His  career  is  highly  creditable  to  himself,  to 
his  native  Virginia,  to  his  country,  to  the  profes- 
sion of  medicine,  and  to  the  human  family.  I 
dislike  the  thought  of  embarrassing  him,  but  I  can- 
not refrain  from  speaking  my  mind  about  him. 


St.  Luke's  News  Note  of  Half  Century  Ago 
(From   the   Richmond   Dispatch    [now   Times-Dispatch], 

July  22nd,  1886) 
The  authorities  of  St.  Luke's  Home  [now  Hospital], 
o£  which  Dr.  Hunter  McGuire  is  chief  surgeon,  have  made 
arrangements  for  giving  two-years'  training  to  women  de- 
sirous of  becoming  professional  nurses,  and  for  this  pur- 
pose have  secured  a  large  and  suitable  building,  1313  Ross 
Street,  nearly  opposite  St.  Luke's.  The  nurses  will  wear  a 
blue  and  white  seersucker  uniform,  w-ith  white  apron  and 
cap,  collar  and  cuffs. 


RADIOLOGY 


For   this  issue,   F.   B.  Mandevh-le,  M.D.,   Richmond,  Va. 
Medical  College  of  Virginia 


Multiple  Myeloma 

Roentgenologists,  during  the  daily  routine  of 
film  interpretation,  are  constantly  impressed  by  the 
large  number  of  cases  of  metastatic  carcinoma  of 
bone  that  have  escaped  previous  clinical  diagnosis. 
Carcinomas  of  the  breast,  prostate,  thyroid,  kidney 
and  adrenal  appear  to  be  the  most  common.  Pri- 
mary tumors  of  bone  discovered  in  the  same  man- 
ner are  by  no  means  rare.  Of  the  latter,  osteogenic 
sarcoma  and  giant-cell  tumor  are  said  to  be  more 
numerous  than  Ewing's  tumor  and  multiple  mye- 
loma. Strangely  enough,  our  recent  exjjerience 
would  lead  us  to  surmise  that  Ewing's  tumor  and 
multiple  myeloma  are  more  common  than  the  num- 
ber of  cases  rejxtrted  would  lead  us  to  believe. 
Time,  and  with  it  the  more  general  and  thorough 
roentgen  examination  of  the  various  bones  of  the 
body,  may  clarify  the  situation  and  greatly  modify 
present  statistics. 

Not  many  years  ago,  Geschickter  and  Copeland' 
emphasized  the  incidence  of  multiple  myeloma  in  a 
chart  which  considered  all  types  of  malignancy.  '■ 
This  chart  gave  the  incidence  of  sarcoma  of  all 
types  as  35  per  cent.;  bone  sarcomas  as  1  per  cent.; 
multiple  myeloma  as  0.03  per  cent.  This  stresses 
the  rarity  of  multiple  myeloma  as  revealed  by  an 
analysis  of  the  literature  from  1848  to  1928 — in 
all,  a  series  of  425  cases. 

Dr.  William  Mclntyre  can  be  credited  for  the 
first  adequate  refiort  of  multiple  myeloma.    He  had 

1.  Geschickter,  C.  F.,  and  Copeland,  M.  M.:  Multiple 
Myeloma.     Archives  of  Surgery,  16:  807-863,  April,  1928. 


August,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


44S 


the  advantage  of  consultation  with  Dr.  Watson,  the 
family  physician;  Dr.  Bence-Jones,  who  examined 
the  urine;  and  Dr.  Dalrymple,  who  undertook  the 
"microscopical  examination  of  the  two  affected 
ribs."  The  case,  which  occurred  in  "a  highly  re- 
spectable tradesman,  aged  45"  showed  Bence-Jones 
protein  in  the  urine  and  was  reported  in  1848. 

Multiple  myeloma,  like  Ewing's  tumor,  is  a  dis- 
ease of  the  bone  marrow.  It  is,  however,  essen- 
tially a  disease  of  later  life,  80  per  cent,  of  the 
cases  occurring  after  the  age  of  40,  and  it  is  more 
common  in  males.  Pain,  often  vague  and  indefi- 
nite, between  the  shoulder  blades  or  in  the  lumbo- 
sacral region,  is  quite  usual.  After  the  first  attack 
the  pain  may  subside  for  several  months,  when  it 
invariably  recurs  and  becomes  unbearable  in  the 
terminal  stages.  The  average  duration  of  the  dis- 
ease is  said  to  be  from  one  to  two  years.  Fre- 
quently, however,  vague  symptoms  of  "back  pain," 
"renal  colic,"  "girdle  pains,"  have  been  present  for 
several  years. 

The  morbid  anatomy  is  most  striking  because  of 
the  multiplicity  of  the  lesions.  The  disease  un- 
doubtedly commences  simultaneously  in  a  number 
of  bones.  The  thoracic  cage  is  most  frequently  in- 
volved, that  is,  the  red-marrow  bones,  sternum, 
ribs  and  vertebrae.  The  skull,  pelvic  bones,  clav- 
icle, and  finally  the  long  bones,  are  involved  in 
approximately  that  order  of  frequency. 

Grossly  the  tumors  in  the  marrow  usually  vary 
from  0.5  to  8  cm.  in  diameter.  At  first  they  appear 
well  circumscribed,  but  they  may  later  become  dif- 
fused throughout  the  marrow.  The  resulting  bone 
destruction  accounts  for  the  frequency  of  patholo- 
gic fractures.  These  fractures  are  more  common 
than  in  any  other  type  of  bone  tumor.  Compres- 
sion fractures  of  the  vertebral  bodies  should  warn 
the  clinician  to  inquire  into  the  possibility  of  mul- 
tiple myeloma. 

Microscopically  four  types  of  cell  have  been  de- 
scribed. Varieties  of  myeloma  are  supposed  to 
arise  from  a  plasma  cell,  a  lymphocyte,  a  myelo- 
cyte and  a  nucleated  red  blood  cell.  The  histology 
is  still  a  matter  of  debate  and  it  seems  probable  that 
all  four  types  may  be  merely  variations  of  the 
same  cell.  The  majority  of  cases  are  of  the  plasma- 
cell  type  with  rounded  or  polygonal  cells,  presenting 
eccentric  nuclei,  having  a  diffuse  arrangement 
and  practically  no  intercellular  substance. 

Bence-Jones  in  1845  described  the  presence  of  a 
peculiar  albumose  in  the  urine.  When  the  urine  is 
heated  to  55°  C.  a  cloud  appears,  which  disappears 
at  85°  C,  but  reappears  on  cooling.  It  is  said  to 
occur  in  two-thirds  of  all  cases  of  multiple  mye- 
loma. It  must  be  kept  in  mind  that  Bence-Jones 
albumosuria  may  be  found  in  leukemia  and  metas- 
tatic carcinoma  of   bone   marrow.     Very   few   of 


our  recent  proved  cases  showed  Bence-Jones  pro- 
tein. 

Due  to  replacement  of  normal  bone  marrow,  a 
secondary  anemia  develops.  There  is  no  charac- 
teristic change  in  the  blood,  although  myelocytes 
and  other  abnormal  cells  are  occasionally  seen. 

Metastases  to  the  internal  organs  are  not  com- 
mon. They  have  been  reported  in  the  Hver  and 
spleen.     The  lungs  are  practically  never  involved. 

The  roentgenogram  of  multiple  myeloma  is  char- 
acteristic. From  it  the  diagnosis  can  be  made.  If 
the  clinician  should  doubt  the  value  of  the  roent- 
genogram, he  is  advised  to  read  Kolodony  on  Bone 
Sarcoma,  or  Ewing's  Neoplastic  Diseases.  The  ra- 
diograph shows  numerous  rounded  and  oval, 
punched-out,  well  circumscribed  areas  of  bone  de- 
struction in  the  flat  and  long  bones  mentioned. 
Pathologic  fractures  are  frequent.  There  is  no  new 
bone  formation. 

Multitple  myeloma  is  an  extremely  radiosensi- 
tive tumor.  Response  is  rapid  and  the  nodules 
melt  away  much  as  in  Ewing's  tumors.  The  effect 
is  probably  less  lasting.  Roentgen  treatment  is 
often  worth  much  in  making  the  patient's  last  days 
more  comfortable  and  in  giving  him  hope. 


New  Shot  Alloy  Less  Harmful  to  Ducks 
(Victor  News,  July) 

Lead  pellets  of  the  kind  now  used  get  two  chances  at 
the  ducks.  Survey  scientists  explain.  The  first  is  the  hun- 
ter's honest  chance  to  knock  down  a  bird  when  he  fires. 
The  second  puts  no  ducks  in  anybody's  pot,  but  only  kills 
fowl  by  slow  lead  poisoning. 

Shotgun  pellets  falling  thick  into  hunted-over  marshes 
are  shoveled  up  as  the  duck  grub  in  the  mud  for  food, 
retained  in  the  gizzard,  and  as  they  are  slowly  rubbed 
down  some  of  the  lead  dissolves  and  finds  its  way  into  the 
blood  stream,  causing  the  typical  symptoms  of  lead  poison- 
ing. Among  these  is  paralysis  of  legs  and  wings,  so  that 
if  the  poison  does  not  kill  the  birds  outright  they  either 
die  of  exposure  or  fall  easy  victims  of  predatory  animals 
and  birds. 

The  new  magnesium-lead  alloy  absorbs  water  and  breaks 
down  into  a  finely  divided  form,  which  is  not,  retained  in 
the  digestive  tract  Ion  genough  to  have  any  poisonous  ac- 
tion. X-ray  pictures  of  ducks  that  have  been  given  doses 
of  the  new  kind  of  shot  showed  that  the  pellets  were  quickly 
ground  up  in  the  gizzard  and  as  rapidly  eliminated. 


The  Elizabethan  B's 


There  is  an  interesting  story  told  of  the  appreciation  that 
Queen  Elizabeth  had  for  bread.  It  seems  that  on  an  occa- 
sion when  she  was  reviewing  the  troops,  a  young  soldier 
stepped  from  the  line  and  knelt  before  her.  When  given 
permission  to  speak  he  reported  a  shortage  in  the  rations 
for  the  troops.  The  Queen  was  highly  indignant  that  her 
soldiers  were  being  expected  to  carry  on  wars  without 
proper  nourishment  and  commanded  a  change  in  the 
rations,  saying  that  the  English  army  would  be  trained 
and  strengthened  on  the  three  B's — Beef,  Bread,  and  the 
Bible. 


No  matter  how  many  years  it  has  existed  it  may  still  be 
itch. 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  10^6 


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.  Hai.I-,  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 

O.  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.        I 

Internal    IVIedlclne 

P.  H.  Ringer,  M.D Asheville,  N.  C. 

Surgery 

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

Obstetrics 

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 

WiNCATE  M.  Johnson,  M.D _.  Winston-Salem,  N.  C. 

Clinical  Chemistry  and   IVIlcroscopy 

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.  Giiaiore,  A.B.,  M.D. Greensboro,  N.  C. 

Public  Haalth 

N.  Thos.  Ennett,  M.D Greenville,  N.  C. 

Radiology 

Allen  Barker,  M.D.         I       Petersburg,  Va. 

Wright  Clarkson,  M.D.  ) 

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


Offerings  for  the  pages  of  this  Journal  are  requested 
and  given  careful  consideration  in  each  case.  Manu- 
scripts not  found  suitable  for  our  usa  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. 


Toward  Doing  Something  About  Automobile 
Wreck  Losses 

In  the  House  of  Delegates  of  the  Medical  So- 
cietj'  of  the  State  of  North  Carolina,  meeting  at 
Asheville  last  May,  Dr.  W.  C.  Bostic,  of  Forest 
City,  offered  a  resolution,  revision  of  which  ap- 
pears below. 

RESOLVED.  TH.\T  THE  HOUSE  OF  DELEGATES 
OF  THE  NORTH  CAROLINA  MEDICAL  SOCIETY 
F.WOR  THE  PRESENT  SCALE  OF  FEES  FOR  AUTO- 
MOBILE LICENSE  TAG  FOR  NORTH  CAROLINA; 
THAT  SO  PER  CENT.  OF  THE  COST  OF  THE  LI- 
CENSES BE  USED  TO  PURCH.ASE  LIABILITY  IN- 
SUR.A.NCE  FOR  EACH  AND  EVERY  AUTOMOBILE 
IN  THE  STATE,  THE  AMOUNT  OF  INSURANCE  TO 
BE  APPLIED,  FIRST.  IN  SUPPLYING  MEDICAL 
.\TTENTION  AND  HOSPITAL  CARE  [THEN  TO] 
REPAIR  OF  D.-VMAGES  TO  AUTOMOBILES  .-VND 
OTHER  PROPERTY. 

That  this  body  in  session  furnish  their  respective  Rep- 
resentatives and  Senators  copies  of  this  Resolution  urging 
them  to  support  this  measure  and  to  see  that  such  a  iill 
is  passed  at  the  next  Legislature  in  1937. 

That  each  and  everj-  member  write  or  wire  endorsement 
of  this  measure  and  in  every  way  urge  the  passage  of  such 
a  bill  in  the  next  Legislature. 

Each  applicant  for  license  to  also  have  the  privilege  of 
purchasing  additional  insurance  when  desired  at  the  same 
rate  as  furnished  by  the  State  by  paying  an  additional 
amount. 

The  State  may  purchase  this  insurance  to  be  furnished, 
the  owners  of  automobiles  from  one  or  more  reliable  in 
surance  companies  at  a  very  low  rate,  but  if  not  able  to 
purchase  it  at  a  very  low  rate  then  the  State  should  create 
an  insurance  department  to  handle  this  insurance  and 
also  other  insurance  needed  to  cover  other  State-controlled 
institutions,  highways,  employees,  hospitals,  schools  and 
school  buses,  if  desired.  The  said  insurance  department 
created  and  controlled  by  the  State  could  use  the  funds 
collected  to  invest  in  North  Carohna  bonds  and  in  this' 
wav  create  in  part  its  own  bondholders  and  market  for 
same,  keeping  all  the  funds  at  home  and  at  work. 

To  operate  an  automobile  on  the  streets  and  highways 
without  being  financially  and  physically  able  to  be  re 
sponsible  for  at  least  a  part  of  the  damage  that  might  be 
incurred  by  an  owner  of  a  car  is  a  growing  menace  to 
society. 

The  owner  and  driver  of  a  second-hand  T-model  Ford 
worth  S50.00,  with  only  two  drinks,  may  rip  off  the  side 
of  your  Buick  or  Packard,  send  you  to  the  hospital  and 
maybe  cripple  you  for  life  or  send  you  to  the  undertakers 
without  any  responsibility  except  perhaps  a  small  fine  or 
road  sentence  to  satisfy  the  court. 

With  this  amount  of  group  insurance  at  least  5500  lia- 
bility could  be  placed  on  every  automobile  in  the  State 
which  will  in  a  measure  cover  a  great  majority  of  all  the 
accidents  and  damages  to  automobiles  and  personal  inju 
ries.  More  than  400,000  automobiles  with  an  average  of 
$3  premium  for  each  automobile  would  be  two  million 
group  premiums  annually,  which  would  make  a  very  nice 
business  for  a  State-owned  and  State-operated  Insurance 
Department,  giving  insurance  at  a  low  rate  to  all  its  insti 
tutions.  \\\  automobile  owners,  doctors,  hospitals,  nurses, 
garage  owners,  auto  mechanics,  supply  houses  and  thou- 
sands of  widows  and  orphans,  and  last,  but  sure,  the  under- 


August,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


447 


takers  should  sponsor  and  favor  such   a   measure,   and   if 
not — why  not? 

The  time  set  for  hearing  Dr.  Bostic  was  late  in 
the  night,  a  time  very  unfavorable  to  full  consid- 
eration and  discussion.  The  matter  was  referred 
to  the  meeting  of  the  Council  of  the  Society,  set 
for  July  20th  at  Roaring  Gap.  In  the  interval 
the  author  had  made  certain  minor  revisions  which 
appeared  indicated  to  better  assure  the  accomplish- 
ment of  his  object. 

Lawyers  of  ability  have  expressed  the  opinion 
that  this  plan  is  feasible  and  its  objectives  desir- 
able. 

Doctors  on  whom  falls  the  care  of  victims  of 
automobile  wrecks  know  haw  unprofitable  and 
unpleasant  the  most  of  such  cases  are.  Doctors 
whose  hospitals  are  practically  forced  to  house, 
feed  and  nurse  such  patients  know  what  a  load  it 
is  to  carry.  Several  years  ago,  when  a  man  injured 
in  an  automobile  wreck  was  taken  into  St.  Peter's 
Hospital  in  Charlotte,  his  partner  walked  across 
the  grass,  tripped  over  a  wire,  fell  on  the  walk  and 
broke  his  leg.  The  hospital  and  local  doctors  took 
care  of  the  two  until  they  were  well,  and  then  the 
second  got  a  local  lawyer  to  enter  suit  against  the 
hospital  for  breaking  his  leg! 

Doctors  have  to  be  out  on  the  roads  when  they 
are  wet  or  covered  with  sleet;  they  must  go  about 
their  work  on  Saturday,  on  Circus  Day,  on  Christ- 
mas Eve,  on  Fourth  of  July — whenever  their  pa- 
tients need  them. 

Against  Dr.  Bostic's  plan  nothing  can  be  said 
except  that  if  it  were  put  into  effect  it  would  cut 
off  a  lot  of  revenue  from  insurance  companies  and 
their  agents.  It  might  well  be  a  beginning  from 
which  the  State  would  take  over  the  insuring  of 
all  its  property  by  itself.  Insurance  agents  argue 
loud  and  long  that  the  reason  an  individual  can 
not  afford  to  carry  his  own  insurance  is  that  he 
does  not  have  the  volume  of  business.  The  State 
has  the  volume  oj  business.  We  would  like  to  see 
a  statement  showing  how  much  the  State,  Counties 
and  Cities  of  North  Carolina  have  paid  in  insurance 
premiums  in  the  past  20  years,  and  how  much  they 
have  collected  from  insurance  companies. 

The  only  way  to  further  Dr.  Bostic's  plan  is  to 
bring  it  before  County  ]\Iedical  Societies,  get  their 
endorsements,  let  the  people  of  the  various  counties 
know  what  we  are  doing,  then  influence  those  we 
have  chosen  as  members  of  the  General  Assembly 
to  really  represent  their  constituencies. 

Closely  related  to  compensation  for  wrecks  is  the 
matter  of  reducing  the  number  of  wrecks  on  the 
roads.  For  nearly  10  years  this  editor  has  urged 
governors  on  cars  as  the  only  effective  means  of 
reducing  the  killings.  Of  late  many  have  expressed 
the  same  opinion.    It  is  a  growing  conviction.  The 


Richmond  Times-Dispatch  has  recently  come  over 
to  this  way  of  thinking  and  now  advocates  me- 
chanically limiting  the  speed  at  which  automotive 
vehicles  can  travel. 

Right  along  with  these  measures  are  two  others, 
simple  and  inexpensive,  which  should  be  put  into 
effect  without  delay.  These  are  running  two 
stripes  on  roads  instead  of  one  and  providing  a 
good  sand-clay  walkway  on  each  side  of  every 
hard-surface  road  in  the  State. 

A  great  number  of  those  driving  cars  really  be- 
lieve that  they  are  driving  just  right  when  their 
inside  wheels  are  running  right  on  the  center  mark, 
that  unless  these  inside  wheels  are  over  to  the  left 
of  the  line  they  are  not  violating  any  law  nor  in- 
curring any  risk.  Observe  as  you  go  along  the 
roads  and  see  what  you  think  about  this. 

It  is  an  outrage  that,  in  building  hard-surfaced 
roads,  the  road-builders  have  torn  up  the  good, 
comfortable,  safe  walking  paths  alongside  our 
roads,  and  provided  nothing  instead. 

Again  doctors  are  urged  to  put  their  strength 
behind  a  movement  to  provide  that  every  automo- 
tive vehicle  operated  on  a  public  road  of  the  State, 
or  on  a  city  street,  be  prevented  by  a  mechanical 
attachment  from  moving  beyond  the  legal  speed 
limit;  that  two  lines  be  painted  24  inches  apart, 
one  12  inches  on  either  side  of  the  present  center 
line;  and  that  a  good,  safe  path  for  walkers  be  run 
on  each  side  of  every  hard-surface  road  in  the 
State. 

To  go  back  to  Dr.  Bostic's  resolution:  That  is 
the  specific  matter  to  which  immediate  attention 
is  urged — and  no  attempt  is  being  made  to  attach 
these  other  provisions  as  riders.  They  are  related 
things,  but  not  very  well  suited  for  consolidating 
into  a  joint  issue. 

If  there  be  a  doctor  in  North  Carolina  who  sees 
a  valid  objection  to  Dr.  Bostic's  plan,  this  journal 
would  appreciate  hearing  what  this  objection  is. 
It  is  hardly  to  be  believed  that  there  is  one  so 
careless  of  his  own  interests  as  to  sit  still  and  "Let 
George  do  it." 

It  is  confidently  hoped  that  every  County  Med- 
ical Society  in  the  State  will  endorse  this  plan  and 
that  the  doctors  of  each  county  will  get  the  people 
generally  in  each  county  to  join  with  them  in  in- 
fluencing those  they  have  chosen  to  go  to  Raleigh 
to  vote  and  work  for  this  great  measure  of  relief 
and  justice. 


Dr.  Fr.ancis  Carter  Wood  says:  "Without  an- 
esthesia and  antisepsis  [proper]  surgical  treatment 
of  cancer  was  impossible.  The  effects  of  these, 
especially  of  anesthesia,  can  scarcely  be  estimated." 
It  will  be  noted  he  does  not  say  "can  not  be  over- 
estimated." 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


The  Brush-up  Course 

In  1933  and  again  in  1934,  on  the  initiative  of 
this  journal,  a  short  course  in  general  medicine 
was  given  in  the  Medical  Library  at  Charlotte. 
These  courses  evoking  enthusiasm,  last  year  such 
a  course  was  in  contemplation  but  the  Committee 
on  Arrangements  had  a  session  with  aestivo-au- 
tumnal  malaria  and  it  was  passed  over. 

Plans  are  now  being  laid  for  a  strictly  practical 
course  of  helps  in  bedside  and  office  medicine 
with  as  much  as  can  be  arranged  of  familiarizing 
with  handy  helps  in  diagnosis  and  treatment. 

A  lot  of  the  less  familiar  tricks  are  not  worth 
doing,  and  a  lot  more  are  pretty  easy  to  do  once 
the  mental  handicap  is  got  over. 

A  good  deal  will  be  said  on  comparative  values. 
The  aim  will  be  to  give  what  should  be  done  in 
each  case,  not  to  describe  all  the  different  things 
that  can  be  done  to  a  patient  in  such  a  case. 

The  time,  tentatively  chosen,  is  September  24th 
and  25th,  and  the  morning  of  the  26th — leading 
right  up  to  the  Carolina-Wake  Forest  game  in  the 
afternoon. 

The  journal  will  be  glad  to  have  requests  and 
suggestions  from  interested  doctors.  Send  a  card 
anyhow,  so  we  will  know  you  are  coming  and  put 
your  name  in  the  barrel. 


Reasoning  on  Facts  About  Cancer 
It  is  easy  to  persuade  ourselves  that  a  certain 
thing  is  true,  if  we  ardently  wish  it  to  be  true. 
Only  a  few  there  be  who  can  judge  fairly  the  issues 
in  a  case  with  which  they  are  prominently  identi- 
fied. One  of  these  few  is  Dr.  Francis  Carter  Wood, 
Columbia's  Professor  of  Cancer  Research.  Dr. 
Wood  is  fitted  by  native  endowment,  by  training 
and  by  position  to  speak  on  this  subject  with  a 
degree  of  authority  which  few  could  or  would 
claim. 

Last  February  Dr.  Wood,  for  the  Annual  Bulk- 
ley  Lecture  before  the  New  York  Academy  of 
Medicine,  chose  as  his  subject.  The  Improvements 
in  the  Ability  of  the  Medical  Profession  to  Treat 
Cancer.  While  he  is  gratified  at  the  progress  made, 
he  does  not  delude  himself  into  believing  or  saying 
more  than  the  facts  will  substantiate. 

"Today,"  he  tells  us,  "the  line  is  more  sharply 
drawn  between  those  tumors  which  can  be  operated 
upon  with  fair_  success  and  those  which  should  be 
treated  with  irradiation,  and  those  which  are  hope- 
less from  any  point  of  view.  Fewer  unnecessary 
operations  are  being  done."  Clearly,  this  authority 
(if  there  be  such  a  person)  on  cancer  is  not  one 
of  those  who  regard  operating  in  every  case  as 
giving  the  patient  the  benefit  of  the  doubt.  For 
the  larger  number  of  the  cases  amenable  to  treat- 


ment, surgery  remains  the  most  effective  agent; 
and  for  those  cases  in  which  operation  should  be 
done,  the  technique  has  been  codified  so  that  no 
one  is  justified  in  attempting  modifications  except 
when  some  extraordinary  circumstance  arises.  This 
technique  permits  of  more  rapid  operation  with  a 
lessened  death  rate  and  more  satisfactory  removal 
of  the  tumor.  Growths  that  are  accessible  and 
radiosensitive  are  effectively  treated  by  irradiation 
and  splendid  results  are  obtained  by  irradiation  of 
cervical  cancer. 

In  hospitals  receiving  the  more  intelligent  pa- 
tients, we  are  told,  70  per  cent,  are  inoperable  on 
admission  and  can  only  receive  palliative  treatment 
from  x-ray  or  radium  and  anodynes.  In  most  of 
the  great  city  institutions,  the  operability  is  little 
over  10  per  cent.,  and  "it  is  fortunate  if  a  5-year 
salvage  of  5  per  cent,  of  the  total  admissions  is 
obtained."  With  the  more  intelligent  it  is  probable 
that  a  20  per  cent.  S-year  salvage  is  the  limit  at 
present,  with  30  per  cent,  as  an  ideal;  but  it  must 
be  remembered  that  these  figures  are  obtained  frohi 
a  limited  group  of  types — for  example,  cancer  of 
the  skin,  lip,  breast,  cervix  and  rectum.  "The 
internal  forms,  such  as  brain,  lung,  stomach,  pan- 
creas, adrenal,  kidney,  do  not  contribute  many 
cures.  Nor  is  there  any  evidence  that  improve- 
ments in  surgical  technique  or  improvements  in 
radiation  technique  will  give  very  much  more  favor- 
able results.  Nor  can  education  be  pushed  beyond 
a  certain  point.  It  is  absurd  to  think  that  we  will 
ever  be  able  to  diagnose  in  the  incipient  stages 
many  of  the  internal  neoplasms." 

.'\11  this  is  well  deserving  of  careful,  earnest  con- 
sideration. It  is  not  pessimistic  statement  of  the 
case:  it  is  as  far  from  discouragement  on  the  one 
hand  as  it  is  from  Polyannaism  on  the  other. 

.'\nimal  experiments  have  clarified  much  of  our 
knowledge  of  human  cancer  and  have  yielded  many 
new  facts,  "but  these  facts  only  reveal  the  im- 
permeability of  the  cloud  which  hangs  about  the 
problem;  but  a  large  field  is  rapidly  developing  in 
which  palliation  and  prolongation  of  life  replace 
the  attempt  to  cure." 

Chordotomy  and  the  injection  of  alcohol  into  the 
nerve  tracts  or  centers  are  valuable  measures  for 
the  relief  of  intractable  pain. 

The  most  notable  palliation  by  means  of  x-ray 
is  the  relief  of  pain  from  bone  metastases,  espe- 
cially those  following  cancer  of  the  breast.  In 
many  instances  moderate  radiation  will  relieve  the 
pain  completely  and  often  render  a  patient  capable 
of  doing  a  considerable  amount  of  work  or  even 
returning  to  normal  activities.  This  palliation  may 
last  for  a  year  or  in  unusual  instances  2  or  3 
years.  Into  this  group  fall  the  treatment  of  Hodg- 
kin's  disease,  leukemia  and  lymphosarcoma.    It  is 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


sometimes  possible  to  keep  a  patient  with  chronic 
lymphatic  leukemia,  or  even  myelogenous  leukemia, 
alive  for  many  years  and  in  great  comfort.  A 
number  of  cases  of  Hodgkin's  disease  are  now  on 
record  which  have  remained  quiescent  for  8  to  10 
years.  Primary  bone  tumors  of  certain  types  can 
be  well  palliated.  Many  patients  with  extensive 
and  neglected  cancers  of  the  skin  may  be  relieved 
and,  occasionally,  the  whole  course  of  the  growth 
checked  by  prolonged  radiation.  Considerable 
progress  has  been  made  in  treating  abdominal  re- 
currences or  extensions  from  ovarian  carcinomata ; 
in  some  cases  it  is  possible  to  produce  a  permanent 
cure,  while  in  some  types  no  benefit  is  obtained 
from  any  amount  of  radiation.  In  carcinoma  of 
the  rectum,  prostate  and  bladder  a  certain  amount 
of  palliation  is  often  possible. 

Certain  svTithetic  sedative  drugs  have  proved 
extremely  useful  in  relieving  the  pain  of  carcinoma. 
Combinations  of  aspirin,  pyramidon  and  codeine, 
for  example,  can  be  made  which  will  keep  the 
jMtient  in  fair  comfort  for  a  long  time  and  delay 
the  use  of  morphine  or  similar  drugs  until  the 
terminal  stage. 

The  last  20  years  has  seen  an  enormous  improve- 
ment in  the  handling  of  the  cancer  patient  for 
whom  there  is  no  hope  of  cure,  making  him  much 
more  comfortable  and  rendering  a  cancer  death 
no  more  terrifying  than  that  from  heart  or  kidney 
disease.  The  fact  that  cancer  is  curable  has  been 
demonstrated  in  a  most  dramatic  fashion  by  the 
collection  of  some  25,000  cases  of  S-year  cures  from 
the  records  of  the  members  of  the  American  Col- 
lege of  Surgeons.  It  will  be  noticed,  however,  in 
reading  the  records  that  most  of  these  cases  are  of 
certain  types,  chiefly  the  accessible  neoplasms.  The 
occasional  miraculous  cures  of  the  internal  group 
that  are  reported  may  never  again  be  repeated. 
With  the  modern  technics  in  well  equipped  institu- 
tions, probably  20  per  cent  of  those  who  are  oper- 
able are  cured. 

This  great  doctor-student  and  investigator  re- 
gards the  easing  of  those  we  can  not  cure  as 
worthy  of  our  earnest  efforts,  and  he  takes  great 
comfort  from  the  proofs  of  thousands  of  5-year 
cures;  but  he  blinks  no  facts. 

Such  rational  dealing  with  this  subject  of  daily 
and  vital  concern  to  every  doctor  will  promote  con- 
fidence in  the  cause  of  reduction  of  cancer  mortal- 
ity. It  will  bring  to  the  support  of  the  movement 
those  who  are  confused  and  discouraged  by  state- 
ments engendered  by  zeal  rather  than  discretion. 


Editor  Nash 

With  this  issue  Dr.  J.  F.  Nash  of  Saint  Pauls 
assumes  charge  of  the  Department  of  Therapeutics 
of  this  journal.  Dr.  Frederick  R.  Taylor  will  con- 
tribute as  a  free  lance  from  time  to  time  as  he  can 
steal  a  few  minutes  from  his  work  on  Oxford  Med- 
icine and  such  formal  writings. 

Most  recent  graduates  agree  that  the  courses  in 
treatment  given  by  their  schools  left  much  to  be 
desired.  Readers  of  medical  journals  can  not  fail 
to  be  disappointed  if  they  look  to  these  periodicals 
for  help  in  the  management  of  their  patients. 

Dr.  Nash  is  a  good  family  doctor.  He  can  make 
a  diagnosis  in  most  of  his  cases  and  he  can  do  some- 
thing for  all  his  patients.  He  is  a  man  whose  prac- 
tical common  sense  takes  into  consideration  all  the 
practical  bearings  of  a  case  and  recommends  what 
is  appropriate  for  that  certain  disease,  in  that  cer- 
tain person,  under  those  certain  circumstances. 

The  Department  will  welcome  queries  as  to,  and 
contributions  which  deal  with,  problems  of  treat- 
ment, particularly  home  and  office  treatment. 


A  wisccrackcr  maintains  that  when  a  politician  makes  up 
his  bed  he  should  lie  in  it.  Unfortunately,  he  srcms  more 
inclined  to  make  up  his  bunk  and  lie  out  of  it. — The 
Kalends. 


Injuring  a  Good  Cause 

It  is  doubtful  which  does  a  cause  more  harm, 
active  opponents  or  indiscreet  champions.  Certainly, 
every  gross  overstatement  of  a  cause  confuses  its 
advocates,  comforts  its  opponents,  and  tends  to 
convert  neutrals  into  opponents.  Unjust  laying  of 
blame  by  an  advocate  is  another  common  way  of 
making  warm  enemies  and  cool  friends  for  the 
cause  advocated. 

The  textbook  recommended  to  our  class  in  genito- 
urinary surgery  taught  that  in  80  per  cent,  of  all 
cases  of  acute  anterior  urethritis  due  to  the  gon- 
ococcus  the  posterior  urethra  became  involved  in 
the  process,  and  that  it  was  doubtful  if  a  case  of 
gonorrheal  posterior  urethritis  was  ever  cured. 
There  was  hardly  a  man  in  the  class  who  believed 
a  word  of  it,  and  there  is  every  reason  to  believe 
that  this  false  teaching  by  so-called  authorities  all 
over  is  a  large  factor  in  the  failure  to  reduce  the 
ravages  of  venereal  disease. 

Both  overstatement  and  unjust  blaming  charac- 
terize most  campaigns  for  remedying  evil  condi- 
tions— whether  political,  religious,  health  or  other. 
A  case  in  point  is  that  of  the  American  Society 
for  the  Control  of  Cancer. 

This  Society  has  a  membership  of  the  highest 
type  and  it  is  expending  its  energies  in  a  warfare 
against  one  of  the  most  threatening  and  one  of  the 
most  terrible  of  the  enemies  to  health.  Its  activi- 
ties in  general  are  to  be  applauded  and  assisted. 
These  activities  are  in  the  interest  of  our  patients, 
of  our  families,  of  our  very  selves.  However,  we 
could  join  in  with   better  heart  if  spokesmen  for 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


the  Society  claimed  less  for  the  methods  advocated 
and  showed  less  disposition  to  blame  the  general 
run  of  doctors. 

It  is  demonstrated  that  periodic  examinations 
and  attention  to  early  symptoms  will  save  lives. 
How  much  good  is  counterbalanced  by  the  evil 
of  instilling  fear  of  cancer  and  of  loss  of  life  from 
needless  operation  we  do  not  know.  In  the  meet- 
ing of  a  State  medical  society  held  last  May  a 
member  declared  that  "Cancer  phobia  does  not 
increase  mortality."  Any  phobia  is  capable  of 
shortening  life,  of  causing  self-destruction,  even; 
and  in  many  another  case  it  will  rob  life  of  all 
that  makes  it  worth  the  living.  However,  this 
member  somewhat  redeemed  himself  by  saying  "I 
can  not  agree  with  ....  in  doing  a  complete  hys- 
terectomy for  non-cancerous  conditions,  for  the 
mortality  rate  in  doing  a  total  hysterectomy  is 
greater  than  is  the  occurrence  of  cancer  in  cervical 
stumps." 

The  number  of  good  doctors  who  die  of  cancer 
affords  proof  that  periodic  examinations  and  atten- 
tion to  early  symptoms,  even  if  generally  adopted, 
would  not  suffice.  In  the  past  few  months  one  of 
the  country's  eminent  oculists  discovered  himself 
to  be  afflicted  with  an  ineradicable  cancer  which 
had  made  no  sign.  Two  years  ago  the  man  whom 
many  called  the  "Father  of  Medicine"  of  our  time 
succumbed  to  cancer.  A  little  further  back  a  sur- 
geon active  in  the  good  work  of  the  Society  for 
the  Control  of  Cancer  fell  a  victim  to  the  enemy 
on  which  he  waged  constant  warfare.  Can  exam- 
inations of  lay  people  disclose  more  than  examina- 
tions of  doctors?  Or  can  a  lay  person  be  expected 
to  interpret  his  or  her  early  symptoms  more  wisely 
than  can  a  doctor? 

Along  with,  and  as  a  part  of,  the  insistence  on 
periodic  examinations  and  attention  to  early  symp- 
toms, goes  the  habit  of  attaching  blame  for  failure 
to  materially  reduce  the  death  rate  from  cancer. 
Quite  naturally  this  blame  is  placed  on  practicing 
physicians,  with  particular  emphasis  on  family  doc- 
tors. 

That  some  of  us  are  negligent  in  this  and  in 
other  particulars  goes  without  saying;  but  the  great 
majority  of  doctors  are  actively  concerned  to  learn 
more  and  do  more  toward  keeping  their  patients, 
members  of  their  families  and  their  own  selves 
from  dying  of  cancer.  But  they  look  at  both  col- 
umns of  the  account;  they  know  that  the  gross 
and  the  net  are  not  the  same;  and  they  refuse  to 
promise  more  than  they  have  a  reasonable  chance 
of  being  able  to  perform. 


BOOK  REVIEWS 


AN  INDEX  OF  DIFFERENTIAL  DIAGNOSIS  OF 
MAIN  SYMPTOMS,  by  Various  Writers,  edited  by  Her- 
bert French,  C.V.O.,  C.B.E.,  M.A.,  M.D.,  Oxon.,  F.R.C.P. 
London,  Consulting  Physician  to  Guy's  Hospital;  late  Phy- 
sician to  H.  M.  Household.  Fifth  edition,  with  742  illus- 
trations, of  which  196  are  colored.  William  Wood  and 
Co.,  Baltimore.      1936.     $16.00. 

The  title  says  what  the  book  purports  to  be: 
the  reviewer  says  it  is  all  that — as  it  has  been  since 
its  first  edition  in  1912.  Excellent  discrimination 
has  been  exercised  in  choosing  what  to  include. 
Every  practitioner  of  medicine  stands  frequently 
in  need  of  a  guide  to  show  him  the  way  through  a 
maze  of  conflicting  evidence  to  a  clear  diagnosis. 
French's  is  the  guide. 


A  TEXTBOOK  OF  OBSTETRICS  FOR  STUDENTS 
AND  PRACTITIONERS,  by  Frederick  C.  Irving,  A.B., 
M.D.,  F.A.C.S.,  William  Lambert  Richardson  Professor  of 
Obstetrics,  Harvard  University  Medical  School,  Visiting 
Obstetrician,  Boston  Lying-in  Hospital.  The  MacMillan 
Company,  New  York.     1936.    $6.00. 

The  author  tells  us  that  he  has  made  no  attempt 
to  embrace  the  entire  field  of  obstetrics,  to  present 
all  sides  of  controversial  subjects  or  to  recount  the 
history  of  the  specialty;  but  to  present  the  results 
of  the  experiences  of  himself  and  his  associates  con- 
cretely for  bedside  use. 

It  is  a  pleasure  to  read  a  book  presenting  without 
word  wastage  the  best  of  teaching,  arranged  after 
the  formal  order  now  seldom  seen. 


No  MATTER  WHOSE  DIAGNOSIS  a  patient  may  come  to  you 
with,  do  not  regard  the  matter  as  closed  till  you  have  taken 
your  own  history  and  made  your  own  examination. 


ABORTION,  SPONTANEOUS  AND  INDUCED:  Med- 
ical and  Social  Aspects,  by  Frederick  J.  Taussig,  M.D., 
F.A.C.S.,  Professor  of  Clinical  Obstetrics  and  CHnical  Gy- 
necology, Washington  University  School  of  Medicine,  St. 
Louis.  Illustrated.  This  volume  is  one  of  a  series  dealing 
with  medical  aspects  of  human  fertility  sponsored  by  The 
National  Committee  on  Maternal  Health,  Inc.  The  C.  V. 
Mosby  Co.,  St.  Louis.     1936.    ?7.S0. 

We  are  told  that  the  practice  of  abortion  is  wide- 
spread among  savages  and  among  civilized  peoples, 
regardless  of  race  or  religion.  Methods  among  dif- 
ferent peoples  and  effects  on  the  individual,  on 
the  family  and  on  society  are  described.  The  dif- 
ficulties in  the  way  of  obtaining  accurate  statistics 
and  obvious  errors  in  some  reports  are  pointed  out. 
A  chapter  is  devoted  to  abortion  in  animals. 

The  clinical  features  of  abortion,  including  indi- 
cations, operative  technique,  accidents  and  compli- 
cations, are  given  in  great  detail.  Sterilization  as  a 
preventive  measure  is  discussed. 

The  theological  and  ethical  aspects  and  legalized 
abortion  in  the  Soviet  Union  make  interesting  read- 
ing. .\bortion  laws  in  the  United  States  are  given 
in  general  and  differences  in  the  laws  of  the  several 
States  are  noted. 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


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August,  1936 


This  is  perhaps  the  best  book  on  this  important 
subject. 


PHYSICIAN,  PASTOR  AND  PATIENT:  Problems  in 
Pastoral  Medicine,  by  George  W.  Jacoby,  M.D.,  Past  Pres- 
ident of  the  American  Neurological  Association  and  the 
New  York  Neurological  Society.  Illustrated.  Paul  B. 
Hoeber,  Inc.,  New  York  and  London.     1936.    $3.50. 

The  introduction  deals  with  medicine  and  relig- 
ion and  attempts  to  compare  their  differences  and 
lay  off  for  them  a  common  meeting  ground.  The 
development  of  medicine  is  traced,  science  and 
philosophy  each  given  its  emphasis.  Discussion 
of  aims  of  treatment  is  particularly  good.  A  ten- 
dency to  extravagant  statement  runs  all  through: 
e.g.,  "There  is  a  popular  fallacy  that  if  one  feels 
well  he  is  well.  Nothing  [Italics  ours. — S.  M.  & 
S.\  could  be  farther  from  the  truth."  Entirely  too 
much  is  made  of  the  woman's  sense  of  modesty 
rebelling  when  the  physician  "is  obliged  to  request 
a  female  patient  to  expose  her  body."  The  author 
does  well  in  saying  the  physician  is  not  godfather, 
employer,  guardian,  dictator,  attorney  or  pastor  of 
his  patient,  and  that  cooperation  between  physician 
and  clergyman  is  beneficial  in  many  cases. 

Superstition,  Mother  of  Medicine  and  Religion; 
Health  and  the  Modern  Orient's  Religions;  Health 
in  Relation  to  Judaism,  Christianity  and  Islam; 
The  Patient's  Faith — all  these  are  attractive  sub- 
jects. 

Among  the  vital  problems  given  as  confronting 
the  Physician  and  the  Clergyman  are:  Contracep- 
tion and  Abortion,  Birth  Control,  The  Divorce 
Problem,  Sterilization,  Mental  Unfortunates,  En- 
thanasia  and  Vivisection. 

The  concluding  chapters  treat  of  The  Medical 
Profession  in  Hygiene  Education,  Modern  Religion 
in  Daily  Life,  and  The  Outlook  for  Medical  and 
Religious  Cooperation. 


DENTAL  INFECTION  AND  SYSTEMIC  DISEASE, 
by  Russell  L.  Haden,  M..\.,  M.D.,  Chief  of  the  Medical 
Division,  Cleveland  Clinic,  Cleveland,  Ohio;  Formerly  Pro- 
fessor of  Experimental  Medicine,  University  of  Kansas 
School  of  Medicine,  Kansas  City,  Kansas;  Formerly  Direc- 
tor of  Medical  Research,  Deaner  Institute,  Kansas  City, 
Mo.;  With  a  foreword  by  Dr.  Edward  C.  Rosenow;  2nd 
edition,  revised;  illustrated  with  63  engravings.  Lea  and 
Febiger,  Philadelphia.     1936.    $2.50. 

For  the  confusion  about  dental  focal  infection  as 
a  cause  of  metastic  disease  the  foreword  blames  the 
nature  of  the  problem  and  the  lack  of  cooperation 
between  physician,  dentist  and  bacteriologist.  We 
are  told  that  periapical  infection  is  the  most  com- 
mon dental  infection  responsible  for  systemic  dis- 
ease, and  the  next  sentence  says  that  such  infections 
are  found  in  a  large  majority  of  adults!  These 
two  statements  would  certainly  suggest  an  import- 
ant  relationship  between   a  great   many  persons' 


teeth  and  their  systemic  diseases. 

Work  in  bacteriological  laboratories  and  animal 
experiments  are  cited.  Cases  of  various  diseases, 
from  Arthritis  to  Thyroiditis,  are  described  as  il- 
lustrating the  relation  of  dental  infection  to  sys- 
temic disease. 


THEORY    AND    PR.'^CTICE    OF    PSYCHIATRY,    by 

William  S.  Sadler,  M.D.,  Chief  Psychiatrist  and  Direc- 
tor, The  Chicago  Institute  of  Research  and  Diagnosis;  Con- 
sulting Psychiatrist  to  Columbus  Hospital;  Fellow  of  the 
American  Psychiatric  Association ;  Member  of  the  American 
Psychopathological  Association;  Author  of  "The  Mind  at 
Mischief,"  "Piloting  Modern  Youth,"  "Worry  and  Nerv- 
ousness," "Physiology  of  Faith  and  Fear,"  "The  Quest  of 
Happiness."  Formerly  Professor  at  the  Post-Graduate 
Medical  School  of  Chicago ;  Fellow  of  the  American  Med- 
ical Association ;  Fellow  of  the  American  Association  for 
the  Advancement  of  Science.  The  C.  V.  Mosby  Co.,  St. 
Louis.     1936.     ?10.00. 

Over  many  years  there  has  existed  a  need  and  a 
demand  for  a  book  on  practical  psychiatry — a  book 
setting  forth  the  symptoms,  signs,  diagnosis,  dif- 
ferential diagnosis,  prognosis  and  treatment  (bet- 
ter, management)  of  disorders  of  the  mind.  The 
great  majority  of  dissertations  on  mental  diseases 
are  either  too  vague  or  too  general  to  be  of  any 
usefulness  to  a  doctor  with  a  mentally  disordered 
patient  on  his  hands.  General  principles  are  not 
neglected  in  this  book.  They  are  well  laid  down. 
But  the  author  does  not  stop  there.  He  goes  on 
from  the  general  to  the  particular. 

This  one  sentence  is  quoted  to  give  a  sample  of 
the  robust  commonsense  of  the  author:  "I  still 
make  a  practice  of  the  routine  scrutiny  of  the 
dream  life  of  my  neurotic  patients,  but  as  a  result 
of  thirty  years  of  this  study  I  am  coming  to  have 
less  and  less  regard  for  the  diagnostic  value  of 
dreams." 

It  may  well  be  doubted  if  there  is  to  be  found 
between  the  lids  of  any  other  book  so  much  in- 
struction of  everyday  usefulness  to  the  doctor  of 
medicine,  for  it  is  a  remarkably  good  textbook  of 
normal  and  abnormal  psychology. 


ENDOCRINOLOGY  IN  MODERN  PRACTICE,  by 
William  Wolf,  M.D.,  M.S.,  Ph.D.  lOlS  pages  with  252 
illustrations.  Philadelphia  and  London:  W.  B.  Saunders 
Company,  1936.     Cloth,  ?10.00  net. 

The  vastness  of  the  subject  of  endocrinology 
baffles  the  minds  of  most  doctors.  The  importance 
attached  to  the  endocrine  glands  by  enthusiasts 
conduces  to  scepticism  in  most,  confusion  in  many, 
overwhelming  conversion  in  a  few. 

First  to  be  discussed  are  the  glands  and  their 
diseases;  then  follow  a  consideration  of  other  hor- 
mones, obesity,  menstrual  disorders,  the  menopause, 
pregnancy  and  sterility:  then  the  endocrine  aspects 
of  non-endocrine  diseases;  and  then  endocrine  diag- 
nosis. 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


For  the  discriminating  doctor-reader  here  is  a 
great  mass  of  information  for  daily  use  in  enabling 
him  to  make  more  complete  diagnoses  and  to  give 
more  helpful  advice. 


HEART  DISEASE  AND  TUBERCULOSIS:  Efforts  In- 
cluding Methods  of  Diaphragmatic  and  Costal  Respiration 
to  Lessen  Their  Prevalence,  by  S.  Adolphus  Knopf,  M.D. 
Tke  Livingston  Press,  Livingston,  Columbia  Co.,  New 
York.     1936.     $1.25. 

The  author  has  conceived  that  heart  disease  may 
ultimately  be  conquered  as  tuberculosis  is  now  be- 
ing conquered;  disregarding  the  fact  that  in  one 
there  is  a  large  element  of  inescapable  wearing  out, 
while  the  other  is  the  result  of  an  infection  which 
may  be  escaped. 

This  booklet  gives  in  abstract  some  advanced 
ideas  of  a  doctor  who  has  had  a  large  experience  in 
these  subjects  of  the  greatest  interest. 


SYPHILIS  AND  ITS  TREATMENT,  by  William  A. 
Hdjton,  M.D.,  Boston.  The  Macmillan  Co.,  New  York. 
1936.     $3.50. 

The  author  deplores  the  fact  that  syphilis  is 
needlessly  prevalent  and  he  is  convinced  that  there 
is  a  real  need  for  a  book  giving  a  clear,  simple 
and  relatively  complete  account  of  the  disease  and 
its  treatment,  for  physicians,  public  health  workers 
and  medical  students.  This  conviction  and  an  in- 
timate and  long  experience  with  many  phases  of 
warfare  on  syphilis  have  brought  forth  a  handy 
volume  well  suited  to  meet  the  needs  of  those  for 
whom  it  is  written,  although  it  is  inevitable  that  a 
book  written  to  be  read  by  lay  health  workers  will 
contain  much  information  ordinarily  assumed  to 
be  common  knowledge  among  physicians.  How- 
ever, too  often  this  assumption  is  unwarranted. 

We  are  told  that  if  all  the  available  knowledge 
were  applied  the  disease  could  be  almost  complete- 
ly stamped  out  in  one  generation;  which  suggests 
Shakespeare's   famous   comment   "Much   virtue   in 

This  book  is  a  reliable  detailed  guide  in  the 
management  of  the  syphilitic  patient  and  it  sup- 
plies the  maximum  of  adequate  authoritative  in- 
formation on  all  phases  of  the  syphilis  problem. 


The  National  Medical  Col'ncil  on  Birth  Control 
was  organized  in  June  for  the  following  purposes: 

1.  To  control  and  supervise  all  medical  policies  of  the 
American  Birth  Control  League. 

2.  To  initiate,  encourage  and  execute  appropriate  scien- 
tific research  in  the  medical  aspects  of  birth  control. 

Virginia  and  Carolina  doctors  hsted  as  members  of  the 
Council  are  Dr.  F.  Bayard  Carter,  Durham;  Dr.  J.  Shelton 
Horsley,  Richmond;  Dr.  F.  O.  Plunkett,  Lynchburg;  and 
Dr.  Milton  J.  Rosenau,  Chapel  Hill. 


AS  AC 

ELIXIR    ASPIRIN    COMPOUND 


Contains  five  grains  of  Aspirin,  two  and  a  half 
grains  of  Sodium  Bromide  and  one-half  grain  Caf- 
feine H\drobromide  to  the  teaspoonful  in  stable 
Elixir.  hSKC  is  used  for  relief  in  Rheumatism,  Neu- 
ralgia, Tonsillitis,  Headache  and  minor  pre-  and  post- 
operative cases,  especially  the  removal  of  Tonsils. 

Average  Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water  as  prescribed  by  the  physician. 

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


Burwell  &  Dunn  Company 

Manujaciuring    (^=^^   Pharmacists 


CHARLOTTE,  N.  C. 

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


MULL-SOY 

VEGETABLE     |^  [  L  K  SUBSTITUTE 


Clinically   Proven 


Send  for  free  sample  and  literature 

THE   MULLER   LABORATORIES 

2935   FREDERICK  AVENUE 
BALTIMORE  -  MARYLAND 


Dl  U  RBITAL 


VASODILATOR 
DIURETIC     •     SEDATIVE 

No  Barbital  Complications 

(  Theobrom.  Sod.  Salyc  —    3  gr. 
FORMULA      Phenobarbital.    ...  VtS'- 

I  Calc.  Lact I'/zSr- 

1   Hypertension  (any  cause) 

)  Hypertensive  Cardio-Renal  Dif 


INDICATIONS 


Arteri 


Cardie 


Deciding  to  operate  in  doubtful  cases  is  by  no  mean.^ 
always  giving  the  patient  the  benefit  of  the  doubt. 


AVAILABLE  j  In  tablets  at  all  drug  stores 

Write  for  literature  and  samples 


GRANT  CHEMICAL  COMPANY 

31S  EAST  77th  STREET        .        •        NEW  YORK,  N.  Y. 


I 


4S4 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


NEWS  ITEMS 


Seventy-two  physicians,  comprising  members  of  the  Ca- 
tawba Valley  Medical  Society  and  their  guests,  were  en- 
tertained by  Dr.  J.  D.  Rudisill  at  a  barbecue  supper  at  the 
Rudisill  Lodge  on  the  Lenoir-Blowing  Roclc  highway  the 
afternoon  of  July  ISth.  The  program  for  the  meeting  was 
as  follows:  Local  Obstetrical  Analgesia,  Dr.  W.  Z.  Brad- 
ford, Charlotte;  Obstetrical  Analgesia,  Dr.  A.  M.  Corn- 
well,  Lincolnton;  Placenta  Praevia,  Dr.  Glenn  S.  Edgerton, 
Hickory;  Birth  Lacerations,  Dr.  H.  H.  Menzies,  Hickory. 
Dr.  L.  A.  Crowell  of  Lincolnton  presented  a  case  report. 

Membership  in  the  society  is  limited  to  physicians  of 
Catawba,  Burke,  Lincoln  and  Caldwell  Counties,  but  large 
numbers  of  visitors  are  always  present  for  the  meeting. 


Buncombe  County  (N.  C.)  Medic^al  Society,  Asheville, 
regular  meeting  evening  of  July  20th  at  the  City  Hall 
Building,  President  Parker  in  the  chair,  34  members  pres- 
ent. 

Committee  on  Public  Health  and  Legislation,  Dr.  P.  H. 
Ringer,  Chr.,  made  a  verbal  report  on  the  matter  of 
Helen  Gertrude  Randle.  His  committee  reported  progress 
and  would  have  a  further  report.     Committee  continued. 

Publicity  Committee,  Dr.  K.  E.  Brown,  Chr.,  presented 
3  recommendations  to  the  society  for  action. 

1.  We,  the  committee,  recommend  that  the  society 
approve  radio  talks  given  through  our  Public  Health  De- 
partments. Motion  made  that  we  adopt  this  recommen- 
dation as  read.  Seconded  by  many  and  carried  by  unani- 
mous vote. 

2.  We  recommend  that  these  talks  be  given  by  the 
Public  Health  Officials  only.     Carried. 

3.  We  recommend  that  the  society  approve  a  classified 
listing  of  the  physicians  in  the  city  for  the  telephone  direc- 
tory according  to  specialties.     Not  accepted. 

Application  for  membership  of  Dr.  Joseph  T.  Sullivan 
read  by  the  secretary  and  referred  to  the  Board  of  Cen- 
sors. 


Dr.  Walter  J.  Bristow  announces  the  removal  of  his 
office  to  the  Doctors  Building,  1S17  Hampton  Street,  Co- 
lumbia, South   Carolina. 


Dr.  Oscar  Dixon  Baxter  announces  to  the  profession 
the  opening  of  his  office  at  119  West  Seventh  Street,  Char- 
lotte. Practice  limited  to  X-Ray  Diagnosis  and  X-Ray  and 
Radium  Therapy. 


Dr.  E.  V.  Moore  has  removed  from  Earl  to  Spindale 
for  the  practice  of  his  profession.  Dr.  Moore  is  a  graduate 
of  the  Medical  College  of  the  State  of  South  Carolina,  class 
of  1933.  His  former  home  was  Boiling  Springs  and  he 
taught  school  at  Shiloh  for  two  years. 


Dr.  William  Earl  Overcash  is  the  new  physician-in- 
charge  of  Pine  Crest  Sanatorium,  Southern  Pines,  N.  C, 
succeeding  Dr.  J.  W.  Dickie.  Dr.  Overcash  has  been  as- 
sistant to  Dr.  Dickie  for  the  past  few  years. 


Dr.  J.  D.  Fitzgerald  has  joined  the  staff  of  the  Rainey 
Hospital,  Burlington,  N.  C,  as  an  associate.  Dr.  Fitzger- 
ald, a  native  of  Davidson  County,  was  graduated  from 
the  Duke  Medical  School  in  1934,  served  a  year  as  interne 
at  Watts  Hospital  in  Durham,  and  the  last  year  there  as 
chief  resident  physician. 


Dr.  Bennett  Edward  Stephenson  has  located  at  Wel- 
don,  North  Carolina. 


Dr.  Addison  Brenizer  sailed  on  the  Nonnandie  August 
Sth.  He  wUl  spend  some  weeks  in  France  and  Germany 
in  recreation  and  attending  clinics. 


Dr.  p.  G.  H.amlln,  Newport  News,  Virginia,  announces 
the  opening  of  an  office  for  the  practice  of  Neurology 
and  Psychiatry  at  The  Buxton  Clinic. 


Dr.  Catherine  M.^cFarlane,  of  Philadelphia,  is  the  new 
president  of  the  Medical  Women's  National  Association. 
Born  in  Philadelphia,  Dr.  MacFarlane  was  graduated  from 
the  Woman's  Medical  College  of  Pennsylvania  in  1898. 
She  is  Professor  of  Gynecology  there  and  Chief  Gynecolo- 
gist of  the  hospital.  She  is  on  the  staff  of  the  Woman's 
Hospital  of  Philadelphia. 


Dr.  James  Breckinridge  Lounsbury,  of  Philipse  Manor, 
New  York,  and  Black  Mountain,  North  Carolina,  and 
Miss  Beatrice  Thomen,  of  Staten  Island,  New  York,  were 
married  on  July  11th.  Dr.  Lounsbury  is  a  member  of  the 
surgical  staff  of  the  University  Hospital,  Ann  Arbor,  Mich- 
igan. 


Dr.  Eppie  Charles  Powell,  jr.,  Rocky  Mount,  North  Car- 
olina, and  Miss  Eleanor  Laura  Bizzell,  Goldsboro,  North 
Carolina,  were  married  in  New  York  City  on  July  1st. 


Dr.  Samuel  Macon  Carrington  and  Miss  Nellie  Up- 
church  were  married  at  Oxford,  North  Carolina,  July 
17th. 


Dr.    Kinloch    Nelson    and    Miss    Alice    MacGill    Deford, 
both  of  Richmond,  were  married  on  July  23rd. 

Deaths 


Dr.  David  F.  Buchanan,  45,  was  injured  fatally  when 
struck  by  a  freight  train  at  Glade  Springs,  Va.,  July  31st 
and  died  at  the  George  Ben  Johnston  Hospital  in  Abing- 
don 20  minutes  after  reaching  there.  He  was  a  son  of 
Mrs.  William  H.  Buchanan  of  Glade  Spring  and  nephew 
of  the  late  Lieutenant-Governor  B.  F.  Buchanan  of  Ma- 
rion and  of  Dr.  J.  David  Buchanan,  Marion  physician. 
He  was  a  World  War  captain  and  was  attached  to  Base 
Hospital  No.  11  with  the  A.  E.  F.  in  France.  For  the 
last  18  months  Dr.  Buchanan  had  been  camp  physician  of 
a  CCC  camp  at  Swarthmore,  Pa.  He  and  his  wife  came 
to  Glade  Spring  three  weeks  ago  to  visit  his  mother. 


Dr.  E.  F.  Long  (M.  C.  V.  '09),  58,  died  suddenly  July 
Sth  while  fishing  10  miles  from  his  home.  He  was  for  12 
years  on  the  staff  of  the  Burrus  Memorial  Hospital. 


Dr.  Charles  Harrison  Frazier,  66,  a  native  of  Philadel- 
phia and  Professor  of  Surgery  in  the  University  of  Penn- 
sylvania, and  famous  as  a  brain  surgeon,  died  July  26th 
after  an  illness  of  several  weeks.  Dr.  Frazier  was  chosen 
dean  of  the  Pennsylvania  University  Medical  School  in 
1901  and  served  until  1910.  From  1900  to  1922,  he  was 
Professor  of  Clinical  Surgery  and  from  1922  to  the  present 
time  he  was  John  Rhea  Barton  Professor  of  Surgery  and 
Head  of  the  Surgical  Department.  He  was  elected  a 
trustee  of  the  University  in  1934. 


Dr.  George  E.  Williams,  61,  physician  of  Valdese  since 
1029,  died  July  29th  in  the  Mount  Alto  Hospital  for 
world  war  veterans  at  Washington,  D.  C,  a  week  after  he 


August,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


For  the  Failitig  Hearts 

Phvllicin 


(theophylline-calciinn  salicylate) 


A  well  tolerated  diuretic  and  myocardial  stimulant 
in  congestive  heart  failure, 
cardiovascular-renal  disease 
and  angina  pectoris. 


DOSE:      1  tablet  (4  grains) 
2  to  4  times  a  day. 


BILHUBER-KNOLL  CORP., 


Literature  and  trial  quantity  upon  request. 

154  Ogden  Ave.,  Jersey  City,  N.  J. 


underwent  a  major  operation,  according  to  information 
received  at  Valdese.  Dr.  Williams  was  born  and  reared  in 
Burke  County  but  lived  in  Western  States  until  he  moved 
to  Valdese  seven  years  ago.  A  graduate  in  medicine  of 
the  University  of  Iowa,  he  did  post-graduate  work  at 
Northwestern  University.  At  one  time  he  was  head  of 
the  medical  department  of  the  Nebraska  State  Peniten- 
tiary at  Lincoln  and  later  in  charge  of  the  medical  depart- 
ment of  the  State  Asylum  for  the  Insane  at  Madison, 
Washington.  He  served  in  the  Medical  Corps  of  the 
United  States  Army  during  the  World  War. 


Dr.  George  T.  Harris,  60,  a  son  of  Dr.  H.  H.  Harris, 
Professor  of  Greek  in  the  University  of  Richmond,  died 
suddenly  at  his  home  in  Madison  Heights,  Lynchburg,  Va., 
July   16th. 


Dr.  William  B.  Meares,  jr.,  37,  formerly  of  Richmond, 
who  died  July  13th  in  a  Richmond  Hospital,  was  grad- 
uated from  the  University  of  Virginia  in  1916.  Dr.  Meares 
was  born  in  Hillsboro,  N.  C,  and  engaged  in  the  practice 
of  medicine  in  Richmond  for  seven  years,  but  about  two 
years  ago  established  his  home  in  Lexington,  N.  C. 


Dr.  Erik  Theophile  Sandberg,  of  Matthews  County,  Va., 
died  July  10th  at  Elizabeth  Buxton  Hospital,  Newport 
News,  Va.  Dr.  Sandberg  was  born  in  Sweden  and  came 
to  this  country  43  years  ago.  He  practiced  medicine  in 
Oklahoma  for  17  years  after  being  graduated  from  the 
University  of  the  South  in  1899. 


Dr.  Alvin  Judson  Hurt,  73  (Grant  Univ.  '93),  for  many 
years  a  widely  known  physician  of  Chesterfield  County, 
Va.,  died  July  21st  at  his  home  at  Chester.  Dr.  Hurt 
was  active  in  civic  affairs  and  was  chairman  of  the  Board 
of  Supervisors  of  his  county  at  the  time  of  his  death. 


Dr.  J.  Edwin  Dougherty,  38,  a  graduate  of  the  Medical 
College  of  Virginia,  died  at  his  home  at  Elkins,  West 
Virginia,  on  July  16th. 


From  D«.  A.  E.  Bakes,  jr.,  Charleston 

The  Second  District  Medical  Association  met  at  5 
o'clock  July  29th,  at  the  Summerland  Hotel  at  Batesburg, 
with  Drs.  W.  A.  Hart,  H.  B.  Heyward  and  Roger  G. 
Doughty  as  speakers. 

One  of  the  most  enjoyable  meetings  of  the  'i'ork  County 
Medical  Society  held  in  years  was  that  at  Sharon,  with 
Dr.  J.  H.  Saye  and  Dr.  C.  0.  Burrus  as  hosts.  Wives  of 
the  physicians  were  in  attendance,  as  the  meeting  was  of 
a  semi-social  nature. 

Speakers  of  the  occasion  were  Dr.  R.  M.  PoUitzer  and 
Dr.  Robert  C.  Bruce  of  Greenville,  and  Dr.  S.  H.  Spivey 
of  Rock  Hill.  Doctor  Bruce  is  president  of  the  South 
Carolina  Medical  Association. 

Of  much  interest  throughout  the  State  is  the  marriage  of 
Dr.  W.  W.  Wild  of  North  Charleston  to  Miss  Christine 
Daniel  of  Indiantown. 

Dr.  and  Mrs.  P.  E.  Payne  of  Columbia  have  taken  a 
house  in  Hendersonville  for  the  remainder  of  the  summer. 

An  interesting  meeting  of  the  Coastal  Medical  Society 
was  held  in  Walterboro,  July  16th.  The  visiting  speaker 
was  Dr.  Wm.  H.  Prioleau  of  Charleston;  Dr.  Homer  Bo- 
wen  of  Walterboro  gave  an  interesting  lecture. 


Plain  Enough 
"Love  reckons  hours  for  months  and  days  for  years  and 
every   little  absence  is  an  age."     Dryiten.     Now   we  under- 
stand why  the  wife  is  so  upset  when  we  come  in  a  little 
late. 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


Our  Medical  Schools 


Duke 


At  the  graduating  exercises  held  at  Duke  University  June 
8th,  thirty-nine  medical  students  received  the  degree  of 
Doctor  of  Medicine  and  twelve  the  degree  of  Bachelor  of 
Science  in  Medicine.  At  the  same  time,  sixteen  nurtj; 
received  their  diplomas  in  nursing  and  one  received  the 
de,-;ree  of  Bachelor  of  Science  in  Nursing. 

During  the  spring  quarter  two  seniors,  Vince  Moseley 
and  Burton  M,  Shinners,  were  elected  to  membership  in 
Alpha  Omega  Alpha. 

The  summer  quarter  commenced  June  22nd,  with  forty- 
six  students  registered  here  and  two  studying  in  England 
and  Ireland  for  credit  here. 

Dr.  Wiley  D.  Forbus,  Professor  of  Pathology,  has  re- 
cently been  elected  to  serve  on  the  National  Board  of 
Medical  Examiners,  succeeding  Dr.  Howard  K.  Karsner. 


Renal  Pain  and  Its  Treatment  by  Denervation  of  the 
Kidney 

(J.  B.  Oldham,  Ijiverpool,  in  Liverpool  Medico-Chirurgi- 
cal   Jl.,  Part   2,   i:)36) 

We  meet  with  patients  who  complain  bitterly  of  pain 
undoubtedly  renal  in  origin,  and  yet  the  most  careful 
examination  fails  to  reveal  the  cause.  Gall  bladders  and 
appendices,  ovaries  and  tube.;  have  been  need'essly  sacri- 
ficed and  in  the  end  recourse  has  been  taken  in  that  bles  eJ 
word  neurotic  as  a  cloak  for  ignorance  and  an  excuse  for 
inaction. 

Forty  years  ago  Mr.  Harrison  of  the  Royal  Infirmary, 
Liverpool,  reported  in  the  Lancet  a  case  of  acute  nephritis 
in  which  he  had  obtained  a  good  result  by  decapsulatin  ^ 


Anal-Sed 

Analgesic,   Sedative   and   Antipyretic 

.■\ffords  relief  in  migraine,  headache,  sciatica  and 
neuralgia.  Rheumatic  symptoms  are  frequently  re- 
lieved by  a  few  doses. 

Description 
Contains   i^/z    grains   of   Araidopyrine,    >4    grain    of 
Caffeine  Hydrobromide  and  15  grains  of  Potassium 
Bromide  to  the  teaspoonful. 


The  usual  dose  ranges  from  one  to  two  teaspoonfuls 
in  a  little  water. 

How  Supplied 
In  pints  and  gallons  to  physicians  and  druggists. 


Burwell  &  Dunn  Company 


Manujaciuring 
Established 


Pharmacists 
in   1887 


CHARLOTTE,  N.  C. 

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


the  kidney.  A  few  years  later  Edebohls  popularized  this 
operation.  It  has,  however,  been  shown  that  the  capsule 
completely  regenerates  inside  50  to  60  days  and  the  new 
envelope  is  tougher  and  and  less  elastic  than  the  normal 
one. 

All  of  my  patients  had,  as  their  chief  complaint,  pain 
in  the  renal  region  and  all  but  7  one  or  more  attacks 
of  typical  renal  colic ;  7  had  previous  abdominal  opera- 
tions without  improvement  in  their  symptoms;  many  of 
the  patients  exhibited  evidence  of  over-activity  of  the 
sympathetic  system.  No  case  was  accepted  for  denerva- 
tion if  the  urine  showed  positive  infection.  Indigo-carmine 
excretion  was  slower  on  the  painful  side,  but  in  only  7 
cases  did  the  dye  take  more  than  10  min.  to  appear.  The 
blood  chemistry  was  within  normal  limits  in  every   case. 

I  have  placed  great  reliance  on  pain  on  filling.  Retro- 
grade pyelography  is  done  careful  and  note  is  taken  of 
the  amount  of  fluid  which,  on  injection,  causes  pain,  and 
the  patient  is  asked  if  the  pain  is  similar  to  the  pain  he 
usually  has.  There  never  seems  to  be  any  doubt  and 
always  the  answer  is  "Yes"  or  "No"  without  hesitation. 
Only  if  this  test  is  positive  can  renal  denervation  be  con- 
sidered. 

When  the  origin  of  the  pain  was  fixed  on  the  kidney 
attempt;  were  made  to  cure  it  by  cystoscopic  and  medical 
method;,  and  in  this  way  many  cases  were  relieved.  'If 
the  symptoms  persisted  then  it  was  explained  to  the  patient 
that,  apart  from  the  fact  that  their  kidney  was  hyper- 
sensitive it  was  comparatively  healthy  and  that  I  would 
not  consider  operation.  Some  of  the  patients  were  satisfied 
by  this  assurance  and  disappeared.  A  few  returned  de- 
manding tre.itment.  If  further  urological  investigations 
confirmed  the  original  findings  denervation  was  consid- 
ered. 

Up  to  the  end  of  Jan.,  1935,  28  patients  fulfilled  these 
qualifications  and  were  operated  on.  In  all,  I  have  per- 
formed renal  denervation  40  times,  but  I  am  excluding 
from  the  present  consideration  cases  associated  with 
nephrolithotomy  and  cases  operated  on  during  the  last  12 
mos.  In  2  cases  operation  was  performed  on  both  kidneys 
and  recently  I  have  denervated  the  left  kidney  of  a  patient 
whose  right  kidney  had  been  removed  for  pyonephrosis. 

The  operation  requires  gentleness  and  patience ;  good 
exposure  and  illumination  of  the  renal  pedicle.  Spinal 
anesthesia  was  used  with  the  addition  of  gas  and  oxygen 
if  the  patient  was  nervous.  Venous  hemorrhage  is  the 
one  real  danger;  the  renal  vein  and  its  branches  tear  very 
easily  and  this  bleeding  may  be  difficult  to  control  or 
may  even  demand  nephrectomy.  I  now  always  start  at 
the  inner  end  of  the  pedicle  and  work  outwards  towards 
the  kidney.  When  the  pedicle  has  been  isolated  the  indi- 
vidual vessels  can  be  recognized  and  the  nerve  filaments 
seen  running  along  and  close  to  the  artery  and  its  branches. 
These  are  picked  up  on  a  grooved  director  and  cut  about 
half-way  along  the  renal  artery;  the  distal  ends  are  held 
with  forceps  and  are  stripped  towards  the  kidney  where 
they  are  again  divided.  This  process  is  repeated  until  the 
vessels  are  dissected  clean  for  at  least  1  in.  Some  years 
ago  Professor  De  Luca,  of  Palermo,  informed  me  that  a 
weak  solution  of  carbolic  acid  would  destroy  sympathetic 
nerve  filaments  without  injuring  the  ureter  or  renal  vessels, 
and  he  has  obtained  a  satisfactory  renal  denervation  by 
simply  painting  the  pedicle  with  a  10%  solution.  I  have 
never  attempted  a  renal  denervation  with  carbolic  acid 
alone,  but  I  generally  paint  the  pedicle  with  the  acid  after 
it  has  been  stripped.  Quite  apart  from  any  effect  it  may 
have  in  destroying  fine  nerve  filaments  which  have  not 
been  cut,  it  rapidly  whitens  them  so  that  they  can  be 
recognized  and  removed. 


August,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


"During  the  hot  summer  months... protein  milk... 
has  saved  more  Hves  than  any  other  one  food" 


"During  the  hot  summer  months, 
when  the  diarrheas  are  severe  and 
difficult  to  correct,  protein  milk  is 
practically  indispensable.  In  the 

■■Simplified  Infant  Feeding,"  Dc 


author's  hands,  it  has  been  more 
prompt  in   its   action  and  saved 
more    lives    than    any   other   one 
jood." 
ictt,  Lippincott.  1926.  Pa^e  141. 


MERRELL-SOULE  POWDERED  PROTEIN  MILK  (CULTURED) 


For  seventeen  years,  this  close  approximation  of  Fin- 
kelstein's  original  eizveissmilck  has  been  a  mainstay  in 
the  dietary  treatment  of:  (1)  summer  diarrheas,  (2) 
atrophy,  (3)  dyspepsia,  (4)  premature  infants,  (5) 
new-born  infants,  (6)  athreptic  infants,  (7)  non-thriv- 
ing nurslings,  (S)  celiac  disease. 


ADVANTAGES:  (1)  economical— no  waste,  (2)  easily 
liquefied  in  the  home,  (3)  uniform  in  composition 
and  texture,  (4)  finely  divided  curd  does  not  clog 
nipple  holes. 

Additional  information   and  samples  will   be  sent 
gladly  on  receipt  of  the  coupon  below. 


Till-:  lioR 

350  Madisc 

UEN  COMP;\NV,  Dept.Z— 50— Jl 
n  Ave.,  New  York,  N.  Y. 

Please  send   me  samples   of  Mer 

Milk  (Cultured). 

i-ell-Knllle    Pow. 

ered    Priilein 

•(flj^nltnf^ 

M.D. 

*••■  '"'^ 

W 

*^|^' 

r;/v 

Sl.if,- 

4S8 


SOUTHERN  MEDICINE  AND  SURGERY 


August,  1936 


Never  divide  an  aberrant  renal  artery  if  it  is  possible 
to  avoid  doing  so.  The  ureter  is  separated  from  its  bed 
and  its  fascial  attachments  to  the  surrounding  tissues — no 
attempt  is  made  to  make  this  stripping  of  the  ureter  as 
complete  as  that  of  the  pedicle.  Finally  the  kidney  will 
be  attached  solely  by  its  denuded  vessels  and  ureter  and 
separated  from  any  connection  with  its  nerve  supply.  The 
kidney  is  replaced  and  the  wound  closed,  with  or  without 
drainage.  The  patient  is  kept  flat  and  the  foot  of  the 
bed  is  raised  for  2  to  3  days  in  order  to  keep  the  kidney 
in  an  approximately  normal  position  until  adhesions  form. 

The  first  2  or  3  days  after  the  operation  practically  all 
patients  complain  of  severe  pain ;  in  the  next  2  or  3  days 
the  pain  eases  off  and  it  is  completely  relieved  inside  a 
week. 

In  all  cases  there  is  a  marked  diminution  in  the  secretion 
of  urine  for  the  first  few  days,  then  the  secretion  rapidly 
increases  and  the  denervated  kidney  is  found  to  be  secret- 
ing more  than  the  normal  kidney,  but  concentration  is 
not  as  deep  as  in  the  urine  from  a  normal  kidney.  Within 
3  to  6  months  these  changes  diminish  and  the  secretion 
from  the  2  kidneys  becomes  equal. 

In  all  my  cas^s  the  urine  and  blood  chemistry  was 
within  normal  limits  before  operation  and  remained  so 
afterwards. 

After  operation  it  was  impossible  to  cause  pain  or  dis- 
comfort by  injecting  fluid  into  the  pelvis.  Between  6 
and  12  mos.  after  operation  some  sensation  returns  but 
they  never  have  any  of  the  severe  pain,  nausea  or  vomiting 
which  occur  so  regularly  before  operation.  Two  cases 
were  not  improved  by  the  operation.  Consideration  of 
these  cases  and  their  after  history  has  convinced  me  that 
it  was  not  the  operation  but  my  diagnosis  and  selection 
of  cases  which  was  at  fault.  The  after  history  of  these 
2  cases  and  the  results  of  postoperative  investigations 
made  on  them  make  it  clear  that  their  pain  was  not 
renal  in  origin.  More  care  in  diagnosis  and  the  insistence 
on  some  objective  evidence  of  pelvic  stasis  would  have 
saved  me  from  such  disappointing  results. 


The  Career  of  the  Heart 


(R.  A.  Kinsella,  St.  Louis,  in  III.  Med.  Jl.,  July) 
Acute  coronary  insufficiency  describes  the  state  of  the 
heart  when  its  blood  supply  is  interfered  with  either  by 
spasm,  relative  occlusion  of  sclerotic  vessels  during  a  mo- 
ment of  unusual  demand,  or  actual  plugging  of  the  coro- 
nary branch.  The  result  of  this  asyphyxia  of  the  heart 
muscle  is  the  pain  so  well  known  to  the  practitioner  of 
medicine.  Curiously,  there  are  at  least  50%  of  such  pa- 
tients who  have  symptoms  other  than  pain.  These  are:  a 
sensation  of  fulness  under  the  sternum,  sudden  attacks  of 
breathlessness,  unexpected  feelings  of  great  weakness  and 
curious  attacks  of  epigastric  distention  usually  attended  by 
a  feeling  of  weakness  or  breathlessness.  This  type  of  heart 
disease  far  exceeds  all  other  types  in  frequency  and  is 
fatal  in  a  much  shorter  time  than  rheumatic  heart  disease. 
The  patients  whose  discomfort  is  brought  about  by  effort 
usually  live  longer,  since  effort  can  be  avoided. 

There  are  too  many  patients  in  whom  the  attention  of 
the  physicians  is  mistakenly  focused  on  epigastric  distress 
leading  to  a  diagnosis  of  disease  of  the  gallbladder  or  on  a 
respiratory  difficulty  with  fever,  leading  to  a  diagnosis  of 
pneumonia. 

Promptness  of  adequate  treatment  saves  many  lives.  We 
mean  complete  rest,  usually  with  the  aid  of  a  ^  gr.  of 
morphine  sulfate.  Adrenalin  is  contraindicated.  Digitalis 
has  a  place  in  the  treatment  of  the  acute  dilatation  and 
its  administration  should  be  by  the  intravenous  route. 
Digitahs  is  not  advised  in  the  later,  prolonged  treatment. 


F'OR 


PAIN 


The  majority  of  the  phy- 
sicians  in  the   Carolinaa 
are  prescribing  our  new 
tablets 


A*"'*S 


751 


Analg«8l«  and  Sedative     ^  "^^^      ^  P^rts       >  POrt 
Aspirin   Phenacetin   Caffein 


JFe  will  mail  professional  samples  regularly 
with  nur  compliments  if  you  desire  them. 
Carolina   Pharmaceutical    Co.,    Clinton,   S.    C. 


For  the  later  treatment,  the  derivatives  of  caffein  and 
theobromine  are  useful  and  small  doses  of  nitroglycerin, 
4  to  5  times  daily,  have  been  found  advantageous.  Thy- 
roidectomy has  not  lived  up  to  early  expectations. 

As  in  the  patient  who  has  a  rheumatic  heart  watch  for 
infections,  notably  those  in  the  urinary  tract  where  such 
infections  can  easily  pass  unnoticed. 


The  Mothers'  Mh-k  Bureau  of  the  Children's  Wel- 
fare Federation,  N.  Y.,  has  announced  the  adoption  of  a 
new  process  of  quickly  freezing  mothers'  milk.  The  proc- 
ess, invented  in  the  research  laboratory  of  The  Borden 
Company,  makes  it  possible  to  keep  mothers"  milk  for 
months,  transport  it,  and  feed  it  to  prematurely  born  or 
ill  babies  without  any  subsequent  action  other  than  thaw- 
ing and  warming. 


Maggot  Study  Yelds  New  Facts  on  Urea. — The  U.  S. 
Department  of  Agriculture  announces  the  possibility  that 
urea  may  be  responsible  along  with  allantoin  for  this  re- 
markable healing  produced  by  maggots. 


The  octogenarian,  during  an  operation  for  rejuvenation, 
became  very  impatient. 

"Don't  be  so  restless,"  growled  the  nurse. 

The  poor  man  went  on  moaning  and  sobbing. 

"Don't  cry,  the  pain  will  soon  vanish." 

"I'm  not  crying  because  of  pain,"  explained  the  old  man, 
"I'm  afraid  I'll  be  late  for  school." — Kablegram. 


"Did  you  hear  about  Mr.  Goofus  the  bridge  expert  be- 
ing the  father  of  twins?" 

"Yes,  looks  like  his  wife  doubled  his  bid." — Od  Quar- 
terly. 


A  man  saw  a  baby  deer  at  a  zoo,  and  asked  the  keeper 
what  it  was  called.  The  keeper  replied,  "What  does  your 
wife  call  you  every  morning?"  And  the  man  replied^ 
"Don't  tell  me  that's  a  skunk!" — Od  Quarterly. 


Nurse  (in  asylum) :  There's  a  man  outside  who  wants 
to  know  if  we  have  lost  a  male  inmate. 

Doctor:     Why? 

Nurse:  He  says  someone  has  run  off  with  his  wife. — 
The  Crucible. 


Journal 

of 

SOUTHERN  MEDICINE   &  SURGERY 


Vol.  XCVIII 


Charlotte,  N.  C,  August,   1936 


No.  9 


F"urther  Observation  of  Heart  Massage  as  a  Final  Resort  for 
Resuscitating  Hearts  Failing  Under  Anesthesia* 

T.  C.  BosT,  M.D.,  Charlotte,  Xorth  Carolina 


THE  expression,  heart  massage,  in  its  surgical 
meaning  implies  intermittent  compression  or 
kneading  of  the  organ  and  has  for  its  ob- 
ject the  reestablishment  of  cardiac  action  which  has 
failed,  as  during  the  progress  of  a  surgical  opera- 
tion or  at  any  time  while  the  patient  is  under  the 
influence  of  an  anesthetic. 

A  word  as  to  the  physiology  of  the  heart  might 
not  be  out  of  place,  and  in  this  connection  the  ques- 
tion might  naturally  arise,  Why  does  the  heart  stop? 
It  is  equally  pertinent  to  ask,  Why  does  the  heart 
beat?  The  prevailing  opinion  holds  contractility  to 
be  an  inherent  function  of  the  cardiac  muscle  and 
the  fact  that  stands  out  preeminently  is  that  the 
greatest  rhythmic  power  resides  in  the  basal  por- 
tion of  the  heart,  that  is,  in  what  corresponds  in 
the  more  primitive  hearts  to  the  sinus  venosus. 

From  a  surgical  standpoint,  the  failure  of  the 
heart  may  be  accounted  for  by:  1)  Reflex  vagus 
inhibition.  2)  Toxic  action  of  the  anesthetic  direct- 
ly upon  the  heart  muscle,  producing  ventricular 
fibrillation.  Leby  of  England  has  shown  that  this 
is  now  rare  because  of  the  disuse  of  chloroform.  3) 
Peripheral  vasomotor  failure — (heart  failure  sec- 
ondary to  low  b.  p.  Medullary  centers  are  easily 
injured  by  b.  p.  below  70.  4)  Chronic  disease  of 
the  heart  muscle  and  its  vessels. 

Heart  massage,  according  to  Keen,  D'Halluin  and 
more  recently  Gunn,  favors  resuscitation  by:  1)  de- 
pletion— mechanically  emptying  the  cardiac  cham- 
l)ers:  2)  acting  as  a  mechanical  irritant,  stim- 
ulating the  reserve  energy  of  the  cardiac  muscle; 
and  3)  creating  an  artificial  circulation  which  keeps 
up  the  nutrition  of  the  myocardium  and  supplies 
fresh  blood  to  the  brain.  Physiologists  have  put 
'great  emphasis  on  the  value  of  artificial  circulation. 
;Gunn,  after  injecting  a  dye  in  a  peripheral  vein 
Sand  detected  it  in  a  peripheral  artery  after  a  few 
compressions  of  an  arrested  heart,  concluded  that 
the   difficulty  lies   in   starting   the   beating   before 


changes  in  the  cortical  cells  have  gone  so  far  as  to 
make  it  impossible  for  these  cells  to  recover.  Gunn 
says  that  the  time  limit  for  revival  of  the  cortical 
cells  is  to  be  calculated,  not  from  the  start  of  spon- 
taneous heart  beats,  but  from  the  time  of  be'jinning 
massage,  pointing  out  the  value  of  artificial  circu- 
lation as  of  fundamental  importance  and  giving  the 
whole  question  of  resuscitation  a  more  hopeful  out- 
look. 

Zezas  attributes  to  the  artificial  circulation  the 
success  of  heart  massage. 

Massage,  as  a  practical  means  of  treatment  in 
cases  of  failure  of  the  pulse  and  respiration,  espe- 
cially those  occurring  during  general  anesthesia,  is 
based  upon  both  physiological  experiments  and 
clinical  evidence. 

The  experiments  began  with  the  work  of  Schiff 
in  1874.  He  chloroformed  a  number  of  dogs  until 
the  heart  ceased  to  beat  and  showed  that,  though 
artificial  respiration  and  stimulation  by  electricity 
were  of  no  avail,  direct  massage  restored  cardiac 
action  after  an  interval  of  11  J/2  minutes.  Tuffier 
and  Hallion  communicated  a  similar  series  confirm- 
ing this  work.  In  1900  Prus  published  the  results 
of  his  experiments  on  100  dogs  killed  by  electricity, 
by  suffocation  and  by  administration  of  chloroform. 
Heart  massage  and  artificial  respiration  were  started 
in  periods  varying  from  SS  seconds  to  an  hour.  Of 
those  in  which  the  heart  was  arrested  by  electricity, 
massage  was  successful  in  14  per  cent.;  of  the  oth- 
ers, over  75  per  cent,  were  resuscitated.  Prus  con- 
cluded that  life  can  be  induced  to  return  even  after 
the  heart  has  ceased  to  beat  for  an  hour.  Provost 
and  Balleti,  from  results  in  animal  experimentation, 
concluded  that  fibrillary  twitchings  of  the  heart  mus- 
cle were  the  greatest  bar  to  successful  massage,  and 
showed  that  the  longer  the  time  interval  between 
stoppage  of  the  heart  and  the  beginning  of  massag? 
the  greater  the  probability  of  these  twitchings  ap- 
pearing.    White,  in  1909,    was    unable    to    restore 


•Presented  to  the  Tri-State 
Una.  February  17th  and  18th. 


Medical  A-ssuciation  of  the  CarolinHS   and    Virginia,    meeting   at   ColumlHa,    South   Caro- 


HEART  MASSAGE— Bost 


September,   1<535 


either  respiration  or  circulation  by  artificial  respira- 
tion alone,  even  by  inflating  the  lungs  with  a  bellows 
after  the  heart  had  ceased.  The  work  of  Crile  and 
Dolley  established  the  fact  that  artificial  respiration 
and  cardiac  massage  should  be  carried  out  simul- 
taneously. 

This  extraordinary  power  of  the  heart  to  regain 
its  function  after  apparent  death  under  certain  phy- 
siological conditions  is  well  known  to  the  laboratory 
worker  in  the  field  of  heart  massage. 

The  first  report  of  massage  of  the  human  heart 
was  made  in  1898  and  the  first  successful  case  was 
as  late  as  1902  by  Starling  and  Lane,  so  that  as  a 
therapeutic  measure  heart  massage  may  be  consid- 
ered of  fairly  recent  application. 

Green  reviewed  the  literature  in  1906  and  gave 
an  abstract  of  40  published  cases.  White  collected 
an  additional  10  in  1909,  making  a  total  of  50  cases. 
In  1923  I  collected  25  more  cases,  which,  including 
two  of  my  own,  made  a  total  of  77. 

Lee  and  Downs  reported  a  case  in  1924  and  added 
23  other  cases  as  having  been  overlooked,  making  a 
total  of  101. 

Since  1924  I  have  collected  8  more  cases,  and 
all  these,  including  the  one  here  reported,  make  a 
grand  total  of  110.  A  few  other  cases  have  been 
reported  in  foreign  literature  since  this  date  but  are 
not  included  here  because  results  are  not  known. 

:Methods  employed  have  undergone  evolution: 

1.  The  thoracic  route.— A  flap  of  the  thoracic 
wall  over  the  cardiac  area  is  cut  and  turned  back. 
This  procedure  is  necessarily  forcible  and  must  ac- 
centuate shock  as  many  intercostal  vessels  and 
nerves  are  involved.  Pneumothorax,  too,  has  oc- 
curred in  several  of  the  published  cases,  and  it  is 
not  surprising  that  the  method  has  been  abandoned, 
except  in  operations  on  the  heart  and  lungs,  in 
which  a  breach  in  the  thoracic  wall  has  already 
been  made. 

2.  The  abdominal  subdiaphragmatic  route. — A 
median  epigastric  incision  is  made  and  the  right 
hand  introduced  below  the  diaphragm  and  the  left 
placed  over  the  cardiac  area,  interposing  the  heart 
between.  This  method  has  been  most  generally 
used,  as  it  was  a  natural  thought  when  the  heart 
action  was  arrested  during  the  progress  of  a  laparo- 
tomy, and  when  promptly  done  the  conditions  are 
favorable  for  resuscitation.  It  is  the  facility  and  the 
promptitude  that  make  for  success.  It  has  been 
demonstrated  in  the  child,  whose  thorax  is  small 
and  tissues  elastic,  that  subdiaphragmatic  compres- 
sion of  the  heart  is  possible  though  difficult,  but 
in  the  adult  it  would  rarely  be  effective  in  the  ob- 
stinate case  as  only  the  apex  can  be  reached,  mak- 
ing it  impossible  to  empty  the  distended  cardiac 
chambers  or  massage  the  base  of  the  heart  where 
the  greatest  rhythmic  power  resides;  hence  the  need 


for  going  through    the    diaphragm    to    reach    the 
base,  when  this  method  fails. 

3.  The  abdominal  transdiaphragmatic  route. — 
In  this  method,  also,  a  median  epigastric  incision 
is  made,  and  the  diaphragm  is  incised  approxi- 
mately anteroposteriorly,  splitting  the  muscle  fibers 
and  gaining  direct  access  to  the  pericardium.  Con- 
tractions of  the  heart  have  been  thus  produced  in 
practically  all  the  cases  however  late  applied — as, 
for  example,  Green's  case,  in  which  an  hour  after 
apparent  death  he  incised  the  diaphragm  and  was 
able  to  produce  a  few  contractions.  While  this 
method  affords  direct  cardiac  massage  and  is  su- 
perior to  the  thoracic,  yet  it  is  objectionable  in 
that  it  is  a  very  difficult  procedure.  The  stomach 
and  left  lobe  of  the  liver  make  it  dift'icult  to  incise 
the  diaphragm  and  there  is  some  risk  of  injuring 
the  musculophrenic  artery  and  causing  concealed 
hemorrhage;  finally,  suturing  the  opening  in  the 
pericardium  and  diaphragm  is  as  difficult  as  it  is 
necessary.  Hence  the  advantage  of  the  author's 
technique  as  worked  out  on  a  cadaver  and  appTied 
in  two  cases. 

4.  Author's  method. — .\n  abdominal  incision  is 
made  in  the  median  line  extending  well  up  to  the 
ensiform  cartilage.  The  left  costal  cartilages  are 
well  retracted,  bringing  the  anterior  diaphragmatic 
insertion  well  into  view.  A  two-inch  incision  be- 
ginning one  inch  to  the  left  of  the  median  line, 
carried  outward  behind  the  costal  margin,  cuts  the 
fibers  of  the  diaphragm  near  their  insertion.  The 
opening  is  rapidly  dilated  with  two  or  three  fingers 
of  the  right  hand,  so  that  the  hand  can  be  passed 
into  the  thoracic  cavity,  and  the  base  of  the  heart 
effectively  massaged.  No  vessels  are  injured  in  this 
incision,  as  the  superior  epigastric  artery  is  to  the 
inner  side  and  the  musculophrenic  branch  enters 
the  diaphragm  deeper  than  the  incision.  The  liver 
and  stomach,  even  if  prominent,  offer  no  obstruc- 
tion to  this  route;  nor  is  the  pericardium  in  risk 
of  being  opened.  During  the  massage  the  parts  fit 
snugly  around  the  wrist  of  the  operator  so  that  air 
is  not  sucked  in,  and  there  is  no  tendency  to  col- 
lapse of  the  lungs.  The  incision  is  easily  closed 
and  made  airtight  with  a  continuous  catgut  suture. 

It  is  pretty  well  agreed  that  the  technique  should 
be  gentle  compression  at  about  half  its  normal  rate 
to  allow  the  heart  to  fill  well,  also  this  is  in  keeping 
with  the  rate  at  which  the  heart  may  be  expected 
to  resume  its  beating.  When  the  heart  starts,  mas- 
sage should  be  stopped  to  allow  it  to  regain  ton? 
and  establish  its  beating  of  its  own  accord,  or  at 
most  compressing  the  heart  only  occasionally. 

The  case  for  report  is  one  of  Dr.  L.  D.  McPhail  anri 
Dr.  Vann  Matthews.  I  was  called  in  to  assist  in  resusci- 
tation when  symptoms  of  shock  developed  after  adminis- 
tration of  a  spinal  anesthetic. 


September,    1036 


HEART  MASSAGE— Bost 


The  patient  was  a  man  of  70  years,  retired,  who  had 
given  a  history  of  health  generally  good,  no  serious  ill- 
nesses. He  had  a  hemorrhoid  operation  10  years  ago  and 
3  months  ago  bowel  movements  became  painful  as  a  result 
of  fissure;  since  a  week  ago  he  had  had  severe  pain  about 
the  rectum. 

Examination:  General  appearance  good,  heart  and  lungs 
nothing  abnormal.  Abdomen  negative.  The  rectum  show- 
ed much  redness  and  induration  extended  from  the  rec- 
tum to  the  left  buttock,  very  tender  and  painful,  not 
fluctuating. 

B.  p.  was  165/95.  leucocyte  count  18,000,  urine  essen- 
tially normal,  p.  85,  t.  101,  r.  18. 

Diagnosis:     Ischiorectal  abscess. 

Operation:  For  low  spinal  anesthesia,  neocaine,  75  mg., 
was  adminstered  at  9:45.  Signs  of  shock  developed  at 
9:55 — very  weak  and  rapid  pulse,  shallow  respiration,  ashy 
color.  Head  of  table  was  lowered  and  adrenalin,  caffein, 
coramine  and  o.^cygen  given,  and  the  rectum  was  dilated. 
Heart  action  suspended  10:05.  Pupils  were  widely  dilated 
and  insensitive  to  light,  deep  cynosis.  Adrenalin  was 
injected  into  the  heart  and  intervenous  saline  250  c.c. 
given.  Rapid  preparation  was  made  and  the  abdomen 
opened  for  heart  massage  at  10:20.  The  heart  was  found 
to  be  very  large  and  flabby.  Subdiaphragmatic  massage 
was  done  for  five  minutes  and  no  contraction  obtained. 
The  diaphragm  was  incised  and  direct  massage  done  for 
three  minutes,  and  then  a  feeble  heart  contraction  was 
felt,  followed  by  very  weak  but  regular  contraction  (30-40 
rate)  rapidly  increasing  in  force,  and  the  radial  pulse  was 
felt  in  two  to  three  minutes;  in  five  minutes  heart  pulsa- 
tion could  be  seen  on  the  chest  over  the  cardiac  area  and 
color  had  become  good. 

The  diaphragm  was  sutured  and  packs  removed  and  I 
was  in  process  of  suturing  the  abdominal  incision  when  the 
heart  action  began  to  weaken  and  gradually  ceased  for  the 
second  time  after  beating  for  IS  minutes.  No  heart  action 
could  be  felt  -by  the  hand  in  the  dome  of  the  diaphragm. 
Subdiaphragmatic  massage  was  again  given  for  two  min- 
utes without  heart  action.  Sutures  were  removed  from 
the  diaphragm  incision  and  direct  massage  done  for  six 
minutes,  and  weak  contractions  started  regularly  and  in- 
creased in  force  but  never  became  very  strong.  Adrenalin 
was  again  injected  directly  into  the  heart  without  response, 
also  digifolin ;  following  digifolin  the  heart  beats  seemed 
to  increase  in  force  but  never  developed  strong  muscular 
contraction,  .'\drenalin  was  again  injected  into  heart;  no 
improvement.  The  contractions  gradually  weakened  and 
finally  ceased  after  going  on  regularly  for  30  minutes  fol- 
lowing the  second  resuscitation.  Further  massage  was 
done  but  heart  action  could  not  be  re-established. 

Comment:  In  this  case  heart  action  was  suspended  for 
15  to  20  minutes  before  massage  was  resorted  to.  The 
heart  was  resuscitated  but  it  seems  that  irreparable  damage 
to  the  cortical  cells  had  already  taken  place  making  ulti- 
mate failure  inevitable.  Had  massage  been  done  sooner 
the  outcome  would  likely  have  been  different.  This  is  the 
second  reported  case  of  heart  failure  under  spinal  anesthe- 
sia in  which  cardiac  massage  was  done. 

I  am  very  much  indebted  to  Dr.  McPhail  and  Dr.  Mat- 
thews for  permission  to  report  this  case. 

SlTMMAKY 

The  present  available  statistics  of  110  cases  in 
which  heart  massage  vfas  used,  show  that  in  30 
(27  per  cent.)  the  treatment  was  successful,  com- 
plete recovery  resulting;  about  35  per  cent,  were 
partially  successful  in  that  the  heart  and  respira- 
tion were  revived,  but  the  patients  died  in  from  a 


half-hour  to  2  or  3  days.  Death  in  several  in- 
stances was  probably  due  to  a  toxemia  which  was 
in  no  way  connected  with  the  resuscitation,  as,  for 
example,  in  my  first  case;  nevertheless  such  cases 
have  been  put  into  the  group  of  partial  successes. 

It  is  interesting  to  note  that  in  the  last  9  cases 
reported,  5  made  a  complete  recovery  and  the 
other  4  made  partial  recovery  in  that  the  heart 
action  was  reestablished  but  it  later  failed.  How- 
ever, massage  was  invariably  successful  in  this 
group  in  reestablishing  cardiac  action. 

From  these  figures  we  can  rightly  conclude  that 
the  results  in  the  main  have  been  favorable,  in 
that  more  than  one-fourth  of  the  patients  have 
been  saved,  and  more  than  half  have  been  resusci- 
tated in  a  measure.  The  question  now  arises: 
How  can  we  adjust  heart  massage  in  proper  accord 
with  its  surgical  bearings  and  save  more  of  these 
patients?  The  cases  in  which  efforts  were  crowned 
with  success  have  been  those  that  were  subjected 
to  massage  early  in  the  syncope,  and  the  possibility 
of  resuscitation  bears  a  somewhat  definite  relation 
to  the  time  that  elapses  between  the  cessation  and 
the  massage.  How  long  one  is  justified  in  waiting 
while  carrying  out  the  ordinary  means  of  resusci- 
tation before  resorting  to  massage,  may  be  judged 
in  a  measure  from  the  fact  that  there  have  been 
but  few  recoveries  when  the  syncope  has  lasted 
more  than  10  minutes,  and  the  largest  measure  of 
success  has  been  when  the  interval  did  not  exceed 
5  minutes.  In  Mollison's  case  good  recovery  was 
effected  after  an  interval  of  IS  minutes,  but  pro- 
found mental  symptoms  were  manifested  for  sev- 
eral weeks.  Mollison  and  others  have  pointed  out 
that  the  anemia  of  the  brain  for  even  a  short  in- 
terval produces  irreparable  damage  to  the  delicate 
brain  cells  and  other  vital  organs. 

Fisher  and  Gunn  advise  boldness  of  procedure 
if  the  heart  has  been  stopped  3  or  4  minutes,  stat- 
ing there  can  be  no  further  risk.  Russell  judges  from 
experiments,  clinical  experience  and  reports  of  re- 
coveries after  massage  that  "we  are  probably  safe 
in  assuming  that  about  S  minutes'  loss  of  circula- 
tion is  the  outside  limit  that  the  human  brain  can 
withstand  and  recover  completely." 

Norbury  has  recently  advocated  massage  after 
giving  other  methods  a  trial  of  only  2  minutes,  and 
concludes  that  we  are  prone  to  overlook  the  fact 
that  artificial  respiration  can  be  of  no  use  in  the 
absence  of  circulation. 

My  conclusions  are  in  entire  accord  with  those 
reached  by  others  having  clinical  experience  and 
by  Fisher,  Gunn  and  Russell  in  research  laborato- 
ries: that  is,  that  massage  should  be  resorted  to 
in  any  case  in  4  or  5  minutes,  and  if  the  abdomen 
be  already  open,  massage  should  be  commenced  at 
once.    A  lapse  of  a  longer  interval  should  not  bar 


HEART  MASSAGE—Bost 


September.   1036 


this  procedure.  When  the  operation  is  decided 
upon  the  subdiaphragmatic  method  should  be  first 
done,  it  being  the  simplest;  but  in  obstinate  cases, 
especially  in  adults,  where  satisfactory  compression 
of  the  heart  below  the  diaphragm  is  impossible, 
this  method  should  be  dispensed  with  in  2  or  3 
minutes  in  favor  of  the  transdiaphragmatic  method. 
Another  point  of  interest  in  this  connection  is 
the  relatively  small  number  of  cases  that  have  had 
the  advantage  of  heart  massage,  as  compared  with 
the  number — probably  going  into  the  thousands — 
reported  as  "Died  on  the  Table"  or  "Anesthetic 
Death,"  that  were  never  given  this  chance.  Nearly 
every  surgeon  of  broad  experience  has  been  con- 
fronted with  this  condition  and,  I  might  add,  al- 
most every  interne  or  resident  physician  has  seen 
these  cases  that  "went  bad  under  the  anesthetic," 
were  given  prolonged  artificial  respiration,  pulmo- 
tors  and  other  resuscitation  appliances  employed, 
and  stimulation  of  various  kinds — yet  all  fail  to 
reestablish  the  circulation. 

Conclusions 

1.  Heart  massage  is  an  established  method  for 
reestablishing  cardiac  action  which  has  suddenly 
failed  under  anesthesia,  and  it  is  based  on  both 
physiological  experiments  and  clinical  work. 

2.  The  possibility  of  resuscitation  bears  a  some- 
what definite  relation  to  the  time  that  elapses  be- 
tween the  stopping  of  the  heart  beat  and  the  be- 
ginning of  massage — the  shorter  the  interval  the 
more  certain  is  the  response. 

3.  If  the  abdomen  be  already  open,  massage 
should  be  instituted  at  once;  otherwise  not  more 
than  4  or  5  minutes  should  be  consumed  in  at- 
tempting resuscitation  by  ordinary  methods.  If, 
for  unavoidable  reasons,  more  than  4  or  S  minutes 
have  elapsed,  the  procedure  should  be  given  a  trial. 

4.  Subdiaphragmatic  massage  may  suffice,  espe- 
cially in  children  and  if  promptly  undertaken,  but 
if  only  the  apex  is  reached  and  the  heart  remains 
unresponsive  after  2  or  3  minutes,  it  should  be  dis- 
pensed with  in  favor  of  the  transdiaphragmatic 
method. 

5.  No  surgeon  should  be  content  to  abandon  a 
patient  without  giving  him  the  benefit  of  cardiac 
massage.  Restorative  measures  are  never  exhaust- 
ed or  completed  unless  heart  massage  has  been 
tried. 

6.  There  is  a  great  need  for  a  more  general  use 
of  heart  massage  as  it  will  serve  as  a  final  trump 
card  for  reviving  many  who  would  otherwise  perish. 

References 

1.  Bost:     Lancet,  Lond.,  1Q18,  Oct.  26th. 

2.  Chile  and  Dolley:     /.  Exp.  Med.,  1006,  vui. 

3.  D'H.^lluin:     Rev.  d.  ckir..  Par.,  1002. 

4.  Fisher:     Brit.  M.  J.,  1020,  no.  6. 

5.  Green:     Lancet,  Lond.,  1006,  ir. 

6.  Gunn:     Brit.  M.  J.,  1921,  Jan.  1st. 


7.  Keek:     Kenn's  Surgery,  vol.  x,  81. 

8.  Mollison:     Brit.  J.  Child.  Dis.,  1917,  xiv. 
Q.  Norbury:     Lancet,  Lond.,  1919,  Oct.  4th. 

10.  Provost  and  B.alleti:     Rev.  med.  de  la  Suisse  Rom., 
1001,  xxr. 

11.  Prus:      Wien.  klin.  Wchnschr.,  1900,  xm,  no.   21. 

12.  Russell:     Clin.  J.,  1909,  xxxiv. 

1.'.  Schife:     Rec.  Mem.  Phys.,  1874,  in. 

14.  Starli.\-g  and  Lane:     Lancet,  Lond.,  1902,  il 

\S.  TuFFiER  and  Hallion:     Bull,  el  mem.  Soc.  chtr.,  Par., 
1S9S. 

16.  White:     Surg.,  Gynec.  &  Obst.,\^0<),  xk,  i?,?,. 

17.  Zezas:     Wien.  klin.  Wchnschr.,  1904,  xxxu. 

15.  Bost:     S.  G.  &  0.,  1923,  36,  276. 

10.  Lee  and  Downs:      Am.  Surgery,  1924,  8,  555. 

Discussion 

Dr.  Cu.«i.es  S.  White,  Washington,  D.  C: 

Dr.  Bost's  paper  needs  no  resuscitation;  it  is  very  much 
alive  and  should  be  left  that  way.  But  there  are  a  few 
things  which  I  might  add  or  amplify. 

It  seems  to  me  this  procedure  has  not  brought  forth 
adequate  discussion  or  had  adequate  use.  because  the 
occasion  has  not  arisen,  our  anesthetics  being  better  than 
they  were  a  few  years  ago  and  our  having  learned  how 
to  use  them  better.  I  do  not,  however,  want  to  bring  up 
the  subject  of  anesthetics,  because  if  I  do  we  shall  be 
here  all  afternoon  discussing  that. 

In  case^  of  failure  under  anesthesia,  first,  we  should  be 
sure  whether  it  is  respiratory  or  heart  failure.  If  it  is 
respiratory  we  have  a  longer  time  to  work;  but  if  the 
heart  stops  we  have  a  very  short  time  in  which  to  apply 
the  measures  of  resuscitation.  You  have  to  act  promptly; 
otherwise  there  will  be  deterioration  of  the  brain  cells 
which   can  not  be  remedied. 

If  \ou  reach  up  in  the  diaphragm  and  grasp  the  heart 
and  feel  it  beat  a  few  times  you  will  get  a  thrill  you  will 
never  forget.  Some  of  the.~e  patients  do  not  survive,  but 
the  fact  that  some  of  them  live  is  enough  to  make  us 
realize  the  value  of  this  measure.  As  I  said  before,  you 
have  to  grasp  this  opportunity  when  you  see  it.  That 
may  be  once  in  a  lifetime,  but  that  once  may  be  enough 
to  save  one  patient. 
Dr.  L.  a.  Crowell,  Lincolnton: 

Resuscitating  these  desperately  ill  patients  and  bringing 
them  back  reminds  me  of  a  case  I  had  2,5  years  ago,  a 
farmer  out  in  the  country  who  had  hemorrhoids.  My 
assistant  and  myself  prepared  to  operate  on  him.  We 
gave  him  chloroform,  and  he  practically  died.  We  resus- 
citated him,  gave  him  artificial  respiration.  They  talked 
it  all  over  the  country  how  that  man  died  and  we  brought 
him   back  to  life. 

Of  all  the  things  a  surgeon  must  do,  performing  a  sec- 
ondary operation  is  a  thing  that  takes  a  lot  of  courage. 
You  operate  on  a  patient,  he  comes  back  in  a  month  or 
two,  and  you  have  to  operate  on  him  again.  The  family 
do  not  understand  it.  Now,  when  you  give  an  anesthetic 
and  the  heart  stops  and  you  start  it  again  you  get  a  lot 
of  credit   for  it. 

The  case  that  I  had  was  that  of  a  Negro  preacher  who 
had  been  in  places  where  he  had  no  business  to  be.  The 
woman's  husband  happened  to  come  home  and  shot  him — 
shot  out  three  or  four  ribs.  I  watched  his  heart  beat 
through  that  hole  in  his  side.  After  several  minutes  it 
stopped.  So  I  put  my  hand  in  and  massaged  it,  and 
presently  it  was  beating  regularly  again.  So  far  as  I 
know,  he  is  still  living.  1  don't  know  whether  I  would 
have  the  initiative  to  do  what  Dr.  Bost  did  or  not.  What 
I  did  di(l  not  require  any  courage. 


September,   1036 


HEART  MASSAGE— Bost 


463 


A  patient  you  have  put  on  the  table,  lying  there  appar- 
ently dead:  I  don't  know  of  anything  that  is  more  terri- 
fying. I  want  to  thank  Dr.  Bost  for  going  into  that  case 
as  he  did.  I  did  not  have  to  do  that,  because  my  patient 
was  already  opened  up. 
Dr.  Stephen  W.  Davis,  Charlotte: 

It  was  my  privilege  to  be  a  witness  to  this  last  case 
that  Dr.  Bost  reported.  When  it  was  realized  that  the 
patient's  heart  had  stopped  beating,  and  then  to  see,  after 
the  hand  was  slipped  into  the  thoracic  space  and  the 
heart  grasped,  and  then  see  the  rapid  pulsation  of  the 
heart,  continuing  until,  as  Dr.  Bost  says,  the  heart  began 
to  stop  and  was  again  revived  and  began  to  beat  with 
about  the  same  force  as  at  first,  there  was  no  time  to 
waste.  A  decision  must  be  arrived  at.  It  takes  a  degree 
of  fortitude  to  make  an  incision  and  grasp  the  heart  and 
massage  it,  but,  otherwise,  the  patient  was  certainly  be- 
yond hope  from  anoxemia  of  the  cerebral  tissues.  In 
dealing  with  injuries  of  the  head  we  have  to  bear  in  mind 
that  the  lowered  oxygen  supply  to  the  brain  is  of  prime 
importance.  We  have  to  realize  that  the  brain  is  in  a 
bony  vault  and  the  space  can  not  be  increased.  If  there 
is  increase  in  cerebrospinal  fluid,  since  the  brain  tissue 
can  not  be  compressed,  there  has  to  be  sacrifice  of  arterial 
blood.  So  it  would  appear  to  me  that  in  such  cases  it 
might  not  be  well,  after  the  patient  is  resuscitated,  to 
place  him  in  a  higher  oxygen  concentration.  If  there  is 
any  impairment  of  respiration  it  is  good  practice  to  fur- 
ther stimulate  the  medulla  by  the  use  of  carbon  dioxide. 
Dr.  Roger  G.  Dou6htv".  Columbia: 

I  thoroughly  enjoyed  Dr.  Bost's  paper,  and  I  think  the 
emphasis  he  places  on  prompt  decision  and  action  is  a 
very  proper  emphasis.  Recently  I  published  a  paper  deal- 
ing with  an  operation  upon  a  patient  who  had  been  stabbed 
in  the  heart,  the  operation  being  done  some  four  or  five 
minutes  after  the  heart  had  stopped  beating.  The  wound 
in  the  heart   was  sutured  and   the   patient   recovered. 

Some  years  ago  I  had  the  experience  of  seeing  a  thyroid 
patient  die  on  the  operating  tabic  and  then  revive,  after 
three  or  four  minutes,  with  resuscitation  of  the  heart. 
That  was  the  first  contact  I  had  with  the  importance  of 
heart  massage.  We  were  preparing  to  make  an  incision 
and  massage  the  heart  when  the  heart  started  of  itself. 

It  has  been  my  fortune,  or  misfortune,  to  operate  on 
three  stab  wounds  of  the  heart.  Six  or  eight  hours  later 
one  of  these  men  died.  I  was  present  when  the  heait 
stopped  beating,  and  I  reopened  the  wound  and  stayed 
there  and  massaged  the  heart  for  an  hour  or  an  hour-and- 
a-half.  The  heart  would  begin  to  beat  and  would  beat 
for  10  or  1,^  min.  and  then  stop;  I  would  massage  it 
again,  and  then  it  would  start  again.  Then  he  finally  died. 
I  removed  the  heart  and  found  in  one  of  the  chambers  a 
large  blod  clot  around  a  suture  traversing  the  chamber. 
That  was  a  definite  technical  error,  permitting  a  suture 
to  go  into  the  heart. 

It  is  well,  I  believe,  for  us  in  the  South  here,  who  see 
Negroes  stabbed  in  the  heart,  to  keep  this  procedure  in 
mind.  If  a  patient  comes  in  with  a  stab  wound  in  the 
heart  and  the  heart  stops  beating,  there  is  no  reason  why 
you  should  let  him  die.  You  can  start  the  heart  up  again, 
and  the  patient   will   live. 

Dr.  Bost  spoke  of  the  thrill  of  putting  your  hand  around 
the  heart  and  feeling  it  beat.  That,  1  think,  can  not  com- 
pare with  putting  your  hand  in  the  chest  wall  and  taking 
out  the  heart  and  laying  it  on  the  chest  wall  and  sewing 
ui)  a  wound  in  it.  That  is  the  greatest  thrill  I  have  ever 
had. 
Dk.  R.  E.  Seibels,  Columbia: 

Dr.  Marion  Sims  once  deraonstrateci   before   the   French 


Academy  his  procedure  for  vesicovaginal  fistula.  The  pa- 
tient was  a  member  of  the  nobility.  Dr.  Sims  saw,  while 
the  anesthetic  was  being  administered,  that  she  had  died. 
You  can  imagine  his  horror.  He  very  promptly  picked 
her  up  from  the  table,  put  her  knees  over  his  shoulders, 
and  jumped  up  and  down  several  times. 

Two  or  three  years  ago  I  saw  Dr.  Potter,  of  Buffalo, 
use  an  indirect  method  of  massage  which  I  have  used  in 
some  of  my  work.  That  is  simply  to  hold  the  baby  up, 
massage  the  trachea  to  get  the  fluid  out,  if  possible,  and 
then  alternately  press  the  thighs  on  the  abdominal  wall 
and  extend  fully,  thus  massaging  the  heart.  If  I  have 
one  of  those  that  does  not  respond,  I  shall  go  in  and  open 
the  diaphragm  and  massage  the  heart  through  the  dia- 
phragm. 
Dr.  James  K.  Hall,  Richmond: 

I  want  to  ask  Dr.  Bost  if  indirect  and  unintentional 
massage  of  the  heart  may  be  a  factor  in  the  restoration 
that  comes  about  after  the  application  of  artificial  breath- 
ing. 

Dr.  Bost:     I  do  not  understand  the  question.  Dr.  Hall. 

Dr.  Hall:     I  want  to  ask  if,  in  the  application  of  me- 
chanical movements  that  brings  about  respiration,  the  in- 
direct and  unintentional   massage   of   the  heart  may  be  a 
factor  in  re-establishing  life. 
Dr.  Bost,  closing: 

I  certainly  am  grateful,  gentlemen,  for  the  generous  dis- 
cussion. 

Dr.  Crowell  brought  out  the  question  of  actually  doing 
these  things.  With  the  patient  apparently  already  dead,  it 
seems  we  are  justified  in  resorting  to  any  possible  heroic 
measure,  and  it  has  been  shown  that  you  can  start  nearly 
all  these  hearts  to  beating.  It  is  a  terrible  thing  for  the 
story  to  get  out  in  the  community,  and  it  does  not  take 
it  long  to  get  out  into  other  communities,  that  so-and-so 
died  on  the  table.  That  is  a  hard  blow  to  surgery.  If 
heart  massage  did  nothing  more  than  restore  heart  action 
until  the  patient  gets  back  into  his  room  alive  the  proce- 
dure would  be  amply  justified.  -And  that  can  be  done, 
and  if  it  is  done  in  a  reasonable  length  of  time  a  certain 
number  of  these  patients  will  live.  But  even  if  they  die 
in  a  few  days,  if  you  can  get  them  back  in  their  rooms 
and  their  people  can  see  them  there,  much  will  have  been 
accomplished. 

Dr.  Davis  spoke  of  the  death  of  the  tissues.  Dr.  Carrel, 
of  the  Rockefeller  Institute,  said  that  a  man  is  legally 
dead  when  his  heart  and  respiration  stop,  but  he  is  a 
long  way  from  being  actually  dead.  This  case  I  reported, 
according  to  that,  was  legally  dead  three  times.  He  uses 
the  terms  reversible  death  and  irreversible  death.  Rever- 
sible death  is  when  life  can  be  induced  to  return,  and 
irreversible  death  when  life  can  not  be  induced  to  return. 
He  goes  further  and  says  that  even  when  gross  signs  of 
life  can  not  be  induced  to  come  back  the  body  is  alive 
and  stays  alive  for  some  time,  but,  since  life  in  general 
can  not  be  re-established,  each  of  the  organs  then  dies  in 
turn. 

I  do  not  know  whether  I  understand  Dr.  Hall  or  not, 
but  in  all  this  work  all  other  helpful  measures,  including 
artificial  respiration,  are  applied  continuously.  These  are 
to  be  continued  the  whole  time — before  you  do  your 
massage,  while  you  are  doing  it,  and  after  you  have  done 
it.  In  the  cases  I  have  seen  where  the  heart  has  stopped, 
you  have  to  keep  up  artificial  respiration  for  a  considerable 
time.  In  one  of  my  cases  I  had  to  do  it  for  half  an  hour. 
Dr.  J  as.  M.  Northington: 

If  I  may  interrupt  you,  Dr.  Bost,  I  think  I  can  explain 
what   Dr.  Hall  meant.     What  he  asked  was  whether  the 


464 


HEART  MASSAGE— Bost 


September,   1936 


movements  in  artificial  respiration  accomplish  their  good 
by  the  incidental  and  unintentional  massage  of  the  heart. 
Was  that  your  question.  Dr.  Hall? 

Dr.  J.AMES  K.  Hall:  I  wonder  if  the  whole  movement 
does  not  massage  the  heart  and,  if  it  is  successful,  whether 
the  person  does  not  come  to  life  because  the  heart  starts 
again. 

Dr.  Bost:  I  think  that  is  true,  perhaps,  especially  in 
children,  where  the  chest  is  compressible.  Putting  such 
patients  in  different  positions,  perhaps  actually  shaking 
them,  as  one  gentleman  mentioned,  would  be  of  some 
help.  But  in  an  adult  I  doubt  whether  it  would  be  of 
much  effect,  because  the  chest  is  rigid. 


822   Operations  on  the   Adrenal  Sytnipathetic  System: 

Essential  Hypertension 

(G.   W.    Crile,   Cleveland.   In    III.    Med.   Jl.,  Aug.) 

I  propose  as  my  major  premise,  that  essential  hyperten- 
sion is  an  example  of  pathologic  physiology  of  the  adrenal 
medulla-sympathetic  complex. 

There  is  no  more  possibility  that  a  gland  could  from  a 
force  within  itself  set  up  an  increased  activity,  than  that  a 
motor  car  could  start  itself  and  by  itself  take  a  trip  down- 
town. 

I  believe  that  the  symptoms  of  hyperthyroidism  are  the 
result  of  excessive  activity  of  the  adrenal  glands  and  the 
sympathetic  nervous  system,  and  that  the  thyroid  gland 
has  nothing  to  do  with  it.  Of  hyperthyroidism  that  recurs 
in  spite  of  repeated  operations,  there  is  present  a  pathologic 
physiology  of  the  sympathetic  nervous  system  which  throws 
the  thyroid  into  this  state  of  pathologic  activity,  because 
there  is  nothing  wrong  with  the  thyroid  secretion  except 
that  there  is  too  much  of  it. 

It  follows  that  if  we  should  denervate  the  adrenal  gland 
and  break  up  some  part  of  the  sympathetic  plexus  we 
should  abate  or  cure  hyperthyroidism.  We  have  now  per- 
formed this  operation  on  119  patients  with  recurrent  hy- 
perthyroidism and,  for  one  reason  or  another,  in  primary 
cases  in  which  there  has  been  an  associated  disease  like 
diabetes  or  hypertension.  In  these  cases  the  thyroid  gland 
has  not  been  touched  at  all.  The  denervation  of  the 
adrenal  gland  abates  the  disease  with  certainty.  The  origin 
of  the  disease  was  in  the  sympathetic  nervous  system  and, 
of  course,  the  medulla  of  the  adrenal  gland  is  part  of  the 
sympathetic  nervous  system.  In  all  these  cases  the  disease 
was  abated  or  cured;  the  symptoms  disappeared,  the  in- 
creased metabolic  rate  disappeared,  the  size  of  the  gland 
receded  to  normal. 

In  neurocirculatory  asthenia,  as  in  hyperthyroidism,  the 
sympathetic  nervous  system  is  at  an  abnormally  high  level 
of  activity. 

We  have  now  performed  874  operations  upon  this  sym- 
pathetic complex  or  upon  some  part  of  this  generating  sys- 
tem, for  various  diseases  including  essential  hypertension. 
Whereas  denervation  of  the  adrenal  glands  relieves  hyper- 
thyroidism and  neurocirculatory  asthenia,  the  b.  p.  tends 
to  return  to  its  former  level.  We,  therefore,  extend  the 
operative  procedure  to  include  resection  of  the  major,  minor 
and  least  splanchnic  nerves,  with  improvement  of  results. 
But  it  became  evident  that  some  other  factor  must  be 
found. 

It  was  at  this  point  we  realized  that  the  mechanism  in- 
volved in  the  production  of  hypertension  must  include  the 
extensions  of  the  sympathetic  system  to  the  aorta  itself. 

In  accordance  with  these  conceptions  we  have  resected 
the  celiac  ganglia,  broken  up  the  sympathetic  complex  and 
denervated  the  aorta  in  25  cases  most  of  which  were  cases 
of  malignant  hypertension  in  an  advanced  stage. 


The  following  observations  summarize  our  experience  in 
the  surgical  treatment  of  hypertension: 

In  cases  of  early  h>-pertension  especially  in  young  sub- 
jects the  blood  pressure  falls  to  the  normal  level  or  becomes 
stabilized  at  a  lower  level. 

In  cases  in  which  the  hypertension  has  been  associated 
with  other  diseases  due  to  a  pathologic  physiology  of  the 
adrenal  sympathetic  system  the  hypertension  disappears 
with  the  disease  with  which  it  is  associated. 

In  regard  to  the  more  recently  adopted  procedure  de- 
scribed above  the  following  statements  may  be  made: 

a.  During  the  operation  in  cases  of  malignant  hyper- 
tension the  b.  p.  is  reduced  to  or  below  the  normal 
level. 

b.  The  operation  is  performed  in  one  seance. 

c.  There  is  but  a  slight  degree  of  shock  as  would  be 
expected  since  the  operation  is  retroperitoneal. 

d.  Since  the  operation  is  performed  in  a  painless  area 
nitrous-oxide  oxygen  provides  ample  anesthesia. 

e.  It  is  still  too  early  to  offer  any  statement  in   regard 

to  the  post-hospital  results.  The  clinical  results 
during  the  postoperative  stay  in  the  hospital  are  bet- 
ter than  those  secured  by  our  former  procedures. 


.•\bdominal  Pain  Due  to  Extea-abdominai,  Disorders 
(J.  H.  Musser,  New  Orleans,  in  Jl.  Med.  Assn.  Ala.,  Aug.) 

Extra-abdominal  disorders  that  may  cause  pain  in  the 
abdomen  may  be  listed  as  follows: 

Thoracic  Diseases:  1)  Coronary  occlusion;  2)  Angina 
pectoris;  3)  Subacute  baterial  endocarditis;  4)  Right-sided 
heart  failure;  5)  Aneurysm;  6)  Pericarditis;  7)  Basal  pleu- 
risy; 8)  Pneumonia;  9)  Pulmonary  tuberculosis;  10)  Dia- 
phragmatic hernia. 

Urogenital  Diseases:  1)  Pyelitis;  2)  Pylonephritis;  3) 
Ureteral  stricture;  4)  Ureteral  calculus;  5)  Rena!  calculus; 
6)  Hydronephrosis;  7)  Renal  ptosis;  S)  Prostato-vesicul- 
itis;  9)  Epididymitis;  10)  Urethritis. 

Acvte  Infectious  Diseases:  1)  Rheumatic  fever;  2) 
Measles;  3)  Typhus;  4)  Septicemia;  5)  Influenza;  6) 
Follicular  tonsillitis;   7)   Scarlet  fever;  8)   Undulant  fever; 

9)  T}  phoid   fever. 

Toxic  Conditions:      1.)    Uremia;   2)    Lead;   3)    Tobacco; 

4)  Mercury;  5)  Emetine;  6)  Arsenic;  7)  Arachnidism; 
8)    Food  poisoning;   9)   Diabetic   coma. 

Cerebral  Diseases:  1)  Acute  epidemic  encephalitis;  2) 
.'\bdominal  migraine;  3)  Epileptic  equivalent;  4)  Hysteria; 

5)  "Diseases  of  brain"  (Wechsler)  ;  6)  Spasmophilia;  7) 
"Fears,  worries,  conflicts,  maladjustments,  repressions,  in- 
hibitions, and  general  emotional  instability"   (Paullin). 

Diseases' of  the  Spine  and  Spinal  Cord:  1)  Intercostal 
neuralgia;  2)  Cord  tumor;  3)  Tabes  dorsalis;  4)  Trans- 
verse myelitis;  5)  Osteoarthritis;  6)  Osteomyelitis;  7) 
Tuberculosis  of  the  spine;  8)   Scoliosis;   9)   Herpes  zoster; 

10)  Psoas  abscess. 

Pain  of  Abdominal  Wall:  1)  Intercostal  neuralgia;  2) 
Fibromyositis;  3)   Epigastric  hernia. 

Endorine  Disorders:  1)  Thyroid;  2)  Pituitary;  3)  Ad- 
dison's  disease. 

Allergic  Causes:      1)   Migraine;  2)   Henoch's  purpura;  3)  i 
.Angioneurotic   edema. 

Miscellaneous:  1)  Arteriosclerosis;  2)  Periarteritis  no- 
dosa; 3)  Syphilis;  4)  Cancer  of  retroperitoneal  glands;  S) 
Rectal  neoplasm;  6)   Pelvic  disease. 


Total  occlusion  of  the  vessels  of  the  ligamentum  teres 
has  been  reported,  with  resulting  necrosis  of  the  area  sup- 
plied by  this  artery. 


September,    1Q36 


SOUTHERN  MEDICINE  AND  SURGERY 


46S 


A  Simple   Approach   to   the   Diagnosis   of   Hyperinsulinism 

Report  of  Fifty  Cases 

George  R.  Wilkinson,  M.D.,  and  Everett  B.  Poole,  M.D. 
Greenville,  South  Carolina 


NU.MEROUS  reports  of  Harris^  -  and  oth- 
ers'' '''  '  ^  '■'  have  shown  that  hyperinsulin- 
ism or  spontaneous  hypoglycemia  is  a 
rather  common  disease.  In  view  of  its  frequency 
there  should  be  some  easier  clinical  approach  to 
the  diagnosis.  Elaborate  anameneses,  detailed 
blood  chemical  studies,  and  prolonged  therapeutic 
trials  are  all  very  well  for  the  rich  and  for  those 
who  practice  under  the  sheltering  arms  of  the  en- 
dowed clinics  or  teaching  establishments,  but  the 
family  physician  in  the  first  line  of  fire  sees  the 
majority  of  the  cases  before  anyone  else.  Some 
approach  should  be  available  to  him  for  weeding 
out  this  abnormality  or  disease  with  reasonable  ac- 
curacy, little  cost  to  the  patient  and  the  minimum 
expenditure  of  the  physician's  time. 

The  object  of  this  communication  is  not  to  add 
to  the  body  of  scientific  knowledge  pertaining  to 
the  subject.  It  is  to  emphasize  certain  salient 
clinical  features  of  the  condition,  which  will,  at 
the  very  outset,  point  to  hypoglycemia  as  a  possible 
causative  agent  in  the  production  of  symptoms  in  a 
sizeable  proportion  of  those  patients  encountered  in 
private  practice  whose  complaints  are  called  func- 
tional. Furthermore  it  is  to  be  stressed  that  the 
clinical  diagnosis  of  hyperinsulinism  can  be  made 
with  ease  by  the  simple  application  of  reasonable 
diligence  in  the  study  of  these  individual  cases,  once 
a  few  fundamental  principles  are  gotten  firmly  in 
mind.  All  that  is  known  pertaining  to  hyperin- 
sulinism can  be  found  in  the  rapidly  accumulating 
contemporary  literature  on  the  subject,  but  only 
those  facts  will  be  stressed  which  the  authors  have 
found  significant  in  a  recent  study  of  50  cases  in 
private  office  practice.  Particular  emphasis  is  to 
be  placed  on  a  simple  diagnostic  triad  which  has 
appeared  in  the  study  of  these  cases  and  which 
will  serve  as  a  convenient  lead  to  the  diagnosis. 
This  triad  consists  of: 

1 .  Rhythmic  symptoms  related  by  a  definite 
time  interval  to  the  taking  of  food. 

2.  A  low  blood-sugar  level  at  the  fourth  hour 
after  the  ingestion  of  glucose  in  the  toler- 
ance test. 

3.  Relief  or  marked  amelioration  of  symptoms 
by  frequent  feedings  of  small  amounts  of 
carbohydrate. 

Hyperinsulinism  is  a  disease  or  an  abnormal 
state  of  metabolism  in  which  there  is  clear-cut 
rhythmicity  or  a  characteristic  clock-like  chain 
of  symptoms  coming    on    when    the    stomach    is 


empty  and  the  blood  sugar  low,  and  wherein  there 
is  a  partial  or  complete  relief  of  symptoms  by  the 
ingestion  of  a  small  amount  of  carbohydrate  ma- 
terial. In  this  series,  70  mgm.  per  100  c.c.  of  whole 
blood  was  taken  as  the  lower  limit  of  normal  sugar. 
This  is  the  figure  generally  accepted  by  Harris^  and 
most  others.  The  etiology  of  this  disease  like  that 
of  its  antithesis,  diabetes  mellitus,  is  obscure;  but 
it  is  generally  accepted  that  the  hypoglycemia  is 
the  result  of  an  overproduction  of  insulin  by  the 
islet  tissue  of  the  pancreas  either  in  association 
with  simple  hyperplasia  or  distinct  tumors  (ad- 
enomata), the  latter  being  usually  located  in  the 
tail  of  the  organ".  Such  tumors  have  been  found 
at  operation  and  relief  of  symptoms  has  followed 
their  removal.  The  condition  has  been  recognized 
for  such  a  short  time  that  comprehensive  statistical 
data  are  not  yet  available.  Apparently  the  sexes 
are  about  equally  affected  and  it  is  probable  that 
the  condition  begins  earlier  than  diabetes,  which  is 
felt  by  some^  to  be  a  condition  of  islet  exhaustion 
following  ling-standjng  islet  overactivity.  It 
seems  that  the  condition  follows  the  same  geo- 
graphic distribution  as  diabetes  mellitus-,  and  it 
has  been  thought  that  the  large  intake  of  carbo- 
hydrate, especially  sugar,  in  this  country  and 
others  with  similar  dietary  habits  has  predisposed 
to  both  conditions;  the  condition  further  seems 
to  be  more  common  where  such  food  is  available 
over  and  above  the  physiological  demands. 

The  practitioner  can  begin  to  recognize  the  con- 
dition by  keeping  it  everlastingly  in  mind,  especially 
among  those  people  who  have  been  going  from  one 
doctor  to  another  in  search  of  relief  and  who  have 
been  diagnosed  as  neurotics,  psychoneurotics,  hys- 
terical individuals  and  the  like.  The  first  key  to 
the  diagnosis  is  the  rhythmicity  of  the  symptoms. 
The  story  of  the  disease  which  is  almost  as  char- 
acteristic as  that  of  prostatic  hypertrophy,  which 
has  become  so  familiar,  can  probably  best  be 
elicited  by  a  careful  review  of  the  symptoms  as 
they  pertain  to  the  gastrointestinal  tract. 

The  most  important  question  is: 

"How  do  you  feel  when  you  are  hungry?" 

Also  important  are  these  two  questions: 
"Do  you   regularly   feel   that   way  at  the  same 
time  of  the  day?" 

"Can  you  keep  time  by  your  stomach?" 
If  these  simple  questions  are  answered  equivo- 
cally or  in  the  negative  the  chances  are  that  the 


HYPERINSULISM— Wilkinson  &  Poole 


September,  1936 


patient  does  not  have  the  disease.  If  they  are 
answered  affirmatively  they  bring  out  facts  of  preg- 
nant import  and  open  up  avenues  of  further  inter- 
rogation the  answers  to  which  will  point  closer  and 
closer  to  the  underlying  difficulty. 

Duodenal  ulcer  is  the  disease  most  commonly 
associated  with  hyperinsulinism  and  it  is  not  sur- 
prising that  a  history  simulating  that  of  ulcer  will 
be  obtained  in  most  of  the  cases.  In  fact,  in  the 
series  of  cases  of  others^  and  in  the  present  group 
many  patients  have  been  found  to  be  suffering 
from  both  diseases;  in  the  ordinary  case  of  ulcer 
the  symptoms  with  relation  to  food  and  time  of 
day  is  prominent  but  when  both  conditions  are 
present  the  rhythmicity  is  striking. 

In  addition  to  an  ulcer-like  syndrome  most  pa- 
tients have  numerous  other  alimentary  symptoms 
such  as  periods  of  nausea,  vomiting  and  constipa- 
tion. As  one  delves  further  into  the  histories  of 
these  patients,  one  can  obtain  rhythmic  symp- 
tomatology affecting  almost  every  organ  and  every 
system  in  the  body^.  To  elicit  these  facts  with  a 
minimum  of  repetition  and  roundabout  effort,  one 
goes  briefly  through  the  various  major  systems. 
The  following  pertinent  questions  are  prefaced  by 
this  modifying  clause:  When  you  are  hungry  or 
when  your  spells  come  on. 
Central  Nervous  System  and  Associated  Organs 

Is  your  vision  blurred?  do  you  have  double  vi- 
sion? do  your  ears  buzz?  are  you  dizzy?  are  you 
forgetful?  are  your  powers  of  concentration  dimin- 
ished? is  your  work  less  efficient?  do  you  have 
mental  lapses?  do  you  faint^  or  drop  things  out 
of  your  hands?  do  you  stagger  or  fall? 
Neuromuscular 

Do  you  get  weak?  do  you  give  out  completely? 
do  you  get  trembly  and  quivery?  do  you  feel  numb? 
Vasomotor 

Do  you  [>erspire  more?  do  you  feel  like  you  are 
about  to  have  a  chill? 

Cardiorespiratory 

Does  your  heart  palpitate?  beat  fast?  beat  slow? 
do  you  get  short  of  breath?  do  you  have  a  tight- 
ness in  your  chest?  do  you  have  a  purring  in  your 
chest?  do  you  have  pain  over  your  heart? 
Genitourinary 

Do  you  have  to  void  more  often  than  usual?  do 
you  have  to  hurry  when  the  desire  to  void  comes 
on?  do  you  feel  as  if  you  cannot  empty  your 
bladder  completely? 

Of  course,  all  these  symptoms  can  be  caused 
by  various  organic  diseases  but  if  the  complaints 
are  definitely  rhythmic  and  especially  if  they  fall 
into  more  than  one  category,  hypoglycemia  becomes 
a  probability,  whether  or  not  associated  organic 
disease  is  found  on  the  general  physical  and  lab- 


oratory examination. 

After  the  symptomatology  has  been  developed 
the  rest  is  easy.  It  is  a  safe  statement  that  95 
per  cent,  of  cases  can  be  definitely  diagnosed  on 
the  history  alone.  The  physical  examination  will 
be  of  little  help  unless  the  patient  happens  to  be 
seen  in  a  hypoglycemic  phase  when  physical  con- 
firmation of  facts  brought  out  in  the  history  is 
possible.  For  instance,  the  irritability  will  be  ob- 
vious, the  emotional  instability  is  easily  seen,  the 
profuse  sweating  and  tachycardia  will  be  demon- 
strable, and  occasionally  bradycardia"^"  will  be 
present.  And  as  one  goes  further  in  the  study  ob- 
servation will  confirm  even  further  his  suspicions. 

The  confirmation  of  the  clinical  impression  de- 
pends on  accurate  blood-sugar  determinations.  In 
order  to  obtain  standard  conditions  the  glucose  tol- 
erance test  was  employed,  all  the  patients  in  this 
series  receiving  on  the  fasting  stomach  1.7  grams 
of  glucose  per  kilogram  of  body  weight.  The  sugar 
was  weighed  out,  mi.xed  with  water,  cooled  mod- 
erately with  ice,  and  lemon  juice  was  added  for 
palatability.  In  34  of  the  SO  cases  determinations 
of  the  blood-sugar  level  were  made  on  the  fasting 
stomach  just  before  the  glucose  administration, 
one  hour  after  the  glucose  ingestion,  and  four 
hours  after  the  glucose  ingestion.  As  Harris  has 
shown  and  as  the  experience  in  this  series  would 
indicate,  the  important  determination  is  that  made 
four  hours  after  the  sugar  is  given.  In  25  of  the 
34  cases  the  fasting  and  one-hour  levels  were  in 
the  normal  range  while  the  four-hour  level  was 
definitely  subnormal  (Group  1,  Table  1).    In  only 


Group      I  (28  cases) 

II  (  4  "     ) 

III  (   2  "     ) 

IV  (16  "      ) 


One      Four 

Fasting     Hour     Hours 

84      118     57 

59      109      58 

58      148      76 

58 


TABLE  1.  Blood-sugar  readings,  averaged,  for  the 
various  groups  explained  in  the  text.  The  numbers  rep- 
resent milligrams  of  sugar  per  100  c.c.  of  blood.  The 
time  represents  the  period  which  had  elapsed  after  the 
patient  had  received  1.7  grams  of  glucose  per  kilogram 
of  body  weight  before  the  blood  sugar  determinations 
were  made. 

four  cases  were  both  levels  below  normal  and  in 
this  group  the  fasting  average  was  not  as  low  as 
the  four-hour  average  (Group  2,  Table  1).  In 
only  two  cases  was  the  fasting  level  below  normal 
when  the  four-hour  level  was  in  the  normal  range 
(Group  3,  Table  1).  These  last  two  cases  were 
of  especial  interest  because  of  the  high  normal 
one-hour  levels  in  the  face  of  the  low  fasting  levels 
and  four-hour  levels  which  did  not  fall  as  low  as 
would  be  expected  from  the  symptoms.  It  was 
inferred  that  these  two  represented  cases  in  which 
the  production  of  insulin  in  moderately  increased 
amounts  was  continuous  regardless  of  food  but 
when  a  large  amount  of  carbohydrate  was  given 


I 


September,    IQ3o 


HYPERINSVLISM— Wilkinson  &  Poole 


the  islets  were  unable  to  respond  readily,  hence 
the  high  one-hour  level  and  the  normal  late  level. 
It  may  be  safe  to  interpret  these  cases  as  repre- 
senting early  pancreatic  exhaustion  following  over- 
stimulation and  over-activity  of  long  standing. 

As  an  explanation  of  the  usual  late  blood-sugar 
drop  to  a  point  lower  than  the  fasting  level,  it  was 
reasoned  by  Harris  that  the  massive  amount  of 
sugar  taken  at  one  time  strongly  stimulated  in- 
sulin production'.  In  the  first  hour  the  large 
amount  of  sugar  being  rapidly  absorbed  offset  a 
depressing  effect  of  this  extra  insulin  on  the  blood 
sugar.  However  it  was  felt  that  the  over-produc- 
tion of  insulin  continued  in  greater  amount  and 
for  a  longer  time  than  was  needed,  thus  producing 
the  marked  hypoglycemia  in  the  late  period. 

During  the  glucose  tolerance  test  it  is  important 
that  the  patient  approximate  his  usual  activity  for 
exercise  lowers  the  blood  sugar  and  a  low  reading 
is  more  likely  to  be  found  during  activity.  In 
hyperinsulinism  and  in  diabetes'^  the  fasting  level 
tends  to  be  relatively  high,  probably  because  of  the 
Icng  interval  of  rest  preceding  the  time  when  the 
blood-sugar  estimation  is  made. 

The  greater  importance  of  the  four-hour  test 
being  apparent,  a  single  four-hour  determination 
after  the  standard  glucose  meal  was  done  on  a 
number  of  patients.  Of  this  group  16  were  found 
with  hypoglycemia,  the  average  being  58  mgm. 
(Group  4,  Table  1).  The  blood-sugar  studies 
checked  very  closely  with  the  clinical  impressions 
of  these  cases.  This  experience  has  consequently 
led  to  the  suggestion  that  as  a  convenient  and  in- 
expensive diagnostic  measure  it  could  be  employed 
by  the  practicing  physician  seeking  confirmation 
of  his  clinical  diagnosis  of  hyperinsulinism.  It  is 
safe  to  say  that  by  far  the  greater  number  of  posi- 
tive cases  will  be  proved  by  this  method  and  those 
few  cases  in  which  the  reading  is  normal  in  the  face 
of  strong  clinical  suspicions  can  be  sent  back  for 
the  complete  routine. 

All  the  determinations  were  made  in  this  series 
by  Folin-Wu  technique*.  (It  should  be  empha- 
sized that  for  accuracy  the  four-hour  test  should 
be  made  using  both  the  100-mgm.  and  the  50-mgm. 
standards,  for,  if  the  actual  blood  sugar  is  below  75 
mgm.  accurate  colorimetric  readings  will  be  possible 
only  with  the  latter  standard). 

Following  the  patient  during  the  course  of  the 
test  one  can  find  a  close  correlation  between  the 
symptoms  and  the  blood-sugar  level.  At  the  be- 
ginning most  patients  are  feeling  fairly  well;  by 
the  end  of  the  hour  many  are  positively  euphoric; 
but  toward  the  third  and  fourth  hours  they  have 
an  exacerbation  of  all  their  symptoms  and  many 
of  them  are  unable  to  stay  on  their  feet  any  longer. 

However,  the  impression  is  not  to  be  given  that 


there  is  always  a  close  relationship  between  the 
blood-sugar  level  and  the  intensity  of  the  symp- 
toms. Likewise  the  same  patient  does  not  always 
react  in  the  same  way  to  a  given  blood-sugar  level. 
Some  of  the  cases  in  this  series  with  sugar  around 
the  sixties  showed  symptoms  of  severe  grade 
approaching  tetany,  syncope,  and  paroxysmal 
vasovagal  crises.  Other  patients  with  sugar  in 
the  forties  complained  merely  of  drowsiness, 
fatigue  and  lack  of  concentration  and  mental 
endurance.  A  patient  who  developed  a  pro- 
found tachycardia  in  the  hypoglycemic  phase  of  the 
first  test,  at  a  later  test  after  a  period  of  dietary 
treatment  which  had  permitted  her  to  get  a  grip  on 
herself,  complained  only  of  a  little  weakness  and 
shakiness,  though  the  hypoglycemia  at  the  four- 
hour  period  was  approximately  the  same.  But,  by 
and  large,  during  the  test  the  clinical  behaviour 
follows  the  blood-sugar  level  pretty  closely. 

With  these  data  in  hand  the  final  part  of  the 
diagnostic  triad,  relief  on  frequent  feedings,  enters 
the  picture.  How  are  these  patients  to  be  treated-'"? 
Radiation  has  been  employed*.  Many^  "^  ^^  feel 
that  operation  should  be  done  more  often  for  the 
purpose  of  searching  for  and  removing  adenomata 
of  the  pancreas,  which  are  usually  located  in  the 
tail.  Others  report  that  the  majority  of  the  pa- 
tients do  well  on  dietary  treatment  and  only  a  few 
should  be  subjected  to  operation.  In  this  series  all 
the  patients  received  marked  or  complete  relief 
from  dietary  measures;  no  case  is  in  urgent  need  of 
surgery  although  one  or  two  of  the  cases  may 
later  come  to  operation. 

Harris'  has  long  advocated  a  diet  low  in  car- 
bohydrate, high  in  fat  and  normal  in  protein  at 
the  three  regular  meals  with  intermediate  small 
carbohydrate  feedings  to  keep  the  blood  sugar  up 
to  normal  all  day  long  and  to  avoid  overstimulation 
of  the  pancreas  at  any  one  time.  As  the  condition 
is  diagnosed  the  patient  should  be  started  out  on 
such  a  regimen  with  liberal  amounts  of  the  5  per 
cent,  and  moderate  amounts  of  10  per  Cent,  vege- 
tables, while  all  the  higher  carbohydrate  foods  are 
excluded.  Beginning  two  hours  after  the  regular 
meal  and  on  the  hour  the  patient  should  take  four 
to  six  ounces  of  orange  juice,  grape  fruit  juice  and 
tomato  juice.  These  feedings  begin  after  breakfast 
and  are  carried  out  until  bedtime.  Rarely  some 
of  the  patients  have  to  get  up  at  night  for  a  small 
snack.  Almost  invariably  marked  improvement  is 
noted  in  just  a  few  days. 

As  the  patient  becomes  more  familiar  with  the 
dietary  and  the  diet  can  be  liberalized,  the  inter- 
mediate feedings  can  be  more  solid  and  thus  can 
be  taken  less  often.  Some  such  plan  as  a  glass 
of  milk  with  a  few  crackers,  a  glass  of  milk  with 
a   little  chocolate  syru[)  added   taken   with   a   few 


HYPERINSVLISM— Wilkinson  &  Poole 


September,  1936 


peanut-butter  cracker  sandwiches,  potato  chipe, 
an  egg  sandwich  with  the  bread  toasted  and  sliced 
rather  thin  (^4  inch),  is  tried.  The  food  is  taken 
once  between  breakfast  and  lunch,  once  before 
lunch  and  dinner,  and  at  bedtime.  The  milder 
cases  can  usually  be  switched  to  such  a  simple 
regimen,  but  the  more  severe  cases  may  continue 
to  need  the  hourly  feedings  of  fruit  juice,  plus  one 
of  the  solid  things  at  the  mid-meal  period. 

The  improvement  is  gratifying  and  the  patients 
are  grateful.  It  is  a  rather  remarkable  thing  to 
see  patients  taken  from  the  category  of  psychoneu- 
roses,  hysteria,  epilepsy  and  the  like  and  placed 
into  a  happier  situation  and  for  the  most  part  re- 
sponding readily  to  rather  simple  control. 

SuikQIAKV     AND     COXCLUSIONS 

An  effort  has  been  made  to  point  out  the  ease 
with  which  the  diagnosis  of  hyperinsulinism  can 
be  approached  and  to  emphasize  the  features  which 
are  so  definite  in  the  vast  majority  of  cases  as  to 
make  a  probable  diagnosis  possible  on  the  history 
alone.  A  simple  and  ine.xpensive  means  of  confirm- 
ing the  diagnosis  has  been  outlined,  which  would 
make  it  feasible  for  the  practicing  physician  to  ob- 
tain laboratory  confirmation  of  his  suspicions  in 
almost  all  his  cases.  The  general  principles  of 
the  dietary  have  been  outlined  and  usual  improve- 
ment which  occurs  has  been  indicated  as  a  further 
confirmation  of  the  diagnosis. 


*The  authors  are  indebted  to  Mrs.  A^ivian  M.  Bridges 
for  the  care  with  which  she  performed  aU  the  blood-sugar 
determinations. 

References 

1.  Harris,  S.:  Hyperinsulinism  and  Dysinsulinism.  Jottr. 
A.  M.  A.,  vol.  S3,  no.  10,  p.  729,  Sept.  6,  1924. 

2.  Harris,  S.:  Hyperinsulinism  and  Dysinulinism.  (Insul- 
inogenic  hypoglycemia)  with  chronological  review  of 
cases  reported  in  the  United  States  and  Canada,  Inter- 
national Clinics,   42nd   Series,  vol.   1,   1932. 

3.  Harris,  S.:  The  Diagnosis  of  Surgical  Hyperinsulinism. 
The   Southern   Surgeon,    vol.   3,    Sept.,    1934. 

4.  Harris,  S.:  Neurologic  Hyperinsulinism.  Southern  Med. 
Jour.,  vol.   28,   no.   11,   p.   959-96S. 

5.  TuTTLE,  G.  H.;  Hyperinsulinism,  New  England  Jour, 
of  Med.,  vol.   204,  p.   1039-1041,   May   14,   1931. 

6.  WoMACK,  N.  A.:  Hypoglycemia  Due  to  .\denoma  of 
the  Islets  of  Langerhans,  Southern  Med.  Jour.,  vol. 
27,  p.    135,   Feb.,    1934. 

7.  Jacobs,  S.:  Hyperinsulinism  with  report  of  a  Case. 
New  OrleOfis  Med.  &  Surg.  Jour.,  vol.  86,  p.  724,/ 
May  1934. 

8.  Barrow,  S.  C:  Hyperinsulinism:  Three  cases  relieved 
by  Radiation.  Radiology,  vol.  24,  p.  320,  March  1935. 

9.  Whipple,  A.  0.  and  Frantz,  V.  K.;  Adenoma  of  Islet 
Cells  with  Hyperinsulinism.  Annals  of  Surgery,  vol. 
101,    p.    1299,    June    1935. 

10.  Wilder,  R.  M.:  Hyperinsulinism.  International  Clinics. 
vol.  2,  p.  1,  June  1933. 

11.  McCauhghan,  J.  M.:  Subtotal  Pancreatectomy  for 
Hyperinsulinism.     Annals    of    Surgery,    vol.    101,    p. 

1336,  June    1935. 

12.  CoTTRELL,    J.    F.:    Convulsions:    Some    Consideration 


from  the  Point  of  View  of  the  Internist.    Med.  Clin, 
of  N.  A.,  p.   233-246,  July   1935. 

13.  ORM.A>fD,  .\.  P.:  Bradycardia  due  to  Spontaneous 
Hypoglycemia:  Report  of  a  Case.  Jour.  A.  M.  A., 
vol.   106,  no.   20,  p.   1726-1728,  May   16,   1936. 

14.  Rogers,  F.  L.:  Daily  Variation  of  Sugar  Content  of 
Blood  and  Urine  During  Treatment  of  Diabetes  Melli- 
tus.  Arch.  Int.  Med.,  vol.   57,  no.  5,  May   1936. 

s.  M.  &  s. 

More  Recent  Developments  in  Diabetic  Treatment 
(E.  R.  Blaisdell,  Portland,  in  Maine  Med.  Jl.,  Aug.) 
In  the  early  part  of  this  year  Dr.  H.  C.  Hagedorn  and 
his  associates,  working  in  the  Steno  Memorial  Hospital  in 
Copenhagen,  Denmark,  announced  a  new  insulin  which 
would  prevent  the  wide  fluctuations  in  blood  sugar  so 
commonly  seen  following  the  use  of  regular  insulin.  Not 
more  than  2  doses  in  24  hours  are  necessary  even  in  the 
severe  diabetic. 

With  the  greatest  respect  for  the  epochal  discoveries  of 
Banting  and  Best,  and  Hagedorn,  I  again  want  to  call 
attention  to  the  importance  of  proper  diet  and  normal  body 
weight  in  the  diabetic. 


-s.  M.  &  s.- 


Water  Balance  of  Sick  Patients 
(F.  A.  Coller,  .■\nn  Arbor,  Mich.,  in  Wise.   Med.  Jl.,  Aug.) 

With  a  calculation  of  the  amount  of  fluid  to  give  to  a 
patient,  the  kind  of  fluid  to  give  should  also  be  consid- 
ered. This  will  depend  upon  what  the  patient  needs  and 
it  should  not  be  given  as  salt  solution  routinely  unless 
losing  sodium  chloride  from  some  place.  This  occurs  from 
vomiting,  and  the  water  and  salt  loss  can  be  well  replaced 
by  an  equal  volume  of  physiological  salt  solution.  Fecal 
fistula  or  biliary  fistula  fluid  should  also  be  replaced  by 
physiological  saline.  The  water  lost  through  the  skin 
by  surgical  patients  generally  carries  little  salt  with  it. 
Where  there  is  any  question  of  a  serious  depletion  of 
sodium  chloride,  blood  chemistry  studies  should  be  done. 
Physicians  are  giving  more  fluids  intravenously  and  sub- 
cutaneously  now  than  ever  before.  The  majority  of  pa- 
tients so  treated  have  not  lost  appreciable  amounts  of 
sodium  chloride,  but  chiefly  need  water.  This  can  be 
supplied  best  by  an  isotonic  (5%)  solution  of  dextrose 
in  distilled  water.  The  dextrose  is  rapidly  oxidized  and 
prevents  ketosis,  and  the  water  is  left  available  for  all 
purposes. 

We  have  found  no  evidence  that  one  can  overload  a 
heart  by  giving  fluid  slower  than  SCO  c.c.  an  hour.  The 
fluid  should  be  given  in  the  daytime  because  the  patient 
is  entitled  to  sleep  at  night. 

-s.  M.  &  B.- 


CoLics   Following   Removal  of  Gallbladder 

(A.  M.  Snell,  J.  M.  McGowan  cS.  W.  L.  Butsch,  Rochester, 
Minn.,  in  R.  I.  Med.  Jl.,  Aug.) 
Colic  IS  associated  with  a  hyperkinetic  and  irritable  state 
of  the  sphincter  of  the  common  duct.  The  pains  appear 
to  depend  on  spasm  of  the  sphincter  with  prolonged  in- 
creases in  intraductal  pressure.  Cases  studied  have  all 
shown  rises  in  intraductal  pressure,  and  pain  after  the 
administration  of  morphine  and  other  opiates.  Nitrites 
relax  spasm  of  the  sphincter  and  lower  pressure,  thus  re- 
lieving pain  both  in  spontaneous  colics  and  in  those  induced 
by   morphine. 


-s.  M.  &  6.- 


Determinations  of  the  basal  metabolic  rate  are  fre- 
quently inaccurately  made.  When  accurately  made  and 
read  they  are  not  infallible  but  must  be  considered  with 
other  findings  and  symptoms,  very  much  as  we  do  the 
leucocyte  count. 


To  keep  from  eating  hog  meat  that  is  not  thoroughly 
cooked — that's  easy  to  do:  to  cure  trichiniasis — that's  hard 
to  do. 


September,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


46«> 


The  Common  Field  of  Psychiatry  and  Internal  Medicine* 

Claude  A.  Boseman,  M.D.,  Pinebluff,  North  Carolina 

The  Pinebluff  Sanitarium 


THERE  was  a  time  in  the  not  too  remote 
past  when  psychiatry  was  thought  of  as 
a  phase  of  medicine  detached  and  isolated, 
having  little  or  nothing  to  do  with  the  general  prac- 
tise of  medicine,  having  little  to  do  with  the  therapy 
of  sick  people  and  having  nothing  to  do  with  life 
as  it  is  ordinarily  lived.  Psychiatrists  dealt  with 
the  insane  and  general  practitioners  of  medicine 
dealt  with  the  sane,  and  their  paths  were  thought 
of  as  divergent,  the  one  ending  in  the  realms  of 
the  philosophical  or  the  occult  and  the  other  in 
the  realms  of  science.  In  fact,  psychiatry  was 
hardly  thought  of  as  a  branch  of  medicine  at  all, 
and  psychiatrists  lived  their  remote,  segregated  and 
futile  lives  as  keepers  of  the  insane  in  what  Dr. 
Karl  Menninger  termed  the  castles  on  the  hill.  Un- 
fortunately this  attitude  toward  psychiatry  still 
prevails  in  some  remote  sections. 

However,  the  last  several  decades  have  witnessed 
a  colossal  change  in  the  attitude  of  both  the  laity 
and  the  medical  profession  toward  psychiatry. 
Happily,  psychiatry  is  no  longer  thought  of  as  a 
remote  but  as  a  very  vital,  a  very  real  and  a  very 
determining  factor  in  the  treatment  of  disease, 
and  most  of  the  larger  hospitals  have  their  psychia- 
tric departments  with  their  clinics  and  outpatient 
divisions  as  integral  parts  of  the  hospital  func- 
tioning along  with  the  other  departments  in  an 
orderly  and  comprehensive  study  of  human  per- 
sonalities. The  castles  on  the  hill  have  filled  up 
their  moats  and  let  down  their  drawbridges.  And 
that  this  change  has  come  about  is  not  entirely 
due  to  the  efforts  of  the  medical  profession;  it  is 
due,  as  well,  to  the  interest  of  students  of  crimin- 
ology, of  sociology,  of  economics  and  of  religion, 
who  have  turned  at  times  to  psychiatry  for  help. 
Judges  of  Juvenile  courts  and  courts  of  domestic 
relations,  social  workers,  school-teachers  and  the 
clergy  have  all  at  times  felt  the  need  of  advice 
from  those  students  of  the  human  mind  and  hu- 
man personality  who  deal  with  the  mind  diseased. 
And  so  it  is  that  psychiatry  has,  in  a  sense,  come 
into  its  own  in  the  field  of  medicine  by  the  back 
door  of  the  sociological  sciences.  But  psychiatry 
is,  was  and  always  will  be  one  of  the  branches  of 
medicine,  with  which  wide,  general,  humanized 
field  we  are  all  here  to-day  concerned. 

We  have  been  accustomed,  all  too  frequently,  to 
think  of  mind  on  the  one  hand  and  bodv  on  the 


•Presented  to  the  Section  on  Practice  of  Medicine  of  the 
May  6th. 


other.  We  have  thought  of  a  human  being  as  a 
duality,  with  a  mind  functioning  in  one  sphere  and 
a  body  in  another.  Psychiatry  has  been  thought 
of  as  concerned  with  the  mind  and  internal  medi- 
cine as  concerned  with  the  body.  That  such  a 
view  is  absurd  needs  no  word  from  me.  It  is  as 
impossible  to  detach  an  aching  tooth  from  the 
thoughts  and  feelings  accompanying  it  as  it  is  to 
think  of  a  free-floating  emotion  confined  in  a  test 
tube. 

In  an  article  entitled  "The  Two-Year  Medical 
School  and  University  Education,"  Dr.  William 
deBerniere  MacNider  of  the  University  of  North 
Carolina  made  the  following  remarks: 

"Likely  one  of  tfie  most  difficult  experiences  of  the  hu- 
man intellect  is  to  be  able,  as  Bacon  suggested,  to  see  things 
in  their  relationship  one  to  the  other,  which  is  the  main 
point.  We  have  become  so  accustomed  to  exercise  the 
analytical  method  in  our  consideration  of  people,  insti- 
tutions and  circumstances,  that  it  has  become  increasingly 
unusual  for  us  to  attempt  an  understanding  of  a  related 
whole.  It  is  only  when  such  relations  can  be  evaluated 
in  a  composite  fashion  that  the  real  value  of  a  movement 
or  organization  can  be  understood  and  given  the  signifi- 
cance which   it   deserves." 

Only  a  great  physician  could  have  made  those 
remarks,  and  only  one  who  was  acutely  aware  that 
a  diseased  kidney  is  not  an  isolated  organ  function- 
ing in  a  laboratory  but  that  it  is  an  intimate  part 
of  a  mentally  integrated  organism  which  also  com- 
prehends the  beauty  of  the  sunset. 

And  so  it  is  that  we  cannot  think,  if  we  think 
at  all,  of  a  human  being  as  anything  other  than 
a  unity.  One  of  the  most  comprehensive  and 
illuminating  contributions  to  the  theory  of  medi- 
cine in  the  last  generation  is,  I  believe,  that  of  Dr. 
Adolph  Meyer,  Professor  of  Psyciatry  at  the  Johns 
Hopkins  University,  in  the  theory  of  psychobi- 
ology.  We  hear  much  of  the  theory  of  psychobi- 
ology  in  psychiatric  circles  but  not  nearly  as  much 
as  it  deserves  in  general  medical  circles.  This  view 
holds  obligatory  the  consideration  of  the  mentally 
integrated  nature  of  the  human  organism.  Man 
is  an  organism  composed  of  parts,  of  kidneys,  lungs, 
spleen,  liver,  heart,  etc.,  all  working  together  in  an 
orderly  fashion  through  the  intricate  ramifications 
of  the  glands  of  internal  secretion  and  the  sympa- 
thetic, peripheral  and  central  nervous  systems — 
the  whole  forming  what  we  term  the  total  person- 
ality which  encompasses  not  only  the  parts  but  all 
past  experiences.  It  is  a  mentally  integrated 
organism. 

Medical  Society  of  the  State  of  North  Carolina  atAshevlUe, 


PSYCHIATRY  &  INTERNAL  MEDICINE— Boseman 


September,  1030 


Hence  the  impossibility  of  consideration  of  a 
diseased  mind  apart  from  the  biological  organism, 
or  of  a  diseased  stomach  apart  from  its  psychical 
components.  A  man  suffering  from  toothache  is 
in  no  sense  the  same  personality  as  one  who  is  free 
from  pain.  A  man  suffering  from  a  deep  depres- 
sion is  quite  a  different  physical  organism  from 
one  who  is  happy  and  free  from  care.  A  man 
suffering  from  an  inoperable  carcinoma  is  quite 
different  mentally,  emotionally  and  behaviouristi- 
cally  from  one  whose  body  is  sound.  Every  physi- 
cal disease  has  its  component  mental  state,  and 
the  two  cannot  be  separated. 

The  beloved  family  physician  of  old  was  prob- 
ably much  more  of  a  psychiatrist  than  an  internist 
in  the  ordinary  sense  of  the  word,  and  rightly  so. 
He  was  the  father  confessor,  the  economic  advisor 
and,  above  all,  the  friend  of  all  his  clientele.  .And 
the  passing  of  the  family  physician  and  his  re- 
placement by  the  ultra-scientiiic  scientist  removes 
from  our  midst  one  of  the  brightest  ornaments  of 
our  civilization.  The  artist  is  replaced  by  the  ar- 
tisan. When  the  internist  refuses  to  aid  the  hys- 
terical, the  psychasthenic  or  the  obsessional  patient, 
and  tells  him  his  troubles  are  imaginary,  he  at  one; 
drives  him  to  the  ministrations  of  the  osteopath, 
the  chiropractor,  the  Christian  Scientist,  or  the 
vendor  of  black  magic.  The  psychiatric  ills  of 
mankind  are  as  real,  as  distressing,  and  as  ruinous 
to  the  individual  as  any  leprosy,  great  white  plague 
or  black  death  in  history.  Were  we  all  as  aware 
as  might  be  of  this  medical  need  we  probably  should 
not  be  witnessing  in  this  state  at  this  time  the 
ridiculous  spectacle  of  an  osteopathic  hospital  treat- 
ing nervous  diseases  with  a  pathetic  termination  in 
the  law  courts  of  the  state. 

But,  despite  all  this,  the  present  is  encouraging. 
One  of  the  most  stimulating  papers  presented  to 
this  Society  last  year  was  one  entitled  The  Diag- 
nosis and  Treatment  of  Nervous  or  Functional 
Vomiting,  by  Dr.  Walter  R.  Johnson  of  Asheville. 
One  of  the  most  interesting  papers  in  a  recent  issue 
of  Southern  Medicine  &  Surgery  was  one  entitled 
Nervous  Indigestion,  by  Dr.  Paul  F.  Whitaker  of 
Kinston.  And  in  a  recent  issue  of  the  Journal  of 
the  A.  M.  A.  Dr.  John  H.  Stokes  of  the  University 
of  Pennsylvania  discussed  comprehensively  the 
psychiatric  aspects  of  a  dermatological  condition. 
All  three  of  these  papers  dealt  with  the  psychiatric 
aspects  of  a  disease  in  an  interesting,  stimulating 
and  comprehensive  manner.  Neither  of  these  phy- 
sicians is  a  psychiatrist  in  the  ordinary  sense  of 
the  word,  but  in  a  deeper,  fuller,  more  comprehen- 
sive sense,  all  of  them  are.  These  papers  indicate, 
too,  the  direction  in  which  the  wind  is  blowing. 

Thus,  we  arrive  at  the  same  goal  by  paths  ap- 


parently divergent  but  ending  all  in  the  total  per- 
sonality. The  common  field  of  psychiatry  and  in- 
ternal medicine  is,  of  course,  the  human  organism 
with  all  its  infinite  capacity  to  think,  to  feel  and 
to  do.  The  psychiatrist  and  the  internist  are  view- 
ing the  same  problem  from  slightly  different  angles, 
with  slightly  different  accentuations.  Neither  one 
can  disregard  the  other.  The  two  fields  are  com- 
plementary. The  beloved  physician  of  the  future, 
as  in  the  past,  will  be  the  one  aware  that  the  keenest 
suffering  of  the  patient  dyin?  from  a  malignant 
growth  is  not  the  physical  pain,  but  the  anguish 
at  the  thought  of  a  destitute  wife  and  children;  and 
he  will  put  into  his  elixir  a  few  drops  of  something 
which  ministers  also  to  the  mind  diseased. 


-S.   M.    &   S.- 


PSYCHO.AN.\LYSIS     .4ND     PSYCHOANALYSTS 

(H.  T.  Hyman,  N>\v  York,  in  Jour.  A.  M.  A.,  Aug.  1) 
The  Psychoanalytic  Society  has  adopted  rigorous  pro- 
fessional standards  in  a  field  where  charlatanism  is  rife. 
The  limitation  in  number  serves  to  increase  the  premium 
which  the  accepted  psychoanalysts  place  on  their  own 
services.  As  an  analysis  is  rarely  terminated  sooner  than 
in  18  months,  or  2  years,  the  total  fee  $5,000  to  $6,000. 
This  would  seem  to  limit  sharply  the  availability  of  a  ther- 
apeutic procedure.  The  reticence  of  psychoanalysts  to- 
ward the  referring  physician  is  another  sore  point  in  analy- 
tic practice.  It  is  only  exceptionally,  and  then  on  repeated 
demand,  that  the  author  has  been  able  to  obtain  any  in- 
telligent information  concerning  the  progress  and  welfare 
of  his  patients.  The  transplanted  European  phychoanalyst 
actively  resents  any  such  request  from  the  practitioner.  It 
is  his  belief  that  the  isolation  of  psychoanalysis  from  the 
rest  of  medicine  is  due  in  large  part  not  to  the  hostility 
of  the  large  body  of  physicians  but  to  the  reticence  and 
arrogance  of  the  analysts.  In  any  field,  free  discussion  be- 
tween the  specialist  and  the  referring  physician  is  con- 
ducive to  a  cordial  interrelationship,  a  warm  feeling  of 
confidence,  invaluable  in  the  education  of  both  physi- 
cians, and  such  an  exchange  of  information  is  helpful  to 
the  patient.  In  sharp  contrast  to  the  taciturnity  of  the 
analysts  toward  the  practitioner  is  their  volubility  in  dis- 
cussing their  work  in  the  living  room,  over  dinner  tables, 
before  meetings  of  mothers,  social  service  workers,  zealous 
pedagogues,  criminologists,  the  literati,  the  artists,  the  in- 
telligentsia, and  other  noncritical  groups  who  possess 
neither  the  knowledge  nor  the  authority  to  question  the 
delineator  of  the  beguiling  peregrinations  of  the  human 
mind  and  soul.  The  parlor  analyst  vies  with  the  parlor 
communist  and  the  parlor  endocrinologist — though  in  some 
instances  the  triad  is  miraculously  concentrated  in  a  single 
superman   of   superior  imagination. 

s.  M.  &  s. 

PSYCHIATKY    CaTCHES    Up    WiTH    ShAKESPEARE 

(P.   R.   Vessie,  Briarcliff  Manor,  New  York,  in   Med.   Rec, 
Aug".  5  th) 

Measure  for  Measure  is  generally  held  to  be  Shakes- 
peare's worst  play.  When  this  play  is  read  in  the  light  of 
modern  psychiatric  knowledge  it  classes  as  one  of  his  most 
astonishing  pieces  of  writing.  One  might  say  that  Shakes- 
peare's universality  contained  within  it  a  special  genius 
for  penetrating  obscure  psychologies  and  morbid  states. 
When  a  psychiatrist  reads  Measure  for  Measure  he  finds 
many  passages  which  seem  almost  like  having  a  conversa- 
tion with  a  colleague. 


September,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


After  Body,  Soul  and  Spirit — What? 

Irving  S.  B.4rksdale,  M.D.,  F.xA.P.H.A.,  Greenville,  South  Carolina 


THE  purpose  of  this  brief  essay  is  to  show 
that  !Man's  make-up  is  divided  into  three, 
or  possibly  four,  great  essential  parts, 
rather  than  two;  that  the  Soul  and  Spirit  of  his 
being  are  separate  one  from  the  other  and  entirely 
different  in  nature;  that  one  great  change  does 
and  must  take  place  within  his  innate  self  at  a 
certain  appointed  time;  also  throughout  the  follow- 
ing paragraphs  some  attempts  will  be  made  to 
classify  functionally  all  of  his  most  important  men- 
tal and  spiritual  attributes. 

Lastly,  both  the  medical  and  lay  reader  will  be 
reminded  of  the  method  involved  when  Man  sud- 
denly goes  from  the  incomplete  into  the  complete 
state  of  being  and  of  all  the  ability  and  power  and 
success  that  can  and  will  come  out  of  this,  the 
happiest  of  all  combinations. 

Formerly,  and  outside  of  the  Scriptures,  Man 
was  considered  as  a  dual  or  dichotomic  being — 
Body  and  Soul  were  and  still  are  with  most  of  us, 
Man's  whole  constitution.  Such  a  combination  is 
crude  and  indefinite,  and  requires  too  broad  an 
interpretation  for  the  term.  Soul.  The  Apostle  to 
the  Gentiles  tells  us  (I  Thessalonians,  v.  23),  "And 
the  very  God  of  peace  sanctify  you  wholly;  and 
I  pray  God  your  whole  spirit  and  soul  and  body 
be  preserved  blameless  unto  the  coming  of  our 
Lord  Jesus  Christ."  The  Scriptures  lead  us  in 
their  beautiful  and  convincing  way  to  the  truth 
that  the  Body  is  to  be  regarded  as  a  container  for 
the  more  important  Soul  and  Spirit:  it  is  indeed, 
the  temporary,  material  thing  which  springs  from 
the  dust  and  soon  returns  whence  it  came.  Though 
material  and  temporary  it  may  be,  it  behooves  us 
to  take  the  best  care  of  this  earthly  Body,  as  we 
are  commanded  to  make  of  our  bodies  fit  Temples 
of  the  Holy  Spirit,  the  greatest  power  of  all.  In- 
deed, being  of  least  importance,  the  Body  should 
at  all  times  be  held  subsidiary  to  the  higher  human 
Parts,  and  constant  care  should  be  taken  that  our 
physical  attributes  do  not  dominate  over  Soul  and 
Spirit.  When  men  become  enslaved  to  the  physi- 
cal appetites,  as  gluttony  and  drink  and  lust,  then 
our  higher  attributes  relinquish  their  role  as  mas- 
ters and  we  find  this  earthly,  temporary  and  physi- 
cal Body  usurping  all  of  that  which  is  rightfully 
the  property  of  our  higher  selves.  When  this  oc- 
curs, we  become  world  men  and  world  women,  or 
men  and  women  "after  the  flesh,"  and  a  great  sin 
has  been  committed  in  the  face  of  Almighty  God. 

Quite  analogous  to  Body,  Soul  and  Spirit  is  the 
layout  of  the  ancient  Hebrew  Tabernacle  as  de- 


scribed in  the  Book  of  Exodus. 

The  Body  is  comparable  to  the  outer  court  of 
this  ancient  Tabernacle  illuminated  by  sunlight  in 
that  it  contains  or  envelopes  the  other  two  more 
important  sections.  Just  inside  the  outer  court  is 
the  Holy  Place  illuminated  by  the  much-reproduc- 
ed seven-branched  candlestick,  comparable  to  the 
meaning  and  importance  of  Man's  Soul.  The  in- 
nermost, the  most  important  part  the  Tabernacle, 
the  Holy  of  Holies,  is  comparable  to  our  spirit — 
hidden  from  view  by  the  revered  veil,  which  was 
rent  from  top  to  bottom  by  the  Hand  of  God  the 
moment  His  son  died  for  us  on  that  fateful  hill 
just  outside  of  Jerusalem  so  that  we  might  know 
and  receive  the  Holy  Spirit.  Of  far  greater  im- 
portance, however,  than  any  part  of  the  Taber- 
nacle, itself,  was  the  Ark  of  the  Covenant  upon 
which  rested  the  Mercy  Seat  where  dwelt  the  Spirit 
of  God  Himself;  this  the  prototype  of  the  Holy 
Spirit  dwelling  in  the  Body  of  man. 

Inasmuch  as  the  function  and  purpose  of  the 
Body  is  so  well  understood,  we  can  pass  from  this 
now  to  a  brief  discussion  of  the  Soul.  The  Soul, 
even  in  the  present  light  of  human  knowledge  is 
only  very  poorly  understood,  even  to  the  extent 
of  considering  Soul  and  Spirit  as  one  and  the  same. 
The  Soul,  briefly  stated  is  really  our  personality, 
as  we  appear  to  our  fellowmen,  our  disposition,  the 
impetus  of  desiring  to  get  along  in  this  world 
from  the  standpoint  of  achieving  success.  A  soul- 
ful man,  or  a  man  after  the  Soul,  is  he  who  pos- 
sesses an  attractive  personality,  is  successful,  a  man 
who  works  hard  for  the  love  of  his  work,  one  who 
takes  an  active  part  in  civic  or  national  affairs,  a 
man  who  is  well-versed  in  current  events,  devoted 
to  his  family,  cultured  and  refined  in  many  ways, 
although  giving  but  little  or  no  thought  to  the 
church  or  to  religious  life — just  a  man  of  the 
world,  a  man  who  cultivates  not  his  Spirit,  but 
worldly  things.  Thus  we  see  that  the  Soul  is  of 
the  world,  belonging  to  the  world  and  serving  the 
world;  and  next  we  come  to  consider  and  discuss 
the  next  highest  part  of  man's  being — the  Spirit. 
Dr.  Stalker,  the  eminent  theologian  and  philoso- 
pher, very  rightly  defines  the  Spirit  as  the  "throne 
of  God"  in  human  nature.  .Ml  thoughts  of  the 
Divine  Being,  all  true  interest  in  the  Divinity,  in 
dwelling  forever  with  one's  own  Creator — Immor- 
tality— all  of  man's  thoughts  regarding  the  salva- 
tion of  his  Soul  (Spirit),  all  of  his  reverence  for 
the  Scriptures,  all  of  man's  innermost  thoughts  of 
all  that  is  good,  beautiful  and  true,  all  of  man's 


BODY,  SOUL  &  SPIRIT— Barksdale 


September,   1036 


innate-self,  and  his  conscience  itself — all  of  these 
come  within  the  Realm  of  his  Spirit.  Briefly, 
Man's  Spirit  is  his  God-consciousness,  as  well  as 
his  desire  to  become  more  upright  and  more  right- 
eous. Moreover,  Mans  Spirit  can  be  considered 
as  his  longing  for  God,  and  his  desire  to  become 
the  Complete  Man.  JNlan's  Spirit,  and  not  his 
Soul,  is  that  part  of  him  that  goes  to  live  with 
God  after  certain  important  changes  have  taken 
place,  regarding  the  relation  of  his  Spirit  and  the 
Holy  Spirit,  all  of  which  will  be  discussed  in  the 
following  paragraphs. 

Truly,  the  greatest  and  most  inspiring  of  all  hu- 
man experiences  is  that  of  going  suddenly  from 
the  incomplete  into  the  Complete  State.     One  of 


where  and  how,  they  knew  not.  Off  to  Jerusalem 
they  went  and  into  that  upper  room,  where  they 
remained  in  watching  and  prayer  until  about  nine 
in  the  morning  of  Pentecost  Day,  when  "Suddenly 
there  came  a  sound  from  Heaven,  as  of  a  rushing 
of  a  mighty  wind,  and  it  filled  all  the  house  where 
they  were  sitting.  And  there  appeared  unto  them 
cloven  tongnes,  like  as  of  fire,  and  it  sat  upon  each 
of  them:  And  they  were  all  filled  with  the  Holy 
Ghost  I  Spirit  | ,  and  began  to  speak  with  other 
tongues,  as  the  [Holy]  Spirit  gave  them  utter- 
ance."' Such  a  dramatic  yet  real  manifestation  of 
the  invisible  Spirit  of  Christ,  and  of  God!  And 
Peter  began  to  preach  as  never  he  had  preached 
before  and  so  powerfully  as  to  win  about  three  to 


Chart  Showing  the  Inter-relationship  of 

the  most  beautiful,  inspiring,  important  and  even 
supernatural  passages  of  the  Scriptures  is  recorded 
in  the  Book  of  Acts.  It  will  be  remembered  that 
before  our  Lord  left  his  Apostles  that  day  at  Beth- 
any on  the  Mount  of  Olives,  He  told  them  that 
it  was  expedient  and  necessary  for  Him  to  leave 
them  in  the  flesh,  to  return  to  His  Father  and 
come  again  to  them  in  the  form  of  the  Holy  Spirit: 
that  while  He  was  present  with  them  in  the  body, 
He  could  only  be  with  them  and  no  others.  As- 
cending to  Heaven  and  then  returning  in  the  form 
of  this  Holy  Spirit,  He  could  not  only  be  with 
them,  but  with  all  men  at  the  same  time,  espe- 
cially all  men  who  wanted  him.  Moreover,  He 
commanded  them  to  go  down  to  Jerusalem,  there 
to  remain  until  He  should  come  again — just  when, 


the  more  Important  Human  Mental  .Attributes 
five  thousand  lives  for  the  Master. 

What  happened  to  this  little  group  of  Apostles 
that  Pentecost  Day  does  happen  to  us  in  these 
modern  times,  although  in  not  quite  such  a  dra- 
matic and  miraculous  manner.  Nevertheless,  the 
Spirit  of  Man  can  experience  this  coming  of  the 
Holy  Spirit  just  the  same.  This  Holy  Spirit  will 
guide  him  onward,  just  as  it  did  St.  Philip  and 
the  others  long  ago  to  work  with  God  and  for  God. 
With  this  Power  with  him,  and  actually  a  part 
of  him,  this  Power  that  actually  created  the  Sun, 
Moon,  Stars  and  the  Earth,  he  can  accomplish  any- 
thing that  God  wills  and  will  fear  nothing,  and 
with  it,  he  experiences  such  joy  of  living  and  doing 
for  God  and  his  fellowman  as  he  has  never  known 
before:    so  radiantly  and  genuinely  happy  is  the 


i 


September,    1036 


BODY,  SOUL  &  SPIRIT— Barksdalc 


473 


Christian,  now  completely  surrendered  to  God,  and 
now  empowered  with  the  might  of  the  Holy  Spirit  1 

Many  of  us,  perhaps  most  of  us,  do  not  know 
how  to  achieve  this  Mighty  Power;  neither  do  we 
realize  that  this  Power  is  truly  the  easiest,  freest 
and  most  valuable  of  all  things  known  to  God  and 
Man.  How  can  we  obtain  this  Holy  Spirit?  Only 
by  asking  God  for  it,  simply  and  earnestly  and 
without  delay?  How  can  we  function  with  it  and 
use  it?  Simply  by  realizing  at  all  times  that  we 
actually  possess  it  once  it  is  asked  for,  and  by 
remembering  that  this  Spirit  like  any  other  power, 
must  be  renewed  daily  through  prayer  and  wor- 
ship. We  should  bear  in  mind  the  famous  saying 
of  Dr.  J.  Wilbur  Chapman,  the  Evangelist,  that 
we  cannot  breathe  out  three  times  and  only  breathe 
in  once;  we  must  draw  more  air  into  our  lungs, 
so  in  like  manner  we  must  breathe  in  more  of  this 
Holy  Spirit.  Once  this  Spirit  has  taken  possession 
of  us,  we  cease  to  be  simply  three-fold  in  our  na- 
ture— Body,  Soul  and  Spirit;  we  become  fourfold, 
or  complete  with  Body,  Soul,  Spirit  and  Holy 
Spirit. 

Genuinely  happy,  capable,  successful  and  all- 
powerful  is  he,  the  physician,  who  has  surrendered 
completely  to  the  Will  of  God,  who  considers  him- 
self only  a  specialized  tool  in  his  Maker's  Hands, 
who  acquires  this  remarkable  Spirit  by  the  mere 
asking  of  God,  who  realizes  its  (His)  Presence 
within  his  own  body,  and  who,  daily  through  pray- 
er and  at  least  weekly  through  worship  renews  this 
Power  of  Powers,  this  Holy  Spirit  within  him. 

ACKNOWLEDGEMENTS 

I  feel  indeed  grateful  to  Dr.  James  M.  Northington, 
Editor  of  this  Journal,  for  asking  me  to  write  this  article; 
to  the  Rev.  Dr.  James  H.  Viser  for  his  helpful,  enlighten- 
ing and  inspiring  interpretation  of  tne  Word  of  God  and 
his  Spiritual  guidance;  to  Laurette  M.  Barksdale  and 
Florence  L.  Deadwyler  for  their  valuable  assistance  in  the 
preparation  of  this  manuscript. 

Bibliography 

The  Holy  Bible:  E.xodus,  Chap.  40;  Acts  of  the  .Apostles, 
Chaps.  2,  7,  8  and  9. 

Stalker,  J.,  D.  D.:     Christian  Psychology. 

Viser,  J.  H.,  D.  D.:  Various  Lectures  and  Conversa- 
tions. 

S.   M.    &   6. 

The  Doctor  as  a  Musician 
(Edw.  Podolsky,  Brooklyn,  in  W.  Va.  Med.  Jl.,  Aug.) 
Apollo  was  the  god  of  both  Medicine  and  Music.  The 
ancient  Hebrews  applied  the  healing  virtues  of  music 
when  King  Saul's  reason  was  tottering.  Xenocrates,  Sarp- 
ander  and  .^rion  used  harp  music  to  curb  the  maniacal 
outbursts  of  madmen. 

Among  the  earliest  of  noted  English  composers  was 
George  Ethridge  (16th  centur\),  one  of  the  most  famous 
of  vocal  and  instrumental  musicians  of  his  day.  He  was 
a  graduate  of  Oxford  and  a  physician  of  great  ability. 
Towards  the  end  of  the  centurv-  Sir  Thoma-  Gresham 
established  a  Professorship  of  Music  at  Oxford  and  the 
first  5  men  to  hold  this  chair  were  all  physicians. 


Probably  the  most  famous  of  early  English  doctor-musi- 
cians was  Henry  Harrington.  His  "Great  is  the  Pleasure" 
has  been  played  and  sung  in  all  quarters  of  the  globe. 
He  was  born  at  Kelston,  Somerset,  England,  in  1727, 
took  first  his  M.A.  and  later  his  M.D.  degree  at  O.xford 
and  entered  medical  practice  at  Bath.  .-Ml  his  leisure  time 
was  devoted  to  Music.  He  was,  in  time,  appointed  "Cora- 
poser  and  Physician"  to  the  Harmonic  Society  of  Bath  on 
its  foundation  by  Sir  John  Davies  in  1784.  In  1800  he 
published  "Elio !  Elio !  or  the  Death  of  Christ,"  a  sacred 
dirge  for  passion  week. 

William  Kitchener,  born  in  London  in  1775,  was  edu- 
cated at  Eton  and  Glasgow  where  he  received  his  M.D. 
degree;  but  his  interests  lay  mainly  in  music.  He  com- 
posed an  operetta,  "Love  Among  the  Roses;"  a  musical 
drama,  "Ivanhoe."  He  was  also  the  author  of  "Observa- 
tions on  Vocal  Music"  and  editor  of  "The  Loyal  and 
National  Songs  of  England,"  "The  Sea  Songs  of  England," 
"The  Sea  Songs  of  Charles  Dibdin,"  and  a  "Collection  of 
Vocal  Music  in  Shakespeare's  Plays."  He  was  also  the 
author  of  some  rather  unusual  literary  works,  among 
them  "The  Cook's  Oracle,"  "The  Art  of  Invigorating  and 
Prolonging  Life,"  "The  Housekeeper's  Ledger,"  "The  Econ- 
omy of  the  Eyes,"  and  "The  Traveler's  Oracle."  His 
medical  views  were  rather  accentric,  but  his  music  was 
wholesome  and  pleasing. 

Florient  Corneille  Kist  was  among  the  most  famous  of 
Dutch  musicians.  Born  at  Arnheim,  1796,  he  took  his  M.D. 
degree  from  the  University  of  Leyden  and  practiced  med- 
icine at  the  Hague.  He  was  a  flutist  and  hornist  of  great 
ability,  and  among  the  greatest  compositions  written  for 
these  two  musical  instruments  are  to  be  found  many  by 
Kist.  He  was  a  founder  of  the  Diligentia  Society  at  the 
Hague,  and  later  of  the  Caecilia  which  is  still  the  most 
important  society  in  Holland.  His  influence  on  Dutch 
music   was   profound. 

Perhaps  the  greatest  of  all  doctor-musicians  was  .•\lexan- 
der  Porfyrievich  Borodin,  the  natural  son  of  a  Russian 
prince.  He  was  born  in  St.  Petersburg  in  1834,  educated 
in  medicine  and  appointed  assistant  professor  of  chemistry 
at  the  St.  Petersburg  Academy  of  Medicine.  He  took  a 
leading  part  in  advocating  medical  education  of  women. 
His  greatest  musical  composition  was  the  opera.  "Prince 
Igor,"  which  he  began  in  186Q  but  left  unfinished  at  his 
death.  It  was  completed  by  Rimsky-Korsakov  and  Gla- 
zounov  in  1889.  Dr.  Borodin's  total  musical  output  is  not 
very  large,  but  it  ranks  among  the  greatest  musical  work 
of   all   time. 

S.  M.  &  s. 

OiR    Lay    Anesthetist   Probleai 
(L.   F.  Anderson,  Buffalo,  in   III.   Med.  Jl.,  Aug.) 

Just  recently  a  few  surgeons  and  the  hospital  authorities 
in  Atlanta,  Ga.,  tried  to  revise  the  constitution  of  the  At- 
lanta .■Academy  of  Medicine  to  provide  that  Radiology, 
Pathology  and  Anesthesia  were  not  the  practice  of  med- 
icine and  even  the  Dean  of  Emory  University  Medical 
School  sided  with  these  destructionists. 

The  code  of  medical  ethics  of  the  British  Empire  removes 
any  physician  from  the  medical  register  who  uses  any  one 
but  a  doctor  to  give  an  anesthetic  or  who  gives  an  anes- 
thetic for  any  one  but  a  registered  doctor. 

S.    M.    &   8. 

Melanomas 
(Dean  Howard  Affleck,  in  Amer.  Jl.  of  Cancer,  May) 
Malignant  melanoma  metastasis  may  take  place  by  way 
of  the  blood  stream  or  lymphatics.  The  most  successful 
method  of  treatment  is  the  removal  of  pigmented  nevi 
while  in  their  quiescent  stage.  These  tumors  are  not  radio- 
sensitive. 


SOUTHERN  MEDICINE  AND  SURGERY 


September,   lQ3h 


Pain — Backache 

Archie  A.  Barron,  M.D.,  F.A.C.P.,  Charlotte.  North  Carolina 

A  BETTER  UNDERSTANDING  of  backache  is  stressed.  Reference  is  made  to  the  many  causes.  Muscle 
weakness  and  fatigue  are  often  important  factors.  Case  reports  of  spinal  cord  tumors,  metastasis, 
myelitis  and  radiculitis  illustrate  the  necessity  of  studying  closely  such  symptoms  as  lumbago, 
sciatica  and  referred  or  radiating  pain.  Promiscuous  pelvic  operations  are  condemned.  Oftentimes, 
psychogenic  states  are  more  damaging  than  the  local  pathology  produced  by   injur.'. 


FOR  many  years  the  importance  of  studying 
the  patient  as  a  whole  has  been  stressed.  I 
feel  that  practically  no  symptom  we  en- 
counter for  diagnosis  should  br  approached  with  a 
more  open  mind  than  that  of  backache,  since  it 
may  be  due  to  one  cause  or  several  causes  and  a 
differential  diagnosis  can  be  made  only  by  the  most 
careful  observation  and  the  exercise  of  the  best 
judgment  in  correlation  of  all  observed  facts.  Why 
this  is  so  becomes  obvious  when  we  realize  the 
following  factors: 

First,  anatomically  sp>eaking,  the  lower  back  is 
a  weak  part  of  the  body,  .'\nomalies  and  variations 
are  common.  Many  variations  are  harmless  and 
play  no  part  in  causing  pain.  Unless  we  have  a 
fairly  clear  understanding  of  these  variations  and 
the  aid  of  a  capable  radiologist,  we  will  frequently 
be  misled.  The  parts  involved  are  the  spinal  cord 
and  nerves,  muscles,  ligaments  and  bony  joints. 
The  lumbosacral  junction  is  the  point  of  division 
between  the  fixed  and  the  flexible  portions  of  the 
vertebral  column,  a  junction  subjected  to  more  or 
less  strain;  hence  a  popular  location  for  trouble. 
The  lower  lumbar  and  upper  sacral  roots  are  larger 
than  those  of  any  other  spinal  nerve. 

Second,  from  a  disease  standpoint,  tack  pain 
may  be  due  to  constitutional  causes,  thoracic,  ab- 
dominal or  pelvic  lesions,  disease  of  the  central 
nervous  system  and  local  pathology  in  the  spine  it- 
self. Such  common  conditions  as  flat  feet,  some 
disturbance  in  posture,  prostatic  disease,  displaced 
uterus,  bad  teeth,  diseased  tonsils  may  exist,  and 
may  or  may  not  cause  backache. 

Lumbago  and  sciatica  are  two  not  uncommon 
clinical  results  of  back  pathology.  We  may  have 
local  pain  confined  to  the  back  or  referred  pain 
felt  in  areas  remote  from  the  back  itself.  Referred 
pain  may  be  felt  in  the  shoulder  or  in  the  neck 
and  down  the  arms  if  the  cervical  region  is  affected. 
Involvement  of  the  thoracic  region  causes  inter- 
costal neuralgia  and  abdominal  pain.  Involve- 
ment of  the  lumbosacral  region  frequently  causes 
sciatic  irritation  and  distribution  of  the  pain  along 
the  course  of  the  sciatic  nerve.  Sciatica  is  rarely 
primary.  It  is  associated  with  or  follows  lumbago 
in   the  majority  of  cases.     The  sciatic  nerve  has 


three  main  roots — the  fifth  lumbar  and  the  two 
sacral.  The  fifth  root  is  much  larger  than  the 
other  two,  yet  the  foramen  through  which  it  passes 
is  much  the  smallest  of  the  three  foramina,  which 
fact  probably  is  an  important  factor  in  predisposing 
this  root  to  irritation,  congestion,  injury  etc. 

The  following  cases  show  the  necessity  of  careful 
study  and  correct  interpretation  of  lumbago,  sciatica 
and  referred  pain. 

A  young  man  after  lifting  a  rock  developed  a  sudden 
backache  simulating  an  acute  lumbago.  It  was  first  thoug^ht 
that  he  had  received  a  simple  strain  and  a  cast  was  ap- 
plied, but  instead  of  getting  better  his  symptoms  became 
gradually  more  pronounced.  He  began  to  suffer  with 
some  weakness  of  lower  extremities  and  was  seen  by  me 
six  months  after  the  accident,  when  he  had  a  bilateral  motor 
weakness  of  lower  extremities,  spastic  reflexes  and  com- 
plete loss  of  sensations  up  to  a  point  corresponding  to 
the  eighth  dorsal  segment.  Lumbar  puncture  revealed  a 
complete  spinal-fluid  block  and  a  slightly  yellow  spinal 
fluid.  It  was  evident  that  he  had  a  spinal  cord  lesion, 
probably  a  tumor.  .\t  operation  an  extramedullar.-  spinal 
cord  tumor  was  removed.  He  made  a  good  recovery  and 
is  now  back  working  with  practically  no  inconvenience. 

Malignant  metastasis  may  be  overlooked  in  the 
explanation  of  a  backache.  The  backache  may 
appear  suddenly  after  an  injury  or  strain  or  it  may 
come  on  more  slowly. 

.A  man  60  years  of  age  was  seen  with  a  history  of  severe 
pain  in  the  lower  back  and  down  back  of  the  thighs  for 
several  years.  He  had  consulted  numerous  physicians 
and  specialists  without  relief  or  a  satisfactory  opinion. 
X-ray  studies  had  been  negative  and  essentially  negative 
findings  were  reported  in  his  prostate.  During  the  past 
few  weeks  difficulty  in  voiding  had  developed.  The  im- 
portant findings  at  this  time  were  typical  horseshoe  an- 
esthesia to  pain  in  and  about  the  rectum,  pointing  defii- 
nitely  to  a  lesion  involving  the  lower  spinal  cord,  the 
Cauda  equina.  \  massive  metastasis  was  found  involving 
the  upper  sacral  region.  A  malignancy  was  later  shown 
in    the   prostate   gland. 

A  woman  26  years  of  age  consulted  me  because  of  sharp 
pains  in  her  right  arm  and  right  upper  chest  and  weakness 
of  lower  extremities.  For  several  months  she  had  an  oc- 
casional pain  in  right  arm  and  chest,  but  she  had  not 
paid  particular  attention  to  it  until  one  night  while  riding 
in  a  berth  on  a  train  the  pain  became  very  severe  and  lan- 
cinating in  type.  In  the  following  six  or  eight  months  she 
began  to  suffer  with  weakness  of  the  lower  extremities.  It 
was  at  this  period  that  I  saw  her.  She  was  well  nourished, 
anesthetic  to  pain,  touch  and  temperature  up  to  fifth  dorsal 
vertebra  and  unable  to  recognize  the  position  of  toes,  and 
there  was  spastic  weakness  of  the  lower  extremities.     The 


September.   1036 


PAFM— BACKACHE— Barron 


spinal  fluid  was  under  increased  pressure,  yellow  and  coagu- 
lated quickly— Froin-syndrome?  A  partial  spinal  fluid  block 
was  present.  The  findings  were  suggestive  of  a  cord 
lesion  at  the  third  dorsal  segment.  (Well  to  remember  that 
the  dorsal  roots  come  out  as  a  rule  two  vertebrae  beneath 
their  origin).  The  exact  pathology  has  not  been  determined. 
The  spinal  cord  was  extremely  soft,  gelatinous  and  bled 
freely.  She  had  an  intramedullary  lesion,  probably  a  glioma 
or  a  possible  spinal  blood  vessel  accident. 

A  young  man  consulted  me  complaining  of  lancinating 
pains  in  his  arms  and  chest  radiating  from  the  upper  back. 
His  arms  had  begun  to  show  some  wasting.  The  pains 
had  lasted  several  months  and  were  so  severe  at  times 
that  opiates  did  not  relieve  them.  The  cause  had  been 
overlooked  for  a  long  while  largely  because  no  one  had 
taken  time  to  look  at  his  pupils  and  also  because  of  fail- 
ure to  remember  that  one  may  have  a  negative  blood 
and  a  positive  spinal  fluid.  This  man  had  clinical  symp- 
toms of  syphilis  and  the  spinal  fluid  gave  a  positive 
Wassermann  reaction.  He  had  a  typical  case  of  radicu- 
litis. 

In  the  further  consideration  of  pain  in  the  ab- 
domen and  chest  we  must  keep  in  mind  tabes  and 
herpes  zoster.  Herpes  zoster  should  also  be  thought 
of  in  certain  cases  of  supraorbital  neuralgia. 

Backache  may  not  always  be  the  principal  symp- 
tom in  the  following  type  of  case  but  again  it  shows 
that  it  is  a  symptom  to  be  carefully  investigated. 
A  young  girl,  under-nourished,  tall,  slender,  anemic,  had 
been  suffering  with  backache  for  some  several  months  and 
had  gradually  developed  weakness  in  the  lower  extremi- 
ties. This  girl  had  a  myelitis.  She  had  a  history  that 
four  months  previous  she  had  suffered  with  a  severe  cold 
and  sore  throat.  Later  she  had  frequent  urination.  She 
felt  exhausted,  inert  and  dull,  so  much  so  that  some  ex- 
pressed the  opinion  that  she  was  a  mental  defective.  (Prior 
to  her  illness  she  was  an  alert  young  girl).  Her  muscula- 
ture was  poor,  the  lower  exeremities  markedly  wasted; 
deep  reflexes  were  lost,  there  were  scattered  areas  of 
anesthesia,  and  she  was  unable  to  recognize  the  position 
of  her  toes.  Spinal  fluid  was  slightly  yellow  and  coagu- 
lated almost  spontaneously.  The  Wassermann  reaction  was 
negative,  as  were  x-ray  studies.  This  patient  had  an  acute 
myelitis.     She   made  a   fairly   good   recovery. 

A  common  cause  of  backache  is  arthritis.  Pain 
in  the  back  occurring  in  rapidly  growing  children 
may  be  indicative  of  osteochondritis  or  epiphysitis. 
This,  in  later  life,  may  contribute  to  osteoarthritis. 
A  careful  history  and  x-ray  studies  are  necessary. 
There  is  no  need  of  a  search  for  local  infections  in 
these  cases.  Rest  and  support  for  the  painful  backs 
are  necessary.  The  uterus  and  its  adnexa  in 
women  and  the  prostate  in  men  should  always  be 
investigated.  Traumatic  injuries  are  not  infrequent 
and  tuberculosis  should  always  be  considered.  Pain 
in  the  back  following  meningitis  in  the  compensa- 
tion case  is  hard  to  evaluate. 

In  the  general  consideration  of  backaches,  there 
are  a  large  number  that  are  due  to  muscle  weak- 
ness, strain  and  fatigue.  This  type  of  backache  is 
not  infrequently  seen  in  the  young  woman  of  poor 
muscular  development.  These  individuals,  as  a 
rule,  get  very   little    outdoor    exercise    and    their 


habits  are  usually  not  conductive  to  good  health. 
They  eat  irregularly,  are  usually  on  the  run,  and 
do  not  take  time  for  the  proper  evacuation  of  the 
bowels.  Most  obese  women  and  most  very  thin 
women,  especially  those  who  have  borne  children, 
complain  of  low  back  pain  during  the  menopause. 
This  complaint  is  not  uncommon  among  the  so- 
called  psychoneurotic  of  all  ages.  In  the  majority 
of  individuals  in  this  group,  especially  those  who 
have  borne  children,  there  is  poor  posture,  weak- 
ness, and  consequent  dragging  of  the  abdominal 
viscera  when  they  are  deprived  of  the  suiport 
formerly  given  by  a  sound  abdominal  wall.  There- 
fore, further  strain  is  thrown  upon  the  ligaments, 
the  articulations,  and  particularly  the  lumbosacral 
joint.  Many  of  these  we  find  to  have  flat  feet, 
displacement  of  the  uterus,  and  numerous  other  ab- 
normal conditions,  making  it  difficult  to  properly 
place  the  blame.  This  group  calls  for  sound  judg- 
ment. These  individuals  usually  give  a  history  of 
chronic  constipation  and  general  exhaustion.  They 
get  up  in  the  mornings  tired.  Sometimes  rest  gives 
relief.  If  these  symptoms  persist,  they  gradually 
grow  worse,  and  the  patient  will  begin  to  suffer 
with  stiffness,  soreness  and  periodical  acute  attacks 
of  pain,  particularly  after  sudden  movement. 
Sooner  or  later  they  will  show  some  joint  abnor- 
malities, possibly  develop  arthritis,  and  a  bizarre 
group  of  symptoms  will  develop  of  more  or  less 
continued  aching,  stiffness,  soreness,  pain  and 
sciatica. 

The  majority  of  us  have  no  doubt  seen  a  largi 
number  of  this  group  undergo  extensive  and  ex- 
pensive treatment  without  relief  For  quite  a  few 
surgery  is  definitely  indicated;  but  for  a  large 
number  it  is  needless  and  useless.  Pelvic  op)era- 
tions  promiscuously  done  on  a  displaced  uterus  for 
relief  of  backache  is  condemned.  We  must  not  b? 
too  hasty  or  allow  ourselves  to  treat  the  result  or 
symptom  instead  of  the  cause  of  the  backache.  Hero 
I  may  say  many  of  the  traumatic  or  accidental 
cases  in  which  there  is  compensation  concerned, 
and  many  others  in  which  compensation  is  not  a 
factor,  who  are  subjected  to  surgery  without  givin:^ 
relief. 

If  we  will  take  time  and  study  these  cases,  w? 
will  find  that  quite  a  few  have  a  psychogenic  back- 
ground and  make-up.  Many  of  these,  theoretically 
speaking  at  least,  are  of  the  thyroid,  the  pituitary, 
or  some  other  deficiency  tyf)e.  I  am  satisfied  that 
the  surgeon  frequently  recognizes  this  state,  bu' 
for  some  reason,  nevertheless,  resorts  to  surgica' 
measures  and  treats  the  make-up  as  a  minor  affair. 
Sooner  or  later,  these  people  are  informed  tha' 
they  are  well  but  are  just  nervous.  They  seem 
to  believe  it  in  spite  of  the  fact  they  still  have  the 
same  symptoms.     Nervousness  does  not  produce 


476 


PAm—BA  CKA  CHE— Barron 


September,  1936 


backache  but  injury  does,  and  surgery  often  serves 
only  to  more  firmly  fix  the  complaint  in  the  mind 
of  the  patient.  One  cannot  distract  by  attracting. 
Surgery  will  certainly  do  this  in  this  group. 

A  man,  37  years  of  age,  was  seen  with  the  complaint  of 
lower  baclcache.  He  was  a  self-centered  individual,  rest- 
less; it  hurt  him  to  sit  down;  he  complained  if  he  had 
to  stand  for  any  length  of  time,  and  walking  troubled 
him.  He  had  had,  during  the  pre\'ious  year,  two  surgical 
operations  on  his  back  for  injury.  It  was  easily  seen, 
regardless  of  whether  he  had  any  local  pathology  in  hi? 
back,  that  the  patient's  disability  was  to  be  found  in  his 
psychogenic  make-up  and  surgery  had  only  served  to  con- 
vince him  of  his  disability,  .\fter  some  six  weeks  of  care 
and  gradual  exercise,  he  was  restored  to  his  previous 
occupation  from  which  he  had  been  absent  for  almost 
two  years. 

It  is  evident  that  many  factors  may  enter  into  the 
causation  of  backache.  We  must  think  in  terms  of 
local  and  remote  causes.  We  must  keep  in  mind 
the  anatomy,  particularly  of  the  lower  back.  De- 
fects or  anatomical  variations  are  common.  If  we 
keep  in  mind  the  severe  stress  and  strain  to  which 
this  region  is  subjected,  it  will  be  quickly  appre- 
ciated how  easily  symptoms  may  develop,  especially 
in  the  defective  case,  after  debilitating  disease  or 
prolonged  muscle  inactivity  due  largely  to  lack  of 
muscle  tone.  Lumbago,  sciatica  and  radiating  or 
referred  pains  are  symptoms  that  demand  careful 
study  and  consideration. 

References 

Dickson:  Back  Pain.  Missouri  State  Med.  Jour.  Dec. 
1028. 

Wall.-\ce:  Lumbago  and  Sciatica.  Can.  Med.  Assoc.  Jour., 
vol.  34,  Feb.,  1936. 

Ritte;  Relief  of  Lumbago  and  Sciatica.  Med.  Clin. 
of  N.  A.,  Jan.,  1936. 

Irons:  Chronic  Arthritis,  .\  General  Disease  Requiring 
Individualized  Treatment.  An.  of  Int.  Med.,  vol.  14,  no. 
12,  June,   1936. 

Henry:    Posture.   Minn.  Med.,  vol.  19,  no  1.  Jan..,  1936. 

Lang:  Backache  in  Women.  III.  Med.  Jour.,  vol.  68, 
Aug.,   1935. 

Andrews:    Backache  in  Women.     Brit.  M.  J.,  2-  1925. 

Graves:  The  Relation  of  Backache  to  Gynecology. 
Boston  M.  &  S.  Jour.,  1928. 

Crossen:  Backache  from  the  Gynecological  Standpoint. 
Missouri  State  Med.  Jour.,  Dec,  192S. 

Caulk:  Relationship  of  the  Genito-Urinary  Organs  to 
Backache.    Missouri  State  Med.  Jour.,  Dec,  1928. 

Henry:  Isolated  Fractures.  Minn.  Med.,  vol.  19,  no.  1, 
Jan.,  1936. 

Anderson:  Accidental  Injuries  and  Sprains.  W.  Va.  Med. 
Jour.,  vol.  31,  no.  4,  April,  1935. 

Reading:  Low  Backache.  Jour.  Med.  Soc.  of  N.  J., 
vol.  32,  no.  7,  July,  1935. 

Williams:  BacKache.  Jour.  .4.  M.  .4.,  vol.  99,  Oct- 
Dec,  1932. 

Frothingham :  Backache.  Boston  Med.  &  Surg.  Jour., 
1923. 

Cochrane:  Low  Backache  and  Sciatica.  Brit.  Med. 
Jour.,  1928. 

S.    M.    &   S. 

Christian  Franz  Paulini  (1643-1712),  of  Eisenach,  rec- 
ommended the  death-sweat  for  warts. — Baas. 


TRE.ATilENT    OR    NO    TrE.^TMENT    IN"    INFLUENZA 

(A.    M.   Glazer,   Cincinnati,    in   Ohio   State   Med.   Jl.,   Aug.) 

.\  fairly  uniform  group  of  patients  with  influenza  under 
standard  conditions  with  4  different  types  of  therapy. 

In  Group  1  the  orders  were: 

1)  .\spirin  compound,  tablets  2  (Acetylsalicylic  Acid, 
Gr.  3^4;  phenacetin  grains  2%;  caffeine  Gr.  %);  pheno- 
barbital  Gr.  IJ-i;  castor  oil  one  oz.;  stat.  2)  Aspirin 
compound,  tablets  2  q  4  h.  until  t.  below  100,  then  1  q 
4  h.  till  t.  is  normal.  3)  Cascara  as  needed.  4)  Bed  rest 
5)  Force  fluids.     6)   Light  diet. 

Group  2 — same  as  Group  1,  plus  soda  bicarbonate  gr. 
XV  on  admission  and  q.  4  h. 

Group  3 — same  as  Group  1.  only  quinine  gr.  v  ::ub5ti- 
tuted  for  aspirin  compound. 

The  patients  in  Group  4  (control)  were  put  to  bed  and 
given  only  one  gelatin  capsule  containing  5  grains  of  glu- 
cose q.  4  h. 

The  patients  were  all  adult,  single  males  between  the 
age  of  20  and  50,  who  were  suffering  from  influenza. 

The  original  series  contained  194  cases  but  62  were 
discarded;  in  several  cases  the  patient  refused  medication, 
some  refused  to  remain  in  bed  until  discharged,  and  other 
cases  diagnosed  as  influenza  upon  admission  turned  out 
to  be  cases  of  pneumonia  within  the  first  24  h.  The  final 
series  contained  42  cases  in  Group  1,  25  in  Group  2,  34  jn 
Group  3  and  31  in  Group  4. 

The  duration  of  pyrexia  and  hospitalization  in  influenza 
seems  to  be  almost  self  limited  and  influenced  little  if  any 
by  therapy.  The  patients  who  received  treatment  did, 
however,  seem  to  feel  better  sooner  than  those  without 
medicine,  but  this  factor  is  difficult  to  evaluate. 

s.  M.  &  s. 

Extracts    From    Letters    of    Thom.as    Newton,    jr..    of 
Norfolk,  Va.,  to  Thomas  Jefferson,   1801-1806 
(From   William    &    Mary    College    Quarterly,   Jan.) 

Mr.   Barnes  has   pd   Mr.   Taylor  &   two   more   pipes   of 

the  same  quality  of  wines  are  forwarded  for  you 

Mr.  Taylor  has  left  some  ver>'  fine  London  Particular 
wines  three  years  old  &  very  little  difference  between  it 
and  the  Brasil  &  fifty  dollars  lower  in  price.  I  can  safely 
recommend  it  as  good  wine.  Ver>'  few  would  know  any 
difference  in  the  taste.  .  .  . 

We  have  bottlers  in  plenty  who  will  tell  >ou  they  im- 
prove liquors,  by  mLxtures,  which  I  am  not  fond  off.  1 
like  genuine  best.  The  packets  from  this  to  .Mcx'drii  are 
respectable  &  but  little  danger  of  adulteration  in  them, 
from  Alex'dria  to  the  City  I  am  not  acquainted,  you'l 
please  to  direct  who  to  deliver  to,  that  care  may  be  taken 
between  those  places 

-\t  the  request  of  Mr.  Campo,  a  Spanish  Gentm.,  I  send 
you  two  boxes  of  best  Segars,  which  be  pleased  to  accept 
of.  They  are  such  as  can  not  be  purchased  &  if  you  do 
not  smoke  Our  friends  Mr.  Burr  &  Mr.  Galatin  &c.  who 
doth  will  enjoy  them  when  you  meet 

Inclosed  is  a  letter  from  the  Consul  of  Mersailes,  with 
a  box  of  artichoke  roots,  which  I  have  sent  by  Capt. 
Butler  who  has  promised  to  deliver  them. 

s.  M.  &  s. 

For  Modesty  in  Doctors 
(Edi.  in  Wise.  Med.  Jl.,  Aug.) 

There  is  plainly  evident  at  this  time  an  increasing  spirit 
of  antagonism  to  the  medical  profession  by  a  certain  por- 
tion of  the  laity.  In  an  attempt  to  clear  up  misunder- 
standings the  profession,  for  a  time  at  least,  might  direct 
attention  to  the  fact  that  there  are  limitations  as  to  what 
the  physician  may  accomplish.  Heretofore  we  have  stress- 
ed our  accomplishments  which  is  perhaps  unnecessary,  as 
they  speak  for  themselves,  and  much  more  gracefully. 


September,    1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Diarrhea  in  Children 

W.  J.  Lackey,  M.D.,  Fallston,  North  Carolina 


DIARRHEA  in  children  can  be  divided  into 
two  main  classes:  first,  diarrhea  due  to 
agents  acting  directly  in  the  gastrointesti- 
nal tract,  the  enteral  group;  and,  second,  the  class 
due  to  agents  acting  outside  of  the  gastrointestinal 
tract,  the  parenteral  group. 

Diarrhea  is  a  symptom  and  not  a  disease.  This 
symptom  is  frequently  brought  to  the  attention  of 
every  medical  man,  especially  to  the  family  physi- 
cian during  the  summer  months.  Thanks  for  our 
ever-increasing  knowledge  of  pediatrics  we  are  now 
able  to  successfully  treat  most  cases  of  diarrhea 
in  the  home. 

To  know  the  etiology  of  diarrhea  in  children 
would  probably  require  a  complete  knowledge  of 
anatomy,  pathology,  physiology,  physiological 
chemistry,  and  last  but  not  least,  neurology.  In 
other  words,  to  know  pediatrics. 

.\s  for  those  cases  of  diarrhea  caused  by  agents 
acting  directly  in  the  gastrointestinal  tract,  we 
know  that  excess  of  carbohydrates  in  the  diet  espe- 
cially during  the  summer  months  results  in  the  so- 
called  fermentative  diarrhea.  This  condition  is 
easily  corrected  without  medication  with  proper 
regulation  of  the  diet.  Another  condition  so  fre- 
quently found  in  the  country  during  summer 
months  is  the  lack  of  facilities  for  keeping  food 
wholesome.  \'ery  few  of  these  homes  have  any 
refrigeration  at  all,  with  the  result  that  the  food, 
especially  the  milk,  acts  as  a  culture  medium  for 
pathogenic  bacteria,  leading  to  pathological  condi- 
tions in  the  gastrointestinal  tract.  The  strepto- 
coccus, the  colon  bacillus  and  amoebae  cause  in- 
fections of  the  gastrointestinal  tract  with  resulting 
diarrhea.  Still  another  type  has  been  reported 
where  epidemics  of  infectious  diarrhea  have  oc- 
curred during  the  neonatal  period.  This  was 
thought  to  be  due  to  a  virus  infection  as  no  causa- 
tive agent  could  be  found. 

In  the  parenteral  group  many  factors  are  con- 
cerned. Over-heating  of  a  child  is  not  an  uncom- 
mon cause  of  diarrhea.  This  heat  e.xposure,  espe- 
cially a  sudden  one,  is  too  much  for  the  heat  mech- 
anisms in  the  child's  body.  .Also  the  Sunday  after- 
noons, or  events  of  too  much  excitement  for  the 
baby,  affect  the  vasomotor  system,  so  as  to  cause  a 
diarrhea.  Another  condition  brought  to  the  general 
practitioner's  mind  is  the  effect  of  upper  respiratory 
infections  on  the  baby's  gastrointestinal  tract.  Often 
we  first  see  a  diarrhea  and  later  on  find  a  discharg- 
ing ear.     1  have  seen  numerous  cases  of  diarrhea 


cleared  up  immediately  after  opening  the  ear  drum. 
Xo  examination  of  the  child  is  complete  unless  the 
ear  drums  have  been  seen.  Any  doctor  with  a 
proper  otoscope  can  by  experience  detect  a  red- 
dened ear  drum  and  puncture  the  drum  when  punc- 
ture is  indicated. 

In  the  treatment,  naturally  all  causative  agents 
should  be  remedied  if  possible.  If  a  case  in  a  child 
under  one  year  of  age  is  seen  early,  I  give  a  small 
dose  of  milk  of  magnesia.  Never  give  strong  pur- 
gatives but  give  the  child  24  hours  or  slightly 
longer  of  starvation.  This  allows  the  gastrointes- 
tinal tract  time  to  empty.  Then  in  many  cases 
protein  milk  is  to  be  given.  If  diarrhea  still  con- 
tinues, I  give  a  bismuth  preparation,  often  adding 
small  doses  of  paregoric.  I  know  many  pediatri- 
cians speak  against  the  use  of  paregoric;  but  I 
have  not  been  able  to  detect  any  ill  effects  from 
its  use  and  I  think  it  shortens  the  period  of  recov- 
ery in  many  cases  if  properly  administered.  I  see 
no  reason  why  we  cannot  treat  an  irritated  intesti- 
nal tract  with  paregoric  as  we  can  treat  an  irritated 
stomach  or  pylorus  with  belladonna  or  atropine. 
Paregoric  gives  the  baby  more  rest  and  I  believe 
gives  its  inflamed  gastrointestinal  tract  more  rest, 
thus  aiding  Nature  in  the  healing  process.  Starch 
enemas  also  give  relief  in  some  cases. 

The  fluid  balance  should  always  be  maintained. 
I  always  give  water  unless  vomiting  prohibits  its 
use,  usually  trying  to  give  2}^  ounces  per  pound 
of  body  weight  in  24  hours.  Dehydration  with 
acidosis  or  alkalosis  are  always  serious  complica- 
tions. If  fluids  cannot  be  given  by  mouth  they  are 
given  intraperitoneally,  intravenously,  or  by  hypo- 
dermoclysis.  Saline  and  glucose  can  be  used  to 
supply  this  fluid.  Recently  Hartman's  solution  is 
becoming  very  popular  for  parenteral  use,  as  it 
can  be  used  in  either  acidosis  or  alkalosis.  If  the 
proper  amounts  of  fluids  are  given  these  babies  the 
mortality  will  be  greatly  reduced.  The  fluids  can 
be  administered  in  the  home  and  in  few  cases  is  it 
necessary  to  move  the  child  to  a  hospital. 

S.   M.    &   S. 

The  Raw  .Apple  Treatment  of  Diarrhea 
(M.    P.    Borovsky,  Chicago,   in    III.    Med.   Jl.,  Aug.) 

The  raw-apple  diet  as  a  treatment  for  diarrhea  in  infants 
and  young  children  deserves  much   more  attention. 

Twenty-three  cases  of  enteral  and  parenteral  diarrhea 
are  reported  with  uniformly  good  results  within  14  to  4S 
hours.  The  youngest  patient  was  IS  days  old.  The  acute 
diarrheas  are  the  quickest  to  respond  with  firm  stools. 
This  diet  must  exclude  all  other  foods  except  weak  tea  or 
water. 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


Case   Reports 


jMeningo-Encephalitis  a  Complication  of 
Undulant  Fever 


C.  E. 

George    F 


Ervin,  M.D.,   Danville,  Pa. 
Geisinger    Memorial    Hospital 


This  case  of  meningo-encephalitis  as  a  compli- 
cation of  undulant  fever  is  reported,  in  view  of  the 
rapid  increase  in  the  incidence  of  the  infection  in 
this  country,  where  much  has  been  written  about 
the  subject  but  with  little  mention  of  involvement 
of  the  central  nervous  system. 

Roger  12  3  4  qJ  France,  has  written  extensively 
of  the  central  nervous  system  complications  of  Br. 
abortus  infections.  Included  in  his  report  are  ex- 
amples of  meningo-encephalitis,  of  myelitis,  of 
radiculo-neuritis  and  of  sciatic  neuritis,  as  well  as 
less  frequent  peripheral  neuritis  due  to  this  infec- 
tion. These  reports  include  a  case  of  optic  neu- 
ritis by  Goodwin",  one  of  meningitis  by  Jordan", 
three  of  papilledema  by  Rutherford",  one  of  retro- 
bulbar neuritis  with  diminished  vision  by  Villard^, 
four  of  cerebral  vascular  spasm  by  Roger®;  and  one 
instance  of  bulbar  paralysis  by  Kohler^",  one  of 
meningitis  by  Sanders^',  and  a  postmortem  report 
by  Hansmann^-.  Roger's  explanation  of  the  evanes- 
cent attacks  of  aphasia,  paresis,  headache,  nausea, 
vomiting  etc.,  on  the  basis  of  vascular  spasm  seems 
to  be  logical. 


consisting  only  of  some  tenderness  of  the  abdomen 
and  moderate  tympany.  July  21st  the  patient  be- 
came quite  lethargic  and  remained  so  until  con- 
valescence was  established  in  the  hospital.  Upon 
admission  he  was  acutely  ill,  stuporous,  aroused 
with  some  difficulty;  when  disturbed  he  was  irrit- 
able and  cried  with  pain  upon  motion;  there  was 
weakness  of  right  side  of  the  face  and  bilateral 
Babinski  sign  with  a  fleeting  bilateral  ankle  clonus; 
the  abdominal  reflexes  on  the  right  side  were  absent, 
patella  tendon  reflexes  sluggish.  The  liver  was  en- 
larged 6  cms.  below  the  costal  margin,  the  spleen 
barely  palpable,  the  temperature  104.2°. 

Initial  laboratory  data:  Spinal  fluid  (8-2-34) 
showed  175  cells — 158  s.  1.,  1  1.  1.,  9  neutrop.,  7 
metamelocytes — sugar  66  mg.,  proteins  40  mg., 
negative  collodal  gold  and  negative  serological  ex- 
amination; blood:  Wassermann  reaction  negative; 
hgb.  689^ ,  red  cells  5,060,000— color  index  .6:  white 
cells  8,650 — neutrop.  65,  s.  1.  30,  1.  1.  2,  metamelo- 
cytes 2 ;  urine  was  negative.  Aggulutination  for 
Br.  abortus  and  B.  typhosis  had  been  negative  6ne 
week  before  admission.  Agglutination  for  Br. 
abortus  was  positive  in  a  titer  of  1 :  160  21  days  after 
admission;   repeated  blood  cultures  were  negative. 

The  illness  was  progressive,  and  two  days  after 
admission  he  was  in  a  critical  condition — stupor  was 
deep;  he  could  not  be  aroused.  There  was  stiffness 
of  the  neck;    right  facial  weakness.     A  diagnosis 


V 

.06- 

V 

'WM 

MIM^ 

fl\ 

I 

A      A.         .A      A    A  /                   f' 

1 

. 

1  I  li          V  . 

y 

(         *-^ 

V       •'^      V     *     ^ 

—— •^ 

*97 

Meningo-encephalitis.    due    to    Br.   abortus    in.cction,  treated  by  typhoid  vaccine,  intravenously. 


A  Case  Report 
An  8-year-old  boy,  admitted  August  2nd,  dis- 
charged August  31st,  1934,  referred  by  Dr.  C.  W. 
Straub  of  Middleburg,  who  saw  the  boy  first  on 
July  19th  and  learned  that  he  had  been  sick  since 
July  12th,  that  his  illness  had  begun  with  fever, 
headache,  soreness  over  the  whole  body,  slight  sore 
throat,  anorexia  and  mild  diarrhea.  The  physical 
findings  at  the  initial  office  visit  were  not  helpful 


of  meningo-encephalitis  due  to  Br.  abortus  was 
made  and  the  patient  treated  according  to  the 
method  used  for  undulant  fever  in  this  hospital^'. 
He  was  given  his  first  treatment  of  0.05  c.c.  typhoid 
mixed  vaccine  intravenously  on  the  ISth  day  after 
admission.  His  t.  rose  to  104°  and  returned  to 
normal  within  24  hours,  remaining  normal  for  sev- 
eral days  when  a  slight  recurrence  was  noted,  so  a  i 
second   injection   was   given.      (See   chart).   Con- 


September,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


valescence  was  rapid  and  dramatic.  Within  24 
hours  after  his  first  treatment  the  lethargic  state 
cleared  rapidly.  He  was  discharged  fnim  the  hos- 
pital 29  days  after  admission,  in  good  physical  con- 
dition. Reexamination  February  7th,  1936,  showed 
a  normal  child  whose  blood  gave  a  negative  agglu- 
tination for  Br.  abortus. 

Comment 
We  have  reported  here  a  case  of  meningo- 
encephalitis as  a  complication  of  Br.  abortus  in- 
fection, a  condition  infrequently  cited  in  American 
literature,  treated  successfully  by  the  intravenous 
use  of  typhoid  vaccine.  The  onset  of  central  ner- 
vous system  symptoms  occurred  early,  on  the  9th 
day  of  the  illness:  recovery  was  completed. 
6— MED 

References 

1.  Roger,  H.:  Cerebral  Complications.  Marseille  med., 
2:591-601,    1929. 

2.  Roger,  H.:  Medullary  Complications.  Marseille  med., 
2:602-616,    1929. 

3.  Roger.  H.  and  Cremieux,  .\..  Melitococcic  Redi- 
culoneuritis  with  Xanthochromia  and  Intense  Albu- 
minocytologic  Reaction  of  Spinal  Fluid;  Cases.  Mar- 
seille med.,  2:617-634,  1929. 

4.  Roger,  H.,  and  Raybaud,  A.:  Melitococcic  Sciatica; 
Cases.     Marseille   med.,   2:635-645,    1929. 

5.  GoD\^^^■,  D.  E.:  Optic  Neuritis.  Am.  J.  Ophth., 
12:747,    1929. 

6.  Hartley,  G.  A.,  Millice,  G.  S.  and  Jordan,  P.  H.: 
Meningitis:  Report  of  Case  with  Recovery.  /.  A.  M.  A., 
103:251-253,    1934. 

7  Rutherford,  C.  W.:  Papilledema:  Case.  /.  A.  M.  A., 
104:1490-1492,    1935. 

8.  Villart,  H.,  Viallefont,  H.  and  Temple,  J.:  Rare 
Complications:  Tabetic  Sydrome  andj  Retrobulbar 
Neuritis  with  Retinal  Arterial  Hypertension;  Case. 
Soc.  D.Sc.  med.  et  biol.  de  Montpellier.,  14:224- 
228,    1933. 

9.  Roger,  H.:  Cerebral  Vascular  Spasms.  Marseille  med.. 
2:727-733,    1931. 

10.  KoHLER,  P.:  Bulbar  Paralysis;  Case.  Med.  Welt., 
7:408-409,   1933. 

11.  Sanders,  W.  E.:  Case  Report— Undulant  Fever  Men 
ingitis.  J.  Iowa  M.  Soc,  21:510-511,   1931. 

12.  Hansmann,  G.  H.,  and  Schenken,  J.  R.:  Melitensis 
Meningo-Encephalitis.  .im.  Jr.  of  Pathologv,  8-435- 
443,   1932. 

13.  Hunt,  H.  F.,  Ervin,  C.  E.  and  Niles,  J.  S.:  Foreign 
Protein  Therapy,  Am.  Jr.  Med.  .SV.,  192.  No.  2 — 
August,   1930— Nu.   ;7i. 


Lateral  Sinus  Thrombosis  With  Recovery 

FuRMAN   Angel,   M.D.,  and   Edgar   Angel,   M.D., 

Franklin,  N.   C. 

Angel    Hospital 

•\  BOY  of  19.  admitted  February  15th,  1936.  re- 
ferred by  Dr.  Frank  K.  Justice,  C.  C.  C.  Camp, 
!-.^.  Clayton,  Georgia,  complained  of  headache, 
larache  and  discharge  from  left  ear.  Onset  was 
five  days  before  admission  with  discharge  from  left 
ear,  had  no  earache  previously  except  when  he  had 
a  discharging  ear  at  age  of  six.    About  twentv-lour 


hours  previous  to  admission  he  began  to  have  pain 
and  tenderness  behind  the  ear. 

There  was  definite  tenderness  over  the  entire 
mastoid,  slight  edema  over  the  lower  portion,  bulg- 
ing of  the  postero-superior  part  of  the  auditory 
canal  and  a  perforation  in  the  antero-superior  por- 
tion of  the  drum  from  which  there  was  a  profuse 
discharge.  The  tonsils  were  present  but  except  for 
a  little  injection  were  normal.  The  head  including 
the  right  ear  was  negative;  the  lungs  were  clear 
and  resonant;  the  heart  of  normal  size  and  position, 
the  abdomen  and  extremities  negative.  A  roentgen- 
ray  examination  revealed  marked  destruction  of  the 
cellular  structure  on  the  left  side,  the  cells  of  the 
small  variety  and  the  lateral  sinus  fairly  super- 
ficial. The  t.  was  103",  p.  100,  b.  p.  108/68, 
leukocytes  9,800  and  urine  negative. 

Under  nitrous  oxide  and  ether  anesthesia  a 
simple  mastoidectomy  was  carried  out.  The  entire 
cellular  structure  was  found  to  be  filled  with  pus 
and  there  was  a  small  Bezold's  abscess  over  the  tip 
of  the  mastoid.  A  rubber  drain  was  inserted  and 
the  skin  closed  with  clips.  The  drain  was  removed 
after  two  days,  at  which  time  the  t.  had  dropped 
to  99.2"  and  the  p.  to  90.  On  the  3rd  day  the  t. 
rose  to  105.2°  and  the  p.  to  108  (chart  1).  T.  and 
p.  then  continued  elevated  until  the  6th  day  when 
the  t.  dropped  from  105.2°  to  95.4°  and  the  p. 
from  120  to  84.  Drainage  from  the  auditory  canal 
at  this  time  had  stopped  and  there  was  a  profuse 
discharge  from  the  wound  after  removal  of  the 
clips.  There  was  some  dulness  in  the  left  lower 
base  and  no  neurologic  signs  that  would  indicate 
meningeal  or  brain  involvement.  The  following 
day  he  began  to  show  signs  of  increased  intracranial 
pressure — vomiting,  headache,  bilateral  papille- 
dema, and  drowiness — and  the  spinal  fluid  was 
found  to  contain  35  cells  p)er  c.  mm.  with  the  pres- 
sure slightly  increased.  The  next  day — seven  days 
following  mastoidectomy — the  t.  continued  to  fluc- 
tuate widely — between  104°  and  95° — and  he  be- 
gan to  have  chills.  At  this  time  he  complained  of 
a  sore  throat  on  the  left  side  and  a  mass  could 
be  felt  extending  down  under  the  left  ear,  which 
was  taken  to  be  a  thrombosed  internal  jugular  vein 
and  with  the  above  symptoms  confirmed  the  diagno- 
sis of  lateral  sinus  thrombosis.  He  was  then  given 
a  direct  blood  transfusion  of  400  c.c.  and  under 
nitrous  oxide  and  ether  anesthesia  the  base  of  the 
old  wound  was  opened  and  exposure  of  the  sinus 
carried  out  posteriorly.  An  abscess  containing  ap- 
proximately 2  c.  c.  of  pus  was  located  over  the 
knee  of  the  sinus  and  evacuated.  The  sinus  itself 
felt  soft  and  a  few  veins  over  the  sinus  bled  freely. 
Due  to  these  findings  it  was  thought  that  there  wa; 
no  thrombus  in  the  sinus  and  therefore  it  was  not 
explored.    The  wound  was  packed  open  with  gauze. 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936- 


September,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


481 


His  condition  did  not  improve  following  the  op- 
eration; his  t.  went  to  106.2%  p.  to  140.  On  the 
same  day  under  nitrous  oxide  and  oxygen  anesthesia 
the  wound  was  again  opened  and  the  sinus  ex- 
plored and  found  to  contain  a  firm  clot  which  ex- 
tended from  the  bulb  to  almost  the  midline  pos- 
teriorly. The  entire  thrombus  was  removed  until 
bleeding  was  produced  from  the  posterior  portion. 
The  sinus  was  packed  wide  open.  The  internal 
jugular  was  then  tied  off  above  the  common  facial 
vein  with  two  chromic  catgut  sutures.  A  rubber 
drain  was  then  inserted  and  the  wound  closed  with 
clips.  The  following  day  the  t.  dropped  to  nor- 
mal and  his  general  condition  seemed  much  im- 
proved. However,  his  t.  did  not  reach  normal  until 
April  1st,  44  days  from  admission — during  which 
time  he  developed  a  pulmonary  infarct  on  the  left 
side,  an  axillary  thrombo-phlebitis  on  the  right  and 
multiple  abscesses  of  both  arms.  During  this  period 
he  was  given  six  additional  blood  transfusions.  At 
the  time  of  his  discharge  (86  days  following  ad- 
mission) both  wounds  were  completely  healed,  the 
weakness  of  the  right  arm  which  had  followed  liga- 
tion of  the  internal  jugular  had  disappeared  and 
his  general  condition  was  quite  satisfactory. 

No  positive  blood  culture  was  obtained  during 
the  entire  period.  The  leukocyte  count  varied 
from  9,800  to  30,200;  the  variations  from  day  to 
day  are  shown  in: 

Table  1 
Feb.     15       0,800  before  mastoidectomy 
22     17,500  before    exposing    sinus 
22     32,000  before    e.xploring    sinus 
Mar.    10     19,500  after  removal  of  thrombus 
and  ligation  of  jugular 
12     19,750 
16,850 
10,000    (on   discharge) 

.\  case  of  lateral-sinus  thrombosis 
secondary  to  acute  suppurative  mastoiditis  is  re- 
ported. Ligation  of  the  internal  jugular  with  ex- 
ploration of  the  sinus  and  evacuation  of  the  clot 
were  carried  out  with  recovery. 

s.  M.  &  B. 

The  CoMMpN  Cold 

(W.  J.  Kerr,  .San  Francisco,  in  Jour.  A.  M.  A.,  Aug.  1) 
Toward  the  end  of  the  last  century  the  medical  pro- 
fession seemed  willing  to  accept  a  bacterial  origin  for  most 
diseases,  used  many  types  of  respiratory  or  cold  vaccines 
for  the  prevention  of  the  common  cold.  If  there  is  any 
value  in  the  procedure  it  is  lil<ely  that  immunity  in  en- 
hanced against  the  action  of  these  organisms  only  as  sec- 
ondary invaders  or  for  some  other  reason  still  unde- 
termined. In  recent  years  Dochez  has  advanced  the  hypo- 
thesis that  the  common  cold  is  due  to  a  filtrable  virus  and 
in  support  of  this  view  has  presented  data  on  careful  and 
extensive  experimental  study,  but  that  this  agent  is  the 
universal  primar\-  cause  of  the  common  cold  may  be 
doubted.  It  may  be  assumed  from  present  knowledge 
that  there  are  a  number  of  agents  which  may  cause  disturb- 
ances in  the  erectile  tissue  of  the  nose.     One  need  mention 


Apr. 

May 


Comment: 


only  the  rhinitis,  hay  fever  and  the  local  effects  on  the 
nasal  mucous  membranes  of  contact  with  fumes,  dusts  and 
other  irritating  substances.  War  gases  and  dusts  from 
the  prairies  are  examples  of  the  last  group.  Influenza  does 
not,  as  a  rule,  begin  with  an  acute  rhinitis.  In  this  disease 
the  pharynx  is  usually  reddened  and  the  nasal  passages  may 
be  irritated,  but  obstruction  and  abundant  secretion  are 
uncommon.  Exposure  to  cooling  after  being  overheated, 
or  excessive  cooling  of  the  extremities  particularly  after 
wetting  of  the  feet  or  sitting  in  a  draft,  will  in  most  sub- 
jects cause  nasal  obstruction,  sneezing  and  watery  secre- 
tions. It  may  be  assumed  that  anything  which  causes 
congestion  of  the  erectile  tissue  and  thereby  obstructs  the 
nose  will  cause  sneezing  and  the  outpouring  of  a  thin, 
watery  secretion  which  is  not  specific  for  the  causative 
agent.  Most  of  the  confusion  in  diagnosis  has  come  be- 
cause of  the  failure  to  recognize  this  fact.  The  general 
symptoms  of  the  common  cold  are  associated  with  con- 
striction of  the  vessels  in  the  skin,  with  coldness,  and  with 
decreased  sweating  which  results  in  the  increased  secretion 
of  urine  that  is  pale  and  of  low  specific  gravity.  Fever 
is  not  an  early  sign;  and  the  t.  usually  subnormal  for  the 
first  24  to  48  hours.  If  the  known  infectious  diseases  that 
produce  respiratory  symptoms,  such  as  measles,  syphilis 
and  influenza,  are  excluded,  it  wiU  be  found  that  there 
remains  a  very  large  group  of  acute  disorders  which  may 
be  classed  as  rhinitis.  Through  history  and  skin-testing 
a  considerable  number  of  reactors  to  allergens  can  be 
recognized,  .\mong  these  persons  will  be  found  many 
who  suffer  from  symptoms  of  rhinitis  during  the  fall  and 
spring  months  when  colds  are  frequent.  They  may  have 
increased  susceptibility  to  changes  in  temperature  as  well 
as  hypersensitiveness  to  allergens.  Subjects  with  chronic 
disorders  of  the  sinuses  and  with  deflected  septums  likewise 
have  symptoms  of  rhinitis  when  sudden  changes  of  tem- 
perature occur.  The  majority  of  the  population,  however, 
experience  from  two  to  four  colds  a  year;  and  it  is  not  clear 
that  they  belong  to  any  of  these  groups.  It  is  the  author's 
opinion  that  they  develop  a  type  of  rhinitis  which  may 
be  designated  as  the  common  cold,  resulting  from  ex- 
posure to  sudden  cooling  of  the  body  due  to  faulty  adapta- 
tion to  their  environment.  There  is  ordi- 
narily no  fever  in  the  early  stages.  Groups  of  subjects 
who  were  known  to  have  frequent  attacks  of  the  com- 
mon cold  and  who  had  not  suffered  from  it  in  recent 
months,  were  placed  in  a  room  where  ideal  environmental 
conditions  for  comfort  could  be  maintained.  Successive 
groups  were  exposed  to  different  individuals  suffering  from 
the  common  cold  in  the  acute  stages.  The  exposure  was 
intimate  and  continued  for  several  hours  in  the  groups 
studied  early  in  this  investigation;  but  in.  the  groups 
studied  later,  in  addition  to  intimate  contact,  fresh  secre- 
tions were  injected  into  the  conjunctival  sacs,  and  ther- 
mometers and  drinking  glasses  were  contaminated  with 
the  secretions.  In  a  total  of  19  subjects  in  5  groups,  and 
exposed  to  5  sufferers,  not  one  positive  result  was  ob- 
tained. This  does  not  prove  that  there  is  no  type  of  rhin- 
itis which  is  contagious,  but  it  does  suggest  that  colds  are 
not  so  readily  transmitted  as  many  assert.  In  the  treat- 
ment of  the  acute  attack,  several  measures  are  of  value. 
These  may  be  grouped  under  two  general  heads:  first,  those 
measures  which  constrict  the  mucous  membranes  of  the 
nose  and  permit  the  passage  of  air  over  them:  second, 
those  which  open  the  peripheral  vessels.  In  the  first  cate- 
gory will  be  found  the  shrinking  solutions  and  appUcations; 
in  the  second,  a  warm  room  and  warm  bed,  a  hot  bath, 
the  mustard  foot-bath,  hot  drinks,  alcohol  (given  to  the 
state  of  diplopia),  acetylsalicylic  acid,  quinine,  powder  of 
ipecac  and  opium,  papaverine  and  many  another  drug. 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


DEPARTMENTS 


OBSTETRICS 

For  this  issue,  J.  Stkeet  Brewer,  M.D.,  Roseboro,  N.  C. 


The  Management  of  Obstetrical  Hemorrhage 
Outside  the  Hospital* 

At  first  thought  one  might  think  that  the  man- 
agement of  obstetrical  hemorrhage  in  the  home 
should  differ  little  from  that  in  the  hospital;  but, 
upon  reflection,  one  realizes  that  the  availability 
of  skilled  assistance  and  the  facilities  for  asepsis 
may  greatly  influence  decision  as  to  what  is  best. 
Hemorrhage  in  a  patient  at  home  frequently  finds 
the  physician  ill-prepared  to  meet  the  exigencies 
of  the  case.  He  is  usually  without  trained  assist- 
ance and  aseptic  technique  is  difficult  to  institute 
and  maintain.  However,  when  there  is  time  for 
preparation  and  proper  attention  is  given  to  details, 
a  fair  degree  of  asepsis  can  be  practiced  even  in 
the  home  of  the  average  parturient;  and  it  is  hardly 
necessary  to  mention  that  there  are  few  obstetrical 
emergencies  that  are  so  urgent  that  one  should 
not  take  time  to  institute  whatever  degree  of  asep- 
sis the  circumstances  admit.  The  loss  of  a  little 
more  blood  may  well  be  compensated  by  steps 
taken  to  avoid  infection. 

The  obstetrical  hemorrhages  may  be  classified 
into  those  (A)  occurring  during  early  pregnancy; 
(B)  occurring  during  late  pregnancy;  and  (C)  oc- 
curring during  parturition  or  soon  thereafter.  The 
hemorrhages  during  early  pregnancy  have  to  do 
with  abortion — threatened  or  inevitable,  incom- 
plete or  complete — and  rupture  of  ectopic  gesta- 
tion. The  hemorrhages  during  late  pregnancy  have 
to  do  with  placenta  previa  and  premature  separa- 
tion of  the  normally  situated  placenta;  those  during 
parturition  or  soon  after  have  to  do  with  the  two 
just  mentioned,  that  of  retained  placenta,  and  those 
due  to  lacerations  and  postpartum  hemorrhage  from 
the  uterus. 

The  management  of  abortion  depends  upon  the 
degree  to  which  it  has  progressed  when  the  physi- 
cian is  called.  Threatened  abortion  is  to  be  treated 
by  bed  rest,  nervous  and  uterine  sedatives,  mor- 
phine in  some  cases,  the  avoidance  of  intravaginal 
manipulations  and  the  use  of  enemas  instead  of 
laxatives  and  purgatives.  The  duration  of  this 
treatment  may  be  from  a  few  days  to  several 
weeks.  Many  women  have  a  tendency  to  abort 
throughout  the  early  months  of  pregnancy  if  they 
are  on  their  feet,  and  the  pregnancy  can  be  con- 
tinued  only  by  keeping  them  in  bed   for  several 


weeks  after  all  threat  of  abortion  has  passed.  In 
these  cases,  as  in  those  of  habitual  abortion,  the 
administration  of  anterior-pituitary-like  hormone 
appears  to  be  of  value.  One  woman  who  had  lost 
eight  successive  conceptions  between  the  third  and 
seventh  months  carried  the  ninth  pregnancy  to  a 
successful  conclusion  when  kept  in  bed  from  the 
beginning  of  the  third  month  until  the  delivery  of  : 
an  eight-pound  boy  at  term. 

When  it  has  been  decided  that  abortion  is  in- 
evitable the  patient  may  be  sent  to  a  hospital,  or, 
if  circumstances   are   suitable   and    the    physician  i 
feels  himself  capable,  he  may  in  the  patient's  home  ■ 
under  narcosis  or  light  ether  anesthesia  gently  dilate  ' 
the  cervix,  if  necessary,  and  introduce  a  firm  pack  ; 
of  sterile  gauze.    Within  24  to  48  hours  the  gauze  • 
should  be  removed,  and  if  the  product  of  concep- 
tion does  not  come  away  with  the  gauze  it  may 
be  removed  by  the  gloved  finger  or  the  placental 
forceps  and  the  blunt  curet. 

In  many  instances  when  the  physician  is  called 
he  finds  that  the  process  has  been  going  on  several 
hours  or  days,  the  woman  is  in  bed  with  profuse 
hemorrhage,  severe,  cramp-like  pains  and  if  the 
fetus  has  not  passed  it  is  evident  that  abortion  is 
inevitable.  In  these  cases  prompt  action  is  often 
imperative  and  immediate  preparation  should  be 
made  for  operation,  and,  under  strict  aseptic  pre- 
cautions, the  uterine  contents  removed.  If  the 
cervix  is  sufficiently  dilated,  this  may  usually  be 
done  without  anesthesia.  Not  infrequently  it  will 
be  found  necessary  to  dilate  the  cervix  under  light 
ether  anesthesia.  The  sharp  curet  should  not  be 
used,  but  gentle  curettage  may  be  done  with  the 
blunt  instrument.  By  using  the  finger  one  may 
feel  more  certain  that  the  uterus  has  been  thor- 
oughly evacuated.  I  have  never  practiced  irrigat- 
ing the  uterus.  Pituitrin  and  ergot  should  be  given 
and,  if  the  bleeding  does  not  soon  cease,  a  strip  of 
gauze  introduced  and  left  for  a  few  hours.  This, 
however,  is  not  often  necessary.  I  am  aware  that 
in  many  hospitals  in  the  case  of  incomplete  abor- 
tion the  practice  is,  in  the  absence  of  profuse  hem- 
orrhage, to  wait  for  a  period  in  the  hop)e  that  with 
the  use  of  oxytocics  the  uterus  may  be  encouraged 
to  expel  its  contents;  but  with  the  patient  in  the 
home  and  the  physician  busy  and  maybe  out  of 
reach  for  hours  at  a  time,  I  consider  the  prompt 
removal  of  the  ovum  in  the  presence  of  incomplete 
abortion  the  best  practice.  Infected  abortion  of 
course  alters  the  practice,  but  it  is  not  within  the 
scope  of  this  paper  to  go  into  the  management  of 
that  complication. 

The  rupture  of  an  extrauterine  or  tubal  preg- 
nancy presents  quite  a  serious  problem  to  the  phy- 
sician when  the  patient  is  many  miles  away  from  a 


•Presented   to   the    Section   on   Gynecology    and    Obstetrics   of   the 
Asheville^  May  6th, 


Medical   Society   of   the    State   of   North   Carolina, 


September,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


hospital.  The  question  is  whether,  during  the 
acute  symptoms,  one  should  transport  the  patient 
many  miles  to  the  hospital  or  combat  the  shock 
and  wait  for  the  acute  symptoms  to  subside  in  the 
hope  that  the  hemorrhage  will  cease.  There  is,  of 
course,  the  chance  that  the  ovum  may  be  com- 
pletely discharged  from  the  tube,  in  which  case  the 
hemorrhage  will  cease;  or  the  rupture  may  occur 
into  the  broad  ligament,  in  which  case  the  need 
for  laparotomy  is  not  imperatively  necessary.  The 
individual  case  should  be  treated  as  the  circum- 
stances merit,  but  it  has  been  my  experience  that 
as  much  or  more  harm  may  be  done  in  the  effort 
to  transport  a  bleeding  woman  to  a  hospital  as  by 
putting  the  patient  at  absolute  rest  and  waiting  a 
few  hours  in  the  hope  that  she  will  survive  the 
acute  symptoms,  when  she  may  be  moved  with 
comparative  safety.  Occasionally  it  may  be  safer 
to  bring  the  surgeon  and  the  operating  room  to  the 
patient  rather  than  to  transport  her  to  the  hospital. 

The  hemorrhages  occurring  during  late  pregnancy 
are  due  to  placenta  praevia  or  to  premature  sep- 
aration of  the  normally-situated  placenta.  They 
may  also  occur  during  labor.  When  painless  hemoi- 
rhage  without  obvious  cause  occurs  in  the  later 
months  of  pregnancy  the  patient  should  be  put  in 
the  hospital  and,  if  the  child  is  viable,  cesarean  sec- 
tion should  be  performed,  unless  one  is  reasonably 
certain  that  the  praevia  is  of  the  marginal  type.  I 
do  not  favor  temporizing  with  this  complication  ex- 
cept when  one  is  delaying  in  the  hope  that  the  child 
may  reach  viability  or  in  the  marginal  type  when 
successful  delivery  by  the  natural  route  may  be 
anticipated. 

But  what  is  the  physician  to  do  when  he  is  con- 
fronted by  a  patient  in  labor  bleeding  from  pla- 
centa praevia?  One  of  several  procedures  may  be 
instituted,  depending  upon  the  condition  of  the 
cervix  and  the  type  of  praevia.  If  the  cervix  is 
not  well  dilated,  it  may  be  tightly  packed  with 
gauze  with  or  without  rupture  of  the  membranes, 
or  the  bag  may  be  inserted  with  or  without  rupture 
of  the  membranes.  One  then  pursues  a  policy  ot 
watchful  waiting  for  the  cervix  to  dilate.  If  the 
bag  is  not  available,  good  results  may  be  obtained 
in  the  marginal  or  lateral  variety  by  simple  rupture 
of  the  membranes  and  the  stimulation  of  the  uter- 
ine contractions  allowing  the  presenting  part  to 
come  down  and  control  the  hemorrhage. 

When  dealing  with  complete  placenta  praevia 
and  an  incompletely  dilated  cervix,  it  is  necessary 
to  perforate  the  placenta  and  place  the  dilating 
bag  above  it  and  wait  for  dilation.  When  the 
physician  finds  that  the  cervix  is  dilated  the  mem- 
branes should  be  ruptured,  when  the  presenting 
part  will  usually  control  the  hemorrhage  in  the 
marginal  or  lateral  variety  and  labor  may  be  per- 


mitted to  follow  its  natural  course.  When,  how- 
ever, one  is  dealing  with  a  complete  praevia  and 
the  cervix  is  found  dilated  or  easily  dilatable,  best 
results  will  usually  be  obtained  by  the  employ- 
ment of  Braxton  Hick's  version,  thus  using  the 
breech  of  the  child  to  control  further  bleeding.  If 
the  bleeding  is  controlled,  the  expulsion  of  the 
child  may  be  left  to  the  natural  forces;  but  if  the 
bleeding  continues,  traction  may  be  made  and  de- 
livery gradually  accomplished.  Particular  care 
should  be  used  in  the  management  of  the  third 
stage  of  labor  in  these  cases  and  unless  the  bleed- 
ing soon  ceases  upon  the  expulsion  of  the  placenta, 
one  should  search  for  cervical  lacerations  and  im- 
mediately repair  any  that  are  found.  The  institu- 
tion of  a  firm  uterina  pack  may  be  necessary  in 
some  cases. 

The  premature  separation  of  the  normally  sit- 
uated placenta  constitutes  one  of  the  gravest  com- 
plications of  pregnancy  and  labor.  Its  occurrence 
is  usually  followed  by  the  inauguration  of  uterine 
contractions.  W'hen  the  separation  is  at  the  lower 
margin  of  the  placenta,  the  hemorrhage  usually 
fmds  its  way  between  the  membranes  and  the  uter- 
ine wall  and  appears  externally.  Prompt  rupture 
of  the  membranes  and  stimulation  of  the  forces 
of  labor  will  usually  admit  of  a  successful  conclu- 
sion in  these  cases.  When,  however,  the  separa- 
tion begins  in  the  central  or  upper  portion  of  the 
placenta,  the  hemorrhage  does  not  readily  find  its 
way  externally,  but  accumulates  between  the  pla- 
centa and  the  uterine  wall,  thus  increasing  the  sep- 
aration. The  management  of  this  complication  of 
labor  outside  the  hospital  presents  a  serious  prob- 
lem. Unless  the  cervix  is  dilated  when  the  patient 
is  first  seen,  and  it  usually  is  not,  immediate  at- 
tempt at  delivery  should  be  avoided.  Accouche- 
ment force,  rapid  dilation  of  the  cervix,  has  no 
place  in  the  management  of  these  cases  and  is  to 
be  condemned.  The  uterus  will  be  found  hard  and 
firmly  contracted,  the  cervix  not  dilated  and  the 
patient  in  constant  pain.  My  best  results  have 
been  obtained  by  the  use  of  full  doses  of  morphine 
and  waiting  for  dilation  of  the  cervix;  then  the 
membranes  are  ruptured  and  the  labor  promptly 
completed  in  the  most  favorable  manner.  After 
delivery  the  prompt  exhibition  of  oxytocics  is 
necessary,  and  frequently  the  uterine  pack.  In 
many  of  these  patients  the  uterine  musculature  is 
so  disassociated  by  hemorrhage  that  effective  con- 
traction postpartum  is  impossible  and  the  patient's 
life  can  be  saved  only  by  the  prompt  supravaginal 
amputation  of  the  uterus.  Couvelaire  has  desig- 
nated this  condition  as  uteroplacental  apoplexy, 
and  it  is  apparently  associated  with  a  toxemic  proc- 
ess. 

Hemorrhage  during  labor  or  soon  after  the  de- 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


livery  of  the  child  may  be  due  to  lacerations  of 
the  cervix  and  perineum  or  to  failure  of  proper 
contractions  of  the  uterus  after  delivery  of  the 
placenta.  When,  after  the  expulsion  of  the  child, 
there  is  unusual  bleeding  and  the  contraction  of 
the  uterus  is  such  that  bleeding  from  that  source 
is  unlikely,  immediate  repair  of  lacerations  will, 
in  many  instances,  control  the  hemorrhage.  Peri- 
neal lacerations  are  rarely  ever  extensive  enough 
to  produce  more  than  transient  bleeding  and  it  is 
to  the  cervix  we  look  for  the  source  of  the  trou- 
ble. As  a  rule,  cervical  tears  may  be  promptly 
repaired,  but  occasionally  a  case  is  encountered  in 
which  the  tear  has  extended  beyond  the  vaginal 
attachment  to  the  cervix  into  the  lower  uterine 
segment.  This  accident  presents  a  difficult  prob- 
lem and  the  placenta  should  be  immediately  de- 
livered and  a  firm  intrauterine  and  vaginal  pack 
applied.  This  may  be  removed  in  24  to  48  hours 
and  another  pack  inserted,  and  the  procedure  re- 
peated 24  hours  later  if  necessary.  Later  exam- 
ination in  many  of  these  patients  will  reveal  the 
laceration  to  be  of  such  extent  that  future  preg- 
nancy is  unsafe;  in  such  cases  sterilization  or  hys- 
terectomy should  be  performed. 

Retained  placenta  occasionally  gives  rise  to  an 
alarming  hemorrhage.  This  complication  may 
usually  be  met  by  a  period  of  watchful  waiting 
after  which  it  is  frequently  possible  to  express  the 
placenta  in  the  usual  manner.  When,  however, 
profuse  bleeding  does  occur,  one  should  unhesitat- 
ingly invade  the  cavity  of  the  uterus  and  with 
the  gloved  hand  remove  the  placenta  and  mem- 
branes. This  is  a  measure  we  all  hesitate  to  per- 
form, but  under  strict  aseptic  technique,  it  is  prob- 
ably not  as  dangerous  an  undertaking  as  we  were 
formerly  taught.  It  has  been  my  misfortune  to 
have  to  manually  remove  the  placenta  on  a  num- 
ber of  occasions,  and  I  have  not  yet  encountered 
a  case  of  infection  from  it.  In  performing  this 
operation,  one  should  never  lose  sight  of  its  dan- 
gers and  the  necessity  for  a  rigidly  aseptic  tech- 
nique. 

The  treatment  of  postpartum  hemorrhage  due 
to  atony  or  faulty  contraction  of  the  uterus  is  too 
well  known  to  require  much  discussion  here.  Mas- 
sage of  the  uterus  through  the  abdominal  wall 
and  the  injection  of  posterior  pituitary  and  ergot 
preparations  will  almost  always  prevent  hemor- 
rhage after  the  uterus  is  emptied.  In  an  occa- 
sional case,  the  bleeding  may  be  of  such  degree 
that  the  physician  feels  warranted  in  applying  an 
intrauterine  pack;  however,  my  feeling  is  that  in 
the  home  of  the  average  parturient  the  degree  of 
asepsis  is  so  questionable  that  the  packing  of  the 
postpartum  uterus  carries  considerable  risk  of  in- 
fection. 


The  management  of  excessive  hemorrhage  out- 
side as  well  as  in  the  hospital  requires  the  usual 
necessary  attentions  to  prevent  shock  and  infec- 
tion. The  body  whose  vitality  has  been  lowered 
by  excessive  blood  loss  presents  an  inviting  field 
for  successful  invasion  of  the  body  by  bacteria. 
After  hemorrhage  is  controlled  one  should  institute 
those  measures  that  are  necessary  to  restore  blood 
loss.  Glucose  and  saline  solutions  may  be  given 
with  little  difficulty.  When  occasion  requires  blood 
transfusions  may  be  done  in  the  home  with  reason- 
able safety,  the  citrate  method  being  the  method  of 
choice. 

It  is  recognized,  of  course,  that  the  hospital  is  a 
better  place  to  meet  and  deal  with  hemorrhage  as 
well  as  other  obstetrical  emergencies.  However, 
only  a  fraction  of  the  deliveries  in  North  Carolina 
take  place  in  hospitals,  and  the  general  practition- 
ers and  country  physicians  have  to  meet  those 
emergencies  whenever  and  wherever  they  occur. 
Laboring  under  the  handicaps  of  no  assistance  and 
insanitary  surroundings,  they  bear  the  primary  re- 
sponsibility of  the  obstetric  emergency  and  are 
ofttimes  unable  to  get  the  patient  to  the  hospital 
before  something  must  be  done.  To  paraphrase, 
the  general  practitioner  must  rush  in  where  the 
obstetric  specialist  would  fear  to  tread. 


Dehydration  Therapy  in  the  Toxemias  of  Pregnancy 
(G.  E.  May,  Boston,  in  N.  E.  Jl.  of  Med.,  Aug.  13th) 
Eclampsia  and  pre-eclampsia  seem  of  endocrine  origin, 
possibly  pituitary  but  more  probably  placental,  not  a  dis- 
ease primarily  of  the  liver  or  of  the  kidneys  but  rather  of 
all  the  small  terminal  arterioles.  There  is  also  an  upset  in 
water  balance.  Fluid  retention  alone  probably  does  not 
account  for  all  the  symptoms  of  toxemia. 

Often  the  differential  diagnosis  between  pre-eclampsia 
and  nephritis  is  impossible.  Cases  were  considered  chronic 
nephritis  which  conformed  most  closely  to:  elevated  blood 
nonprotein  nitrogen ;  history  of  a  previous  pregnancy  toxe- 
mia or  previous  predisposing  diseases;  albuminuric  retinitis; 
moderate  anemia;  b.  p.  over  160  sys.  with  little  or  no  albu- 
minuria. 

In  caring  for  the  outpatient  cases,  a  very  detailed  toxemic 
history  was  taken,  and  each  patient  received  the  following 
printed  instructions: 

From  6  tonight  until  6  tomorrow  nigiit,  save,  measure 
and  record  the  total  amount  of  urine  that  you  pass. 
During  this  period  do  not  take  any  more  than  4  glasses 
of  any  Itind  of  fluid.  The  next  day  restrict  your  total 
fluid  (water,  tea,  coffee,  milk,  beer,  soups,  fruit  juices) 
intake  to  one  glass  less  than  the  total  urine  passed. 
Similarly  each  day  keep  track  of  the.  urine  voided  and 
during  the  succeeding  day  take  one  glass  less  of  fluid, 
aiming  always  to  take  in  less  fluid  than  you  have  passed 
urine.  Keep  a  daily  record  of  the  urine  output  and  fluid 
intake  and  bring  this  record  to  the  clinic  with  you  at 
each  visit.  Take  1  or  2  teaspoonfuls  of  Epsom  salts  every 
morning  so  that  you  will  have  from  2  to  4  loose  bowel 
movements  each  day.  Use  no  salt  on  your  food.  Eat 
meat  once  a  day.  Eat  no  sweets  or  desserts.  Eat  4 
small  meals  a  day.  Do  not  eat  or  drink  between  meals. 
The  treatment  of  the  hospitalized  patients  was  carried 
out  along  similar  lines.  Severe  cases  no  fluids  at  all  dur- 
ing the  first  24  hours  and  catharsis  was  increased.  Occa- 
sionally the  severe  case  received  either  100  c.c.  of  S0% 
glucose  solution  or  20  c.c.  of  10%  magnesium  sulphate 
solution  intravenously. 


September,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


It  has  not  been  found  necessan-  to  continue  dehydration 
after  delivery. 

Pre-edamptic  toxemias:  20  cases  in  each  group.  None 
of  the  dehydrated  group  developed  eclampsia,  abruptio 
placentae  or  macerated  fetus. 

Mild  nephritic  toxemias:  26  cases  in  each  group.  All 
but  2  of  the  dehydrated  group  went  to  full  term  and  9  in 
the  control  group  terminated  prematurely.  There  were  no 
macerated  fetuses  in  the  dehydrated  group  but  there  were 
4  macerated  fetuses  and  one  stillbirth  in  the  control  group. 
One  case  in  the  control  group  developed  abruptio  placentae. 

Severe  nephritis:  The  dehydrated  and  control  groups 
19  cases  in  each.  The  dehydrated  cases  did  considerably 
better  than  those  not  dehydrated.  Five  of  the  cases,  which, 
under  dehydration  were  carried  to  full  term,  had  been  in- 
duced in  their  previous  pregnancies  at  periods  varying 
from  6  to  S  months. 

s.  M.  &  s. 

Antiseptic  Delhtry  in  the  Home 
(F.  L.  Wood,  Lynden,  Wash.,  in  Clin.  Med.  &  Surg.,  Aug.) 

I  wish  to  discuss  the  aH(/septic  versus  the  aseptic  man- 
agement of  obstetric  cases  and  point  out  how  safely  moth- 
ers can  be  delivered,  in  a  cottage  or  mansion,  in  hospital 
or  hovel,  if  a  safe,  conservative  policy  is  followed  and 
careful  attention  is  paid  to  the  lavish  use  of  antiseptics 
at  every  stage  of  the  birth  process. 

It  should  be  manifest  to  anyone  that  there  can  be  no 
such  thing  as  asepsis  in  these  cases. 

Cresol  solution  is  a  powerful  antiseptic;  it  is  harmless 
to  the  tissues  in  rather  strong  concentrations;  it  is  soapy; 
and  it  is  cheap,  so  that  it  may  be  used  lavishly.  I  use  2 
or  3  drams  to  each  quart  of  water  and  this  water  is  not 
always  boiled  or  sterile.  Each  time  I  examine  the  patient 
or  perform  any  other  internal  manipulation,  I  first  wash 
my  gloved  hands  in  concentrated  cresol  solution  and  rinse 
them  in  a  weaker  solution.  After  first  scrubbing  the  field 
of  operations  with  as  strong  a  solution  as  the  patient  can 
bear  comfortably,  I  have  been  able  to  perform  hundreds 
of  internal  manipulations,  including  the  application  of 
forceps,  versions,  and  the  manual  chssection  of  adherent 
placentas  from  the  uterine  wall,  in  surroundings  often 
insanitary  and  frequently  filthy,  without  the  slightest  evi- 
dence of  infection.  My  only  case  of  milk-leg  occurred  in 
a  patient  to  whom  I  was  called  too  late  to  render  any 
assistance  whatever  and  whose  home  and  linen  were  clean 
and  sanitary.  The  2  or  3  cases  of  mild  puerperal  sepsis 
in  more  than  1,(K)0  consecutive  deliveries  were  in  patients 
in  whom  there  had  been  no  internal  interference  of  any 
consequence. 


-S.    M.    &    S.- 


UROLOGY 

HAiiiLTO.N  VV.  McKay,  M.D.,  Editor,  Charlotte,  N.  C. 


The  Influence  of  Stasis  on  Chronic  Urinary 
Infections 
The  important  function  of  the  urinary  tract  is 
to  deliver  the  excreted  urine  to  the  outside  world 
without  impediment  for  it  to  perform  normally. 
The  excretory  portion  of  the  kidney  and  the  entire 
tract  must  be  free  from  any  form  of  stenosis  that 
will  slow  the  stream  of  urine  down  sufficiently  to 
cause  stasis  or  that  more  obvious  type  of  obstruc- 
tion that  causes  an  actual  damming  up  of  urine 
with  back  pressure  on  the  upper  tract  and  damage 


and  destruction  of  the  organs  as  an  end  result. 

One  may  well  illustrate,  by  comparing  the  hydro- 
dynamics of  the  urinary  tract  to  a  spring  which 
feeds  a  stream.  Slight  impediment  along  the 
stream's  course  causes  a  slowing  down  of  the  nat- 
ural flow  with  resulting  accumulation  of  trash  and 
dirt  on  top  of  the  water;  while  complete  damming 
up  of  the  stream  causes  backing  up  and  widening 
with  great  pressure.  With  stasis  we  should  asso- 
ciate, as  a  rule,  mild  chronic  obstruction  of  slight 
degree  and  generally  long  standing.  With  partial 
or  complete  obstruction,  we  are  accustomed  to  as- 
sociate acute  damming  up  with  severe  pain,  ful- 
minating infection,  and  back  pressure.  Lesions 
causing  obstruction  are  very  common  along  the 
course  of  the  urinary  tract  and  are  most  likely  to 
occur  at  the  normal  physiological  constrictions, 
namely: 

1.  Ureteropelvic  junction. 

2.  Pelvic  brim. 

3.  Intravesical  portion  of  the  ureter. 

4.  Bladder  neck. 

5.  External  urinary  meatus. 

We  then  expect,  as  a  result  of  these  obstructive 
uropathies,  stasis  or  partial  or  complete  obstruc- 
tion. As  a  result  of  stasis  we  are  naturally  on  the 
lookout  for  infection  which  is  one  of  the  major 
problems  with  which  urologists  have  to  cope.  Then 
we  can  conservatively  say  that  some  form  of  steno- 
sis, mild  or  severe,  is  very  common  and  whichever 
type  of  obstruction  is  usually  found  is  very  likely 
accompanied  by  infection. 

Causes  of  stasis  are  congenital  and  acquired. 
Some  of  the  congenital  lesions  causing  stasis  are  as 
follows: 

1.  Congenital  stricture  at  the  pelviureteral  junc- 
tion. 

2.  Aberrant  vessels  at  the  pelviureteral  junc- 
tion. 

3.  Congenital  stricture  along  the  course  of  the 
ureter. 

4.  Congenital  stenosis  of  the  ureterovesical  ori- 
fice. 

5.  Congenital  valves  of  the  posterior  urethra. 

6.  Congenital  stricture  of  the  urethra. 

7.  Congenital  stricture  or  stenosis  of  external 
urinary  meatus. 

Some  of  the  acquired  causes  of  stasis  are  enum- 
erated below: 

1.  Any  disease  or  operation  which  will  cause  a 
narrowing  or  distortion  of  the  normal  lumen 
of  the  ureter.  Illustrations  are  urinary  tu- 
berculosis and  abdominal  operations  with  se- 
vere postoperative  adhesions. 

2.  Impacted  stone  may  cause  acute  obstruction, 
'  partial  or  chronic  obstruction.     If  the  bed 

of  the  stone  becomes  ulcerated  stricture  often 


SOUTHERN  MEDICINE  AND  SURGERY 


September,   10.^6 


5. 


follows. 

Kinks  and  various  distortions  which  are  re- 
sponsible for  narrowing  of  the  ureter's  lu- 
men. 

Stenosis   of    the    intramural    portion    of    the 
ureter,  especially  the  ureteral  meatus. 
Obstructions  at  the  bladder  necic  including: 

(a)  All  forms  of  prostatic  enlargement,  be- 
nign and  malignant,  and  prostatic  bars. 

(b)  Contracture  of  the  bladder  neck. 

6.  Stone  in  the  urethra. 

7.  Stricture  of  the  urethra  and  especially  sten- 
osis of  the  external  urinary  meatus. 

Many  cases  of  persistent  pyuria  can  be  diagnosed 
clinically  by  careful  history  and  inspection.  Sub- 
jective symptoms  of  long  duration  as  diurnal  and 
nocturnal  frequency,  urgency,  pain,  and  burning 
on  urination.  Change  in  size  and  force  of  stream 
with  macroscopically  cloudy  urine  is  sufficient  evi- 
dence to  make  one  strongly  suspect  obstruction 
which  causes  the  pyuria  to  persist. 

There  is  not  sufficient  evidence  of  careful  study 
and  well  ordered  management  of  one's  cases  when 
patients  are  treated  for  weeks  and  months  for  a 
pyelitis  when  the  real  reason  for  the  lack  of  im- 
provement has  never  been  searched  for. 

Partial  stenosis  of  a  mild  or  severe  degree  is  a 
very  common  condition  in  both  infancy  and  adult 
alike,  and  is  the  answer  to  most  of  the  so-called 
stubborn  cases  of  pyelitis  which  do  not  clear  up 
satisfactorily  under  medical  treatment. 


Investigation  is  now  easily  carried  out  by  gen- 
eral practitioner  and  pediatrician  alike  by  means 
of  intravenous  urography.  Therefore,  the  whole 
object  of  this  paper  is  to  urge  investigation  of  the 
urinary  tract  for  obstruction,  mild  or  severe,  when 
treatment  for  a  reasonable  time  has  failed. 

The  following  case  report  illustrates  complete 
destruction  of  the  kidney  by  congenital  obstruc- 
tion: 

A  single  man,  aged  20,  was  admitted  for  examination 
May  2Stii,  1936,  with  the  following  clinical  symptoms: 
Recurrent  attacks  of  pain  in  left  kidney  region.  Some- 
times the  pain  radiated  across  the  abdomen,  sometimes 
into  chest,  occasionally  into  penis.  The  family  and  the 
past  medical  history  were  irrelevant ;  venereal  disease  was 
denied.  For  the  past  two  or  three  years  he  had  suffered 
recurrent  attacks  of  severe  left-sided  abdominal  pain  with 
marked  tenderness,  nausea  and  vomiting.  Cloudy  urine 
had  been  passed.  The  pain  would  require  repeated  hypo- 
dermics of  morphine  sulphate  for  relief.  No  cystoscopy  or 
study  of  the  case  had  been  made. 


Fig.    I— Shows   pyi-lugrani   ot    tl 

,■    left    kidney.      Amount   o 

purulent   fluid  aspirated   7uli   c 

■.      Note   c.mplete   destruc 

tion  ot  kidney  by   congenital   ( 

listruction   at   the  uretero 

pelvic  junction. 

Cystoscopic  examination  revealed  trigonitis  grade  I.  No 
tumors,  stones,  or  ulcers  were  seen.  The  left  ureter  was 
catheterized  and  a  continuous  flow  of  urine  obtained.  The 
kidney  drained  for  twenty-four  hours.  Pyelograms  showed 
unusually  large  pyonephrosis;  700  c.c.  of  cloudy  fluid  was 
aspirated.  (See  Fig.  II.)  The  bladder  urine  contained 
albumin,  x;  w.  b.  c.  x;  r.  b.  c.  12-15  to  the  h.  p.  f.;  rod- 
shaped  bacilli,  X.  The  left-kidney  urine  contained  pus, 
cocci  and  bacilli.  By  the  indigo-carmine  test,  the  right- 
kidney  appearance  time  was  11  minuter,  concentration  good. 
From  the  left  kidney  no  dye  appeared  in  ,?0  minutes. 

Diagnosis:     Pyelonephrosis,  left. 

Operation:  Left  nephrectomy.  Discharged  from  the 
hospital  on  the  fourteenth  day — cured. 


September,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


RADIOLOGY 


Wright  Claekson,  M.D.,  and  Allen  Barker,  M.D., 
Editors,  Petersburg,  Va. 


\'alue  of  Roentgenography  of  the  Epiphyses 

FOR  THE  Diagnosis  of  Preadult 

Endocrine  Disorders 

Much  accurate  information  has  been  gathered 
in  recent  years  concerning  both  the  diagnosis  and 
the  therapeusis  of  endocrinopathies,  and  it  is  not 
over-optimistic  to  predict  that  the  science  of  endo- 
crinology will  ultimately  rehabilitate  a  large  group 
of  individuals  who  have  in  the  past  been  classed  as 
incurable. 

Recently,  Clark^  and  Shepardson-  presented  the 
clinical  and  roentgen  findings  in  certain  important 
endocrine  disorders  and  it  is  the  purpose  of  this 
communication  to  review  their  work  briefly  and 
to  bring  the  roentgen  phases  of  endocrinology  to 
the  attention  of  a  larger  number  of  physicians. 

Roentgenography  has  provided  an  easy  method 
of  epiphyseal  study  in  a  large  number  of  healthy 
individuals  and  we  have  learned  with  a  great  de- 
gree of  accuracy  the  normal  time  of  appearance 
and  union  of  the  epiphyses,  and  the  variations  of 
normal  which  are  not  to  be  considered  pathologi- 
cal. Preadolescent  endocrine  disorders  usually 
cause  gross  disturbances  of  the  normal  epiphyseal 
development  and  thus  the  practical  value  of  roent- 
genography in  determining  previously  unsuspected 
endocrinopathies  is  obvious. 

Most  of  us  see  patients  daily  who  are  suffering 
from  endocrine  imbalances;  yet  we  do  not  always 
recognize  them  because  of  our  unfamiliarity  with, 
or  lack  of  interest  in,  such  cases.  An  impression 
of  the  number  of  such  patients  may  be  gained  from 
the  studies  of  Marinus  and  KimbalP  who,  in  a 
survey  of  Detroit  school  children,  found  some  form 
of  endocrine  imbalance  in  18.6  per  cent,  of  those 
studied.  Shelton*  found  an  osseous  retardation  of 
two  years  or  more  in  IS  per  cent,  of  560  unselected 
children  in  Santa  Barbara  County  public  schools. 

Since  endocrinology  is  essentially  concerned  with 
a  study  of  biochemical  processes  and  since  biochem- 
ical imbalances  are  frequently  reflected  in  an  indi- 
vidual's metabolism,  one  of  the  first  steps  in  the 
examination  of  a  suspected  endocrine  disorder  is 
to  determine  the  individual's  metabolic  rate.  This 
is  readily  accomplished  in  the  adult  by  the  respira- 
tory method,  but  in  the  very  young  it  is  obviously 
impossible  to  determine  in  this  way,  and  certain 
authorities  on  the  subject  state  that  the  basal 
metabolism  as  ordinarily  done  is  inaccurate  until 
the  age  of  puberty.  Before  this  period  in  the 
child's  growth  there  are  so  many  individual  and 
unknown   variations   that   no  known  standards   of 


basal  metabolic  rates  can  be  deduced.  On  the 
other  hand  a  roentgen  examination  of  the  epiphyses 
can  be  done  at  any  age.  Clark,  however,  urges 
caution  in  the  interpretation  of  roentgenograms  of 
the  epiphyses  made  between  birth  and  the  age  of 
one  year,  and  states  that  during  this  period  the 
value  of  a  roentgen  examination  of  the  epiphyses 
is  definitely  limited.  The  roentgen  method  of  de- 
termining an  endocrine  imbalance  enables  one  to 
make  a  diagnosis  and  institute  treatment  before 
the  disturbances  cause  pronounced  deformities  and 
permanent  disabilities. 

The  roentgenologist  must  have  a  thorough 
knowledge  of  the  normal  time  for  the  appearance 
and  union  of  the  epiphyses,  and  of  the  normal  va- 
riations. Many  investigators,  among  them  Hodges,'' 
have  published  their  studies  regarding  the  normal 
time  of  appearance  and  union  of  the  osseous  cen- 
ters. However,  in  any  roentgen  report  of  varia- 
tions from  normal,  the  clinician  must  take  into 
consideration  the  fact  that  age  for  age  the  skeletal 
development  of  girls  is  in  advance  of  boys,  and 
that  race,  climate,  heredity,  general  health  and 
nutrition  are  also  responsible  for  certain  variations 
in  epiphyseal  growth.  These  variations  can  be 
properly  evaluated  only  by  a  careful  correlation  of 
the  roentgen  with  the  clinical  findings. 

Since  it  would  be  both  economically  impossible 
and  confusing  to  examine  all  the  epiphyses,  it  is 
wise  to  examine  the  hands  and  wrists  of  all  cases, 
as  these  regions  include  a  greater  number  of  ossi- 
fication centers  than  any  other,  and  the  time  and 
sequence  of  the  appearance  of  these  centers  is  dis- 
tributed over  a  relatively  long  period.  In  certain 
cases  it  is  wise  to  include  the  ankle  and  foot,  and 
the  elbow  or  knee. 

The  hormones  chiefly  concerned  in  the  control 
of  osseous  development  and  growth  are  the  thyroid 
hormone,  the  sex  hormone  and  several  of  the  pitui- 
tary hormones. 

Hypothyroidism  (juvenile  myxederna)  is  the 
most  frequent  preadult  endocrinopathy.  Even  mild 
deficiencies  are  rapidly  recognizable  by  means  of 
roentgen  examination  of  the  epiphyses.  Osseous 
development  is  invariably  retarded,  the  degree  de- 
pending upon  the  severity  and  duration  of  hormone 
insufficiency,  and  this  retardation  of  osseous  devel- 
opment (late  appearance  of  the  centers  of  ossifica- 
tion) is  the  chief  sign  upon  which  to  base  the 
diagnosis  of  hypothyroidism.  Delayed  epiphyseal 
closure  is  also  commonly  observed  in  this  condi- 
tion, but  this  delay  is  probably  the  result  of  a 
secondary  hypogonadism  and  the  roentgen  diagno- 
sis of  hypothyroidism  must  not  be  made  on  the 
basis  of  delayed  closure  of  the  epiphyses,  as  the 
thyroid  probably  plays  no  important  role  in  this 
particular  growth  phenomenon. 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


Delay  in  the  appearance  of  the  ossification 
centers  may  also  result  from  defective  germinal 
protoplasm,  which  includes  certain  supposedly  con- 
genital or  hereditary  conditions,  and  the  differential 
diagnosis  depends  on  a  careful  history  and  clinical 
examination  or  on  a  therapeutic  test. 

Preadult  hj^Derthyroidism  occurs  occasionally  but 
usually  runs  such  an  acute  course  that  character- 
istic skeleton  changes  do  not  have  time  to  appear. 

Preadolescent  hypogonadism  occurs  quite  fre- 
quently. It  produces  the  preadolescent  eunuchoid, 
sometimes  called  the  eunuchoid  giant.  The  patient 
is  tall  with  disproportionately  long  extremities  and 
a  narrow  fiat  chest.  Closure  of  the  epiphyses  is 
greatly  delayed,  probably  as  a  result  of  the  loss 
of  the  growth-inhibiting  hormone  which  supposedly 
comes  from  the  interstitial  tissue  of  the  ovaries 
and  testes.  A  lack  of  this  growth-inhibiting  hor- 
mone in  the  presence  of  an  active  growth-stimulat- 
ing principle  (produced  normally  from  the  anterior 
pituitary)  causes  the  delay  in  the  epiphyseal  clos- 
ure and  thus  permits  growth  to  continue  long  after 
it  should  have  normally  ceased.  This  naturally 
produces  a  form  of  gigantism. 

Hypergonadism  is  relatively  rare,  and  it  is  char- 
acterized by  sexual  precocity  and  rapid  growth 
until  the  onset  of  puberty,  which  takes  place  very 
early.  It  may  be  primary,  but  some  believe  that 
it  is  secondary  to  hyperpituitarism.  The  roentgen 
findings  consist  of  early  appearance  of  the  ossifica- 
tion centers,  rapid  bone  growth  and  early  closure 
of  the  epiphyses.  The  patients  are  larger  and 
stronger  than  their  mates  of  the  same  age,  but  at 
puberty  epiphyseal  closure  occurs  rapidly  and  they 
lose  this  advantage.  This  condition  is  often  asso- 
ciated with  tumors  of  the  pituitary,  adrenals,  or 
gonads.  The  accelerated  bone  age  in  these  cases 
of  hypergonadism  cannot  always  be  differentiated 
roentgenologically  from  that  resulting  from  supra- 
renal hyperactivity  and  both  are  characterized  by 
precocious  puberty.  Therefore,  it  is  often  difficult 
to  designate  the  gland  primarily  at  fault. 

Hypopituitarism  produces  pituitary  dwarfism.  It 
is  primarily  a  result  of  a  deficiency  of  the  hor- 
mones of  the  anterior  lobe.  In  considering  the 
various  forms  of  dwarfism,  we  find  that  roentgen 
examinations  of  the  epiphyses  are  valuable  in  two 
types — the  hypothyroid  and  the  hypopituitary 
dwarfs.  In  the  former  (hypothyroidism)  there  is 
a  delay  in  the  ossification  centers  (thyroid  defi- 
ciency) ;  growth  is  usually  delayed,  also,  due  to 
an  associated  pituitary  involvement  (growth  hor- 
mone deficiency) ;  and  closure  of  the  epiphyses 
occurs  late  (sex  hormone  deficiency).  In  contrast 
to  the  hypothyroid  dwarf,  the  ossification  centers 
appear  at  the  normal  time  in  hypopituitarism,  but 
growth  is  markedly  retarded.     Due  to  a  lack  of 


the  gonad-stimulating  quality  of  the  pituitary  hor- 
mone, there  may  also  be  a  concomitant  deficiency 
of  the  gonadotropic  fraction,  and  consequently  a 
delay  in  sexual  maturity  and  in  suture  closure  as 
seen  in  hypothyroid  dwarfs. 

Hyperpituitarism  may  occur  as  a  result  of  ex- 
cessive secretion  of  growth  hormones  from  an  ap- 
parently normal  anterior  lobe  of  the  pituitary.  The 
acidophilic  elements  are  at  fault,  but  there  is  no 
evidence  of  pituitary  tumor.  In  these  patients  ossi- 
fication centers  appear  at  the  normal  time,  but 
grow  extremely  rapidly,  producing  a  true  gigan- 
tism before  normal  epiphyseal  closure  occurs.  The 
fault  here  is  is  not  due  to  a  lack  of  the  growth- 
inhibiting  hormone  of  the  gonads  but  to  an  over- 
production of  the  growth-stimulating  hormones  of 
the  pituitary.  If  there  is  an  associated  hypogon- 
adism, the  epiphyses  remain  open  and  growth  con- 
tinues further.  If  the  epiphyses  close  normally 
while  the  growth  hormone  is  still  produced,  acro- 
megaly results,  the  degree  depending  on  the  amount 
of  hormone  excreted  and  on  the  length  of  the  pe- 
riod over  which  it  acts. 

Hyperpituitarism  may  also  result  from  pituitary 
neoplasms  of  the  acidophilic  type.  The  accelerated 
skeletal  growth  is  here  limited  to  the  active  phase 
of  the  tumor  and  if  epiphyseal  closure  precedes  the 
active  phase,  acromegaly  also  results  in  these  cases. 

This  brief  summary  emphasizes  the  value  of 
roentgen-ray  studies  in  the  differential  diagnosis  of 
the  more  common  and  important  endocrinopathies. 
Furthermore,  it  is  at  once  apparent  that  roentgen 
studies  repeated  at  intervals  afford  excellent  criteria 
of  the  eft'ectiveness  of  the  indicated  therapy. 

References 

1.  Clark,  D.  M.:  The  Practical  Value  of  Roentgenogra- 
phy of  the  Epiphyses  in  the  Diagnosis  of  Pre-Adult 
Endocrine  Disorders.  Am.  J.  Roentgenol.  &  Rad.  Ther- 
apy, June,  1P36,  35,  752-771. 

2.  Shepardson,  H.  C:  The  Importance  of  Roentgeno- 
graphic  Studies  of  Osseous  Development  in  Endocrine 
Diagnosis.     Radiology,  June,  1036,  26,  685-690. 

3.  Marinus,  C.  J.,  and  Kimball,  0.  P.:  Endocrine  Dys- 
functions in  Retarded  Children  and  their  Response  to 
Treatment.     Endocrinology,   1930,   14,   309-318. 

4.  Shelton.  E.  K.:     Quoted  by  Clark. 

5.  Hodges,  P.  C:  Epiphyseal  Chart.  Am.  J.  Roentgenol. 
&  Rad.  Tlierapy,  1933,  30,  809-810. 

S.   M.    &  6. 

The   First   Lite  Insurance   Policy  Was   Contested 
(A.  C.   H.,  in   Milwaukee   Med.  Times,  Aug.) 

The  year  1583  is  said  to  be  the  earliest  date  on  record 
for  a  formal  life  insurance  policy.  It  amounted  to  $2,000 
and  was  a  policy  for  the  period  of  one  year  on  the  life 
of  one  William  Gibbons  .  .  .  and  it  appears  to  have  been 
a  wager  by  16  London  gentlemen.  When  Mr.  Gibbons 
died,  20  days  before  the  end  of  the  year,  the  "gentlemen" 
contested  payment  of  the  obligation  on  the  ground  that 
12  months  are  legally  12  times  4  weeks  of  28  days,  and 
by  this  form  of  figuring  Mr.  Gibbons  died  9  days  after  the 
expiration  of  the  "policy."  The  courts  ruled,  however, 
that  the  gentlemen  had  to  pay. 


September,    IQJo 


SOUTHERN  MEDICINE  AND  SURGERY 


GENERAL  PRACTICE 

WiNGATi  M.  JoHNioN,  M.D.,  Editor,  Winston-Salem,  N.  C. 


How  Free  is  the  Press? 

In  Tkc  Forum  for  July  appeared  an  article  by 
one  James  Rorty  who,  apparently,  is  a  professional 
propa"andist  in  the  employ  of  the  group  who  are 
hell-bent  upon  forcing  state  medicine  upon  this 
country.  Just  before  it  appeared,  the  editor  of 
The  Forum  sent  me  an  advance  copy,  with  this 
note: 
"Dear  Dr.  Johnson, 

I  enclose  an  advanced  proof  of  an  article  by 
James  Rorty  entitled  "Medicine's  Horse  and  Bug- 
gy"" which  will  appear  in  the  July  issue  of  The 
FORUM. 

Mr.  Rorty  maintains  that  the  .American  Medi- 
cal .Association,  led  by  Dr.  Morris  Fishbein,  is 
blocking  health  insurance  in  the  United  States 
and  he  endeavors  to  substantiate  his  claim  in  this 
excellent  article. 

You  may  or  may  not  agree  with  Mr.  Rorty  but 
I  hope  you  will  feel  moved  to  send  us  a  brief  com- 
ment with  permission  to  quote  you  in  Our  Ros- 
trum. 

Sincerely  yours, 

Henry  Leach,  Editor.  " 

Just  as  soon  as  I  could  spare  the  time  from  my 
practice  I  prepared  and  sent  a  reply  to  iMr.  Leach 
— I  thought  in  ample  time  for  publication.  Evi- 
dently Dr.  Olin  West  was  asked  to  do  likewise. 
Dr.  West's  reply,  with  the  most  vital  parts  omit- 
ted, was  published,  but  mine  was  omitted.  Since 
I  hate  to  see  so  much  energy  go  to  waste  in  this 
hot  weather,  I  am  using  my  reply  to  Mr.  Rorty 's 
article  to  fill  my  space  this  month. 

To  the  Editor: 

There  is  an  old  story  about  a  schoolboy  who 
suddenly  won  local  fame  for  the  ease  with  which 
he  translated  Cicero's  orations  against  Catiline. 
When  pressed  by  his  classmates  for  the  secret  of 
Ills  success,  he  modestly  replied  "Whenever  I  don't 
Inow  what  to  say,  I  just  go  to  cussing  Catiline." 
Mr.  James  Rorty  seems  to  have  used  the  same 
principle  in  "Medicine's  Horse  and  Buggy,'  pub- 
lished in  the  July  Forum.  Five  of  its  seven  pages 
are  devoted  to  a  savage  attack  upon  Dr.  Morris 
Fishbein,  editor  of  the  Journal  of  the  American 
Medical  Association.  The  very  head  and  front  of 
the  doctor's  offending,  one  gathers  between  vitu- 
perations, is  that  he  is  opposed  to  compulsory 
health  insurance.  Inasmuch  as  the  sub-title  of  the 
article  is  "The  American  Medical  Association 
Fights  Health  Insurance,"  it  is  quite  flattering  to 
Dr.  Fishbein  to  be  singled  out,  by  inference,  as 
the  whole  A.  M.  A.;   but  personal  abuse  is  not 


conducive  to  clear,  logical  thinking.  As  a  member 
of  that  organization,  may  I  offer  a  few  comments 
on  Mr.  Rorty "s  article. 

First,  as  a  member  of  the  A.  M.  A. — one  of  its 
"average  doctors" — I  dissent  from  Mr.  Rorty's 
opinion  that  "organized  medicine  tends  to  be  con- 
trolled by  medical  politicians  who  in  turn  tend  to 
exploit  the  economic  prejudices  and  ignorances  and 
the  more  or  less  chronic  distress  of  the  average 
doctor.'"  I  grant  freely  that  medicine  has  its  poli- 
ticians; but  for  a  number  of  years  I  have  been  a 
member  of  the  House  of  Delegates  of  the  .\.  M.  A., 
and  I  know  there  is  no  more  truly  democratic  or- 
ganization in  America  than  that  body. 

Second,  I  heartily  agree  with  the  subtitle  of  the 
article.  The  A.  M.  A.  does  light  health  insurance 
— the  whole  Association,  and  not  alone  the  editor 
of  its  Journal.  I  was  present  at  the  special  meet- 
ing of  the  House  of  Delegates  called  to  consider 
the  stand  the  A.  M.  A.  should  take  on  compulsory 
health  insurance.  The  question  was  discussed — 
with  absolutely  no  gag — for  a  day  and  a  half.  Rep- 
resentatives from  every  State  in  the  L'nion  were 
there — including  Michigan  and  California — and 
when  the  vote  was  taken,  the  opposition  to  any 
form  of  compulsory  health  insurance  was  abso- 
lutely and  heartily  unanimous. 

JNIr.  Rorty,  in  his  efforts  to  discredit  Dr.  Fish- 
bein, says  that  "On  November  19th,  1933,  the 
Chicago  iMedical  Society  demanded  of  the  A.  M.  A. 
Council  that  Dr.  Fishbein  be  censured  for  an  arti- 
cle by  him  in  the  American  Mercury."  Mr.  Rorty 
failed  to  say,  however,  that  in  this  same  meeting 
the  Chicago  Medical  Society  adopted  a  resolution 
commending  an  article  in  the  Forum  against  state 
medicine.  He  also  failed  to  state  that  the  Journal 
of  the  Illinois  Medical  Society  is  one  of  the  most 
militant  foes  of  state  medicine  in  the  country.  And 
a  bit  of  information  which  may  be  of  interest  is 
that  after  "the  California  Medical  Society  issued 
a  pamphlet  which  .  .  .  endorsed  the  general  prin- 
ciple of  insurance  in  its  application  to  sickness," 
Dr.  F.  C.  Warnshuis,  Secretary  of  the  California 
?vledical  Society,  for  years  the  Speaker  of  the 
House  of  Delegates,  was  replaced  at  the  ne.xt  meet- 
ing by  Dr.  van  Etten  of  New  York,  an  outspoken 
opponent  of  state  medicine.  And  this  was  not 
done  by  Dr.  Fishbein,  but  by  the  vote  of  the  whole 
House  as  a  protest  against  California's  action. 

Third,  Mr.  Rorty  must  indeed  be  living  in  the 
h(jrse  and  buggy  age  if  he  thinks  that  lack  of  med- 
ical care  alone  is  responsible  for  "increasing  mor- 
tality rates,  especially  from  tuberculosis  and 
among  infants,  and  increased  malnutrition  among 
children."  What  is  needed  to  prevent  this  state  of 
affairs  is  for  our  paternal  government  to  devise 
means  of  having  the  "surplus"  corn,  wheat,  hogs, 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  lo.'o 


and  other  foodstuffs  transferred  in  edible  form  into 
the  stomachs  of  these  malnourished  ones  instead 
of  being  burned;  for  having  "surplus"  cotton  made 
into  clothing  and  blankets  instead  of  being  plowed 
under:  for  making  up  "surplus"  leather  into  shoes 
for  their  bare  feet  instead  of  being  destroyed;  and, 
if  possible,  for  making  statesmen  out  of  politicians. 

Finally,  Mr.  Rorty  naively  assumes  that  the 
adoption  of  compulsory  health  insurance  in  the 
United  States  is  a  consummation  devoutly  to  be 
wishes,  and  the  Forum  readers  are  expected  to 
accept  this  conclusion  largely  from  such  dogmatic 
statements  as  "Some  form  of  compulsory  health 
insurance  is  clearly  inevitable." 

Space  forbids  giving  in  detail  the  reasons  why 
compulsory  health  insurance  is  not  desirable;  but 
there  is  one  paramount  reason  why  John  Krisko 
should  be  opposed  to  it.  He  may  be  willing  to 
shoulder  his  share  of  the  additional  four  billion 
dollar  addition  to  the  nation's  ta.x  burden  that 
compulsory  health  insurance  would  cost,  even 
though  25  per  cent,  of  the  national  income  is  al- 
ready absorbed  by  taxes,  and  if  the  budget  were 
balanced  this  would  be  increased  to  35  per  cent, 
(and  John  Krisko  should  know  by  now  that  he 
will  have  to  pay  his  share  of  any  new  tax  levy, 
sugar-coat  it  as  you  will).  He  may  be  willing  to 
give  up  his  choice  of  physician  and  accept  the  one 
the  government  will  provide.  He  may  be  generous 
enough  to  allow  the  government  to  add  to  its  pay- 
roll more  non-medical  administrators  of  the  health 
insurance  system  than  there  are  doctors  in  it.  He 
may  not  resent  being  treated  as  one  of  a  herd, 
instead  of  as  an  individual.  He  will  perhaps  not 
know  that  he  must  help  pay  for  the  enormous 
number  of  malingerers  who  will  sponge  on  the 
government  for  free  vacations  at  home  with  pay. 
Not  being  a  doctor,  John  Krisko  cannot  understand 
the  intense  loyalty  a  family  doctor  in  private  prac- 
tice feels  for  his  families,  nor  the  keen  sense  of 
responsibility  for  their  welfare  that  makes  him 
willing  to  make  all  sorts  of  sacrifices  of  time  and 
personal  comfort  for  them — which  would  be  lost 
under  state  medicine.  But  what  John  Krisko 
should  and,  if  intelligent  enough,  would  object  to, 
is  lessening  very  materially  the  chances  he  and  his 
family  have  of  living  out  their  normal  life  span. 
The  figures  show  that  the  United  Kingdom  of  Eng- 
land, Scotland,  Ireland  and  Wales — with  perhaps 
the  best  compulsory  system  of  health  insurance  in 
Europe— had  in  1920  a  death  rate  of  12  per  1,000; 
in  1928,  11.9;  and  in  1933,  the  last  year  available, 
12.5.  On  the  other  hand,  the  United  States  of 
America,  with  its  so-called  horse  and  buggy  med- 
icine, has  shown  a  steady  improvement  in  its  mor- 
tality ratj;  in  1920,  13.1  per  1,000;  in  1928,  12; 
in  1933,  10.7.    .And  other  yardsticks  for  measuring 


efficiency  are  just  as  favorable  to  the  United  States. 
Let  us  hope  that  John  Krisko  is  intelligent  enough 
to  draw  his  own  moral. 

S.    M.    &    S. 

Encroachment   of   State  Memcxne  With   Lay    Control 

Responsibility   of   the    Specialist 

(Edi.,   Ml.   Med.  Jl.,  Aug.) 

To  a  certain  extent  the  specialist  who  can  see  no  path 
but  his  own  is  responsible  in  that  the  specialist  "dressed 
in  a  little  brief  authority."  for  a  time  could  see  only  other 
specialists  and  none  of  them  could  visualize  anywhere  in 
the  scheme  of  preventive,  diagnostic  or  curative  medicine 
that  staple  ingredient  for  public  health  and  welfare  and 
individual  health  and  happiness,  the  general  practitioner 
and  family  physician.  Though  a  tendency  for  the  better 
looms  upon  the  horizon,  not  altogether  has  the  medical 
profession  escaped  from  having  the  tail  wag  the  dog ! 

This  error  has  cost  the  profession  dearly,  and  will  cost  the 
general  public  more  dearly !  In  the  gaps  between  the 
specialists,  in  crept  the  propagandists  for  state  medicine. 

Behold  as  a  result  the  hundreds  of  foundations,  of 
clinics  and  of  funds.  Business  men  have  gleaned  their 
harvest  from  this  land  of  plenty  and  of  promise,  and 
finding  time  heavy  on  their  hands,  become  imbued  with  a 
mock  philanthropy,  a  false  sense  of  the  humanities  and 
coupling  this  with  their  inherent  gift  for  management  and 
cultivated  curiosity  as  to  everybody  else's  affairs,  would 
beat  down  beneath  their  fists  and  their  finances  any  pro- 
fession, any  industry  that  hitherto  had  escaped  them. 

The  modern  family  has  come  to  insist  upon  high-priced 
hospitalization  for  a  sick  member  of  the  family,  even  when 
it  can  not  be  afforded,  rather  than  to  endure  the  discom- 
fort of  a  sick  person  in  the  house.  As  a  result  hospital 
bills  far  too  frequently  go  unpaid,  and  the  "high  cost  of 
sickness"  is  laid  at  the  doctor's  door  and  plans  to  get  it 
back,  literally  out  of  his  hide,  are  set  afoot  by  propagand- 
ists and  backed  up  by  lay  philanthropists  of  mistaken 
aims. 

s.  M.  &  s. 

THERAPEUTICS 

J.  F.  X.isii.  M.D.,  Editor,  Saint  Pauls,  N.  C. 

Obstetrical  Analgesia 

The  most  interesting  and  perplexing  of  all  prob- 
lems are  those  concerning  the  initiation  and  ter- 
mination of  life.  Perhaps  you  remember  when, 
as  a  small  chap  you  used  to  see  that  wizened,  frail 
old  neighborhood  granny — red  bandanna  around 
her  head,  barefooted,  a  spotlessly  laundered  white 
towel  pinned  about  her  neck  and  her  long  dress 
(that  was  before  the  day  of  knee  lengths  I )  tied  up 
several  inches  with  a  hip  cord,  as  she  wended  her 
unhurried  and  withal  stately  way  to  some  nearby 
colored  home;  and  how,  for  you,  she  embodied  all 
the  mysticism  of  the  ages,  for  she  balanced  on 
her  head  a  half -bushel  gourd,  and  by  that  sign  you 
knew  a  baby  was  being  carried  to  that  house  1 
The  granny  and  the  gourd  were  indisputable  evi- 
dence of  an  approaching  "increase;"  and  when 
you  were  older  and  learned  that  the  gourd  was 
simply  the  armentaria  receptacle  it  was  like  find- 
ing out  who  Santa  was. 


September,   10.36 


SOUTHERN  MEDICINE  AND  SURGERY 


491 


Until  the  advent  of  ether  and  chloroform  a  gourd 
might  have  served  the  physician's  purpose  equally 
well,  for  until  then  practically  nothing  was  done 
to  alleviate  the  pains  of  labor,  though  mention  is 
made  in  the  ChUdhearer's  Cabinet  of  1653  of  direc- 
tions to  help  "the  wringings  and  pressings  of  the 
belly  in  childbed  women  by  outward  and  inward 
means  and  by  drinks.  "  Possibly  this  lack  of  in- 
terest in  allaying  the  pangs  of  travail  was  due  to 
the  influence  of  the  clergy,  to  the  poor  means  of 
communication,  or  to  a  desire  for  personal  and 
professional  aggrandizement — witness  the  discovery 
of  the  obstetrical  forcep  by  Chamberlen,  and  the 
safeguarding  of  the  secret  so  well  that  he  and  his 
family  were  the  sole  users  of  the  instrument  for 
three  generations. 

\\.  the  1936  meeting  of  the  A.  M.  A.,  Dr.  Ger- 
trude Xielson,  herself  the  mother  of  three,  advo- 
cated less  use  of  anesthetics,  stating  "labor  should 
be  a  vital  experience  and  sacred  memory  not  to  be 
taken  from  her  by  the  amnesia  of  twilight  sleep." 
However,  most  doctors  and  all  mothers  disagree 
with  her  and  hold  to  the  credo  of  minimum  suffer- 
ing consistent  with  maternal  and  fetal  safety. 

A  long  first  step  in  reducing  pains  of  labor  is 
made  by  assuring  the  gravidum  at  prenatal  visits 
that  her  physical  condition  is  satisfactory,  that  she 
may  confidently  e.xpect  to  have  no  difficulties  and 
that  there  will  be  but  slight  sensation  of  pain. 
This  advice  is  excellent  psychological  medicine,  for 
many  a  woman  dreads  the  ordeal  solely  on  account 
of  what  she  has  been  told  by  the  neighborhood 
gossips.  There  can  be  no  invariable  rule  of  pos- 
ology  to  fit  each  case  of  pregnancy,  for  many 
conditions  affect  and  influence  the  effective  re- 
sults of  medication.  The  patient's  nervous  and 
mental  stamina,  individual  idiosyncrasy  to  certain 
drugs,  physical  impairments,  whether  delivery  is 
to  be  in  hospital  or  home,  availability  of  assist- 
ants— all  these  are  factors  bearing  on  the  amount 
and  variety  of  anesthesia.  But  whether  it  be  twi- 
light sleep;  ethel-oil  instillation;  intravenous  or 
spinal  anesthesia;  or  the  recent  effectual  and  com- 
mendable barbiturates,  aided  in  the  second  stage 
by  ether  or  chloroform  inhalations,  it  can  not  be 
gainsaid  that  all  gravida  deserve,  and  but  few  need 
be  denied  some  amnesia!  It  is  pleasant  to  have 
them  say  "Doctor,  it's  no  trouble  to  have  a  baby, 
for  I  have  no  recollection  of  pain." 

S.    M.    &    S. 

The  Medical  Management   of  Toxic   Goiter 
(Arnold    Minning,    Denver,    in    fvied.    Rec,   Aug.    19th) 
If    tobacco    is    not    relinquished,    treatment    is    practically- 
useless. 

Alcoholic  drinks  of  all  kinds  must  be  (;iven  the  same 
taboo  as  tobacco. 

Dr.  Bier  of  Berlin  has  given  animal  blood  since  1931  and 
has  found  in  it  a  new  and  more  helpful  treatment  of  toxic 


Koiter  than   surgery-. 

He  uses  5  c.c.  of  freshly-obtained  sheep  blood  intra- 
gluteally.  Following  this  injection  there  is  elevation  of  t. 
usually  not  over  2°.  The  patient  feels  as  though  he  has 
influenza.  There  is  more  or  less  of  a  local  reaction  and 
frequently  an  urticaria ;  this  passes  in  .:!  or  4  days.  During 
this  period,  the  patient  should  be  kept  in  bed  constantly, 
and  preferably  on  a  milk  diet.  Following  the  reaction 
complaint  is  made  of  weakness;  2  weeks  later,  .S  c.c.  of 
freshly-obtained  beef  blood  are  injected  into  the  gluteal 
region.  After  this  injection  5  c.c.  of  sheep  blood  alterna- 
tion with  5  c.c.  of  beef  blood  are  injected  at  monthly  inter- 
vals: 6  injections  are  all  that  are  required  in  the  average 
case. 

Improvement  frequently  begins  after  the  first  injection , 
appetite  is  increased. 

The  mortality  is  nil. 

I  have  treated  22  cases  by  this  method  in  the  past  year. 
Everyone  has  shown  symptomatic  improvement.  The  im- 
provement in  most  cases,  even  in  the  very  severe  ones,  was 
almost  miraculous. 

S.    M.    &    S. 

DioTHANE  IN  Hemorrhoids 

(E.    H.    Terrell,    Richmond,    in    Stuart    Circle    Hosp.    Bui., 

Aug. ) 

To  those  who  have  frequent  attacks  of  thrombotic  hem- 
orrhoids, hosoitalization  for  drainage  of  all  the  crypts  is 
recommended.  In  removing  blood  clots  and  in  other  minor 
surgical  procedures  in  the  office,  I  have  been  using  re- 
cently, as  an  anesthetic,  1%  diothane  added  to  an  equal 
amount  of  a  1-1000  solution  of  nupercain.  It  will  be 
noted  that  in  this  solution  the  diothane  is  reduced  to  yk  of 
1%.  Where  a  stronger  preparation  had  been  used  a  slough- 
inz  was  observed  occasionally.  The  nupercain  produces 
immediate  anesthesia  lasting  an  hour  or  more,  while  the 
diothane  lasts  1  or  2  days. 

s.  M.  &  B. 


Calcium  Therapy  in  Acute  and  Subacute  Sai.pingitis 
(BenJ.   Parvey,   Boston,   in   IVIed.    Rec,   Aug.   5th) 

In  the  44  cases  here  reported  17  patients  with  acute 
gonorrheal  salpingitis  received  medical  and  nursing  care 
for  such  cases  and  in  addition  were  given  10  c.c.  calcium 
gluconate,  10%  ampule  solution  (calglucon)  intravenously 
twice  daily  for  the  first  week.  In  several  urgent  cases  the 
20%  ampule  solution  was  given  by  slow  intravenous  infu- 
sion because  of  the  greater  concentration  of  the  calcium 
ion  contained.  Thereafter  only  one  injection  was  given 
daily  but  this  was  supplemented  by  tablets  or  one  heaping 
teaspoonful  of  the  powder  ,1  times  daily  mixed  with  cereal 
or  dissolved  in  milk.  The  pain  and  tenderness  subsided 
rapidly  and  no  opiates  were  required  in  the  majority  of 
cases.  Within  10  days  the  t.  had  returned  to  normal,  in 
2  to  .i  weeks  apparently  normal  conditions.  In  2  patients 
Bartholinian  abscess  developed;  but  acute  symptoms  sub- 
sided in  a  week  and  the  sac  was  easily  removed.  Three 
patients  subsequently  became  pregnant  indicating  that  gon- 
orrheal salpingitis  does  not  always  cause  occlusion  of  the 
fallopian    tubes. 

In  the  group  of  11  patients  with  subacute  infections  the 
patients  responded  the  same  except  for  the  somewhat 
greater  length  of  time  required.  Three  patients  developed 
arthritis  and  were  treated  with  gonococcus  vaccine  in  addi- 
tion to  calcium.  The  average  period  of  disability  was  re- 
duced one-half. 

In  the  group  of  P  chronic  infections  calcium  therapy  was 
apparently  less  effective  but  the  pain  subsided,  the  t.  re- 
turned to  normal  and  the  leucorrhea  was  greatly  reduced. 

In  the  7  postabortive  cases  the  results  of  calcium  therapy 


492 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1Q36 


resembled  closely  those  obtained  in  the  acute  and  subacute 
groups. 

Quite  apart  from  infections,  calcium  therapy  has  proved 
useful  in  metrorrhagia,  5  cases  of  which  have  been  success- 
fully so  treated.  Ten  c.c.  of  the  calcium  ampule  solution 
was  injected  daily;  this  was  supplemented  by  oral  dosage 
with  3  chocolate  tablets  or  a  heaping  teaspoonful  of  the 
granules  3  times  daily.  The  smallest  number  of  injections 
required  was  20  and  the  greatest  53. 

s.  M.  &  B. 

PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 
Pitt  County  Health  Officer 


The  Superintendent  of  Schools  and  the 
Health  Officer 

The  public  schools  will  open  in  September. 

Educators  now  admit  that  in  the  matter  of  educa- 
tion, health  comes  first.  It  it  be  true  that  in  educa- 
tion health  does  come  first,  then  the  matter  of  con- 
serving the  health  of  the  school  child  is  a  distinct 
challenge  to  the  superintendent  of  schools. 

There  is  another  officer  whose  function,  in  a  re- 
stricted sense,  is  as  truly  educational  as  is  that  of 
the  superintendent  of  schools;  this  is  the  local  health 
officer.  More  and  more  is  the  health  officer  be- 
ginning to  realize  the  truth  of  this  statement. 

I  am  not  asserting  that  the  health  instruction  of 
the  school  child  is  carried  on  solely  through  the 
superintendent  of  schools  and  the  health  officer. 
Such  a  statement  would  not  bear  the  light  of  in- 
vestigation, for  there  is  another  agency  in  every 
community  which  is  a  factor  of  even  greater  im- 
portance than  either  the  superintendent  of  schools 
or  the  health  officer.  It  is  the  family  physician. 
Not  only  does  the  family  physician  in  his  daily 
rounds  instruct  the  child  in  health  and  hygiene  mat- 
ters, but  even  in  a  more  positive  and  effective  way 
does  he  reach  the  child  through  the  instruction  of 
the  mother. 

Notwithstanding  the  fact,  however,  that  the  fam- 
ily physician  does  daily  spread  the  gospel  of  hy- 
giene and  preventive  medicine,  this  is  not  his  chief 
work.  His  chief  work  in  our  present  social  order 
is  the  cure  of  disease  rather  than  instruction  in  its 
prevention.  In  other  words,  health  instruction  is, 
at  present,  an  auxiliary  service  of  the  family  physi- 
cian, a  service  for  which  he  cannot  charge;  while 
in  the  case  of  the  health  officer,  not  only  is  he  paid 
for  it  but  it  constitutes  his  chief  work. 

As  with  the  health  officer,  so  also  is  it  with  the 
superintendent.  And  we  are  ready  to  assume  that, 
if  the  question  were  put  squarely  up  to  the  super- 
intendent of  schools,  he  would  readily  admit  that 
health  education  should  be  the  primary  object  in 
all  school  instruction. 

But  when  it  comes  to  organizing  a  health  pro- 
gram and  carrying  it  out  in  the  school,  the  super- 


intendent must  rely,  largely,  on  his  teachers.  And 
right  here,  generally  speaking,  we  reach  the  weakest 
link  in  the  whole  chain  of  health  instruction.  Few 
teachers  have  been  sufficiently  trained  for  teaching 
health  and  hygiene.  To  carry  on  health  education 
effectively,  the  teacher  must  not  only  know  how  to 
correlate  health  instruction  with  the  other  subjects 
in  the  curriculum;  she  must  know  how  to  present 
the  matter  in  an  interesting  and  attractive  way. 

We  have  long  believed  that  the  average  teacher 
training-school  or  teacher  college  sends  the  teacher 
out  very  poorly  prepared  to  teach  the  fundamentals 
of  health.  And  to  make  a  bad  matter  worse,  those 
who  are  prepared  find,  as  a  rule,  that  the  daily 
program  allots  so  little  time  to  health  and  hygiene 
that  she  cannot  teach  the  subject  of  health  effect- 
ively. 

It  is  the  writer's  opinion  that  the  credit  for  what 
progress  we  are  making  in  teaching  health  to  the 
people  as  a  whole  is,  to  a  large  extent,  due  to  the 
instruction  the  people  receive  through  the  family 
physician.  But  it  is  also  the  writer's  opinion  thSt 
if,  when  the  superintendent  of  schools  is  employing 
a  teacher,  he  makes  her  ability  to  teach  health  a 
prerequisite  to  her  employment,  we  will  then  see  a 
new  day  dawn  in  the  advancement  of  public  health, 
for  the  school  is  unquestionably  the  greatest  edu- 
cational force  in  the  world. 

To  summarize,  we  believe  that  the  improvement 
in  public  health  is  dependent  upon  education.  We 
believe  there  are  three  great  potential  sources  of 
Ihis  education,  the  family  physician,  the  school  and 
the  health  department.  We  believe  that,  of  the 
three,  the  family  physician  is,  at  present,  accom- 
plishing most  in  this  direction.  We  also  believe 
that  the  average  superintendent  of  schools  and  the 
average  health  officer  are  falling  far  short  of  their 
opportunity  along  this  line.  We  also  believe  that 
if  the  superintendent  of  schools  and  the  health  of- 
ficer would,  together,  make  up  a  health  program 
for  the  schools  and  cooperate  fully  in  putting  this 
program  into  effect,  it  would  improve  health  instruc- 
tion in  such  a  way  as  to  cause  preventive  medicine 
to  go  forward  by  leaps  and  bounds. 

If  the  reader  is  in  sympathy  with  this  article,  may 

I  suggest  that  he  make  inquiry  of  his  own  health 

officer  or  superintendent  of  schools  and  learn   in 

what  way  they  are  cooperating  in  formulating  and 

executing  a  health  program  for  the  public  school. 

s.  M.  &  B. 

HiCH-SuLPHUR   Low-Carbohydrate  Diet  in   Arthritis 

(J.   C.    Forbes,   R.   C.    Neale,   O.   L.    Hite,    D.    B.   Armistead 

&   S.    L.   Rucker,   Richmond,  in  Jl.    Lab.   &  Clin.    Med., 

July) 

Diet:  Meats,  5%  vegetables,  2  large  oranges,  tomatoes, 
or  one  grapefruit  or  its  equivalent  dally;  no  sweets,  bread 
limited  to  3  slices  of  toast  daily,  at  least  1  qt.  of  milk  or 
buttermilk  daily,  no  alcohol. 


September,  193(5 


SOUTHERN  MEDICINE  AND  SURGERY 


On  high-protein  low-carbohydrate  diet  patients  with 
chronic  arthritis,  definite  improvement  in  the  majority  of 
cases,  the  best  results  being  obtained  in  those  patients  with 
rheumatoid  arthritis.  Especially  good  results  were  obtained 
in  \oung  individuals  in  early  stages  of  the  disease.  Co- 
incident with  improvement,  the  indoluria  which  almost 
invariably  accompanied  the  disease  in  its  active  stages, 
diminished  and  finally  disappeared.  It  is  suggested  that 
indole  is  causally  related  to  chronic  arthritis,  and  that 
diets  rich  in  sulphur  aid  in  the  detoxification  of  indole 
with  consequent  clinical  improvement  in  the  condition. 
s.  M.  &  s. 

HOSPITALS 

R.  B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  Editor,  Greensboro.N.  C. 


Visiting  Hours 

X'isiTiNG  hours  are  fort-the  benefit  and  welfare 
of  the  patient.  The  sooner  the  well  people  of  the 
community  realize  and  appreciate  this  fact  the 
better  it  will  be  for  all  parties  concerned.  They 
concern  the  nursing  staff,  the  attending  physicians 
and  the  dietary  department,  and  so  these  hours 
should  be  chosen  with  all  of  these  services  in  mind, 
not  forgetting,  of  course,  the  convenience  of  the 
community. 

Visiting  hours  should  not  conflict  with  the  nurs- 
ing service,  especially  the  morning  and  evening 
treatments  and  baths.  If  visitors  begin  coming  in 
before  baths  are  given,  the  nurses,  in  an  effort  to 
please  both  patients  and  visitors,  hurry  through 
their  work,  and  many  times  it  is  not  done  prop- 
erly. Further,  the  proper  time  is  not  spent  mas- 
saging backs  and  giving  other  treatments  which 
usually  come  in  the  morning  from  7  to  10.  The 
visitors  lose  valuable  time  while  waiting  on  the 
outside  of  the  room  for  the  nurses  to  complete  their 
work.  This  they  do  not  come  to  the  hospital  to 
do  and  are  not  pleased  when  they  are  kept  waiting 
longer  than  a  few  minutes. 

The  patient  who  has  not  received  a  good  bath,  a 
good  rub  down  and  a  complete  head  and  face  toilet 
will  not  begin  the  day  with  the  same  amount  of 
comfort  and  satisfaction  that  one  does  who  has 
received  these  things. 

When  the  attending  physician  makes  his  rounds 
it  is  desirable  that  he  be  able  to  see  his  patients, 
inquiring  into  their  general  welfare  and  specifically 
as  to  any  pain  they  may  be  suffering.  Also  he 
wishes  to  know  if  the  hospital  service  is  satisfac- 
tory. It  is  a  strange  thing  that  patients  so  reluct- 
antly confide  in  their  physician  on  this  point.  They 
will  tell  him  all  of  their  family  secrets  without 
hesitation,  and  I  do  not  understand  why  it  is  so 
hard  to  get  them  to  tell  about  the  hospital  service 
when  it  is  not  satisfactory.  For  this  reason  it  is 
very  essential  that  the  patient  have  nothing  to 
prevent  him  or  her  from  giving  this  information, 
and  visitors  will,  of  course,  absolutely  prevent  this 


opportunity. 

If  dressings  are  to  be  done  they  can  be  much 
more  quickly  applied  when  the  room  does  not 
have  to  be  cleared  of  visitors. 

It  is  well  known  that  meals  are  served  three 
times  a  day  in  the  hospitals,  and  arranging  visiting 
hours  so  as  not  to  conflict  with  the  serving  of 
meals  and  clearing  away  of  trays  is  a  great  help 
to  the  dietary  department.  As  a  general  rule  pa- 
tients need  to  be  quiet  and  relaxed  when  they  eat. 
They  masticate  their  food  much  better  when  there 
are  no  visitors  to  carry  on  a  conversation  with.  If 
anything  is  wrong  with  the  food  the  patients  will 
always  tell  the  visitors,  but  almost  never  will  they 
complain  to  the  dietitian. 

Maids  can  clear  tKe  trays  from  the  room  with  a 
great  deal  more  ease  when  they  do  not  have  to 
fall  over  the  feet  of  visitors.  Most  housewives  do 
not  invite  guests  into  the  dining  room  during  the 
preparation  of  a  table  and  the  guests  are  usually 
invited  out  of  the  dining  room  before  the  dishes 
are  taken  away  and  the  table  cleared. 

Last  but  not  least,  a  "No  Visitors"  sign  in  most 
hospitals  commands  about  as  much  respect  as  a 
bantam  rooster  with  the  croup.  This  should  not 
be  so.  Someone  in  authority  has  placed  this  notice 
upon  the  door  with  the  welfare  of  the  patient  in 
mind.  No  sane  person  will  enter  a  room  with  a 
"No  Visitor"  sign  on  the  door  if  he  will  stop  for 
30  seconds  and  consider  why  the  sign  was  placed 
there.  The  trouble  lies  in  the  fact  that  they  will 
not  stop  long  enough  to  think. 

As  stated  in  the  beginning  paragraph  of  this 
article  visiting  hours  are  designated  for  the  benefit 
and  welfare  of  the  patient  and,  when  the  visiting 
public  realizes  this,  patients  will  recover  much 
quicker  and  easier. 

There  may  be  times  when  the  rule  of  visiting 
hours  has  to  be  temporarily  altered  for  a  visitor, 
but  such  visiting  privileges  should  be  granted  only 
when  the  superintendent  or  someone  in  authority 
has  passed  upon  the  merits  of  the  case. 


-S.   M.    &   B.- 


CARDIOLOGY 

"Clyde  M.  Gllmore,  A.B.,  M.D.,  Editor,  Greensboro,  N.  C. 


Two  Problems  in  the  Management  of  Coro- 
nary Disease 

There  seems  to  be  general  agreement  now  as 
to  the  criteria  of  diagnosis  of  coronary  disease  and 
the  management  is  practically  the  same  everywhere 
except  for  the  answers  to  the  following  questions: 

1.  What  must  I  tell  the  patient  as  to  his  con- 
dition? 

2.  What  shall  be  done  with  focal  infection? 


494 


SOUTHERN  MEDICINE  AND  SURGERY 


September.   1Q,?6 


This  is  best  illustrated  by  the  following  typical 
case: 

A  merchant,  aged  54,  had  a  dull  ache  in  his 
upper  chest  after  walking  up  hill,  especially  severe 
after  eating,  and  gradually  he  came  to  require  two 
or  three  pillows  for  comfort  and  sleep.  His  ankles 
were  slightly  swollen  in  the  evenings,  his  breath 
short  after  exertion.  He  reported  to  his  local  phy- 
sician who  advised  him  to  stop  work  for  a  month 
and  rest  most  of  the  time,  and  gave  him  a  prescrip- 
tion but  did  not  give  a  diagnosis,  merely  mention- 
ing a  run-down  condition.  The  physician,  how- 
ever, advised  the  family  that  he  had  a  heart  con- 
dition which  information  was  withheld  from  the 
patient. 

To  obtain  the  rest  advised  a  daughter  in  an- 
other town  was  paid  a  visit.  Becoming  apprehen- 
sive over  his  symptoms  the  daughter  insisted  that 
her  physician  be  consulted.  After  examination  a 
diagnosis  of  "vascular  disturbance"  with  "failing 
circulation'  was  given,  with  advice  that  several 
abscessed  teeth  and  infected  tonsils  should  be  re- 
moved at  once,  further  that  he  go  to  the  hospital 
and  remain  there  for  a  prolonged  stay.  Privately 
the  daughter  was  informed  that  anything  done  to 
this  patient  was  attended  by  serious  dangers. 

Apprehensive  over  the  difference  between  the 
advice  of  Dr.  A  and  Dr.  B,  a  family  conference 
decided  to  request  his  family  physician  to  send 
him  to  a  specialist  in  Philadelphia.  After  a  long 
and  thorough  study  this  specialist  said  the  patient 
had  coronary  heart  disease  with  angina  pectoris, 
that  he  should  retire  from  business  and  should  have 
a  few  weeks  absolute  rest,  also  that  though  he 
showed  evidence  of  infection  around  teeth  and  in 
tonsils  he  should  emphatically  not  have  the  tonsils 
removed  and  that  all  teeth  should  remain  in  situ 
unless  local  symptoms  made  extraction  imperative- 
ly necessary. 

This  case  history  is  given  entirely  from  the  pa- 
tient's viewpoint  as  reported  to  me.  His  state  of 
mind  when  he  came  to  see  me  a  month  after  the 
beginning  of  his  illness  can  be  imagined.  From 
his  viewpoint  he  had  consulted  three  of  the  best 
men  he  knew  and  he  had  been  told: 

By  Dr.  A,  that  what  he  needed  was  a  month's 
vacation ; 

By  Dr.  B,  that  what  he  needed  was  a  prolonged 
stay  in  the  hospital  with  removal  of  teeth  and  ton- 
sils; 

By  Dr.  C,  that  what  he  needed  was  to  retire 
from  business  and  lead  the  life  of  an  invalid  and 
that  his  teeth  and  tonsils  must  not  be  removed. 

After  his  visit  to  the  first  doctor  he  felt  that 
his  condition  was  due  to  overwork  and  that  all  he 
needed  was  a  rest;  after  his  visit  to  the  second  doc- 
tor he  felt  his  condition  was  due  to  poison  from 


infection  and  that  removal  of  sources  of  infection 
would  cure  him;  after  his  visit  to  the  third  doctor 
he  felt  that  the  end  was  near  and  it  was  too  late 
to  do  anything.  By  that  time  his  fears  and  appre- 
hensions were  giving  him  more  trouble  than  the 
original   condition. 

It  is  fully  realized  that  had  this  patient  simply 
followed  the  advice  of  his  family  physician  he 
would  have  been  much  better  off  all  the  way 
through;  but  few  patients  go  through  a  chronic 
illness  such  as  coronary  disease  without  for  some 
reason  or  other  consulting  several  doctors  in  the 
course  of  their  illness;  hence,  the  disagreement  of 
the  medical  profession  about  what  to  tell  the  pa- 
tient and  what  to  do  about  focal  infection  becomes 
an  added  factor  for  apprehension  on  the  part  of 
most  patients  with  this  disease. 

Northington,  of  Charlotte,  suggests  (see  edito- 
rial Southern  Medicine  &  Surgery,  July,  1936): 
"Before  telling  the  patient  anything  be  sure  your 
diagnosis  is  correct  both  as  to  the  anatomical  lesion 
and,  what  is  more  important,  whether  or  not  t"his 
has  resulted  in  functional  impairment."  The  last 
two  paragraphs  of  this  editorial  are  so  pertinent  to 
this  subject  that  although  published  two  months 
ago  in  this  same  journal  I  feel  the  contents  justify 
repeating: 

"Finally  (and  this  may  have  been  what  was  in 
the  mind  of  the  doctor  responsible  for  this  expres- 
sion), there  is  the  problem  of  how  much  we  are  to 
tell  patients  we  know  to  have  heart  disease.     My 
opinion  is  that  it  is  best  to  tell  any  patient  of  aver- 
age sense,  afflicted  with  a  chronic  disease,  the  full  i 
facts  so  far  as  we  know  them.     The  attempt  to ' 
withhold  anything  of  consequence  will  almost  cer- 
tainly fail  of  its  object,  and  the  main  result  will 
be  loss  of  confidence  in  his  doctor — maybe  all  doc-J 
tors.     History  goes  to  show  that  apprehension  of 
disaster  weighs  heavier  on  the  mind  than  does  its  i 
certainty.     Jailers  say  prisoners  sleep  much  better 
the  night  before  they  are  to  be  hanged  than  they ' 
do  the  night  before  they  are  to  be  tried.     The 
German   submarine   crews   mutinied   after   a   few ' 
months  during  which  no  report  came  back  of  the 
ships  that  went  out  and  were  swallowed  up  in  i 
silence.     The  British  Admiralty  knew  its  psychol- 
ogy- 

"On  the  other  hand,  the  ninety-and-nine  can 
bear  with  astonishing  equanimity  the  most  appall- 
ing news,  when  it  is  broken  by  a  doctor  in  whose 
head  and  heart  they  have  confidence,  and  when, 
with  the  news,  goes  the  assurance  that  the  doctor 
will  stand  by.  And  every  doctor  should  be  satur- 
ated with  the  conviction  that  a  good  doctor  can  do 
something  valuable  for  a  patient  as  long  as  breath 
remains,  and  every  doctor  who  gives  his  orders  on 
the  principle  that  everything  a  patient  enjoys  is 


September,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


49S 


bad  for  him  and  everything  he  detests  is  good  for 
him  should  quit  the  practice  of  medicine.  If  your 
patient  enjoys  fishing,  let  him  go  fishing.  You 
don't  know  when  he  is  going  to 'die  and,  if  he 
should  die  on  the  trip,  one  place  is  as  good  as 
another  as  a  starting-point  for  Heaven.  There  is 
no  sense  in  the  prescription : 

All  those  things  that  you  don't  do,  do. 
And  the  things  that  you  do  do,  don't." 
In  an  effort  to  get  the  answers  to  these  two 
questions  standardized  I  wrote  to  several  prominent 
physicians  in  the  State  and  asked  them  to  give  me 
their  answers  to  these  two  questions,  which  I  shall 
attempt  to  summarize  in  next  month's  issue. 


ORTHOPEDIC  SURGERY 

John  Stuart  Gaul,  M.D.,  Editor,  Charlotte,  N.  C. 


Flat  Feet — Painful  Feet 

Various  doctors  give  different  names  to  condi- 
tions that  simulate  what  the  laity  are  pleased  to 
designate  as  fiat  feet.  Among  these  terms  are 
fallen  arches,  pronated  feet,  valgus  foot,  foot  strain, 
depressed  longitudinal  or  transverse  arches  and 
foot  sprain. 

As  a  matter  of  fact  persons  in  this  group  are 
suffering  with  painful  feet  and  legs  because  of 
weight-bearing  stresses  in  them  due  to  improper 
distribution  of  the  weight  through  the  legs  and 
feet. 

Nature  has  provided  that  the  weight  should  be 
taken  on  a  triangular  base,  with  the  weight  prac- 
tically in  the  center  of  the  triangle  so  as  to  be 
adequately  distributed  throughout  the  triangle.  In 
addition  to  this,  it  is  provided  the  weight  should 
be  distributed  through  this  triangle  by  trusses  su- 
perimposed on  the  triangle.  This  triangle  is  de- 
limited by  a  line  passing  from  the  tubercle  of  the 
OS  calcis  to  the  heads  of  the  first  and  fifth  meta- 
tarsal bones  respectively;  and  by  a  line  passing 
from  the  first  to  the  fifth  metatarsal  heads.  Super- 
imposed on  these  are  the  longitudinal  arches 
formed  on  the  medial  side  of  the  foot  by  the  os 
calcis,  astragalus,  scaphoid,  internal  cuneiform  and 
first  metatarsal  bones;  and  on  the  outside  of  the 
foot  by  the  os  calcis,  the  cuboid  and  the  fourth 
and  fifth  metatarsal  bones.  In  addition,  there  is 
the  anterior,  or  transverse,  arch,  made  by  the  heads 
of  the  metatarsal  bones.  It  is  also  provided  thai 
this  entire  trussed  triangle  should  be  movable 
within  certain  limits.  This  movement  is  accom- 
plished by  the  long  plantar  muscles,  the  chief  of 
which  are  the  posterior  tibial  and  peroneus  longus. 
The  principal  function  of  the  posterior  tibial  acting 
with  the  other  long  flexors  is  to  lift  the  longitudi- 


nal arch.  The  principal  function  of  the  long  pero- 
neal is  to  depress  the  head  of  the  first  metatarsal 
and  at  the  same  time  to  lift  the  anterior  arch.  In 
addition  to  these  movements  the  astragalus  rocks, 
and  the  scaphoid  and  the  forward  part  of  the  foot 
move  inward.  The  anterior  tibial  is  an  opponent 
of  the  long  peroneal  and  does  lift  the  arch  to  clear 
the  toes  from  the  floor. 

With  this  understanding  of  the  physiology  of 
the  foot  we  can  seek  the  causes  of  painful  and 
flat  foot. 

General  conditions  such  as  arthritis,  vascular 
disturbances  occurring  in  diabetes,  Raynaud's  dis- 
ease, Buerger's  disease  and  syphilis;  and  local  con- 
ditions such  as  osteoporosis,  osteomyelitis,  perios- 
titis, bone  cysts,  spur  formation,  fractures,  sprain 
fractures,  bursitis  and  tenosynovitis  must  be  ruled 
out. 

Given,  then,  a  patient  whose  feet  are  seen  to 
be  flattened,  with  the  tendency  to  walk  on  the 
inner  surface  and  complaining  of  pain  through  the 
instep  and  just  in  front  of  the  internal  malleolus, 
without  any  of  the  conditions  enumerated  above, 
in  all  probability  the  cause  lies  in  unusual  stress 
on  the  peroneus  longus,  the  posterior  tibial  and 
at  times  on  the  long  flexors  of  the  toes;  or,  be- 
cause of  the  failure  of  these  muscles  to  function, 
too  much  rocking  is  taking  place  in  the  midtarsal 
joint,  or  in  the  articulation  of  the  astragalus  with 
the  tibia  and  fibula.  Again,  it  may  be  due  to  too 
much  torsion  taking  place  in  the  midtarsal  joints. 
These  are  the  factors  which  must,  in  the  vast 
majority  of  patients,  be  corrected  to  give  relief. 

If  there  is  burning  pain  in  the  forefoot  and 
cramping  in  the  toes — principally  the  third  and 
fourth  and  extending  back  into  the  foot — we  are 
dealing  with  a  nietatarsalgia  due  to  the  failure  of 
the  peroneus  longus  to  pull  down  the  head  of  the 
first  metatarsal  and  lift  the  heads  of  the  remaining 
metatarsals  from  the  metatarsal  filaments  of  the 
external  plantar  nerve. 

In  some  cases  the  shifting  of  the  os  calcis  out- 
ward permits  excessive  rocking  in  the  midtarsal 
joint,  the  scaphoid  also  being  thrown  inward,  pro- 
ducing unusual  strain  in  this  joint. 

We  find  two  types  of  this  so-called  flat  foot — 
the  rigid  and  the  relaxed.  The  rigid  foot  results 
from  trauma  over  a  period  of  time  which  event- 
ually produces  fibrosis  in  the  ligaments  of  the 
tarsal  and  tarsometatarsal  joints,  the  foot  being 
held  constantly  in  the  flat  foot  position;  and  of 
course  the  muscles  named  above  have  ceased  to 
function  because  of  the  rigidity. 

Other  conditions  causing  painful  feet,  often  as- 
sociated with  the  flat  foot,  often  resulting  from  the 
flat  foot,  but  in  no  way  the  cause  of  the  flat  foot, 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


are  corns,  calluses,  bunions,  hallux  valgus,  hallux 
rigiditus  and  hammer  toe.  These  are  obvious  and 
when  present  should  result  in  a  search  for  their 
cause. 

The  treatment  of  painful  feet,  obviously,  is  not 
a  simple  matter.  A  painstaking  search  for  the 
imderlying  factor  is  necessary.  Shoes  play  a  large 
part  in  bringing  about  these  mechanical  changes; 
improper  walking  and  gait  play  a  part ;  short  stock- 
ings in  early  life  contribute;  also  excess  weight; 
or  a  prolonged  stay  in  bed — any  one  or  more  may 
be  essential  factors  in  the  production  of  painful 
flat  feet.  It  is  not  enough  to  tell  the  patient  to 
get  a  pair  of  arch  supports,  for,  too  often,  not  only 
is  this  a  makeshift,  but  the  condition  is  actually 
made  worse. 

The  problem  is  to  restore  as  nearly  normal  an- 
atomy and  physiology  as  is  possible.  In  the  rigid 
flat  foot  the  use  of  the  Davis  wrench  is  indicated 
to  get  the  foot  in  proper  anatomical  position.  With 
the  shifted  os  calcis,  particularly  in  the  adult,  an 
osteotomy  of  the  os  calcis  may  be  indicated  to 
get  the  heel  under  the  patient;  and  in  the  mark- 
edly relaxed  foot  the  Cotton  operation  may  be 
necessary,  carrying  the  scaphoid  attachment  of  the 
calcaneo-scaphoid  ligament   farther   forward. 

Fortunately  these  more  drastic  procedures  are 
necessary  in  only  a  minority  of  cases.  In  the 
greater  number  the  indication  is  to  support  the 
foot  temporarily  with  a  piano-felt  arch,  a  wedged 
Thomas  heel,  or  a  metatarsal  bar,  either  singly  or 
in  combination;  while  the  patient,  by  following 
instructions  in  exercises,  reestablishes  the  function 
of  the  long  plantar  muscles  to  maintain  balance  in 
the  foot. 

Corns,  calluses  and  bunions  are  best  treated  by 
attacking  the  underlying  cause.  Improp)erly  fitting 
shoes  should  be  discarded  for  shoes  with  a  broad 
but  not  too  high  heel,  with  a  proper  length  vamp, 
and  with  a  sole  to  extend  beyond  and  behind  the 
heads  of  the  first  and  fifth  metatarsal  bones. 

The  painful  foot,  with  cramping  of  the  toes,  is 
in  need  of  a  temporary  metatarsal  bar  until  the 
peroneus  longus  can  be  restored  to  its  function  in 
holding  up  the  anterior  arch. 

Hammer  toe  requires  special  operative  attack. 
Before  attempting  operative  procedure,  especially 
if  it  be  associated  with  an  unusually  high  instep, 
see  that  the  cause  does  not  lie  in  a  lesion  of  the 
central  nervous  system  such  as  a  syringomyelia. 

Hallux  valgus  and  rigiditus  may  or  may  not  re- 
quire operation  for  their  correction. 

Above  all,  it  is  essential  the  patient  be  interested 
in  his  condition,  and  his  cooperation  enlisted  if  an 
anatomical,  physiological  and  mechanical  restora- 
tion of  the  foot  is  to  be  accomplished. 


DERMATOLOGY 


The  Therapy  of  Eczema 
(Fred   Wise  &   Jack  V*/olf,  New  York,   in  Jl.    Lan.,   Aug.) 

Rest  in  bed  facilitates  the  proper  application  of  reme- 
dies and  may  remove  the  patient  from  sources  of  contact. 

The  successful  treatment  of  eczema  is  dependent  upon 
the  relief  of  its  most  distressing  symptom,  pruritus.  Drugs, 
such  as  benzocain,  which  relieve  pruritus  by  their  effect 
on  the  terminal  nerve  endings,  are  rather  frequent  sensi- 
tizers. We  perform  patch  tests  and  determine  the  patient's 
reaction  to  these  substances  before  prescribing. 

If  the  pruritus  is  at  all  pronounced  its  relief  must  be 
accomplished  by  the  use  of  general  sedatives — bromides, 
barbiturates,  salicylates,  carbamides. 

An  aid  to  the  treatment  of  severely  pruritic  eruptions  is 
the  use  of  the  ordinary  spUnt  to  prevent  the  bending  of 
wrist  and  elbow.  M.  times  even  the  lower  extremities  will 
require  splints.  Once  the  patient  has  learned  the  value  of 
the  splint  he  will  insist  on  it  to  prevent  scratching. 

In  general  we  advise  against  the  use  of  baths  in  the 
acute  and  subacute  processes.  In  the  dry  chronic,  infil- 
trated, extensive  cases  medicated  baths  add  much  to  the 
patient's  comfort. 

Except  for  the  cases  in  which  some  specific  food  »or 
foods  are  at  fault,  diet  plays  a  rather  small  part  in  treat- 
ment. Obstinate  cases  deserve  a  trial  with  the  salt-free 
diet. 

Diuretics  are  of  some  benefit  in  the  bloated,  obese  indi- 
vidual with  edematous  skin.  Potassium  nitrate  in  half 
gram  doses  is  useful.  One  to  1^/2  oz.  of  Glauber's  salts  in 
a  pint  of  warm  water,  in  the  morning,  and  during  the  day 
only  liquids  without  any  food  value,  water  and  fruit  juices; 
the  following  day  the  regular  diet  is  resumed. 

Cabinet  baths  are  especially  recommended  for  the  gener- 
alized, subacute  and  chronic,  dry,  infiltrated  eczemas. 

With  intravenous  administration  of  calcium,  sodium  thio- 
Eulphate  and  10%  strontium  bromide  in  glucose  solution 
and  typhoid  vaccine,  our  own  experience  has  been  dis- 
appointing. Injections  of  the  patient's  own  blood,  turpen- 
tine and  various  forms  of  milk  have  sometimes  proved 
effective. 

Start  with  the  weaker  remedies  and  gradually  proceed 
to  the  stronger.  The  first  signs  of  intolerance  call  for  a 
return  to  a  milder  remedy. 

The  patient  should  be  instructed  minutely  in  every  de- 
tail; advised  to  massage  (if  indicated)  the  salve  into  the  ■ 
affected  area  for  several  minutes  by  the  clock,  to  apply  a 
liberal  layer,  to  cleanse  the  area  with  olive  oil  before  each  ' 
application,  and  wherever  possible  to  bandage  the  affected 
part.  Wet  dressings  must  be  kept  wet.  Lotions  are  to 
be  applied  often  and  liberally.  Once  daily,  the  caked  and 
crusted  lotion  should  b€  removed  by  sopping  the  part 
with  a  3%  aqueous  solution  of  boric  add  or  with  olive 
oil. 

In  the  acute  erythematous  and  vesicular  stage  wet  dress- 
ings are  cooling,  soothing,  anti-pruritic,  allow  for  drainage 
of  serum,  relieve  swelling,  and  give  the  patient  more  com- 
fort than  any  other  single  remedy.     Boric  acid  3%,  liquor  . 
alumini  acetatis  (N.F.)  diluted  1:10,  resordnol  2-4%,  tan- 
nic acid  2-5%,  salicylic  acid  2% — are  all  effective  and  sat-  • 
isfactory.     In    impetiginized    eczema     resorcin     2-4%,     or 
1:2000  solution  bichloride  of  mercury  should  be  used  for 
their  bactericidal  powers.     Silver  nitrate  Vs-]47o,  does  not  _ 
enjoy  sufficient  popularity  as  a  wet  dressing — but  for  the 
staining  qualities  which  preclude  its  use  on   exposed  por- 
tions of  the  body,  it  would  be  the  wet  dressing  of  choice; 
it  is  to  be  highly  recommended.     Wet  dressings  should  be 


September,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


497 


bandaged  wherever  practicable  and  kept  wet  until  the  dry, 
scaly  stage  is  reached.  Cellophane  acts  as  an  excellent  pro- 
tective covering  for  a  wet  dressing. 

Lotions  and  pastes  are  prescribed  when,  for  one  reason 
or  another,  a  v.'et  dressing  is  not  deemed  advisable.  The 
following  are  recommended: 

1)  Liquor  Burowi  IS,  Zinc  Oxide  &  Talc  aa  30,  Glycer- 
ine 24,  Aqua  calcis  ad  120. 

2)  Calamine  Lotion — Calamine  12,  Zinc  oxide  IS,  Glycer- 
ine 12,  .^qua  calcis  IS,  Aqua  rosae  ad  120. 

3)  Bismuth  subnitrate  30,  Zinc  oxide  60,  Olive  oil  & 
Liquor  calcis  aa  ad  240. 

4)  Zinc  oxide.  Talc,  Glycerine,  Aqua  calcis — v.  s. 

5)  Zinc  oxide  25,  Talc  2S,  01.  Olivae  SO. 

6)  Burow's  Paste— Liquor  Burowi  10,  Lanolin  anhydrous 
20,  Lassar's  paste  30. 

In  the  dry  desquamative  stage  a  bland  ointment  such  as 
boric  acid  (U.  S.  P.),  zinc  oxide  or  Lassar's  paste,  until 
there  is  a  return  of  the  skin  to  normal,  is  indicated. 

The  subacute  stage  we  are  partial  to  lotions.  Benzocain, 
5%,  and  menthol  ^s-H%  should  be  added  whenever  nec- 
essary to  control  the  pruritus. 

Superficial,  unfiltered,  x-ray  therapy  in  fractional  dosage 
is  a  useful  adjunct  in  the  treatment  of  subacute  eczema. 

Tar  is  the  most  important  and  reliable  single  agent  used 
in  the  treatment  of  chronic  eczema.  Lichenification  and 
thickening  require  ointments.  The  addition  of  saUcylic 
acid  3-10%  and  resorcin  4%  to  10%  promotes  the  effects 
of  tar  by  their  keratolytic  action. 

In  those  cases  which  do  not  yield  to  tar,  chrysarobin 
(fresh)  is  strongly  recommended.  The  patient  should  be 
warned  against  the  transference  of  chrysarobin  to  the  eyes: 
severe  conjunctivitis  will  result. 

Frequently  x-ray  is  the  only  satisfactory  form  of  treat- 
ment, and  patches  which  have  resisted  topical  remedies  of 
all  kinds,  will  yield  to  4  or  S  weekly  exposures.  In  the 
acute  vesicular  dermatitis  of  the  extremities  with  swelling 
and  tension,  elevation  of  the  affected  extremity,  upper  or 
lower,  will  hasten  a  return  to  normal. 

In  the  subacute  and  chronic  eczemas  of  the  extremities, 
especially  the  lower,  the  application  of  Unna's  zinc  gelatin 
boot  will  bring  relief  and  promote  healing.  The  extremity 
is  encased  in  a  stockinette  bandage,  and  the  warmed,  liquid 
zinc-gelatin  mixture  (zinc  oxide  and  calamine  15  parts, 
gelatin  28,  glycerine  28,  water  28)  is  applied  directly  to 
the  stockinette  and  is  then  firmly  bandaged  with  the  ordi- 
nar>'  gauze  bandage. 

The  bandage  may  be  preceded  by  the  application  of  tar 
ointment  or  gentian  violet,  2%,  in  50%  alcohol.  The  latter 
is  useful  in  the  nummular,  vesicular,  crusting  patches  so 
often  found  on  the  extremities. 

Eczema  of  the  axillary  and  pubic  region  is  best  treated 
with  lotions  or  with  alcoholic-aqueous  solutions.  Salves 
in  these  areas  lead  to  an  annoying  folliculitis. 

The  eyelids  are  best  treated  with  wet  dressings  of  boric 
acid  solution  or  diluted  Burow's  solution.  In  the  cases 
with  dry,  scaly,  fissured  canthi  we  suggest  boric  ointment 
or  the  commonly  used  1%  yellow  oxide  of  mercury  oint- 
ment. 

In  infantile  eczema  rest  must  be  assured,  with  the  ex- 
tremities tied  or  splinted  to  prevent  scratching  and  irrita- 
tion. Errors  in  diet  must  be  corrected.  Milk  or  some 
other  article  of  food  is  often  at  fault,  EUmination  of  a 
food  product,  boiling  the  milk,  addition  of  hydrochloric 
acid,  substitution  of  a  soy-bean  preparation  for  milk,  are 
all  helpful  measures.  Ointment  of  2  parts  of  zinc  oxide  and 
crude  co;il  tar,  and  16  parts  each  of  starch  and  paraffin, 
offers  the  best  results.  The  tar  and  zinc  oxide  are  mixed, 
the  starch  and  paraffin  are  mixed  and  then  these  2   com- 


binations are  thoroughly  mixed.  If  a  distilled  crude  coal 
tar  product  is  used  the  folliculitis  which  commonly  follows 
the  ordinary  crude  coal  tar  will  be  prevented.  The  salve 
should  be  thoroughly  applied  and  then  covered  with  a 
mask.  A  mild  infantile  eczema  will  often  yield  to  treat- 
ment with  10%  naftalan  in  zinc  oxide  ointment. 


HUMAN  BEHAVIOR 

Jamm  K.  Hall,  M.D.,  Editor,  Richmond,  Va. 


Lawyers  and  Liquor 

'Way  back  towards  the  beginning  of  the  present 
century  the  General  Assembly  of  North  Carolina 
enacted  a  prohibition  law,  and  the  act  was  popu- 
larly referred  to  by  the  name  of  the  legislator  who 
formulated  the  act  and  brought  about  its  adoption 
— Colonel  Alston  Davidson  Watts.  In  making  the 
state  dry,  legally,  the  Colonel  was  making  whiskey 
inaccessible  to  himself  as  well  as  to  others,  for 
resort  to  its  use  had  frequently  caused  him  em- 
barrassment and  suffering.  In  fighting  for  prohibi- 
tion legislation,  therefore,  Colonel  Watts  knew  what 
he  was  doing.  He  was  always  a  realist.  Even 
when  experiencing  the  effect  of  spirits  the  Colonel 
exhibited  little  sense  of  humor.  His  world  was 
occupied  by  facts.  He  knew  much  about  the  con- 
sequences of  alcohol  as  a  beverage  both  upon  him- 
self and  upon  others.  He  was,  therefore,  unusually 
well  qualified  by  frequent  disastrous  personal  ex- 
perience to  discuss  liquor  legislation  in  all  its 
phases.  The  Watts  Law  was  an  early  prohibition 
law  in  North  Carolina. 

Colonel  Watts  was  fundamentally  a  politician. 
He  liked  everything  associated  with  political  life. 
Interest  in  politics  kept  his  spacious  mind  busy. 
He  had  little  desire  to  occupy  political  office,  but 
he  enjoyed  selecting  and  designating  others  for  high 
office.  I  suppose  that  with  him  political  activity 
took  the  place  of  golf  and  tennis  and  fishing  and 
hunting  and  generally  of  poker.  He  had  a  power- 
ful mentality,  and  the  most  roomy  and'  tenacious 
memory  I  have  ever  known.  Some  of  his  own 
qualities  he  did  not  admire,  but  he  was  always 
candid  and  truthful  and  no  one  ever  charged  him 
with  hypocrisy.  He  was  one  of  the  most  intellectual 
men  I  have  known,  and  the  scope  and  the  variety 
of  his  knowledge  were  astounding.  Yet  many,  to 
the  day  of  his  death,  thought  him  only  a  small 
politician.  Even  though  he  were  looking  from  the 
celestial  portico  down  upon  me  as  I  write  these 
lines  the  Colonel  would  not  shake  his  head  in  dis- 
approval, because  he  knew  of  my  affection  for  him, 
and  of  my  admiration  for  his  intellectual  capacity. 

Colonel  Watts  will  not  be  a  member  of  the 
Liquor  Commission,  recently  appointed  in  response 
to  legislative  mandate,  by  John  Christoph  Blucher 


498 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  l')i6 


Ehringhaus,  Governor  of  North  Carolina,  because 
Colonel  Watts  is  dead.  And  that  is  a  pity,  for 
North  Carolina  has  missed  him  every  second  since 
he  died.  He  had  more  sense  than  anybody  I  have 
personally  known  in  public  life  in  North  Carolina 
or  elsewhere.  Emotional  and  new-thought  legisla- 
tion was  as  distasteful  to  him  as  attendance  upon 
an  August  campmeeting  in  upper  Iredell  would  be 
to  the  Bishop  of  London.  He  had  too  much  in- 
telhgence  to  permit  himself  to  be  inveigled  into 
senseless  attempts  at  political  purifications  and 
moral  and  civic  upliftings.  But  Governor  Ehring- 
haus has  organized  a  Liquor  Commission  of  seven 
members.  I  may  seem  to  be  speaking  of  a  spiritual 
body  irreverently  by  not  making  use  of  its  proper 
legislative  name.  But  I  do  not  know  its  right  name. 
But  the  function  of  the  Commission  is  to  investi- 
gate the  alcoholic  situation  in  North  Carolina  for 
the  purpose  of  becoming  able  to  advise  the  next 
meeting  of  the  General  .'\ssembly  what  legislation 
to  adopt  with  reference  to  the  distribution,  sale 
and  consumption  of  alcohol  as  a  beverage.  Both 
because  he  is  a  lawyer  himself  and  because  he 
knows  also  that  the  next  legislature  will  be  dom- 
inated by  lawyers,  Governor  Ehringhaus  named  five 
lawyers  to  the  Commission  of  seven.  One  of  the 
other  members  is  a  business  man,  perhaps  a  banker, 
and  the  other  is  a  newspaper  editor.  I  think  it 
remarkable  the  Governor  did  not  designate  lawyers 
for  all  seven  of  the  places. 

But  why  should  so  many  of  the  members  be 
lawyers?  Alcohol  is  a  poison,  and  a  deadly  poison. 
I  have  not  the  slightest  doubt  that  its  use  kills  and 
maims  more  mortals  than  any  other  single  poison. 
There  is  a  science  that  deals  with  poisons.  The 
science  is  known  as  toxicology.  Chemists  and  phar- 
macologists and  physicians  and  certain  criminolo- 
gists and  some  teachers  and  sociologists  have  scien- 
tific and  practical  knowledge  of  the  effect  of  alcohol 
upon  the  human  being  when  alcohol  is  used  as  a 
beverage.  Why  did  not  the  Governor  name  some 
scientists  to  such  an  important  Commission?  I  do 
not  know  that  any  member  of  the  Commission  has 
had  personal  experience  with  the  use  of  alcohol.  I 
doubt  it.  The  Governor  could  not  use  as  a  wntness 
in  court  the  opinion  about  alcohol  of  a  single  one 
of  them.  The  members  of  the  Commission  are  ap- 
parently being  called  upon  to  do  something  about  a 
problem  which  they  know  nothing  about. 

Had  the  Governor  been  authorized  to  organize  a 
commission  to  evaluate  the  state  constitution  and 
to  suggest  changes  in  it,  does  any  member  of  the 
congregation  suppose  that  he  would  have  named  on 
the  Commission  any  save  lawyers?  I  evolve  an 
explanation  of  the  Gubernatorial  action.  Lawyers 
are  called  upon  to  give  counsel  about  so  many 
things  it  is  easy  enough  to  suppose  that  a  lawyer 


eventually  believes  himself    to    be    capacitated    to 
offer  an  opinion  or  advice  about  anything. 

Here  in  the  ancient  Commonwealth  of  Patrick 
Henry  and  Thomas  Jefferson,  and  George  Campbell 
Peery  separated  from  those  two  eminent  Guberna- 
torial predecessors  by  much  more  than  a  mere  cen- 
tury or  so,  the  state's  Liquor  Monopoly  is  managed 
entirely  by  a  board  of  three  referred  to  briefly  by 
the  abbreviations:  A.  B.  C,  which  may  be  a  con- 
traction of  the  full  title — .'\lcohol  Beverage  Con- 
trol Board.  Of  this  Board  of  three  two  are  law- 
yers, and  the  third  is  a  dealer  in  paints,  .^nd  I 
doubt  if  any  single  member  of  the  Board  has  any 
more  scientific  knowledge  of  alcohol  than  I  have, 
for  instance,  of  the  flora  of  New  Zealand.  .A,t  a 
public  hearing  before  the  A.  B.  C.  Board  I  once 
heard  the  former  Chairman  remark  that  no  one 
could  know  less  about  alcohol  than  he  knew  about 
it.  What  would  have  been  the  public  thought  had 
the  President  of  the  Supreme  Court  of  the  Com- 
monwealth remarked  that  he  knew  nothing  about 
the  laws  of  the  state;  and  if  the  Commissioner  of 
Health  had  confessed  that  he  knew  nothing  about 
medicine?  How  may  one  e.xp>ect  intelligent  and 
helpful  legislation  about  the  alcoholic  situation 
unless  the  problem  be  studied  by  those  who  already 
know  something  about  it,  and  who  are  fitted  and 
inclined  by  training  to  learn  more  about  it,  and 
who  are  interested  in  it  as  a  health,  economic  and 
civic  scourge,  and  not  as  a  political  plaything? 

The  outlook  for  Democracy  is  gloomy  because 
Democracy  exists  by  the  forbearance  of  the  ma- 
jority, and  the  majority  are  not  intelligent.  I  infer 
that  the  so-called  political  liquor  liberals  in  North 
Carolina  hof>e  to  formulate  legislation  so  wise  that 
it  will  simultaneously  stop  whiskey  drinking  and 
so  enrich  the  public  treasury  that  the  state's  sale 
tax  can  be  abolished.  And  why  not?  Did  I  not 
lately  read  that  the  State  of  Virginia,  within  a 
given  period,  perhaps  a  year,  had  derived  enough 
revenue  from  the  state's  sale  of  alcoholics  to  make 
possible  the  allocation  to  every  person  in  the  state 
of  fifty  cents,  one  half-dollar?  The  resort  to  the  , 
simplest  mathematics  and  the  diplomatic  advocacy  . 
of  the  increasing  consumption  of  alcoholics  would 
eventually  enable  the  Commonwealth  of  Virginia  to 
live  on  the  liquor  tax  alone.  And  how  could  the 
citizen  be  more  pleasantly  and  more  helpfully  pa- 
triotic than  by  the  generous  imbibition  of  imported 
state  liquor?  If  the  citizen's  constitution  should 
fail  him  in  his  high  civic  endeavor  surely  the  state 
would  ask  to  be  permitted  to  incise  on  his  head- 
stone: 

DULCE  ET  DECORUM— PRO  P ATRIA   MORI. 


Antivenin   for  treatment   in   cases  of  bite   of  the  black 
widow  spider  is  now  available. 


September,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


499 


Licensing  Lawyers  and  Doctors 

Within  the  last  two  or  three  months  a  number 
of  persons  have  been  licensed  by  the  proper  ex- 
amining boards  to  practice  law  and  to  practice 
medicine  in  North  Carolina.  I  have  read  the  offi- 
cial statement  that  of  the  64  who  took  the  medical 
examination  63  passed;  of  the  165  who  took  the 
law  examination  80  passed.  I  realize  that  doctors 
are  taught  to  save  and  not  to  kill,  and  that  many 
lawyers  apparently  have  no  objection  to  the  inflic- 
tion of  capital  punishment,  but  I  find  myself  won- 
dering why  the  slaughtering  has  so  suddenly  in- 
creased. Time  was,  and  not  so  long  ago,  when 
practically  all  applicants  for  license  passed  the 
legal  examining  board.  I  do  not  believe  that  appli- 
cants are  now  more  poorly  educated  academically 
and  in  the  law  than  formerly.  Must  one  infer  that 
the  legal  profession  has  been  asleep  to  its  duty  to 
the  public  until  the  last  year  or  two,  and  that  it 
has  just  discovered  that  its  principal  obligation  is 
to  see  to  it  that  only  well-trained  young  people 
shall  be  permitted  to  be  lawyers?  Or — is  the  legal 
profession  already  crowded?  Machiavelli  is  re- 
puted to  have  said  that  morality  springs  from  herd 
pressure.  IVIany  other  phenomema  may  also  be 
due  to  herd  pressure. 

I  wonder  how  many  members  of  the  legal  licens- 
ing board  could  pass  the  examination  the  board 
puts  up?  Were  a  State  Board  of  Medical  Exam- 
iners to  slaughter  half  the  applicants  as  a  result  of 
the  examination  I  do  not  doubt  that  there  would 
be  some  assaults  and  perhaps  a  homicide  or  so.  The 
graduates  of  a  first-class  medical  school  who  has 
good  character  and  a  good  academic  education 
should  be  permitted  to  practice  medicine  anywhere 
in  the  L'nited  States  without  further  examination. 

It  would  seem  that  the  legal  profession  should 
promptly  take  steps  to  prevent  so  much  slaugh- 
tering at  examination  time.  Hasn't  an  applicant 
of  good  character  with  an  academic  and  a  law 
degree  who  fails  to  secure  license  been  already  pro- 
scribed? Is  the  legal  profession  becoming  union- 
ized? Is  one  not  obliged  to  assume  that  the  ex- 
amining boards  have  either  become  too  rigid  in 
their  requirements  or  that  they  have  been  hereto- 
fore too  lax?  If  the  latter,  a  large  proportion  of 
the  members  of  the  legal  profession  must  be  unfit 
to  practice  law.  Warfare  and  the  ploughing  under 
process  are  far-reaching  in  their  ramifications. 

I  am  not  a  believer  in  the  theory  that  all  p>eople 
are  educable  in  the  academic  meaning  of  the  term. 
My  own  notion  is  that  every  educated  person  is 
self-educated;  that  education  has  no  necessary  ref- 
erence to  the  use  of  books,  and  that  literacy  and 
education  are  generally  looked  upon  as  inter-related. 
I  have  known  a  few  individuals  who  could  not  read 


and  write,  yet  who  had  well-developed  and  well- 
trained  minds.  And  I  have  known  also  not  a  few 
individuals  who  had  no  little  knowledge,  but  who 
lacked  the  capacity  to  use  their  knowledge  and 
who  were  consequently  helpless.  They  had  no  wis- 
dom. Some  such  individuals  are  probably  being 
licensed  to  practice  law.  But  thej'  can  never  be 
lawyers.  There  is  no  substitute  for  intelligence — 
and  the  academic  tests  for  its  possession  are  diffi- 
cult and  uncertain.  For  intelligence  is  scarcely 
mensurable  and  definable. 


SURGERY 

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


Anoxemia  of  the  Brain 

C.^SE  1. — A  slender  negress  26  years  old,  married  but 
without  pregnancies,  came  for  the  relief  of  abdominal  pain 
about  McBurney's  point.  Her  heart,  lungs,  blood  pressure 
and  routine  urine  e.xaminations  were  negative,  as  was  the 
pelvic  examination.  She  was  without  fever  and  a  blood 
count  was  not  made.  Under  spinal  anesthesia  a  chronically 
diseased  appendix  was  removed.  As  the  McBurney  incision 
was  being  closed  she  stopped  breathing  and  was  pulseless. 
.-Mthough  no  heart  sounds  could  be  heard  through  the 
stethoscope  and  no  pulsation  ^could  be  felt  over  the  apex, 
artificial  respiration  was  done  for  10  minutes.  She  was 
apparently  dead.  Adrenalin  was  injected  directly  into  the 
heart  muscle  without  effect.  A  midline  incision  was  hur- 
riedly made  and  the  heart  massaged  from  below  the  dia- 
phragm by  the  gloved  hand  in  the  abdomen.  The  heart 
began  to  beat  but  had  to  be  stimulated  by  massage  several 
times  before  it  continued.  She  lived  4  days  and  died  in 
coma.     Her  blood  Wassermann  was  positive. 

Case  2. — A  colored  woman  of  30  years,  also  apparently 
in  good  condition,  for  no  apparent  reason  quit  breathing 
while  being  operated  upon  under  ether  anesthesia  for 
chronic  pelvic  inflammatory  disease.  She  was  pulseless. 
Artificial  respiration  was  given  and  adrenalin  administered 
by  needle  into  the  heart  muscle  without  improvement.  The 
heart  began  to  beat  when  massaged  through  the  diaphragm. 
She  lived  a  week  without  regaining  consciousness  and  died 
in  coma. 

Both  these  cases  were  apparently  good  operative 
risks  yet  both  had  anesthetic  deaths  similar  in 
character  but  of  a  most  unusual  kind.  The  right 
for  autopsy  was  not  obtained  in  either  case.  Bul- 
lock (Annals  oj  Surgery,  June,  1936)  tells  of  an 
ultimate  phase  of  life  after  the  heart  and  lungs 
cease  to  function  in  which  it  is  possible  to  restart 
these  functions. 

The  ability  to  withstand  drastic  reduction  in  the 
oxygen  content  of  the  blood  varies  with  the  age 
and  with  the  vitality  of  the  individual.  The  body 
is  composed  of  many  groups  of  highly  specialized 
cells,  each  group  having  a  special  function  to  per- 
form and  largely  dependent  upon  every  other  group 
for  perfect  performance.  The  more  highly  organ- 
ized cells  receive  a  greater  and  a  more  lasting  dam- 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  Hjo 


age  from  anoxemia  than  do  the  less  highly  organized 
cells.  The  brain  is  the  most  highly  organized  or- 
gan and  when  a  patient  dies  of  hemorrhage  he  dies 
of  anemia,  anoxemia,  of  the  brain.  For  this  reason 
the  head  should  be  lowered  in  hemorrhage. 

Man's  supremacy  in  the  animal  kingdom  is  from 
his  ability  to  think,  to  reason,  to  know,  and  this 
power  lies  in  the  cortical  cells  of  the  brain.  Their 
reaction  to  anoxemia  depends  upon  its  severity  and 
its  duration.  The  effect  may  be  only  transient  or 
it  may  be  permanent  as  manifested  in  changes  in 
personality  and  in  character.  In  the  two  cases 
briefly  described  after  temporary  paralysis  of  the 
respiratory  and  the  circulatory  centers  these  func- 
tions were  resumed  and  continued  fairly  normally 
for  some  days.  However,  consciousness,  which  is 
a  cortical  function,  was  never  restored.  Because 
there  was  no  ultimate  phase  of  life  in  them  as  it 
related  to  the  cortical  cells  of  the  brain  these  pa- 
tients died. 

We  realize  that  it  is  difficult  to  reconcile  the 
above  conception  with  the  fact  that  cases  have 
been  reported  of  drowning  persons  being  restored 
to  good  health  with  no  mental  impairment  after 
having  been  under  water  from  8  to  20  nunutes.  In 
these,  however,  although  respiration  had  ceased 
there  must  have  been  continued  heart  contraction 
and  circulation  of  blood,  very  feeble  though  it  was. 
One  must  not  forget  that  in  these  two  operative 
cases  there  also  may  have  been  abnormal  suscepti- 
bility of  the  brain  cells  to  the  anesthetic  drugs. 
Chemical  change  from  this  may  have  been  a  factor 
in  the  outcome. 

In  the  complicated  mechanism  of  human  physi- 
ology the  various  organs  of  the  body  are  coordi- 
nated and  controlled  by  the  brain.  When  this  con- 
trol is  lost  death,  not  only  of  the  brain  itself  but 
of  the  entire  body,  takes  place.  Each  vital  organ 
is  in  effect  a  link  in  a  chain  and  no  chain  is  stronger 
than  its  weakest  link. 


PEDIATRICS 

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


Vincent's  Infection  of  the  Mouth 
The  incidence  of  Vincent's  infection  of  the 
mouth  increases  with  the  advent  of  warm  weather. 
More  of  such  cases  have  been  seen  this  summer 
than  usual,  and  so  many  following  cases  of  epi- 
demic pharyngitis  that  some  connection  between 
the  two  conditions  would  naturally  be  expected. 
Smears  of  the  throat  from  these  epidemic  pharyn- 
gitis cases  do  not  reveal  Vincent's  organisms.  As 
the  throat  picture  leaves,  the  mouth  evidence  of 
Vincent's  infection  begins.     Smears  of  the  gums 


and  between  the  teeth  reveal  the  usual  organisms  Ti 
in  abundance,  spirochetes  and  fusiform  bacilli.    It  • 
has  been  suggested  that  the  pharyngitis  infection 
probably  lowers  the  natural  resistance  to  Vincent's   ' 
organisms,  and   thus  accounts   for  the  immediate 
sequelae. 

Several  cases  of  fever  of  103  to  104'"  have  been 
seen;  fetid  odofr  and  bleeding  from  congested, 
edematous  gums  are  consistently  found.  Dirty 
gray  membrane  is  seen  late  in  the  disease.  Care- 
fully-made smears  reveal  the  organisms  with  sim- 
ple stains. 

These  children  refuse  to  eat,  due  no  doubt  to 
the  painful  condition  of  the  mouth.  One  child 
without  fever,  examined  because  it  would  not  eat, 
was  found  to  have  a  far-advanced  Vincent's  infec- 
tion. 

We  must  not  lose  sight  of  the  fact  that  this  in- 
fection can  go  down  into  the  gastrointestinal  tract 
or  into  the  lungs.  Serious  complications  may  arise 
in  either  system,  but  especially  in  the  lungs. 

Sodium  perborate  applied  by  cotton  applicators 
to  the  gums  and  between  the  teeth  is  a  satisfactory 
local  application.  Remind  the  parents  that  sodium 
perborate  must  foam  profusely  when  it  comes  in 
contact  with  the  saliva  or  it  is  stale  and  valueless. 
The  liberated  oxygen  as  represented  by  the  foam 
is  the  therapeutic  agency.  Bismuth  violet  locally 
to  the  gums  has  also  been  helpful.  Sodium  bismuth 
tartrate,  1  c.c.  intramuscularly  on  alternate  days 
for  4-6  injections,  is  the  best  therapy  so  far  dis- 
covered. Neoarsphenamine  in  small  doses  intra- 
venously is  also  quite  valuable  and  is  preferred 
by  some.  Stovarsol,  ^  tablet  twice  daily  for  chil- 
dren, has  been  used  to  advantage  in  chosen  cases. 
A  combination  of  local  treatment  of  the  gums  and 
some  form  of  parenteral  injection  usually  brings 
the  disease  under  control  in  a  few  days.  One 
never  can  be  certain  when  the  infection  is  cured. 
It  hides  between  the  teeth  and  returns  at  inoppor- 
tune times.  So,  treat  the  patient  longer  than  seems 
necessary  for  safety's  sake. 


HISTORIC  MEDICINE 


Notes  From  Col.  Wm,  Byrd's  "History  of  the  Dividinc 
Line,"  Year  1728 

A  clear  sky  spangled  with  stars,  was  our  canopy,  which, 
being  the  last  thing  we  saw  before  we  fell  asleep,  gave  us 
magnificent  dreams. 

For  their  greater  safety  the  commissioners  took  care  to 
furnish  them  with  Peruvian  bark,  rhubarb,  hipocoacanah 
[ipecac],  in  case  they  might  happen  in  that  wet  journey 
to  be  taken  with  fevers  or  fluxes. 

We  made  a  shift  to  push  a  line  half  a  mile  [in  Dismal 
Swamp]  in  three  hours,  and  then  reached  a  small  piece 
of  firm  land,  about  100  yards  wide.     Here  the  people  were 


September,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


501 


glad  to  lay  down  their  loads  and  lake  a  little  refreshments, 
while  the  happy  man  whose  lot  it  was  to  carry  the  jug 
of  rum,  began  already,  like  Aesop's  bread-carrier,  to  find 
it  grow  a  good  deal  lighter. 

In  the  meantime  the  three  commissioners  returned  out 
of  the  Dismal  the  same  way  they  went  in,  and  having 
joined  their  brethren  proceeded  that  night  as  far  as  Mr. 
Wilson's.  This  worthy  person  lives  within  sight  of  the 
Dismal,  in  the  skirts  whereof  his  stock  ranges  and  maintain 
themselves  all  the  winter,  and  yet  he  knew  as  little  of  it 
as  he  did  of  Terra  Australia  Incognita.  He  told  a  Canter- 
burj-  Tale  of  a  North  Briton  whose  curiosity  spurred  him 
a  long  way  into  this  great  desert,  as  he  called  it,  near  20 
years  ago,  but  he  having  no  compass,  nor  seeing  the  sun 
for  several  days  together  wandered  about  until  he  was 
almost  famished,  but  at  last  he  bethought  himself  of  a 
secret  his  countrymen  make  use  of  to  come  out,  being  for 
the  most  part  appilot  themselves  a  dark  day.  He  took  a 
fat  louse  out  of  his  collar,  and  exposed  it  to  the  open 
day  light  on  a  piece  of  white  paper,  which  he  brought 
along  with  him  for  his  journal.  The  poor  insect,  having 
no  eyelids,  turned  himself  about  until  he  found  the  darkest 
part  of  the  heavens,  and  so  made  the  best  of  his  way  to- 
wards the  north.  By  this  direction  he  steered  himself  safe 
out  and  gave  such  a  frightful  account  of  the  monsters  he 
saw  and  the  distresses  he  underwent  that  nobody  since 
had  been  hardy  enough  to  go  upon  the  like  dangerous 
discovery. 

The  Quakers  prevailed  much  in  this  part  of  the  country, 
for  want  of  ministers  to  pilot  the  people  a  decenter  way 
to  heaven. 

Not  so  mucn  as  a  irog  can  "n  j;ire  .-o  aguish  a  situa- 
tion. 

One  thing  may  be  said  for  the  inhabitants  of  North 
Carolina,  they  are  not  troubled  with  any  religious  fumes, 
and  have  the  least  superstitions  of  any  people  living.  They 
do  not  know  Sunday  from  any  other  day.  But  they  keep 
so  many  Sabbaths  every  week  that  their  disregard  of  the 
seventh  day  has  no  manner  of  cruelty  in  it  either  to  ser- 
vants or  cattle. 

The  men  for  their  part,  just  like  the  Indians,  impose  all 
the  work  upon  the  poor  women.  They  make  their  wives 
rise  out  of  their  beds  early  in  the  morning,  at  the  same 
time  that  they  lie  and  snore  till  the  sun  has  risen  one- 
third  of  its  course  and  dispersed  all  the  unwholesome 
damps.  Then,  after  stretching  and  yawning  for  half  an 
hour,  they  light  their  pipes  and  under  their  protection  to 
secure  them,  so  that  the  building  is  a  cloud  of  smoke,  ven- 
ture out  into  the  open  air. 

At  EdentoD  there  may  be  40  or  SO  houses,  most  of  them 
small  and  built  without  expense.  A  citizen  here  is  counted 
extravagant  if  he  has  ambition  enough  to  aspire  to  a  brick 
chimney.  Justice  herself  is  but  indifferently  lodged,  the 
court  bouse  having  much  the  air  of  a  common  tobacco 
house.  I  believe  this  is  the  only  mctropoUs  in  the  Chris- 
tian or  Mohametan  world  where  there  is  neither  church, 
chapel,  mosque,  synagogue,  or  any  other  place  of  public 
worship  of  any  sect  or  religion  whatsoever.  What  little 
devotion  there  may  happen  to  be  is  much  more  private 
than  their  vices. 

This  much,  however,  may  be  said  of  the  inhabitants  of 
Edenton,  that  not  a  soul  has  the  least  taint  of  hypocrisy 
or  superstition,  acting  very  frankly  and  above  board  in 
all  their  excesses. 

The  borderers  chose  much  rather  to  belong  to  Carolina, 
where  they  paid  no  tribute  either  to  God  or  Caesar. 

I  found  some  plants  of  that  kind  of  rattlesnake  root 
called  star-grass.  The  root  Is  in  shape  not  unlike  the 
rattle  of  that  serpent  and  is  a  strong  antidote  against  the 


bile  of  it.  ll  is  very  bitter  and  wnere  it  meet^  with  any 
poison,  works  by  violent  sweats,  but  where  it  meets  with 
none,  has  no  sensible  operation  but  thai  of  putting  the 
spirits  in  a  great  hurrj',  and  so  promoting  perspiration. 
The  rattlesnake  has  a  strong  antipathy  to  this  plant.  Once 
in  July,  when  these  snakes  are  in  their  greatest  vigor,  I 
besmeared  a  dog's  nose  with  the  powder  of  Ihi.s  root  and 
made  him  trample  on  a  large  snake  several  times,  which, 
however,  was  so  far  from  biting  him  that  it  perfectly  sick- 
ened at  the  dog's  approach  and  turned  his  head  from  him 
with  the  utmost  aversion. 


INTERNAL  MEDICINE 

Paul  H.  Ringm,  A.B,,  M.D.,  F.A.C.P.,  Editor 
Ajheville,  N.  C. 


The  Art  of  Treatment 

It  is  not  often  that  we  see  a  truly  original  book 
on  therapeutics  emerf^e  from  the  booksellers.  One 
has  appeared  recently,  however  ,entitled  The  Art 
of  Treatment,  by  Dr.  William  R.  Houston,  now 
of  Austin,  Texas,  but  who  was  formerly  Professor 
of  Clinical  Medicine  at  the  University  of  Georgia 
and  also  spent  some  ten  years  as  Visiting  Professor 
of  Medicine  at  Yale-in-China. 

Dr.  Houston  takes  up  the  whole  subject  of  med- 
ical diseases  and  shows  at  once  two  things:  first, 
that  he  is  profoundly  versed  in  the  various  methods 
of  treatment  of  disease;  and  second,  that  he  is 
equally  profoundly  versed  in  the  treatment  of  the 
patient  that  has  the  disease. 

The  first  portion  of  the  bfX)k,  which  he  terms  an 
introduction,  lakes  up  the  various  aspects  of  ther- 
apeutics and  reaches  the  following  five  conclusions: 

"1.     That  treatment  is  the  goal  of  all  medical  studies. 

2.  That  medical  men  are  not  committed  to  the  use  of 
medicines  or  drugs  as  a  dogma  or  article  of  faith. 

3.  That  therapeutics  requires  thinking  of  the  highest 
order. 

4.  That  diagnosis  h  not  to  be  limited  to  the  extent  of 
discriminating  between  two  diseases  nor  even  of 
estimating  the  condition  and  function  of  the  various 
organs  of  the  body,  but  that  it  should  include  a 
comprehensive  survey  of  the  patient's  constitution 
and  personality  as  well  as  bis  social,  family,  and 
economic  conditions. 

5.  That,  understood  in  this  sense,  diagnosis  must  be 
the  coastant  companion  and  guide  of  treatment. 

I  should  not  like  anyone  to  suppose  that  the  above  state- 
ments are  in  any  sense  to  be  taken  as  paradoxical  and 
still  less  that  they  represent  merely  the  perwjnal  views  of 
the  writer.  They  are  the  views  held  by  the  thoughtful, 
well-balanced  leaders  of  the  profession.  They  are  empha- 
sized here,  not  because  they  arc  novel  but  becau.se  in  some 
places,  and  particularly  in  medical  schools,  they  are  likely 
to  be  forgotten." 

This  portion  of  the  book  is  full  of  the  very  best 
kind  of  philosophy — a  kindly  altitude  toward  the 
frailties  of  humanity,  a  keen  insight  into  the  vaga- 
ries of  the  human  temperament,  an  analytical  skill 


502 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


in  sifting  the  grain  from  the  chaff  and  arriving  at 
the  roots  of  the  trouble. 

Dr.  Houston  deplores  slavish  acceptance  of  au- 
thority and  says: 

"There  is  nothing  to  indicate  that  therapeutic  discoveries 
are  to  be  expected  solely  from  marble  halls  and  richly  en- 
dowed laboratories.  In  fact,  these  citadels  of  experiment 
have  for  the  most  part  proved  singularly  sterile  of  results. 
It  was  a  country  practitioner  that  discovered  vaccination, 
a  modest  doctor  in  the  little  Georgia  town  of  .'Vthens  [sic] 
that  first  employed  ether  anaesthesia." 

The  chapter  on  Therapeutic  Thinking  is  particu- 
larly good,  as  is  the  one  on  Honesty.  It  is  obvious 
through  the  introduction,  as  well  as  in  the  lengthy 
section  devoted  to  psychotherapy  (consisting  of  255 
pages  in  a  72S-page  book),  that  Dr.  Houston  is  a 
great  believer  in  this  important  element  of  the  art 
of  treatment.    Indeed,  he  says: 

"Every  patient  who  consults  a  doctor  is  suffering  from 
fear.  He  may  laugh  off  the  suggestion  that  he  has  fear,  yet, 
however  small  his  ailment,  the  thought  has  flashed  through 
his  mind  of  a  case  in  which  grievous  consequences  followed 
such  a  trivial  beginning.  The  reassurance  the  patient  gets 
from  the  physician's  visit  is  psychotherapy,  and  not  infre- 
quently is  the  main  benefit  the  physician  can  offer.  I  have 
known  more  than  one  physician  who  never  read  a  book  on 
psychotherapeutics  and  yet  practiced  such  psychotherapeu- 
tics excellently  well." 

The  part  dealing  with  organic  disease  first  takes 
up  those  conditions  which  are  to  be  treated  chiefly 
by  nursing  care,  and  gives  a  lengthy  chapter  on 
typhoid  fever  simply  because  this  no  longer  serves 
as  the  prototype  of  those  conditions  which  are  to  be 
treated  mainly  by  nursing. 

There  follows  a  section  on  specific  measures,  in 
which  is  included  diabetes;  then  the  long  section  on 
psychotherapy  previously  referred  to.  The  fifth 
section  is  on  Diseases  Which  Impose  a  Limitation 
Upon  Life  as  the  Condition  of  Treatment,  and 
includes  such  topics  as  obesity,  heart  disease,  an- 
gina pectoris,  arteriosclerosis,  etc.  Then  follows  a 
section  on  Disorders  in  Which  Physiological  Con- 
siderations Guide  Treatment,  and  finally  allergic 
diseases  are  considered. 

One  of  the  many  attractive  things  about  the 
book  is  the  style  in  which  the  information  is  pre- 
sented. It  is  a  long  while  since  the  editor  has  en- 
joyed reading  a  large  medical  book  page  by  page 
from  beginning  to  end;  and  while  he  has  not  yet 
finished  Dr.  Houston's  book,  he  knows  that  the 
grasp  which  it  has  secured  upon  him  will  not  be 
loosened. 

In  one  portion  of  his  introduction,  he  takes  a 
fling  at  surgery,  toward  which  he  seems  a  bit  wrath- 
ful, and  says: 

"Surgical  treatment  was  a  thing  of  horror.  The  agony 
of  the  operation  without  an  anaesthetic,  the  long  and 
doubtful  heaHng  of  wounds,  always  infected,  made  the 
'fatal  bistoury'  the  most  dreadful  of  therapeutic  resources. 
An  operative  mortality   of  seventy-five  per  cent,   was  re- 


ported by  distinguished  surgeons.  The  advent  of  asepsis 
and  anaesthesia  changed  all  this.  The  surgeon  soon  found 
himself  the  most  honored  of  medical  men.  Writers  of 
romance  delighted  to  celebrate  his  skill,  coolness  and  dar- 
ing. Surgical  aid  was  invoked  not  merely  to  save  life  but 
to  obiviate  discomfort.  It  was  not  long  before  unhappy 
neurotics  were  flocking  to  the  surgeon  in  the  hope  that  he 
would  cut  out  sickness.  Surgery  satisfied  more  brilliantly 
and  decidedly  than  any  other  medical  regimen  the  need  for 
doing  something.  To  the  people  of  America,  with  their 
restless  impatience  for  action,  it  made  a  particularly  strong 
appeal. 

The  last  decade  has  witnessed  a  steadying  down  in  the 
zest  for  surgery  as  the  treatment  of  choice.  The  successive 
disappointments  that  followed  a  series  of  operations  on 
people  who  fundamentally  were  suffering  from  the  psycho- 
neurotic disorders  have  sown  seeds  of  distrust  as  to  the 
universal  applicability  of  surgen,',  not  only  among  the  pro- 
fession but  in  the  minds  of  the  public.  The  limits  of  surgi- 
cal art  are  being  defined.  It  has  become  clear  that  it  is  a 
therapeutic  method  which  cannot  be  expanded  indefinitely." 
Dr.  Houston's  remarks  about  the  surgeon  simply 
emphasize,  however,  his  faculty  of  independent 
thinking,  and  it  is  this  faculty  which  gives  a  great 
part  of  its  value  to  this  exceptional  volume,  whifh 
certainly  should  be  in  the  hands  of  every  practi- 
tioner. 


Gallbladder  Disease 
(From  p.  503) 
in  the  acute  cases  there  is  likelihood  of  pancreatitis 
developing.  A  careful  study  of  each  patient,  an 
accurate  diagnosis  and  prompt  institution  of  treat- 
ment are  essential  in  handling  patients  who  have 
gallbladder  disease. 


-S.    M.    &   S.- 


Sy:mptomless   Gonorrhea  and  the   Gonococcus   Carrier 
(A.  L.  Wolbarst,  New  York,  in  Med.   Rec,  Aug.  19th) 
Some   individuals  are  so   constituted  that  they   seem   to 
possess  a  selective  and  more  or  less  permanent   immunity  ^ 
against  gonococcal  infection.    They  expose  themselves  freely  \ 
and  frequently   under  the  most   hazardous  conditions   and 
escape  infection.     The  immunity  sometimes  fails  and  they 
become  infected  from  the  most  unexpected  sources. 

In   111    women  affected  with  genital  gonorrhea,   Martin 
found  that  30%  also  had  gonorrhea  of  the  rectum. 


Catawba  Valley  (N.  C.)  Medical  Society,  regular 
meeting  in  the  City  Court  room  at  Hickory,  September 
Sth,  at  7:15  p.  m. 

Program:  The  Diagnosis  and  Treatment  of  the  Com- 
mon Causes  of  Indigestion,  by  Dr.  W.  G.  Bandy,  Lincoln- 
ton;  Purpura  Haemorrhagica,  by  Dr.  J.  W.  Saine,  Lincoln- 
ton.  A  group  payment  plan  for  medical,  surgical,  dental 
and  hospital  care  for  the  Catawba  Valley  district,  discus- 
sion led  by  Dr.  Fred  Lula,  of  Lenoir,  representing  the  Ex- 
ecutive Committee. 

L.  A.  Crowell,  jr.,  M.D.,  Sec-Trens. 


"Doc,  I  want  you  to  look  at  my  son-in-law.     I  shot  at 
him  yesterday  and  took  a  piece  out  of  his  ear." 
"Shame  on  you,  Zeb,  shooting  at  your  son-in-law!" 
"Huh!    He  warn't  my  son-in-law  when  I  shot  him." 


September,   1936 


SOUTHERN  MEDICINE  AND  SURGERV 


503 


Surgical   Observations 

A  Column  Conducted  by 

The  Staff  of  the  Davis  Hospital 
Statesville,  N.  C. 


Diagnosis  of  Gallbladder  Disease 
Disease  of  the  gallbladder  may  vary  from  a 
mild  irritative  condition  to  a  severe  inflammation 
with  gangrene.  Stones  in  the  bladder  or  ducts 
may  cause  almost  no  symptoms  or  violent  attacks 
of  colic  and  sometimes  even  perforation.  The 
symptoms  are  often  out  of  proportion  to  the  ap- 
parent pathology;  e.g.,  when  a  small  stone  becomes 
lodged  in  the  ampulla  of  Vater  causing  obstruction 
with  consequent  backflow  of  bile  into  the  pancreas 
causing  pancreatitis,  or  when  a  gallbladder  con- 
tains a  number  of  stones  and  the  patient  has  no 
symptoms  at  all. 

I  once  examined  many  records  at  the  Philadel- 
phia General  and  University  Hospitals  and  found 
that  in  a  large  number  of  autopsies,  in  which  gall- 
stones were  found,  there  were  many  cases  showing 
no  symptoms  whatever  of  gallbladder  disease. 

Six  unusually  interesting  cases  of  gallbladder 
disease  were  examined  and  operated  upon  in  this 
clinic  within  the  past  few  days. 

Case  1. — .\  lady  46  years  of  age  was  admitted  complain- 
ing of  indigestion,  attacks  of  colic,  the  pain  being  across 
the  right  upper  abdomen  and  radiating  to  the  back  and 
occasionally  to  the  right  shoulder-blade  region.  There  was 
no  jaundice. 

For  several  years  this  patient  has  been  having  periodic 
attacks  of  discomfort  after  eating.  She  would  feel  bad  at 
times  and  slight  nausea  would  come  on  an  hour  or  two 
after  meals.  Following  this  she  would  have  headaches 
with  discomfort  in  the  right  upper  abdomen.  The  dis- 
comfort became  worse  and  finally  developed  into  real  pain, 
severe  at  times. 

A  careful  .^t-ray  examination  revealed  no  gallbladder 
shadow  after  two  doses  of  the  proper  dye.  X-ray  exam- 
ination of  the  gastrointestinal  tract  was  negative  except 
that  the  duodenal  cap  was  small  and  rather  contracted, 
and  evidence  suggestive  of  a  healed  ulcer. 

At  operation,  through  a  high  right-rectus  incision,  the 
gallbladder  was  found  to  be  thickened  and  inflamed  and 
to  contain  17  smooth,  faceted  stones.  There  was  an  old, 
healed  ulcer  on  the  anterior  surface  of  the  duodenum  just 
distal  to  the  pylorus,  which  was  probably  giving  no  trou- 
ble. 

Case  2. — A  man  S3  years  of  age  was  admitted  complain- 
ing of  jaundice  and  bad  health  since  January  of  this  year. 
He  stated  that  since  January  he  had  been  jaundiced  and 
had  indigestion  after  eating.  Occasionally  he  noticed  dark, 
tar-like  stools.  The  jaundice  had  been  persist'jnt.  There 
had  been  no  marked  pain.  The  principal  symptoms  were 
persistent  jaundice  and  indigestion. 

At  operation  the  gallbladder  was  found  to  be  enormously 
enlarged  and  filled  with  bile.  There  was  a  marked  hepa- 
titis. Throughout  the  abdomen  there  were  several  spots 
indicating  pancreatitis.  The  pancreas  was  considerably  en- 
larged but  not  very  nodular.  In  this  case  it  was  difficult 
to  differentiate  between  a  pancreatitis  and  a  malignant 
growth. 


Case  3. — \  patient  43  years  of  age  was  admitted  com- 
plaining of  severe  attacks  of  colic  in  the  right  upper  abdo- 
men. There  was  indigestion  at  times  but  not  very  severe. 
The  principal  trouble  that  this  patient  complained  of  was 
severe  attacks  of  pain  in  the  right  upper  abdomen  lasting 
from  one  to  five  or  six  hours,  occurring  at  intervals  of 
two  to  three  weeks.  The  pain  did  not  radiate  to  the 
shoulder  but  did  radiate  at  times  to  the  back.  X-ray  ex- 
aminations showed  gallstones,  but  no  other  disease  of  the 
gastrointestinal  tract. 

At  operation  the  gallbladder  was  found  to  be  of  normal 
size  and  tightly  packed  with  stones  of  various  sizes,  the 
wall  thickened  and  chronically  inflamed.  No  stones  were 
found  in  the  common  duct. 

Case  4. — A  man  65  years  of  age  was  admitted  complain- 
ing of  jaundice  which  had  persisted,  with  little  pain,  since 
February  of  this  year,  and  chills  at  no  particular  time  of 
the  day  averaging  one  each  week  for  the  past  six  weeks. 
He  thought  that  his  urine  was  quite  dark  and  at  times 
yellowish.  The  principal  symptom  was  persistent  jaundice 
without  much  pain.  .A.lso  a  tumor  was  noted  in  the  left 
upper  abdomen  in  the  region  of  the  spleen.  A  diagnosis 
of  gallbladder  disease  was  made. 

On  opening  the  abdomen  the  liver  was  found  to  be 
shghtly,  the  gallbladder  greatly,  enlarged  and  its  wall  thick- 
ened and  chronically  inflamed.  It  contained  a  large  amount 
of  sludge  with  a  moderate  amount  of  fine  gravel.  There 
was  one  large  stone  in  the  common  duct.  This  case  simu- 
lated somewhat  the  picture  of  malignancy.  There  was, 
however,  no  sign  of  a  cancerous  growth.  The  spleen  was 
considerably  enlarged. 

Case  S. — A  man  SO  years  of  age  was  admitted  complain- 
ing of  violent  pain  in  the  abdomen,  nausea  and  vomiting. 
For  a  number  of  years  he  had  attacks  of  pain  in  the  right 
upper  abdomen  lasting  for  a  few  minutes  and  sometimes  an 
hour  or  more  and  usually  followed  by  vomiting.  These 
attacks  have  become  more  frequent  until  the  past  ten 
days,  during  which  he  has  had  five  attacks  so  severe  as  to 
require  morphine. 

On  admission  this  patient  was  suffering  agonizing  pain 
in  the  right  upper  quadrant,  and  t.  was  99.6,  p.  SO,  w.  b.  c. 
18,200 — polys.  89,  lymphocytes  10,  monos.  1.  There  was 
no  jaundice.  .\n  immediate  operation  was  done  and  the 
gallbladder  was  found  to  be  gangrenous. 

Case  6. — A  lady  41  years  of  age  complained  that  for  the 
past  two  years  she  had  had  attacks  of  severe  upper  ab- 
dominal pain,  mostly  on  the  right  side,  which  would  come 
on  suddenly  and  last  from  one  hour  to  two  or  three  days, 
during  which  lime  she  would  be  greatly  prostrated.  At 
times  there  was  slight  jaundice,  but  the  principal  symptoms 
were  attacks  of  pain  with  great  prostration,  nausea  and 
vomiting.  The  pain  was  so  severe  that  she  was  in  constant 
terror  of  a  recurrence.  Sometimes  there  would  be  two 
attacks  within  one  week  and  again  for  three  months  she 
suffered  little  or  no  pain.  There  was  no  icterus,  but  the 
patient  thought  at  times  there  had  been  slight  jaundice. 

At  operation  a  small,  round  stone  was  found  lodged  in 
the  ampulla  which  had  evidently  been  causing  obstruction 
at  intervals.  Transduodenal  removal  of  the  stone  was  done 
and  this  should  give  the  patient  permanent  relief. 

A  careful  study  of  the  patient  generally  and  x- 
ray  examinations  of  the  gallbladder  and  the  whole 
gastrointestinal  study  will  usually  enable  one  to 
make  a  fairly  accurate  diagnosis  of  gallbladder 
disease.  If  treatment  is  too  much  delayed  in  the 
mild  cases  liver  damage  will  ultimately  result  and 

(to  p.  S02) 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


Southern  Medicine  and  Surgery 

Official  Organ  or 

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,  DBS Charlotte,  N.  C 

Eye,    Ear,    Nose   and   Throat 
Eye,  Ear  and  Throat  Hospital  Group  --     Charlotte,  N.  C. 

Ortliopedic   Surgery 

O.  L.  Miller,  M.D ) Charlotte,  N.  C. 

John  Stuart  Gaul,  M.D.) 

Urology 

Hamilton  W.  McK.^y,  M.D  I     Charlotte,  N.  C. 

Robert  W.  McKay,  M.D.    ..  I 

Internai    IVIedicine 

P.  H.  Ringer,  M.D Asheville,  N.  C. 

Surgery 

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

Obstetrics 

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

Gynecology 

CnAS.  R.  Robins,  M.D Richmond,  Va. 

Pediatrics 

G.  W.  Kutscher,  jr.,  M.D Asheville,  N.  C. 

General   Practice 

WiNGATE  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.  Gilmore,  A.B.,  M.D... Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Ennett,  M.D _.... Greenville,  N.  C. 

Radiology 

Allen  Barker,  M.D.        I     Petersburg,  Va. 

Wright  Clarkson,  M.D. ) 

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


Offerings  for  the  pages  of  this  Journal  are  requested 
and  given  careful  consideration  in  each  case.  Manu- 
scripts not  found  suitable  for  our  use  w/ill  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. 


-Abstracts   in    this    Issue:    Long-Accepted   and 
True  Not  Synonyms 

Within  the  past  few  months  more  than  the 
usual  number  of  articles  have  come  out  tending  to 
upset  accepted  medical  teaching.  Some  articles  ab- 
stracted in  this  issue  are  noteworthy  for  this  reason, 
some  because  of  other  things. 

An  editorial  in  the  excellent  Illinois  Medical 
Journal  blames  many  of  the  ills  of  medicine  on  the 
scant  consideration  for  family  doctors  shown  by 
specialists. 

A  piece  by  Crile  says  hyperthyroidism  and  essen- 
tial hypertension  come  from  over-activity  of  the 
adrenal  glands  and  the  sympathetic  nervous  sys- 
tem, and  reports  favorably  on  822  operations  based 
on  this  idea. 

Anderson,  of  Buffalo,  speaks  against  the  admin- 
istration of  anesthetics  by  non-doctors. 

Members  of  the  Mayo  Clinic  tell  us  that  nitrites 
relieve  certain  colics,  not  amenable  to  morphine, 
even  induced  or  made  worse  by  morphine. 

Terrell,  of  Richmond,  describes  the  advantages 
derived  from  the  prolonged  local  anesthesia  follow- 
ing the  injection  of  diothane. 

Parvey,  of  Boston,  strongly  recommends  calcium 
for  salpingitis,  acute  and  subacute,  and  adduces  the 
evidence  afforded  by  a  number  of  cases  of  his  own 
to  support  his  opinions. 

Mussey,  of  New  Orleans,  lists  threescore  condi- 
tions outside  the  abdomen  which  may  cause  pain 
inside  the  abdomen.  It  would  be  well  for  every 
doctor  to  cut  out  this  list  and  read  over  the  names 
each  time  a  patient  complains  of  pain  in  this  region 
before  deciding  on  a  surgical  operation. 

Wood,  of  Washington  State,  makes  out  a  good 
case  for  practicing  an/;septic,  rather  than  making 
futile  attempts  at  aseptic,  delivery  in  the  home,  and 
describes  the  technique. 

Coller,  of  Ann  Arbor,  p>oints  out  that  a  patient 
may  need  water  when  he  does  not  need  salt,  and 
that  discrimination  should  be  used  in  deciding  what 
to  run  in  through  a  needle. 

The  editor  of  the  Wisconsin  Medical  Journal 
tells  us  that  we  have  stirred  up  a  lot  of  trouble  for 
ourselves  by  making  exaggerated  statements  of 
what  we  can  do,  and  reminds  that  self  praise  is  at 
least  half  a  scandal. 

May,  of  Boston,  writes  convincingly  against  the 
commonly-held  teaching  that  an  abundance  of 
fluids  is  to  be  drunk  by  every  pregnant  woman. 
/Rehydration  has  proved  itself  good  treatment  in 
his  hands. 

Right  here  comes  to  mind  accumulated  evidence 
that  another  notion,  accepted  as  fact,  for  a  longer 
time  is  covered  by  records,  is  not  a  fact  at  all.    A 


September,    1936 


SOUTHERN  MEDICINE  AND  SURGERY 


SOS 


number  of  statistical  studies  show  that  dry  labors 
are  shorter. 

Pithy  comments  of  Col.  Wm.  Byrd  indicate  his 
conception  of  how  dreams  are  influenced,  that  his 
purveyor  knew  what  medicines  would  be  needed 
on  the  expedition,  that  he  was  devoted  to  the  An- 
glican Church,  and  that  he  credited  North  Caro- 
linians for  making  up  in  frankness  what  they  lacked 
in  piety. 

Lord  Horder's  discourse  on  goiter  tits  in  pretty 
well  with  Crile's  conclusions,  and  with  the  teachings 
of  Israel  Bram's  Exophthalmic  Goiter  and  its  Med- 
ical Treatment  (second  edition  just  out);  and  Min- 
ning,  of  Denver,  describes  the  benefits  derived  from 
injecting  sheep  and  beef  blood  into  goiter  patients. 

It  strikes  us  that  the  abstracts  in  this  month's 
issue  are  unusually  interesting  and  instructive,  and 
that  it  might  be  worth  while  to  suggest  that  every 
reader  who  finds  any  sample  to  his  taste  would  do 
well  to  write  the  author  asking  for  a  reprint.  Au- 
thors love  to  get  such  requests  and  by  sending  them 
you  get  a  maximum  of  the  information  you  desire 
and  a  minimum  of  the  other  sort. 


A  Lesson  in  Ways  of  Fighting  Cancer 

Ten  years  ago  there  was  worked  out  in  Massa- 
chusetts a  plan  of  campaign  against  cancer,  and 
this  plan,  as  modified  from  time  to  time,  has  been 
energetically  carried  out  throughout  the  decade  just 
past.^  The  program  embraces  hospitalization,  tu- 
mor diagnostic  service,  research,  diagnostic  clinics 
and  public  instruction.  Provision  is  made  for  ex- 
amination of  tissue  at  the  request  of  any  physician 
or  hospital.  The  main  object  in  instruction  was 
to  impress  the  public  with  the  early  signs  of  can- 
cer, the  danger  of  delay  and  the  availability  of 
modern  facilities  for  treatment  and  care. 

In  the  fall  of  1934  the  whole  cancer  program  was 
reviewed  and  efforts  were  made  to  improve  it. 
Group  consultation  was  made  mandatory  in  all 
clinics,  and  cities  having  the  clinics  divided  among 
several  hospitals  were  urged  to  unite  at  one  hos- 
pital. The  clinics  were  advised  to  become  consul- 
tation clinics  for  the  profession.  Prior  to  this 
time  newspaper  material  had  advised  an  individual 
with  symptoms  of  cancer  to  go  to  his  physician  or 
to  a  cancer  clinic;  the  advice  to  go  to  a  cancer 
clinic  has  been  discontinued  and  all  educational 
material  now  directs  the  patient  to  go  to  his  phy- 
sician. The  physicians  are  advised  to  use  the  can- 
cer clinics  as  consultation  centers.  Uniform  med- 
ical records  are  demanded  of  the  clinics  and  spe- 
cial teaching  clinics,  at  least  one  a  year,  are  also 
required.     At  the  teaching  clinics  either  the  local 


1.     H.    D.    Chadwick    and    H. 
Journal  of  Medicine,  Aug.  13th. 


L.    Lombard,    in    N.    E. 


Staff  or  a  consultant  brought  in  from  some  other 
locality  gives  a  demonstration  clinic  for  the  pro- 
fession in  that  locality.  Physicians  are  urged  to 
go  with  their  patients  to  the  clinics  and  avail  them- 
selves of  this  free  consultation  diagnostic  service. 

The  delay  between  first  symptoms  and  first  con- 
sultation with  a  physician  has  decreased  over  the 
period,  but  not  to  the  extent  desired.  The  time 
period  between  the  first  visit  to  a  physician  and 
attendance  at  a  clinic  has  shown  much  improve- 
ment in  the  last  four  years,  but  this  delay  is  still 
too  great.  The  percentage  of  patients  referred  to 
clinics  by  physicians  has  increased  greatly.  There 
is  less  medical  shopping  as  evidenced  by  the  in- 
creased percentage  of  patients  being  referred  by  the 
first  physician  consulted. 

The  results  point  toward  cure  or  at  least  pro- 
longation of  life  in  most  of  the  24.3%  of  cancer 
patients  attending  the  clinics  who  are  alive  at  the 
end  of  eight  years,  .-^n  unpublished  study  of  un- 
treated cancer  shows  only  0.7%  of  the  patients 
alive  after  eight  years. 

The  physician  must  be  the  pivotal  figure  in  can- 
cer control.  With  this  in  mind,  the  organization 
in  every  city  and  town  in  the  State  of  a  cooperative 
cancer  control  committee  was  begun.  Each  of  these 
committees  includes  representatives  of  all  organiza- 
tions in  the  community — social,  racial,  religious, 
fraternal,  service,  military  and  political.  Each 
member  is  asked  to  arrange  that  the  organization 
he  represents  hold  at  least  one  meeting  a  year  at 
which  cancer  will  be  discussed  by  one  of  the  local 
physicians.  The  physician  has  to  keep  fully  in- 
formed on  the  subject  so  that  he  can  teach  and 
answer  questions  that  will  be  put  by  the  layman. 

This  can  well  be  an  important  means  by  which 
the  medical  profession  can  render  great  service, 
and,  at  the  same  time,  maintain  its  standing  and 
influence — even  rehabilitate  itself — with  the  pub- 
lic. 

Gratifying  results  have  been  obtained  and  those 
attacking  this  problem  in  Massachusetts  have 
shown  their  wisdom  by  revising  their  program,  as 
experience  indicated.  It  will  be  noted  that  the 
principal  changes  made  were  in  more  strongly  em- 
phasizing the  importance  of  the  role  of  the  family 
doctor.  There  is  something  in  most  of  us  which 
responds  when  much  is  expected  of  us,  something 
that  makes  us  strive  to  come  up  to  the  expectations 
of  those  who  have  confidence  in  us;  and  no  one 
enjoys  seeing  credit  for  what  he  has  done  well  given 
to,  or  taken  by,  others. 

Julius  Caesar  never  failed  to  give  credit  to  his 
subordinate  officers  and  his  privates  in  the  ranks; 
and  no  commander  ever  led  armies  to  victory  in  so 
many  battles  over  so  long  a  period  of  time.  If 
privates  do  not  win  battles  why  not  let  them  go 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  l'P36 


home  and  make  war  supplies  for  the  generals  to 
fight  with? 

Can  we  not  plan  a  campaign  in  North  Carolina, 
guided  by  the  experiences  of  the  Massachusetts 
Department  of  Public  Health,  and  put  it  into  oper- 
ation without  delay?  The  results  obtained  are  en- 
couraging; the  modifications  of  the  program  show 
level-headedness :  and  the  modesty  of  the  claims 
as  to  results  obtained  affords  a  clinching  argument 
that  these  are  good  people  to  follow. 


About  Our  Brush-up  Course  in  This  JNIonth 

The  program  for  this  informal  practical  course  is 
taking  form.  The  place  is  the  Medical  Library  in 
Charlotte,  the  dates  September  24th,  25th  and 
26th.  In  choosing  this  time  note  was  taken  of 
the  big  football  game  here  on  the  afternoon  of  Sat- 
urday, the  26th,  and  arrangements  made  for  run- 
ning our  program  up  to  within  comfortable  reach 
of  the  ball  game. 

The  general  aim  of  the  course  is  to  arrange  for  a 
mutually  helpful  discussion  of  problems  which 
come  up  in  every-day  practice.  A  definite  objec- 
tive is  to  evaluate  a  good  many  of  the  laboratory 
methods  in  common  use,  to  indicate  that  a  great 
many  of  the  most  valuable  of  them  are  simple, 
inexpensive  and  not  time-consuming,  and  to  en- 
courage the  use  of  these  in  every  doctor's  office. 

In  general,  patients  will  be  presented  whose  cases 
will  illustrate  the  subjects  discussed.  A  patient 
case  is  worth  a  whole  lot  more  than  a  textbook  case. 
A  patient  case  describes  what  actually  happenecd: 
a  textbook  case  gives  what  may  happen. 

Another  objective  is  to  diffuse  latest  information 
on  the  details  of  treatment,  with  a  view  to  being 
helpful  to  doctors  in  the  front  lines  in  managing 
their  cases  themselves. 

In  so  far  as  is  feasible  examinations  with  special 
instruments  will  be  demonstrated  in  such  a  way 
that  those  demonstrated  to  may  walk  by  sight,  or 
hearing,  or  feeling,  rather  than  by  faith  in  what 
the  demonstrator  says  he  sees,  or  hears,  or  feels. 

In  the  belief  that  a  doctor  is  advantaged  most 
by  increasing  his  ability  to  recognize  and  manage 
the  illnesses  he  commonly  encounters,  and  next  by 
recognizing  early  those  he  can  not  manage  ade- 
quately, patients  who  have,  or  have  had,  conditions 
requiring  very  expert  care  will  be  shown  and  their 
cases  discussed.  A  doctor  feels  better,  his  people 
stand  by  him  better  and  he  gets  to  be  a  better  and 
better  doctor,  as  he  makes  more  and  more  of  his 
own  diagnoses,  whether  or  not  he  must  refer  this 
or  that  patient  for  treatment. 

Some  non-footballist  doctors  have  to  keep  their 
shops  on  Saturdays.  Any  of  these  who  will  be 
present  on  either  of  the  other  days  and  wants  some 


certain  subject  discussed  on  a  certain  day,  please 
write  this  journal  right  away  giving  subject  and 
day,  and  it  will  be  arranged. 

About  ten  days  ahead  of  the  meeting  printed 
programs  will  be  available  and  one  will  be  mailed 
to  any  doctor  sending  a  card  requesting  it. 

It  will  help  us  a  good  deal  in  making  arrange- 
ments if  you  will  send  a  card  saying  you  will  be 
would  like  to  attend  and  can  attend,  come  right 
ahead  and  you  will  find  a  hearty  welcome, 
with  us;  but,  if  the  meeting  should  creep  up  on 
you   and  you   find  at   the  last   moment   that  you 


Non  Noccre 

Almost  without  exception  is  it  that  a  remedial 
agent  which  -is  potent  for  good  under  a  certain  set 
of  circumstances  is  potent  for  evil  under  other  cer- 
tain circumstances.  Perhaps  the  most  important 
primary  division  of  materials  prescribed  by  doctors 
is  into  potent  and  impotent. 

The  history  of  medicine  is  interspersed  with  ac- 
counts of  the  rise  and  fall  of  remedies  that  were 
touted  loudly  for  their  pleasant  or  beneficial  effects 
until  time  enough  had  passed  for  doctors  to  learn 
their  evil  effects  for  themselves.  There  is  a  story 
that  heroin  was  introduced  to  the  profession  and 
had  considerable  vogue  as  a  cure  for  the  morphine 
habit ! 

You  will  not  need  to  have  been  in  practice 
many  years  to  have  had  many  such  deceptions  come 
within  your  own  observation. 

Within  the  past  fortnight  there  has  come  to  the 
attention  of  the  editor  a  startling  bit  of  informa- 
tion along  this  line.    Here  it  is: 

"It  has  been  shown  experimentally  that  excessive  amounts 
of  estrin  may  be  a  factor  in  the  development  of  carcinoma 
of  the  breast,  cervix  uteri  and  fundus  uteri." 

And  the  author  is  no  less  a  person  than  Crossen, 
of  Saint  Louis. ^ 

Evidently  this  remedy,  like  all  other  potent  ones, 
must  be  used  with  discriminating  judgment  and 
after  careful  differential  diagnosis;  not  in  a  slap- 
dash manner  for  "female  diseases,"  or  in  response 
to  a  curbstone  request  for  something  to  regulate 
"ladyship." 

Write  Dr.  Crossen  for  a  reprint. 


I 


The  Reverend  John  Jasper  Preached  "De  Sun 
Do  Move."    Well,  Do  It? 

Louis  Graves,  in  his  Chapel  Hill  Weekly  of  July 
17th,  gives  abstracts  from  a  copy  of  the  Philadel- 
phia Public  Ledger  of  May  6th,  1836.  One  of  his 
comments  is: 


September,    19ib 


SOUTHERN  MEDICINE  AND  SURGERY 


507 


The  patent  medicine  advertisements,  with  their 
extravagant  and  obviously  lying  claims,  lead  one 
to  reflect  sadly  that  many  newspapers  of  the  pres- 
ent day,  in  this  respect,  show  no  improvement  over 
those  of  a  century  ago. 


Obituary 

Doctor  James  Edwin  Smithwick 

On  the  twenty-fourth  day  of  the  month  just  past 
another  vacancy  was  made  in  the  ranks  of  faithful 
supporters  of  organized  medicine  in  this  State 
and  section,  and  of  practitioners  of  family  medicine 
of  the  highest  type. 

That  day  marked  the  death  of  James  Smithwick, 
family  doctor  for  forty-years-lacking-one  to  the 
village  of  Jamesville  and  the  east  end  of  the  Coun- 
ty of  ^Martin. 

In  the  past  few  years  Dr.  Smithwick  lost  two 
of  his  devoted  friends  in  the  profession — Dr.  Cyrus 
Thompson,  of  Jacksonville,  and  Dr.  William  E. 
Warren,  of  Williamston.  At  each  meeting  of  the 
Tri-State  Medical  Association  all  three  would  be 
seen  much  together,  and  each  contributed  largely 
to  the  success  of  these  meetings. 

Dr.  Smithwick  made  frequent  visits  to  clinics  and 
educational  medical  meetings,  and  these  visits  were 
devoted  to  improving  and  increasing  his  ability  to 
serve  his  p)eople. 

To  his  family,  to  his  patients,  to  his  fellow 
doctors,  to  his  friends  generally  and  to  his  com- 
munity he  was  devoted,  faithful  and  a  tower  of 
strength. 

In  the  churchyard  of  old  Saint  Paul's  in  Eden- 
ton  sleeps  a  progenitor  and  cut  in  the  marble  over 
him  may  be  be  read  the  family  coat-of-arms  and 
the  proud  name,  Smythwyck.  With  the  passing 
of  the  years  the  spelling  of  his  patronymic  under- 
went a  slight  change;  but  Dr.  Smithwick 's  life  por- 
trays all  that  is  suggested  on  this  stone  under  the 
walls  of  the  church  in  which  worshipped  the  gen- 
tlefolks of  this  early  capital  and  metropolis  of  the 
Colony  of  North  Carolina. 


Thyrotoxicosis 
IRt.  Hon.  Lord  Horder,  London,  Jour.  A.  M.  A.,  July  25) 
There  is  no  indisputable  evidence  that  exophthalmic 
tioiter,  "toxic  goiter,"  or  "toxic  adenoma"  owes  its  evo- 
lution to  the  circulation  of  disordered  thyroid  secretion. 
That  exophthalmic  goiter  is  an  expression  of  mere  hyper- 
thyroidism there  is  even  less  evidence.  There  are  facts 
which  suggest  that  the  thyroid  hyperplasia  is  not  the 
primary,  but  a  secondary,  phenomenon.  The  causa  causans 
remains  hidden.  That  same  poison  is  at  work  seems  an 
irresistible  conclusion.  Thyroidectomy  may  interrupt  a 
vicious  circle  and  so  do  good  in  quite  another  fashion  than 
by  getting  rid  of  the  primary  cause  of  the  trouble.     The 


exophthalmos  may  be  only  a  symptom,  the  thyroid  gland 
may  be  secondarily  and  not  primarily  affected,  the  invol- 
untary nervous  system  may  be  stimulated  from  without 
and  not  from  within,  and  the  basal  metabolic  rate  may  be 
low  rather  than  high.  That  there  is  a  diathesis  in  ex- 
ophthalmic goiter  is  generally  accepted.  But  whether  the 
flaw  resides  in  the  involuntar>'  nervous  system  or  in  the 
psyche,  or  in  the  endocrine  balance,  or  in  some  other  as  yet 
unrecognized  tissue  or  function,  or  in  more  than  one  of 
these,  we  do  not  know.  Of  exciting  causes  there  are  the 
sex  epochs,  there  are  psychic  traumas,  and  there  is  focal 
sepsis.  The  exophthalmos,  the  tachycardia,  the  goiter  and 
the  tremor  constitute  the  cardinal  features.  Loss  of  weight 
is  very  common,  though,  as  in  diabetes,  which  is  one  of 
the  family  associations,  the  patient  may  be  fat  rather  than 
lean.  Lesser  degrees  of  the  disease  are  recognizable  and, 
given  favorable  conditions,  these  quite  frequently  abort. 
The  diagnosis  of  exophthalmic  goiter  may  be  very  easy  or 
it  may  be  very  difficult.  The  difficulty  lies  in  a  recognition 
of  the  early  and  the  incomplete  pictures.  Exophthalmic 
goiter  in  its  early  stages  is  a  disease  of  the  patient  and  not 
of  her  organs.  Be  it  observed  that  the  "stare"  is  not 
merely,  or  perhaps  not  at  all,  a  matter  of  exophthalmos: 
there  are  the  enlarged  palpebral  fissures,  the  infrequency  of 
blinking,  the  dilated  pupils,  and  the  immobile  forehead. 
But  there  is  also  the  manner  of  entering  the  room,  the  hot 
hand,  quickly  given  and  quickly  withdrawn,  the  restless- 
ness, the  rapidity  of  movement,  the  lack  of  poise,  the  ex- 
cess of  gesture,  the  record  short  time  spent  in  undressing 
and  in  dressing,  the  moist  skin,  and  the  flush  on  the  neck 
and  chest.  Unexplained  loss  of  weight,  especially  in  men 
who  are  past  middle  age,  should  always  raise  the  question 
of  exophthalmic  goiter.  So  also  should  certain  changes  in 
the  patient's  conduct,  whether  noticed  by  others  or  by  the 
patient;  unwonted  lack  of  control,  irascibility,  excessive 
show  of  emotions,  and  the  quick  expenditure  of  an  unac- 
customed store  of  nervous  energy  without  apparent  fatigue. 
The  physician  must  concern  himself  with  prevention  when- 
ever the  diathesis  is  recognized:  a  thankless  task,  for,  as  a 
philosopher  has  truly  observed,  it  is  not  to  be  expected 
that  human  beings  will  accept  advice  when  they  wUI  not 
accept  warning.  If  these  "larval"  types,  or  "forms  frustes," 
are  noted,  the  physician  has  a  better  chance  than  if  com- 
mittal symptoms  have  declared  themselves.  The  chief 
difficulty,  next  to  the  temperament  of  the  patient,  lies  in 
securing  the  necessary  relief  for  those  who  are  forced  by 
their  economic  position  to  earn  their  daily  bread  by  jobs 
which  make  excessive  demands  on  their  nervous  system. 
If  the  symptoms  persist  in  spite  of  controlhng  the  patient's 
routine  of  Ufe,  and  in  all  cases  in  which  the  full  syndrome 
has  developed,  the  degree  of  physiologic  and  psychic  rest 
should  be  absolute  and  should  be  continued  for  at  least 
three  months.  Bed  is  the  only  place  where  such  rest 
can  be  guaranteed.  If  focal  sepsis  is  present,  this  should 
be  eliminated  as  far  as  possible.  There  is  no  specific  drug, 
though  there  are  drugs  that  help:  iodine  certainly,  and 
in  all  cases  in  which  the  thyroid  is  involved  (but  surely 
there  is  room  for  more  research  into  the  best  methods  of 
exploiting  this  drug  to  its  best  advantage)  ;  belladonna 
(introduced  by  Trousseau)  in  some;  the  bromides  in  others. 
There  remains  the  important  question  of  partial  thyroidec- 
tomy, a  form  of  treatment  which  has  justified  itself  of  late 
years.  In  the  author's  own  experience,  the  operation 
should  be  undertaken  whenever  the  disease  remains  active 
after  six  months  of  carefully  supervised  medical  treatment, 
and  also  in  cases  which  relapse  in  spite  of  the  patient's 
routine  of  life  being  adequately  controlled.  The  operation 
is  indicated  in  all  cases  in  which  auricular  fibrillation  has 
(to   p.   512) 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  19io 


NEWS  ITEMS 


The  Post-Graduate  Assembly  of  the  Medical  Society 
OF  THE  State  of  North  Carolina  was  held  at  Pinnacle 
Inn  and  Grace  Hospital,  Banner  Elk,  August  20th  and 
21st. 

Program:  Afternoon,  August  20th — presiding.  Dr.  James 
W.  Vernon — Welcome  and  Invocation,  Rev.  M.  J.  Mur- 
ray, Pastor  Presbyterian  Church,  Banner  Elk;  My  Ex- 
perience With  Influenza,  Dr.  Wingate  M.  Johnson,  Win- 
ston-Salem; Pneumonia,  Dr.  Verne  S.  Caviness,  Raleigh; 
Rheumatic  Heart  Disease,  Dr.  Clyde  Gilmore,  Greensboro; 
Evolution  of  the  Modern  Treatment  of  Tuberculosis,  Dr. 
C.  H.  Cocke,  Asheville;  Backache,  Dr.  D.  W.  Holt,  Greens- 
boro; and  The  Inheritance  of  Shaking  Palsy,  Dr.  William 
Allan,  Charlotte.  Dr.  L.  B.  McBrayer,  of  Southern  Pines, 
also  made  a  talk. 

A  banquet  was  held  at  the  Pinnacle  Inn  at  S  p.  m..  Dr. 
C.  H.  Cocke,  toastmaster,  addresses  by  Dr.  Paul  Ringer, 
Asheville,  and  Dr.  John  H.  Musser,  Professor  of  Medicine 
at  Tulane. 

On  August  21st,  at  Grace  Hospital,  Drs.  R.  H.  Hardin 
and  C.  L.  Sherrill,  presiding,  clinics  and  demonstrations 
were  given  by  Dr.  Musser. 


The  midsummer  meeting  of  the  Fourth  District  (Va.) 
Medical  Society  was  held  at  Emporia,  August  19th.  Dr. 
Frank  Mallory,  Lawrenceville,  presided  in  the  absence  of 
Dr.  Thomas  G.  Hardy,  the  president.  Doctors  on  the 
program  were  C.  E.  Martin  and  J.  B.  Kiser.  Dr.  G.  W. 
Brown,  of  Williamsburg,  was  unable  to  attend.  His  place 
on  the  program  was  filled  by  Dr.  Terrell,  of  Williams- 
burg. Dr.  E.  M.  Parker,  an  honorary  member  and  the 
oldest  physician  in  Greensville  County,  was  the  guest  of 
honor.  The  next  regular  meeting  will  be  held  in  Chase 
City,  Nov.  10th. 


Buncombe  County-  (N.  C.)  Medical  Society,  regular 
meeting  evening  of  August  3rd,  at  the  Biltmore  Hospital, 
Vice  President  Kutscher  in  the  chair,  47  members  present. 

The  program  consisted  of  a  Symposium  on  Nutrition, 
a  round-table  planned  and  typed  discussion  to  last  45 
minutes.  Dr.  W.  R.  Johnson  acted  as  the  chairman; 
in  his  absence  his  part  was  read  by  Dr.  A.  C.  Ambler; 
participating  were  Drs.  W.  T.  Freeman,  E.  W.  Schoenheit, 
Curds  Crump,  W.  S.  Justice,  S.  L.  Crow  and  A.  B.  Crad- 
dock. 

The  secretary  introduced  Dr.  C.  H.  Barnwell. 

No  business  taken  up.  After  adjournment  the  members 
participated    in    a    collation. 

Buncombe  Coxjnty  Medical  Society,  regular,  but  post- 
poned, meeting  held  the  evening  of  August  24th  at  the 
City  Hall  Building,  Asheville,  Pres.  Parker  in  the  chair,  73 
members  present,  visitors:  Dr.  Richardson  of  Johns  Hop- 
kins Univ.,  Dr.  Jaeckel  of  Wash.  Univ.,  St.  Louis,  Dr. 
Hardin  of  Banner  Elk,  Dr.  Folsom  of  Swannanoa,  Dr. 
Sullivan  of  Asheville,  several  physicians  from  Oteen  and 
nearby  towns,  and  many  ladies. 

Dr.  C.  H.  Cocke  introduced  our  guest  speaker,  Dr.  John 
H.  Musser,  Professor  of  Medicine,  Tulane  University,  who 
spoke  on  Some  Observations  on  Coronan,*  Occlusion.  Upon 
the  conclusion  of  the  presentation  several  questions  were 
asked  the  essayist  by  Drs.  Crow,  Smith,  Craddock,  Ringer, 
Edwards  and  Cocke. 

Application  for  membership  of  Dr.  C.  H.  Barnwell  was 
read  by  the  secretary  and  referred  to  Board  of  Censors. 


Dr.  M.  L.  Stevens  requested  the  society  to  have  our  next 
regular  meeting  scheduled  for  September  21st  for  dmner 
at  the  Asheville  Countr>-  Club  as  his  guests.  Dr.  L.  M. 
Griffith  moved  we  accept  the  in\ntation.  Dr.  Cocke  sec- 
onded.    Motion  carried  unanimously. 

The  president  announced  that  our  next  meeting  falling 
on  Labor  Day  would  be  dispensed  with  according  to  cus- 
tom. 

(Signed)     M.  S.  Broun,  M.D.,  Sec. 


At  a  meeting  held  .August  5th  in  Staunton,  the  .\ugusta 
County  Medical  Society  elected  Dr.  Guy  R.  Fisher,  of 
Staunton,  President ;  Dr.  Glenn  C.  Campbell,  County 
Coroner  and  member  of  the  Staunton  Board  of  Health, 
vice  president;  Dr.  Alex  F.  Robertson,  Staunton,  secre- 
tar>';  and  Dr.  T.  M.  Parkins,  Staunton  Health  Officer, 
treasurer.  Dr.  Fisher  and  Dr.  R.  0.  Robertson  were  elected 
delegates  to  the  meeting  of  the  Medical  Society  of  Vir- 
ginia, to   be   held   in   October. 


Announcement. — Dr.  Michael  Hoke,  having  finished  hit 
undertaking  with  the  Georgia  Warm  Springs  Foundation, 
announces  his  association  with  Dr.  Lawson  Thornton  and 
Dr.  Calvin  Sandison  in  the  practice  of  Orthopedic  Surgery, 
Atlanta,  Georgia. 


Dr.  F.  R.  Fleming  opened  offices  in  Statesville  Sept.  1st 
for  the  general  practice  of  medicine.  Dr.  Fleming  is  a 
native  of  Yadkin  County.  He  spent  four  years  at  the  Uni- 
versity of  North  Carohna,  where  he  took  the  A.B.  degree, 
two  years  in  the  medical  school  at  Wake  Forest  College  and 
two  years  in  Jefferson  Medical  College.  He  served  a  year 
of  interneship  in  Atlantic  City  Hospital,  .Atlantic  City,  N.  J. 


ASAC 

ELIXIR    ASPIRIN    COMPOUND 


Contains  five  grains  of  Aspirin,  two  and  a  half 
grains  of  Sodium  Bromide  and  one-half  grain  Caf- 
feine Hydrobromide  to  the  teaspoonful  in  stable 
Elixir.  ASAC  is  used  for  relief  in  Rheumatism,  Neu- 
ralgia, Tonsillitis,  Headache  and  minor  pre-  and  post- 
operative cases,  especially  the  removal  of  Tonsils. 

Average  Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water  as  prescribed  by  the  physician. 

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


Burwell  &  Dunn  Company 

Manufacturing 
Established 

CHARLOTTE,  N.  C. 

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


September,  1036  SOUTHERN  MEDICINE  AND  SURGERY 

Eli  Lilly  and  Company 

FOUNDED     18  76 

^Makers  oj  ^Medicinal  Products 

ENTORAL 

{Oral  Cold  Taaine,  Lilly) 

'Entoral'  contains  the  species-broad  hetero- 
phile  antigens  and  the  species-specific  antigens 
of  carefully  selected  cultures  of  pneumococci, 
^  y(emopbihis  wfluenzae,  streptococci,  and ^f icrccocciis 
catanhalis.  'Entoral'  is  distinctive  alike  for  its 
chief  immunizing  principle  (heterophile)  and  its 
method  of  administration. 

Peroral  vaccination  vi'ith 'Entoral' has  lessened 
the  incidence  of  the  common  cold  50  percent  to 
70  percent  in  controlled  groups  through  in- 
creased heterophile  antibody  titer  and  specific 
bacterial  resistance. 

'Enteral'  makes  more  practical  the  frequent  ad- 
ministration of  respiratory  antigens,  which  is 
essential  in  the  short-lived  immunities  of  upper 
respiratory  infections. 

'Enteral'  (Oral  Cold  Vaccine,  Lilly)  is  supplied 
in  bottles  of  20  pulvules  (filled  capsules)  (V-4G4). 


Prompt  Attcntiou  Qiveii  to  Professional  Jncfuiries 

PRINCIPAL    OFFICES    AND    LABORATORIES,    INDIANAPOLIS,    INDIANA,    U.S.A. 


Please  Mention  THIS  JOURNAL  When  Writing  to  Advertisers 


510 


SOUTHERN  MEDICINE  AND  SURGERY 


September,   1936 


Dr.  W.  Carey  Hedgpeth.  Lumberton,  announces  the 
opening  of  his  office  over  McMillan's  drug  store  for  the 
practice  of  Gynecology  and  Obstetrics.  Dr.  Hedgpeth  is 
a  graduate  of  Wake  Forest  College  and  Northwestern  Uni- 
versity Medical  School  and  served  an  interneship  in  Mc- 
Keesport  (Pa.)  Hospital.  In  July,  1934,  he  returned  to 
Lumberton  as  resident  physician  in  the  Thompson  Memo- 
rial Hospital,  where  he  remained  for  19  months.  Dr.  Hedg- 
peth was  in  Chicago  taking  work  in  Gynecology  and  Ob- 
stetrics under  Drs.  Karl  A.  Meyer  and  Edward  L.  Cornell. 


Dr.  E.  N.  Booker,  Selma,  N.  C,  was  guest  of  honor  at 
a  barbecue  dinner  given  by  Mrs.  Booker  at  their  home 
August  21st.  Dr.  Booker  spoke  a  few  words  of  welcome 
to  his  guests  and  Dr.  George  D.  Vick  responded. 


Duke  University  School  of  Medicine  has  arranged  a 
3-day  course  in  heart  and  kidney  diseases  for  October 
15th-17th. 


Colonel  Wn-LiAii  N.  Bisphaii,  U.  S.  A.  Medical  Corps, 
a  native  of  Warrenton,  Va.,  has  assumed  his  duties  in 
Baltimore.  He  was  stationed  previously  in  .\tlanta.  In 
Baltimore  he  succeeds  Colonel  Frederick  A.  Dale,  who  re- 
tires August  31st. 


Dr.  Joseph  Bear,  Richmond,  announces  the  removal  of 
his  offices  to  609  Professional  Building.  Hours  10  to  1 
and  by  appointment. 


Dr.  W.  R.  Brandon,  of  New  York  City,  has  lately  visit- 
ed his  mother  in  States ville. 


Dr.  J.  Frank  Arthur,  of  the  staff  of  the  United  States 
Veterans'  Bureau  in  Atlanta,  has  lately  visited  relatives  in 
States  ville. 


Dr.  Richard  S.  Ker  has  been  appointed  coroner  of 
Staunton,  Virginia,  in  succession  to  Dr.  Thomas  M.  Par- 
kins, who  recently  died  as  a  result  of  an  automobile  ac- 
cident. 


Dr.  H.  Aurelia  Gill,  of  Richmond,  has  been  elected 
resident  health  officer  and  head  of  the  Department  of 
Biology  of  Mary  Baldwin  College,  Staunton,  Virginia. 


From  Dr.  A.  E.   B.aker,  Charleston,  S.   C. 

Dr.  Riddick  Ackerman,  jr.,  of  Walterboro,  is  in  Chicago, 
doing  observation  work  at  the  Cook  County  Hospital  in 
the  treatment  of  diseases  of  the  bone  and  fractures. 

Funeral  services  for  Dr.  John  S.  Wimberly,  of  Branch- 
ville,  who  died  at  his  summer  home  in  Hendersonville,  N. 
C,  after  a  long  illness,  were  conducted  Thursday  afternoon, 
Aug.  30th,  by  his  pastor,  the  Rev.  W.  L.  Parker,  of  the 
Branchville  Methodist  Church,  and  the  Rev.  W.  S.  Henry, 
of  Columbia,  a  former  pastor.  The  ."American  Legion  was 
in  charge  of  the  burial  services.  Just  before  the  casket 
was  lowered  into  the  grave  a  squad  of  Orangeburg  national 
guardsmen  fired  a  volley  and  taps  was  sounded. 

The  funeral,  one  of  the  largest  ever  held  in  the  com- 
munity, was  attended  by  hundreds  from  all  over  this  State, 
Georgia,  North  Carolina  and  Tennessee. 

Dr.  Wimberly  was  56  years  of  age.  Born  in  St.  George, 
he  was  educated  at  Wofford  College  and  the  Medical  Col- 
lege of  the  State  of  South  Carolina.  He  had  practiced 
medicine  in  Branchville  since  his  graduation  until  three 
years  ago  when  he  was  forced  to  give  up  his  practice  on 
account  of  his  health. 


The  State  Board  of  Health  will  ask  the  State  Finance 
Committee  to  pass  as  soon  a;  possible  upon  a  proposed 
$20,000  bond  issue  for  enlarging  State  Park  Sanatorium, 
Dr.  James  \.  Hayne,  State  Health  Officer,  has  announced. 
The  1936  legislature  authorized  the  bond  issue,  subject  to 
approval  by  the  finance  committee  of  the  plan  adopted  by 
the  board  of  health  to  restore  the  bonds.  Doctor  Hayne 
said  funds  to  repay  the  bonded  debt  would  be  raised  from 
a  charge  of  SI  per  bed  daily  on  60  beds  to  be  placed  in 
the  new  strjcture  for  tuberculosis  patients.  .\  fraternal 
organization  already  has  assured  funds  for  the  beds  for  two 
years  if  necessary  and  several  counties,  including  Spartan- 
burg and  Charleston,  have  agreed  to  pay  for  a  certain 
number  of  beds  to  be  allotted  for  patients  from  their  coun- 
ties. 


-s.  M.  &  s.- 


Miss  Marie  Lee  Keiley  and  Dr.  James  Graham  Shaw,  of 
Columbia,  S.  C,  at  high  noon,  Aug.  2Sth,  in  St.  James 
Episcopal  Church,  Richmond,  the  Rev.  Dr.  Churchill 
J.  Gibson,  officiating.  Mrs.  Shaw,  the  granddaughter  of 
the  late  Judge  Anthony  M.  Keiley,  former  Mayor  of  Rich- 
mond, and  also  Chief  Justice  of  the  International  Court  at 
Cairo,  attended  St.  Catherine's  School  and  graduated  from 
the  College  of  William  and  Mar\-  at  Williamsburg  in  1933. 
Dr.  Shaw  is  the  son  of  Dr.  and  Mrs.  Arthur  E.  Shaw,  of 
Columbia,  and  a  graduate  of  the  University  of  South  Caro- 
lina, and  of  the  Medical  College  of  South  Carolina.  After 
a  Southern  motor  trip,  Dr.  and  Mrs.  Shaw  will  make  their 
home  in  Columbia. 


Miss  Cary  Valentine  Cutchens,  daughter  of  Mr.  and 
Mrs.  Louis  E.  Cutchins,  of  Richmond,  and  Dr.  A.  La- 
fr.yette  Stratford,  August  7th.  Following  a  cruise  to  the 
New  England  States,  they  will  make  their  home  at  1106 
West   Franklin   Street,  Richmond. 


Dr.  William  Earl  Overcash,  of  Southern  Pines,  for- 
merly of  Statesville,  was  married  to  Miss  Marjorie  Skin- 
ner, at  her  home  in  Elizabeth  City  on  August  8th. 


Dr.  Oscar  William  Cranz,  of  Kinston,  was  married  to 
Miss  Mary  Margaret  Hudson,  of  Mooresville,  on  August 
7th. 


Dr.  William  Hume  Hoskins,  of  Venice,  Florida,  and 
Miss  Elizabeth  Braxton  Henry  Watson,  of  Richmond,  Au- 
gust 22nd. 


Dr.    William    Angle    Young    and    Miss    Margaret    Male  \ 
Owens,  August  15th.     Mrs.  Young  was  formerly  a  student  ■■ 
at  William  and  Mary  College  and  is  a  graduate  of  the  Uni- 
versity of  Richmond.     Dr.  Young,  a  graduate  of  Roanoke 
College  and  the  Medical  College  of  Virginia,  is  house  phy- 
sician at  the  Retreat  for  the  Sick  Hospital. 

s.  M.  &  s. J 

Deaths  1 


Dr.  William  H.  Mayer,  64,  former  president  of  the 
Pennsylvania  Medical  Society,  died  .August  23rd  after  a 
week's  illness.  Physicians  said  an  injur>-  to  his  back  re- 
ceived while  playing  football  in  his  youth  was  indirectly 
the  cause  of  death.  He  completed  his  study  at  the  Uni- 
versity of  Pennsylvania  with  his  back  in  a  cast.  Dr. 
Mayer  was  born  in  suburban  Kno.xville.  His  parents  came 
from  Richmond. 


'September,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


sn 


The  Tulane   UniVersit:g  of  Louisiana 
GRADUATE  SCHOOL  of  MEDICINE 

Postgraduate  instruction  offered  in  all  branches  of  medicine. 

Special  Courses: 

Surgery,  Gynecology  and  Obstetrics — May  10  to  June  5,  1937. 
Tropical  Medicine  and  Parasitology — June  14  to  July  24,  1937. 

Courses  leading  to  a  higher  degree  are  also  given. 

A  bulletin  furnishing  detailed  information  may  be  obtained  upon  application  to 

THE  DEAN,  GRADUATE  SCHOOL  OF  MEDICINE 

1430  Tulane  Avenue,  New  Orleans,  La. 


Miss  Mar>'  Lewis  Wyche,  7S,  died  August  22nd,  at  her 
ancestral  home,  Wychwood,  near  Henderson,  N.  C,  after 
a  long  illness  which  terminated  in  pneumonia.  She  was  born 
in  Vance  County  February  26th,  1858,  the  eldest  daughter 
of  the  late  Benjamin  and  Sarah  Hunter  Wyche.  She  was 
one  of  the  first  women  in  North  Carolina  to  enter  the 
field  of  modern  nursing  and  was  founder  and  first  president 
of  the  North  Carolina  Nurses  Association.  One  of  her 
last  tasks  was  the  gathering  and  compiling  of  material  for 
her  North  Carolina  History  of  Nursing,  yet  to  be  published. 
For  several  years  she  had  made  her  home  at  Wychewood. 

After  finishing  her  course  of  training  at  the  Philadelphia 
General  Hospital  Miss  Wyche  returned  to  her  native  State 
and  for  40  years  followed  her  chosen  profession.  She  was 
superintendent  of  Rex  Hospital,  Raleigh,  for  a  number  of 
years  and  while  there  organized  in  the  hospital  the  first 
training  school  for  nurses  in  North  Carolina.  For  many 
years  Miss  Wyche  served  as  superintendent  of  Watts  Hos- 
pital in  Durham  and  it  was  during  her  administration  there 
that  the  present  large  hospital  was  built. 


iJr.  S.  E.  Gunn,  of  Hopewell,  died  Aug.  26th,  in  the  Pe- 
tersburg Hospital,  where  he  was  taken  the  day  before  after 
becoming  ill  at  his  home  in  Mansion  Hills.  He  underwent 
an  opcmtion  and  was  found  to  be  suffering  from  acute 
pancreatitis. 

A  native  of  Sutherland,  Dinwiddle  County,  Dr.  Gunn 
had  practiced  in  Hopewell  for  10  years.  He  received  his 
education  at  William  and  Mary  College  and  attended  th. 
Medical  College  of  Virginia,  from  which  he  graduated  ir 
1926,  serving  his  interncship  at  Grace  and  Memorial  Hos 
pitals  in  Richmond. 


Dr.  John  W.  Scott,  81,  retired  physician  of  Gordonsville, 
Virginia,  died  Aug.  2Sth,  at  a  Richmond  hospital.  Ho 
was  born  in  1855,  at  "Waverly,"  Orange  County,  a  son 
of  the  late  Major  William  C.  Scott,  C.  S.  A.,  quartermaster 
of  General  A.  P.  Hill's  Corps,  A.  N.  Va.  Dr.  Scott  was  an 
alumnus  of  the  University  of  Virginia  and,  in  medicine,  of 
the  University  of  Maryland.  He  had  served  as  the  health 
officer  of  Gordonsville  and  was  president  of  the  Town 
Council  for  30  years.  He  had  also  taken  a  leading  p.irl 
in  fraternal  activities  and  was  a  past  master  of  the  Gor- 
donsville Lodge  of  Masons. 


Dr.    Thomas    Moorman    Parkins,    Coroner  and    Health 

Officer  of  Staunton,  Virginia,  died  at  the  age  of  70  at  his 

home  on  August  10th   from  injuries  received  in  an  auto- 
mobile accident. 


after  an  illness  of  six  weeks.  He  was  bom  at  "Locust 
Hill,"  near  Ivy  Station,  Albemarle  County,  Va.,  a  grand- 
son of  the  Dr.  Meriwether  L.  Anderson  who  was  a 
nephew  of  Meriwether  Lewis,  widely  known  hi  history 
as  the  head  of  the  Lewis-Clark  Expedition  which  explored 
the  Missouri  and  Columbia  Rivers  in  the  early  years 
of  the  last  century.  Dr.  Anderson  attracted  patients  from 
all  sections  of  Richmond  and  from  the  nearby  counties,  and 
came  to  be  regarded  as  dean  of  the  general  practitioners 
in   his  city. 


Dl  U  RBITAL 


VASODILATOR 
DIURETIC     •     SEDATIVE 

No  Barbital  Complications 

iTli*obrom.  Serf.  Saiyc  —  3  p. 
PhtncbarblUl  .  .  .  ~  V.  gr. 
Cale.  Uict — I'/iEr. 

{Hyp«rt«n»lon  (any  •s«s«) 
Hypartanalva  Ordlo-Ranal  Dl>e*» 
*rt»riosol*r.  Cardlo-Vaacul  Olaaaaa 
Myocardltta 
AVMLABLE  |  In  lablats  at  all  dnif  atoraa 

Wrlt»  tor  IHeratur*  and  sample* 


GRANT  CHEMICAL  COMPANY 

315  EAST  77th  STREET        •        •        NEW  YORK,  N.  Y. 


FOR 


PAIN 


The  majority  of  the  phy- 
sicians  in  the   Carollnaa 
are  prescribing  our  new 
tablets 


^AMDS 


751 


Antlgail*  ind  Saditiv*     '  »?';•»  „'  »»'♦•       I  »»rt 
Aiplrtn  Phanafetln  Ctff«lD 


Dr.  Meriwether  Lewis  Anderson,  63,  for  more  than  thirty 
years  a  prominent   Richmond  physician,  died   .August  4th. 


ITe  will  mail  professional  samples  regularly 
with  our  compliments  if  you  desire  them. 
Carolina   Pharmaceutical   Co.,    Clinton,   S.  C. 


SOUTHERN  MEDICINE  AND  SURGERY 


September,  1936 


BOOK  REVIEWS 


A  TEXTBOOK  OF  PATHOLOGY,  by  W.  G.  MacCai.- 
LUM,  Professor  of  Pathology  and  Bacteriology,  Johns  Hop- 
kins University,  Baltimore.  Sixth  Edition,  Entirely  Reset. 
1277  pages  with  697  illustrations.  Philadelphia  and  Lon- 
don.    W.  B.  Saunders  Company,  1936.     Cloth  $10.00  net. 

Instead  of  following  the  usual  order  of  taking  up 
each  organ  and  describing  its  various  pathological 
alterations,  this  edition  begins  with  the  cause  of  a 
disease  and  follows  its  effects  throughout  the  body. 

Just  as  it  used  to  be  said  that  Osier's  Practise 
oj  Medicine  was  an  excellent  textbook  of  pathology, 
so  it  is  that  MacCallum's  A  Text-book  oj  Pathology 
is  one  of  the  best  treatises  on  clinical  medicine. 

MacCallum's  early  made  a  place  all  its  own  and 
each  new  edition  fixes  it  the  more  firmly  in  the 
affections  of  those  who  look  forward  to  its  appear- 


AN  INTRODUCTION  TO  PSYCHOLOGICAL  MEDI- 
CINE, by  R.  G.  Gordon,  M.D.,  D.Sc,  F.R.C.P.  (Ed.), 
Physician  to  Royal  United  Hospital,  Bath,  Physician  to 
Bath  and  Wessex  Orthopaedic  Hospital,  Bath,  Associate 
Physician  to  the  Institute  of  Medical  Psychology,  Consult- 
ing Neurologist  to  Stoke  Park  Colony,  Bristol;  N.  G. 
Harris,  M.D.,  B.S.  (Lond.),  D.P.M.,  Physician  in  Charge 
to  Woodside  Hospital,  Physician  for  Psychological  Medi- 
cine, Middlesex  Hospital,  Lecturer  in  Psychological  Medi- 


Anal-Sed 


Analgesic,   Sedative   and   Antipyretic 

.Affords  relief  in  migraine,  headache,  sciatica  and 
neuralgia.  Rheumatic  symptoms  are  frequently  re- 
lieved by  a  few  doses. 

Description 
Contains   3^    grains   of   Amidopyrine,    ''2    grain    of 
Caffeine  Hydrobromide  and  IS  grains  of  Potassium 
Bromide  to  the  teaspoonful. 

Dosage 
The  usual  dose  ranges  from  one  to  two  teaspoonfuls 
in  a  little  water. 

How  Supplied 
In  pints  and  gallons  to  physicians  and  druggists. 


Burwell  &  Dunn  Company 


Manufacturing 
Established 


Pharmacists 
in   1887 


CHARLOTTE,  N.  C. 

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


cine,  Middlesex  Hospital  Medical  School,  Late  Assistant 
Medical  Officer,  Springfield  Mental  Hospital,  Late  Assistant 
Department  for  Psychologi&l  Medicine,  St.  Thomas  Hos- 
pital, and  J.  R.  Rees,  M.D.,  M.D.,  D.P.H.  (Camb.),  Med- 
ical Director,  Institute  of  Medical  Psychology.  Oxford  Uni- 
versity Press,  New  York  and  London.     1936.     $4.00. 

The  authors  note  the  dearth  of  instruction  in 
psychological  medicine  and  set  about  formulating  a 
plan  for  supplying  such  instruction,  beginning  with 
giving  a  "unified  conception  of  the  human  being" 
and  his  departures  from  bodily  and  mental  health. 
A  complete  and  adequate  plan  of  instruction  in  this 
phase  of  medicine  is  outlined  to  fit  into  a  four- 
year  medical  course. 

The  book  points  out  the  need  for  better  instruc- 
tion in  psychological  medicine,  and  then  it  goes  on 
and  supplies  this  instruction  in  an  admirable  way. 


A  DIABETIC  MANUAL  FOR  PRACTITIONERS  AND 
PATIENTS,  by  Edward  L.  Bortz,  A.B.,  M.D.,  F.A.C.P., 
Associate  Professor  of  Medicine,  Graduate  School  of  Medi- 
cine, University  of  Pennsylvania ;  Chief  of  Medical  Service 
B,  The  Lankenau  Hospital,  Philadelphia;  with  a  foreword 
by  George  Morris  Piersol,  B.S.,  M.D.,  F.A.C.P.,  Pro- 
fessor of  Medicine,  Graduate  School  of  Medicine,  University 
of  Pennsylvania.  Illustrated.  F.  A.  Davis  Co.,  Philadelphia, 
1936. 

A  book  for  the  patient  first,  afterward  for  the 
student  and  the  physician,  emphasis  is  placed  on 
prevention.  Hereditary  influence,  its  relation  to 
marriage  and  pregnancies,  optimum  weight,  insulin  ' 
and  insulin  substitutes,  diabetes  in  childhood  are 
helpfully  touched  on.  The  reader  is  told  that  dia- 
betes generally  can  be  treated  in  the  doctor's  office. 
Care  of  the  teeth  and  the  feet  is  described,  and 
dieting  and  urine  testing  well  given.  A  helpful 
glossary  is  included. 


Thyrotoxicosis  ' 

(From  p.  507) 
developed,  and  still  more  when  signs  of  congestive  heart 
failure  are  present,  whether  the  cardiac  rhythm  be  so 
affected  or  not.  To  delay  when  any  of  these  three  criteria 
have  arrived  is  to  lose  valuable  time  and  to  lessen  the 
benefit  which  may  otherwise  be  expected.  The  author 
understands  that  those  who  have  studied  most  fully  the 
results  of  total  thyroidectomy  in  congestive  heart  failure 
have  quite  recently  come  to  the  conclusion  that,  despite  the 
striking  immediate  effect  on  the  decompensation  and  on 
associated  anginoid  symptoms,  the  procedure  is,  in  the 
majority  of  cases,  scarcely  worth  the  patient's  while. 


".\re  you  positive  that  the  defendant  was  drunk?"  asked 
the  judge. 

"No  doubt,"  growled  the  officer. 

"Why  are  you  so  certain?" 

"Well,  I  saw  him  put  a  penny  in  the  patrol  box  on 
Fourth  street,  then  look  up  at  the  clock  on  the  Presby- 
terian Church  and  shout:  'Can't  understand  it;  I've  lost 
fourteen  pounds. 


The  ambulant  treatment  of  hernia  is  a  subject  well 
worth  looking  into.  J 


Journal 

of 

SOUTHERN  MEDICINE    &  SURGERY 


Vol.  XCVIII 


Charlotte,  N.  C,  October,  1936 


No.  10 


Influenza — Some  Observations  and  Impressions'' 

WiNGATE  M.  Johnson,  M.D.,  Winston-Salem,  North  Canilina 


SINCE  1918  the  disease  variously  called  in- 
fluenza, grip,  or  the  upper  respiratory  infec- 
tion has  assumed  major  importance.  It  is 
always  present,  though  far  more  frequent  in  the 
winter  months,  and  for  a  period  of  four  to  six 
weeks  every  year  since  1918  it  has  been  prevalent 
enough  to  be  called  an  epidemic.  Brenneman  of 
Chicago  has  said  that  it  constitutes  from  50  to 
100  per  cent,  of  his  practice.  The  Committee  on 
the  Costs  of  Medical  Care  estimates  that  it  is  re- 
sponsible for  62  per  cent,  of  disabling  illness. 

'At  the"  cFose  ^of  every  epidemic  I  have  firmly 
resolved  that  the  next  time  one  comes  along  I  will 
try  to  collect  some  statistics  about  it;  but  when  it 
does  come,  it  is  so  much  like  fighting  a  prairie  fire 
that  there  is  no  time  to  do  any  bookkeeping.  At 
the  close  of  last  year's  epidemic,  however,  I  did 
jot  down  some  observations,  impressions  and  re- 
flections, based  upon  the  accumulated  experience 
of  the  epidemics  of  the  past  17  years,  including 
an  annual  personal  attack. 

The  severity  of  the  disease  has  gradually  les- 
sened every  year  since  the  devastating  pandemic 
of  1918,  though  every  wave  is  apt  to  bring  a  few 
cases  of  the  fatal  type  of  pneumonia.  Each  epi- 
demic lasts  from  four  to  sLx  weeks,  and  leaves  in 
its  wake  much  work  for  the  specialists  in  infected 
sinuses,  ears  and  mastoids.  At  the  beginning  of 
the  epidemic  the  cases  are  usually  comparatively 
mild,  becoming  more  severe  as  it  progresses,  and 
again  milder  toward  the  end. 

Almost  any  definition  is  open  to  criticism,  and 
the  one  I  am  offering  is  certainly  not  perfect;  but 
at  least  it  gives  a  fair  idea  of  the  disease  under 
discussion:  An  acute  infectious  disease  of  unde- 
termined etiology,  highly  contagious,  characterized 
by  pharyngitis,  general  malaise,  great  prostration 
and  a  tendency  to  numerous  complications. 

The  pandemic  of  1918,  it  will  be  recalled,  began 
in  the  summer  months  and  reached  its  climax  in  a 


gorgeous  October.  Every  year  since  then,  how- 
ever, it  has  come  in  the  winter  or  early  spring, 
oftenest  in  January.  The  layman  is  disposed  to 
blame  it  on  the  weather  and  to  wish  for  cold 
weather  or  warm  weather  or  for  rain  or  dry  weath- 
er, depending  upon  what  we  do  not  have;  but  the 
wave  of  new  cases  goes  serenely  on  until  its  force 
is  spent.  It  is  my  observation  that  a  dry,  dusty 
spell  is  more  likely  to  bring  about  a  crop  of  respira- 
tory infections  than  is  any  other  kind  of  weather. 

No  age  is  exempt,  though  it  was  noted  in  1918 
and  since  that  the  disease  could  show  a  rough  kind 
of  chivalry  in  dealing  more  gently  with  children 
and  old  people  than  with  those  in  the  prime  of 
life.  Fatigue  and  exposure  play  a  large  part  in 
lowering  the  resistance.  The  sex  of  the  individual 
makes  little  difference  in  the  etiology.  The  ab- 
normally dry  atmosphere  produced  in  most  of  our 
houses  by  modern  methods  of  heating  quite  possi- 
bly plays  a  part. 

The  organism  causing  it  is  still  an  unknown 
quantity.  Francis  of  New  York^  says  he  has  been 
able  to  transmit  upper  respiratory  infections  to 
ferrets  by  a  virus  obtained  from  the  sputum  of 
human  patients  sent  him  from  Puerto  Rico,  though 
previously  he  had  been  unable  to  infect  these  ani- 
mals with  material  from  patients  in  New  York. 
His  work  is  quoted  by  Rivers-  with  approval  in 
his  clinical  lecture  on  virus  diseases  given  at  the 
Kansas  City  meeting  of  the  A.  M.  A. 

My  own  opinion  is  that  a  combination  of  germs 
may  be  responsible,  and  that  the  way  in  which 
they  are  combined  may  determine  the  type  of  the 
individual  case,  also  how  much  prostration  is  pro- 
duced. It  may  be  possible  that  a  virus  initiates 
the  attack  and  that  the  organisms  usually  found 
in  the  nose  and  throat  may  be  secondary  invaders, 
but  responsible  for  the  complications  that  follow. 

The  immunity — if  any — produced  by  an  attack 
is  short  lived.     Reasoning  by  analogy,  this  would 

•Presented  to  the  Post  Graduate  Assembly,  Medical  Society  of  the  State  of  North  Carolina,  at  Banner  Elk,  Augu.st 
20th. 


INFLUENZA^Johnson 


October,   1036 


argue  against  a  virus  as  the  sole  cause  of  the  dis- 
ease, since  most  if  not  all  the  other  virus-produced 
diseases  we  have  confer  lasting  immunity. 

The  incubation  period  is  short — from  a  few  hours 
to  three  days.  The  symptoms  of  the  typical  case 
are  too  well-known  to  require  description;  though 
their  protean  character  may  make  the  diagnosis 
difficult.  Perhaps  most  characeristic  is  prostra- 
tion out  of  all  proportion  to  the  other  symptoms, 
and  which  may  last  for  weeks  after  defervescence. 
As  the  late  Peter  Finley  Dunne  made  his  famous 
character  of  bygone  days,  Mr.  Dooley,  say  to  his 
friend  Hogan,  "Tis  a  quare  disease,  Hogan;  it 
makes  you  so  damned  sick  after  you  get  well." 

Three  most  frequent  types  are  recognized,  al- 
though they  may  shade  into  one  another. 

1.  The  respiratory  type  is  most  frequent. 
Laryngitis  or  tracheitis  is  present  almost  from  the 
beginning,  with  a  dry,  harassing  cough,  and  there 
is  a  tendency  to  pneumonia,  the  incidence  of  which 
varies  in  different  epidemics.  The  nose,  sinuses 
and  ears  are  also  subject  to  attack. 

2.  The  intestinal  type  is  characterized  by  the 
general  malaise  of  the  disease  plus  one  or  more 
of  the  intestinal  symptoms:  nausea,  diarrhea  or 
pain.  Appendicitis  may  be  simulated  so  as  to 
puzzle  an  expert.  The  intestinal  type  may,  for  a 
week  or  ten  days,  resemble  closely  typhoid  fever, 
with  a  coated  tongue,  anorexia,  a  slow  pulse,  nose 
bleed,  and  occasionally  a  fair  imitation  of  rose 
spots.  Here  the  diagnosis  usually  settles  itself  by 
defervescence  just  when  the  Widal  reaction  should 
become  positive  in  typhoid,  or  labial  herpes  may 
rule  out  typhoid.  Sometimes  there  is  an  enteritis 
with  bloody  mucus  or  even  pure  blood  in  the 
stools. 

3.  In  the  nervous  type  an  unusually  severe 
headache,  with  vomiting,  photophobia  and  stiffness 
of  the  neck  may  strongly  suggest  meningitis,  but 
the  leukocyte  count  and — rarely  necessary — a 
spinal  puncture  should  rule  it  out.  This  type  of 
case  is  apt  to  have  a  prolonged  convalescence, 
during  which  the  patient  may  suffer  the  tortures 
of  a  mental  depression.  Severe  insomnia  is  not 
infrequently  a  sequel. 

The  complications  of  influenza  are  legion,  and 
no  attempt  is  made  even  to  name  them  all.  The 
late  J.  C.  Wilson  was  accustomed  to  begin  his 
six-weeks'  series  of  lectures  on  typhoid  fever  by 
the  statement  that  the  study  of  typhoid  and  its 
complications  and  of  pneumonia  and  its  compli- 
cations constituted  an  epitome  of  the  practice  of 
medicine.  This  statement  might  with  equal  justice 
be  applied  to  influenza  alone  now,  since  pneumonia 
is  its  most  important  complication. 

The  complications  of  the  respiratory  type  are 
only  too   familiar   to   all   practitioners — laryngitis. 


bronchitis,  pneumonia,  sinusitis,  otitis  and  mas- 
toiditis. Those  of  the  intestinal  type  have  already 
been  mentioned,  but  I  would  like  to  suggest  that 
the  appendix  is  more  susceptible  to  inflammation 
after  an  attack  of  influenza.  In  the  genitourinary 
tract,  nephritis,  pyelitis,  or  pyelonephritis  may  de- 
velop, pyelitis  being  the  more  frequent.  In  my 
experience  both  it  and  nephritis  usually  clear  up 
quickly. 

The  glands  of  the  neck  or  other  parts  of  the 
body  may  be  inflamed,  but  seldom  suppurate.  In 
a  patient  of  mine  operated  on  for  acute  appendi- 
citis two  weeks  after  a  severe  intestinal  influenza, 
the  mesenteric  glands  were  markedly  enlarged. 

In  a  typical  severe  attack  every  muscle  in  the 
body  seems  to  ache,  but  occasionally  one  muscle 
may  be  particularly  involved.  Several  patients 
seen  last  winter  were  seized  suddenly  with  such 
terrific  pain  in  the  intercostal  muscles  that  it  re- 
quired a  hypodermic  injection  of  morphine  to  re- 
lieve them.  Two  of  my  patients  had  a  myositis, 
one  involving  the  muscles  of  the  forearm,  tlie 
other  of  the  leg.  In  both  there  was  considerable 
wasting  but  eventually  complete  recovery. 

The  joints  usually  share  in  the  general  misery 
that  goes  with  a  well-developed  case  of  influenza. 
Sometimes,  however,  one  or  more  may  be  involved 
— sometimes  several  in  succession — with  swell- 
ing and  tenderness  much  like  that  of  rheumatic 
fever,  but  usually  less  severe  and  of  shorter  dura- 
tion. 

The  skin  often  manifests  a  macular  eruption,  a 
little  like  that  of  German  measles,  but  usually 
fainter.  In  my  experience  it  nearly  always  comes 
after  defervescence  and  lasts  only  three  or  four 
days.  I  have  come  to  regard  it  as  of  favorable 
significance.  Rarely  erythema  nodosum  may  be  a 
complication. 

Phlebitis  occasionally  occurs.  A  general  blood- 
stream infection  may  be  a  complication. 

That  encephalitis  is  apt  to  develop  as  a  sequel 
of  influenza,  particularly  after  several  attacks  re- 
peated in  close  succession,  has  been  observed  for 
many  years;  but  just  what  the  connection  is  has 
not  yet  been  definitely  determined.  Alvarez-"*  has 
recently  advanced  the  idea  that  mild  infections 
with  neurotropic  viruses  may  be  much  more  fre- 
quent than  has  been  thought  hitherto,  and  could 
explain  the  indefinite  nervous  breakdowns  that  are 
not  infrequently  seen  in  the  wake  of  influenza. 

In  1932  I  discussed  before  the  Tri-State  Asso- 
ciation'*  the  theme  that  such  a  general  infection  as 
influenza  often  profoundly  influences  local  lesions: 
for  example,  interfering  with  the  healing  of  lacera- 
tions or  surgical  incisions,  or  activating  a  latent 
abscess  at  the  root  of  a  tooth. 

It  is  as  interesting  to  note  how  the  characteris- 


October,  1036 


INFLUENZA— John 


51S 


tics  of  the  malady  will  vary  from  one  year  to  the 
next  as  it  is  to  observe  the  changing  styles  in 
automobile  lines.  In  the  1918  pandemic  the  res- 
piratory type  was  the  prevailing  one,  with  pneu- 
monia as  the  chief  complication — a  pneumonia  in 
which  the  patient  often  literally  drowned  in  his 
own  secretions.  Atropine,  digitalis,  caffeine  and 
the  whole  list  of  circulatory  and  respiratory  stim- 
ulants were  as  ineffective  as  sterile  water.  The 
next  year  infections  of  the  ears  and  sinuses  were 
prevalent.  In  other  years  the  intestinal  type  was 
most  frequent — the  least  dangerous  but  the  most 
miserable  to  experience.  Some  years  neuralgias 
were  quite  annoying,  particularly  of  the  scalp.  In 
1926  influenza  departed  from  its  usual  custom  and 
began  to  present  a  marked  leukocytosis  instead  of 
a  leukopenia,  the  polymorphonuclear  cell  count 
being  relatively  high.  The  fact  that  the  intestinal 
type  with  severe  abdominal  pain  was  then  quite 
frequent  added  to  our  gray  hairs  in  trying  to  dif- 
ferentiate it  from  appendicitis.  We  were  helped 
by  the  fact  that,  as  is  usually  the  case  when  a 
villain  assumes  false  colors,  the  attempt  was  over- 
done, and  influenza  gave  a  much  higher  average 
leukocyte  count  than  did  true  appendicitis. 

The  question  of  individual  susceptibility  is  a 
very  interesting  one.  Why  will  one  individual  go 
through  epidemic  after  epidemic  unscathed?  Why 
will  another  go  safely  through  a  dozen,  then  suc- 
cumb to  the  thirteenth?  Why  will  still  another 
contract  it  every  time  it  comes  along,  or  even  be- 
tween epidemics  when  he  gets  his  feet  wet  or  be- 
comes unduly  fatigued?  Why,  as  the  laity  often 
ask,  do  doctors  go  through  epidemics,  coming  in 
close  contact  with  patient  after  patient,  yet  escape 
until  exhaustion  lowers  their  resistance? 

The  first  three  questions  I  leave  for  some  one 
else  to  answer,  and  will  attempt  only  a  guess  at 
tlie  last  one.  The  most  plausible  explanation  that 
recurs  to  me  is  that  the  continual  bombardment 
V.  ith  the  causative  organisms  stimulates  the  for- 
mation of  antibodies  or  whatever  the  body  forms 
to  fia;ht  off  infections  with,  until  the  system  is  at 
a  high  state  of  preparedness.  This  protection  holds 
until  overcome  by  the  fatigue  toxins  which  result 
from  the  strain,  worry,  and  loss  of  sleep  that  go 
with  an  epidemic.  My  personal  experience  sup- 
ports this  theory.  I  have  had  the  disease  every 
year  but  one  since  1918;  but  every  time  have  suc- 
cumbed either  at  the  beginning  of  an  epidemic, 
before  having  a  chance  to  establish  any  immunity, 
or  at  the  end,  when  well-nigh  exhausted. 

The  diagnosis  of  the  typical  case,  especially  dur- 
ing an  epidemic,  is  quite  easy;  but  it  may  be  dif- 
ficult tc  distinguish  some  cases  of  it  from  menin- 
gitis, appendicitis,  typhoid  fever,  the  preeruptive 
stage  of  smallpox  or  measles,  or  from  other  infec- 


tious diseases.  The  limits  of  this  paper  will  not 
permit  a  discussion  of  the  various  differential  diag- 
noses, but  I  do  want  to  emphasize  the  sign  that 
to  me  is  the  most  characteristic  single  finding  in 
influenza,  which  I  consider  important  enough  to 
include  in  the  definition ;  namely,  pharyngitis.  Often 
the  patient  will  say  his  throat  does  not  hurt — 
especially  if  he  is  a  child — but  inspection  will 
show  a  red  pharynx  all  the  same.  The  inflamma- 
tion may  vary  from  a  simple  redness  to  the  ap- 
pearance of  raw  beef.  At  times  the  congestion 
may  be  severe  enough  for  the  mucous  membranes 
to  bleed.  In  patients  with  tonsils,  the  inflamma- 
tion seems  to  shoot  between  them  and  hit  the 
back  of  the  throat.  I  would  hesitate  to  make  a 
diagnosis  of  influenza  without  this  sign. 

Another  characteristic  finding,  though  not  so 
constant  as  the  pharyngitis,  is  a  red  rim  around 
the  edge  of  the  drum  membrane  which  may  involve 
only  the  external  canal  of  the  ear  immediately  ad- 
jacent to  the  drum,  or  the  edge  of  the  membrane 
itself.  This  does  not  usually  cause  pain  in  the 
ear. 

Still  another  marked  characteristic  is  a  decided 
fall  in  blood  pressure,  though  this  does  not  always 
occur  at  the  beginning.  It  persists  for  a  varying 
time  after  defervescence,  and  is  a  sort  of  gauge  of 
the  patient's  weakness. 

One  very  firm  impression  I  have  formed,  though 
I  have  no  statistics  available  to  confirm  it,  is  that 
the  higher  the  initial  temperature,  the  more  quickly 
it  is  apt  to  subside,  and  the  less  the  prostration 
afterward.  This  may  be  due  to  a  high  tempera- 
ture stirring  up  more  resistance  and  so  overcoming 
the  invading  organisms  more  quickly.  If  correct, 
this  observation  leads  to  the  disquieting  reflection 
that  we  may  do  more  harm  than  good  with  anti- 
pyretics. May  it  not  come  eventually  to  pass  that 
we  shall  go  through  the  same  cycle  with  antipyret- 
ics in  influenza  that  we  did  in  typhoid  fever?  Cer- 
tainly we  know  that  the  coal-tar  products  tend  to 
lower  the  blood-pressure,  which  is  exactly  what  the 
disease  itself  does.  Years  ago,  in  a  classic  ex- 
periment,'' Pasteur  demonstrated  that  it  was  not 
possible  to  inoculate  a  chicken,  which  had  a  normal 
temperature  of  107  F.,  with  anthrax,  unless  it 
were  first  submerged  in  a  tub  of  ice  water  long 
enough  to  bring  its  tempjerature  down  to  the  hu- 
man range.  Any  poultryman  familiar  with  capon- 
izing  male  chickens  will  testify  that  it  is  impossible 
to  infect  the  wound,  no  matter  how  dirty  the  in- 
struments used  in  the  operation.  This  would  argue 
that  fever  may  be  a  beneficial  process.  Of  late 
the  artificial  production  of  fever  by  malaria,  by 
vaccines  given  intravenously,  by  foreign  proteins, 
or  by  electrical  means,  is  being  advocated  in  the 
treatment  of  certain  diseases;    yet  when  Nature 


INFLUENZA— Johnsott 


October,  1936 


provides  fever  gratuitously  in  influenza,  we  attempt 
to  get  rid  of  it  as  quickly  as  possible.  I  wonder 
if  we  are  as  smart  as  we  thing  we  are. 

Until  the  specific  cause  is  established,  the  treat- 
ment must  be  empirical.  E.^cept  for  the  avoidance 
of  fatigue  and  the  proper  treatment  of  sinus  in- 
fections— whatever  that  treatment  may  be — there 
is  little  to  offer  in  the  way  of  prophylaxis.  In  the 
treatment  of  the  attack,  certain  rules  appear  to 
be  fairly  well  standardized. 

First,  absolute  rest  in  bed  for  at  least  24  hours 
after  the  temperature  is  normal,  and  another  day 
or  two  of  lounging  around  the  house  before  going 
outdoors.  The  late  Dr.  J.  INI.  Templeton  told  me, 
a  short  time  before  he  died,  that  if  he  had  his 
professional  career  to  live  over  again,  the  greatest 
change  he  would  make  in  treating  his  patients 
would  be  to  keep  them  in  bed  longer  after  infec- 
tious diseases. 

Second,  a  light  diet  with  plenty  of  fluids,  espe- 
cially fruit  juices. 

Third,  avoid  chilling  the  patient.  Most  of  us 
veterans  lost  some  of  our  enthusiasm  for  fresh 
air — certainly  for  cold  air — during  those  hectic 
days  of  1918  when  we  first  began  to  get  acquaint- 
ed with  the  "Spanish  influenza." 

Fourth,  relieve  the  physical  discomfort  of  the 
disease  by  sedatives  and  hypnotics  if  necessary, 
though  drugs  are  the  least  important  part  of  the 
treatment.  My  own  pet  capsule  is  composed  of 
aspirin,  5  grains;  phenobarbital  and  codeine,  aa 
%  grain  (unless  the  patient  is  known  to  tolerate 
any  opiate  badly).  Amidopyrin  was  my  favorite 
until  it  was  incriminated  as  the  chief  offender  in 
granulopenia  (153  out  of  172  cases:  Kracke, 
Journal  A.  M.  A.,  Sept.  21st,  1935.)  Even  phen- 
acetin  is  under  suspicion,  though  I  admit  some- 
times using  it.  As  already  indicated,  however,  I 
doubt  the  wisdom  of  using  any  antipyretic  drug, 
though  still  guilty  of  the  practice. 

For  the  pharyngitis,  equal  parts  of  soda  and 
salt,  one  level  teaspoonful  to  the  cupful  of  warm 
water,  make  an  excellent  and  economical  gargle. 
A  few  drops  of  tincture  of  iodine  add  to  its  anti- 
septic quality.  Laxatives  are  used  only  as  indi- 
cated, likewise  cough  sedatives.  Of  late  years  I 
am  more  and  more  using  dilute  hydrochloric  acid 
both  during  and  after  the  febrile  period,  giving 
half-teaspoonful  doses  in  tomato  juice  or  butter- 
milk t.  i.  d.  with  meals.  Very  often  it  is  the  only 
tonic  used  during  convalescence. 

Finally,  I  want  to  present  briefly  a  few  case 
reports  to  suggest  a  possible  short  cut  through  the 
prolonged  period  of  prostration  that  so  often  fol- 
lows the  disease. 

A  lady,  aged  30,  had  an  unusually  severe  attack  of  in- 
fluenza  of   the   intestinal   type   which   left   her   extremely 


prostrated.  Her  total  leukocyte  count  was  2,000  with 
only  0%  pmn.  cells.  Inasmuch  as  the  only  drug  she  had 
taken  for  months  was  milk  of  magnesia,  and  as  her  throat 
was  not  ulcerated  nor  her  gums  inflamed,  her  blood  con- 
dition was  regarded  as  an  extreme  post-influenza]  leuko- 
penia rather  than  a  granulopenia.  Nevertheless  I  decided 
to  give  her  eight  minims  of  turpentine  in  the  deltoid  muscle 
to  stimulate  leukocyte  production,  as  recommended  by 
Roberts  and  Kracke.*"  Next  day  her  leukocytes  had  in- 
creased to  2600,  within  a  week  to  6400  with  62%  granulo- 
cytes, and  within  ten  days  to  10,200  with  71%  granulo- 
cytes. Her  arm  became  quite  inflamed  at  the  site  of  the 
injection  and  within  a  week  it  looked  as  though  suppura- 
tion were  inevitable,  but  the  inflammation  then  subsided 
rapidly. 

Instead  of  the  long  lingering  convalescence  that  usually 
follows  such  a  severe  attack,  she  regained  her  accustomed 
strength,  appetite  and  vigor  with  amazing  rapidity.  Her 
b.  p.  returned  to  normal  far  more  quickly  than  is  usually 
the  case,  and  when  her  cook  fell  ill  a  few  days  after  she 
got  out  of  bed,  she  was  able  to  do  her  housework  with 
little  effort. 

.\nother  patient  who  learned  of  this  case  was  so  wretch- 
edly prostrated  after  an  attack  of  influenza  that  she  asked 
for  the  same  treatment.  Her  leukocyte  count  was  4800 
with  51%  pmn.  when  given  four  minims  of  turpentine: 
24  hours  later  her  leukocytes  were  13,200  with  86%  pmn. 
Four  days  later  the  count  was  18,100  with  91%  pmn.  On 
the  fifth  day  it  had  dropped  back  to  13,300  with  86% 
pmn.,  and  after  ten  days  it  was  8200.  She  reported  that 
her  fatigue  disappeared  the  day  after  the  turpentine  was 
given,  and  that  the  discomfort  of  the  sore  arm  was  more 
than  compensated  by  her  renewed  vitality. 

In  a  third  patient  I  tried  dilute  hydrochloric  acid  intra- 
venously, but,  while  painless,  it  had  little  effect.  The  next 
step  was  to  use  one  minim  of  turpentine  mi.xed  with  four 
minims  of  olive  oil.  This  caused  very  little  discomfort, 
but  gave  very  little  leukocyte  response — raising  the  total 
count  to   7500  with   68%   pmn. 

Later  injections  have  been  made  with  varying 
proportions,  and  I  have  found  three  minims  ol 
turpentine  and  five  of  olive  oil  will  give,  usually,  a 
fairly  satisfactory  leukocyte  response  without  much 
discomfort.  So  far  I  have  not  had  an  abscess  in 
my  small  series  of  cases. 

This  treatment,  I  admit,  is  rather  heroic,  and  I 
would  not  advise  its  use  indiscriminately.  I  would 
like  to  find  some  other  agent  that  would  stimulate 
the  phagocytes  as  promptly  and  as  effectively  as 
turpentine,  but  have  not  yet  done  so. 

SinvEMAKY 

1.  Since  1918  we  have  had  an  annual  epidemic 
of  a  disease  variously  called  influenza,  grip,  or  up- 
per respiratory  infection. 

2.  The  specific  cause  is  unknown  though  possi- 
bly a  combination  of  several  organisms  rather  than 
a  single  one. 

3.  Three  main  types  are  recognized — respira- 
tory, intestinal,  and  nervous. 

4.  The  chief  complications  are  briefly  discussed. 

5.  The  question  of  individual  susceptibility  is 
raised  but  left  unanswered. 

6.  An  initial  high  temperature  is  probably  bene- 


October,  1936 


INFLUENZA—Jnfitison 


S17 


ficial,  and  drugs  to  lower  it  probably  harmful. 

7.  The  treatment  is  chiefly  empirical. 

8.  The  possible  value  of  turpentine  injections  to 
stimulate  leukocyte  production  is  discussed. 

References 

1.  Francis,  T.,  tr  :  Recent  Advances  in  the  Study  of 
Influenza.  Jour,  oj  the  A.  M.  A..  July  27th,  1935,  pp. 
251-4. 

2.  Rivers,  T.  M.:  Recent  .\dvances  in  the  Study  of  the 
Viruses  and  Viral  Diseases.  Jour,  oj  the  A.  M.  A., 
July  ISth,  1936,  p.  208. 

3.  .'\lvarez,  W.  C:  Problems  of  Present  Day  Gastroen- 
terology. Am.  Jour,  o)  the  Med.  Sc,  Oct.,  1931,  p. 
450. 

4.  Johnson,  W.  M.:  The  Influence  of  General  Infections 
upon  Local  Lesions.  Southern  Medicine  &  Surgery, 
Jun-;,   1932. 

5.  \allerv-Radot,  D.:  The  Life  of  Pasteur.  Garden 
City  Publishing  Company,  pp.  267-277. 

6.  Roberts,  S.  R.,  and  Kracke,  R.  R.:  Further  Studies 
on  Granulopenia.    An.  of  Int.  Med.,  Aug.,  1934,  p.  115. 


Pneumonia  Following  the  Aspiration  of  Oils 

(H.  G.  Reineke,  Cinti.,  and  J.  E.  Whiteleather,  Memphis, 
in  Jl.  of  Med.,  Sept.) 

Pneumonia  following  the  aspiration  of  oils,  also  known 
as  lipoid  pneumonia  and  oil  inspiration  pneumonia,  has 
been  recognized  for  a  little  more  than  a  decade.  It  is  now 
of  relatively  frequent  occurrence. 

The  incidence  of  oil  aspiration  pneumonia  is  largely  in 
infants  although  a  number  of  cases  in  adults  have  been 
reported.  The  extensive  use  of  oils,  particularly  in  pedia- 
tric practice,  both  as  a  food  and  for  therapeutic  purposes, 
has  been  carried  out  with  hardly  a  thought  of  any  possible 
harm  to  the  individual  patient. 

Vegetable  oils,  with  the  exception  of  chaulmoogra  oil, 
are  relatively  harmless  and  inert.  Mineral  oil  is  not  hydro- 
lyzed;  it  behaves  like  a  foreign  body  and  causes  active 
proliferative  reaction  and  phagocytosis.  .Animal  oils  are 
poorly  hydrolyzed,  often  causing  exudative  inflammation 
and  consequent  fibrosis  through  the  liberation  of  free  fatty 
acids  and  partly  act  as  a  foreign  body  either  in  a  free 
state  or  as  an  insoluble  oxidation  product,  stimulating 
fibrosis  and  the  production  of  giant  cells.  This  is  the 
reason  for  the  use  of  poppyseed  oil,  a  vegetable  oil,  as  a 
base  for  iodized  oils  now  widely  used  as  opaque  media  in 
roentgen  diagnosis. 

Oil  aspiration  pneumonia  is  practically  confined  to  de- 
bilitated children  and  its  frequence  is  greater  than  has  been 
suspected. 

The  constant  and  conspicuous  presence  of  oil-laden 
macrophages  and  foreign  body  giant  cells  is  the  cardinal 
feature. 

Liquid  petrolatum,  cod  liver  oil  (halibut  liver  oil)  and 
certain  medicated  oils  (usually  with  liquid  petrolatum  as  a 
base)  appear  to  be  by  far  the  most  important  oils  con- 
cerned. The  accidental  aspiration  of  milk  must  always  be 
regarded  as  a  potential  source  of  danger. 

The  indiscriminate  use  oj  nasal  oil  drops  is  fraught  with 
dan:.;er,  particularly  when  it  is  done  without  the  physi- 
cian's knowledge  and  consent  over  prolonged  periods  of 
time.  The  attending  physician  must  ascertain  by  careful 
history  taking  whether  or  not  this  practice  has  been  carried 
out  in  any  given  case  where  the  symptoms  can  not  be 
clearly  defined  on  any  of  the  more  common  grounds. 


Heredity  and  Radiation 
(M,  Demerec,  Cold  Spring  Harbor,  N.  T..  in  Radiology, 
Aug.) 
It  can  hardly  be  doubted  that  the  laws  of  heredity, 
known  as  the  Mendelian  laws,  are  universal  biologic  laws. 
They  have  been  found  to  hold  true  for  all  groups  of  living 
organisms  which  have  been  tested.  These  tests  covered  a 
wide  range  of  organisms — in  the  animal  kingdom:  proto- 
zoa, molluscs,  Crustacea,  insects,  fishes,  amphibia,  reptiles, 
birds  and  mammals;  in  the  plant  kingdom:  bacteria,  fungi, 
algae,  mosses,  ferns,  grasses,  and  a  large  number  of  orders 
of  higher  plants. 

The  responsibility  for  the  transmission  of  any  hereditary 
characteristic  can  be  definitely  traced  to  a  minute  particle 
present  in  the  germ-cell  called  a  gene.  The  whole  set  of 
genes  of  an  organism  works  as  a  unit  and  it  forms  a  bal- 
anced system  which,  with  the  environment  in  which  the 
organism  develops,  determines  the  appearance  and  the 
characteristics  of  the  individual. 

The  total  number  of  genes  in  an  organism  is  large. 
Detailed  studies  of  certain  of  these  deficiencies  revealed 
that  they  have  a  lethal  effect  on  even  a  small  patch  of  cells 
which  is  surrounded  by  otherwise  normal  tissue.  This 
indicates  that  genes  perform  ver>'  important  functions,  not 
only  for  the  organism  as  a  whole  but  also  for  every  indi- 
vidual cell  of  that  organism. 

Genes  are  ultramicroscopic  particles,  probably  single  or- 
ganic molecules,  very  stable,  and  they  possess  the  power 
of  self-reproduction. 

There  is  ample  evidence  to  show  that  genes  are  not 
affected  by  ordinary  environmental  factors,  viz.,  that  the 
ordinary  environment  is  ineffective  in  producing  heredi- 
tar\'  changes.  The  only  effective  agencies  in  producing 
changes  in  genes  are  those  which  are  able  to  reach  the 
gene  without  injuring  the  cell.  The  most  effective  ones 
are  x-ray  and  related  radiations,  which  invariably  produce 
changes  in  genes.  Ultraviolet  rays  are  effective  also,  but 
because  of  their  low  penetration  they  can  be  applied  only 
in  specific  cases.  High  temperature  is  the  third  environ- 
mental agent  known  to  affect  genes;  however,  it  also  can 
be  used  effectively  only  in  special  instances. 

The  hereditary  changes  produced  by  x-rays  are  of  two 
types,  viz.,  changes  in  genes  and  various  chromosomal  re- 
arrangements. 

A  geneticist  would  not  oppose  treatment  applied  to 
somatic  tissues.  It  is  very  likely  that  the  organism  will 
take  care  of  detrimental  genetic  changes  produced  by  it. 
However,  difficulties  might  arise  if  the  application  is  given 
to  fast-growing  tissues  or  to  embryos.  A  geneticist  would 
not  hesitate  to  predict  that  indiscriminate  x-ray  treatment 
of  germ-cells  will  increase  the  number  of  carriers  of  detri- 
mental hereditary  characteristics  in  any  race  in  which  that 
treatment  is  practiced,  and  if  continued  long  enough,  will 
have  a  grave  detrimental  effect  on  the  race  as  a  whole. 


Yeast  No  New  Remedy 
.Xcligan  has  found  yeast  of  great  service  in  intense 
tympanitis  following  parturition.  The  dose  is  2  table- 
spoonsful  every  3  hours,  and  it  may  be  given  in  camphor 
mixture  or  peppermint  water.  Yeast-poultice  forms  an 
excellent  stimulating  application  to  foul  and  irritable  sores. 
It  is  composed  as  follows:  Take  of  yeast  6  fl.  oz.;  flour, 
14  oz.;  water  heated  to  100°,  6  fl.  oz.;  mix  the  yeast  with 
the  water,  and  stir  in  the  flour;  then  place  the  mass  near 
the  fire  till  it  rises.  This  poultice  should  be  renewed  every 
6  or  8  hours. — United  Editors  Enc.  &  Dictionary,  1907. 


Beri-beri — A  case  is  reported  as  occurring  in  New  Jersey 
last  year. 


Many  cases  of  impetigo  are  made  chronic  by  the  use  oi 
strong  antiseptics. 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


Prostatic  Resorption  and  Prostatic  Resection  in  Early 
Prostatism 


Maximilian  Stern,  M.D.,  F.A.C.S.,  Daytona  Beach,  Florida 


AT  the  1926  meeting  of  the  A.  M.  A.  I  pre- 
sented the  resectoscope  operation^  for  ob- 
structions at  the  vesical  orifice,  soon  after 
its  initial  presentation  by  me-  before  the  New  York 
Academy  of  Medicine,  when  I  stressed  the  value 
of  electrosurgery  in  early  prostatic  disease  as  a 
prophylactic  measure.  Since  then,  many  have 
voiced  the  same  opinion  and  resection  of  vesical- 
neck  obstructions  is  now  a  rather  common  proce- 
dure. 

Despite  the  many  encouraging  reports  as  to  the 
percentage  of  cases  to  which  it  is  applicable,  sub- 
sequent experience  has  made  me  doubt  if  resection 
is  in  fact  the  method  of  choice  in  cases  of  early 
prostatism. 

When  one  considers  all  the  factors  operating  for 
and  against  this  operation,  doubt  must,  perforce, 
arise  if  only  for  the  reason  that  occasionally  resec- 
tion converts  a  seemingly  insignificant  affair  into 
a  serious  one. 

The  patients,  for  the  most  part,  complain  of  a 
slight  diurnal  increased  frequency  and  a  newly 
observed  nocturia.  There  are  no  symptoms  of  an 
acute  process.  The  urine  is  clear  and  they  are  in 
no  wise  deterred  from  following  their  usual  pur- 
suits. They  feel,  usually,  that  their  trouble  is 
insignificant,  and  more  or  less  natural  to  their  time 
of  life.  Radical  treatment  does  not  seem  to  be 
indicated  and  they  lend  a  willing  ear  to  what  seems 
to  be  offered  as  a  very  innocent  and  innocuous  alter- 
native. 

My  reluctance  to  perform  a  resection  operation 
in  such  cases  arises  out  of  the  fact  that  it  cannot 
be  done  without  incurring  the  risk  of  possible  renal, 
epididymal  or  vesical  infection.  Despite  the  fact 
that  in  the  majority  of  instances  these  sequelae 
are  entirely  avoidable  or  only  of  minimal  severity, 
they  must  be  taken  into  consideration  when  the 
resection  operation  is  contemplated  in  the  case  of 
a  patient  who  is  little  inconvenienced  by  his  pros- 
tatic disease. 

In  the  majority  of  cases  turbidity  of  the  urine 
persists  for  several  weeks  following  the  operation, 
and  with  it  vesical  symptoms  of  as  great,  or  greater, 
severity,  than  those  from  which  the  patient  sought 
relief.  With  these  facts  in  mind  it  has  often  seem- 
ed to  me  that  this  operation  is  more  radical  than 
conditions  seem  to  warrant,  and  that  an  undue 
responsibility  is  often  assumed  by  the  surgeon. 

These  circumstances  have  prompted  me  to  seek, 


for  these  early  cases,  a  more  rational  method  of 
treatment  in  which  the  element  of  risk  might  be 
reduced  to  a  minimum,  or  at  least  be  made  more 
commensurate  with  the  conditions  to  be  met. 
Prostatic  Resorption 

^ly  interest  in  this  subject  dates  back  to  1925, 
when  I  was  engaged  in  my  early  experiments  with 
under-water  cutting,  with  the  first  resection  equip- 
ment. 

At  that  time  the  current  at  my  disposal  was  only 
weakly  capable  of  cutting  under  water,  and  it  was 
found  that  unless  the  loop  was  made  quite  small 
it  would  frequently  pass  over  the  surface  of  the 
intruding  tissue  leaving  in  its  wake  a  white  desic- 
cated line.  Many  unavailing  efforts  to  adjust  the 
current  so  as  to  cause  it  to  cut  would  thus  be 
made  upon  a  patient  at  a  single  sitting.  Following 
these  vain  efforts  our  patients  would  frequently  ex- 
hibit a  mild  febrile  reaction,  but  it  was  observed 
that  many  would  show  an  early  improvement  in 
their  symptoms,  and  subsequent  cystoscopic  exam- 
ination would  reveal  marked  regressions  in  the  size 
of  their  prostatic  intrusions. 

Since  that  time  it  has  been  my  practice  in  many 
early  cases  to  administer  this  form  of  treatment 
with  highly  gratifying  results. 

These  findings  were  reported  by  me  in  January, 
1933,'  and  in  the  same  month  I  also  presented  sur- 
face coagulation  as  a  preparatory  measure  to  the 
resection  operation,  and  described-  an  "Ironing 
Electrode,"  for  its  accomplishment.  This  work  was 
to  have  been  presented  at  the  annual  meeting  of 
the  American  Medical  Association  in  June,  1933,^ 
under  the  same  title  as  the  present  communication. 
Kirwin'*  at  about  the  same  time  made  reference 
to  "Shrinkage"  of  the  prostate  by  this  "Xon-de- 
structive  method,"  employing  for  the  purpose  the 
roller  electrode  to  merely  "heat"  the  tissue.  Dr. 
Clinton  K.  Smith'  has  also  contributed  to  the  sub- 
ject, and  observes  that  the  febrile  phase  is  more 
likely  to  be  associated  with  the  first  resection  in 
two-step  operations.  This  has  been  my  experience, 
and  it  was  also  found  that  when  resection  followed 
preliminary  coagulation  treatment  the  incidence  of 
infection  was  much  reduced. 

Examination  a  week  or  ten  days  after  the  coag- 
ulation reveals  an  ischemic,  white  mucous  mem- 
brane instead  of  the  usual  vascular,  edematous 
membrane.  Coincident  with  this  change  there  is 
regression  of  the  intruding  masses  and  restoration 


October,   1936 


PROSTATIC  RESORPTION  &  RESECTIOX—Slerii 


of  vesical  function. 

It  has  been  observed  by  many  that  the  prostate 
is  capable  of  shrinking  after  the  removal  of  a  few 
sections  of  its  intruding  parts — probably  due  to 
the  resorption  phenomena  so  noticeable  in  the 
superficial-coagulation  treatment.  What  actually 
takes  place  in  the  tissues  is  a  matter  of  conjecture, 
yet  it  is  but  logical  to  assume  that  the  softer  and 
more  succulent  cells  are  destroyed  and  absorbed. 
The  degree  of  destruction  is  not  sufficient  to  im- 
pair circulation,  thus  reparative  processes  are  not 
suspended.  The  prostate  will  shrink  when  sub- 
jected to  a  temperature  capable  of  causing  changes 
in  its  more  succulent  cells  without  causing  actual 
death  of  tissue  and  sloughing.  Because  of  these 
phenomena,  I  have  designated  this  form  of  treat- 
ment "Prostatic  Resorption." 

It  has  been  generally  conceded  that  when  resec- 
tion has  been  performed  in  two  stages,  the  second 
operation  is  always  more  easy  of  accomplishment, 
and  attended  with  less  bleeding.  The  tissue  is  less 
spongy,  and  far  less  vascular.  This  same  phe- 
nomenon is  observed  after  the  resorption  treatment, 
thus  obviating  in  suitable  cases  the  necessity  for 
resection. 

For  desiccation  of  the  mucosa  this  means  may 
suffice;  but,  in  the  presence  of  bars  and  contract- 
ures, probably  no  lasting  benefit  will  result,  and 
in  more  than  moderate-sized  inflammatory  enlarge- 
ment of  the  middle  and  lateral  lobes,  examination 
after  a  week  or  two  will  yield  information  upon 
which  one  can  easily  decide  as  to  the  advisability 
of  further  measures. 

Should  resection  be  deemed  necessary  it  will  be 
found  that  the  operation  is  easier  of  accomplish- 
ment because  the  tissue  to  be  resected  is  firmer 
and  the  bleeding  less,  and  safer  because  infection 
is  less. 

The  "Ironing  Electrode"  is  constructed  of  solid 
metal,  convex  laterally,  and  has  a  surface  area  of 
O.S  sq.  cm.,  mounted  on  a  shaft  so  that  it  will  fit 
the  Stern  resectoscof>e,  taking  the  place  of  the  loop. 

The  operation  consists  of  engaging  the  protu- 
berant masses  in  the  fenestra,  and  with  single 
strokes  of  the  electrode,  making  serial,  linear  stria- 
tions  1  cm.  apart.  Thus  the  entire  mucosa  over 
the  prostatic  lobes  is  destroyed,  and  the  under- 
lying tissue  affected  by  the  heat  to  a  considerable 
depth.  Xo  rule  as  to  the  current  strength  can  here 
be  set  down  because  of  the  variable  factors  present 
in  machines  of  different  makes. 

Several  other  workers  in  this  field  have  estab- 
lished this  procedure  in  their  routine  preparation 
for  the  resection  operation. 

It  is  now  my  practice  to  make  the  resorption 
application  at  the  time  of  my  first  cystoscopy,  at 
which  time  I  also  do  a  partial  vasectomy  opera- 


tion. Only  a  few  days  of  preliminary  catheter 
drainage  is  required,  thus  adding  little  to  the  prep- 
aration time  of  the  patients  upon  whom  resection 
is  subsequently  performed.  In  many  instances  a 
single  resection  will  be  found  to  suffice  where  two 
would  have  been  required.  The  resorption  opera- 
tion is  admirably  adapted  to  cases  complicated  by 
bleeding,  or  intolerant  to  permanent  catheter  drain- 
age. Great  care  should  be  taken  in  such  cases  not 
to  coagulate  deeply,  just  as  it  is  in  the  first  of  a 
two-stage  resection  operation,  in  order  that  suffi- 
cient healing  and  regression  of  the  intruding  lobes 
may  be  possible  before  the  second  step,  a  week 
or  two  later.  The  coagulation  current  should  be 
employed  where  machines  having  this  modality  are 
available,  and  experiments  upon  meat  will  afford 
information  as  to  current  strength  required  and 
speed  of  the  thrust.  The  proper  current  strength 
is  that  just  capable  of  causing  a  faint  pallor  to 
the  tissue  as  the  electrode  is  moved  slowly  over  if. 
The  roller  electrode  has  the  disadvantage  of  mak- 
ing rather  a  sharp  line  upon  which  the  current  is 
concentrated.  The  current  thus  penetrates  to  a 
greater  depth,  and  is  more  likely  to  cause  slough- 
ing than  when  a  flat-surfaced  electrode  is  employ- 
ed. It  is  feasible  to  use  the  cutting  loop  for  this 
purpose,  but  great  care  must  be  exercised  to  ad- 
just the  current  finely  so  that  the  loop  will  ride 
over  the  surface  of  the  presenting  tissue  and  not 
dig  in.  For  this  purpose  a  new  loop  when  straight- 
ened out  serves  admirably,  especially  when  em- 
ployed with  the  No.  24  Stern-McCarthy  resecto- 
scope. 

Following  this  procedure  the  treatment  is  in  all 
particulars  the  same  as  for  resection.  Catheter 
drainage  is  instituted  employing  one  of  small  size 
as  there  are  no  clots  to  be  contended  with;  bleed- 
ing should  be  slight  and  of  traumatic  origin  when 
present  at  all. 

Conclusions 
It  should  be  understood  that  the  method  here- 
with described  is  not  intended  to  replace  the  resec- 
tion operation  any  more  than  the  latter  can  replace 
enucleation. 

In  deciding  upon  the  procedure  to  be  followed 
out  in  the  management  of  prostatic  patients  con- 
sideration should  be  given  to  certain  factors  which 
represent  distinct  indications  for  either  enucleation, 
resection  or  resorption. 

The  enucleation  operation  is  indicated  in  the 
presence  of  certain  definite  conditions,  and  should 
also  be  chosen  when  for  any  reason  the  resection 
operation  cannot  be  carried  out  with  a  perfect 
technic  in  every  detail. 

The  resection  operation  is  in  all  probability  in- 
dicated in  the  majority  of  prostatic  cases;  it  should 
n(jt,  however,  be  regarded  as  applicable  to  all  cases, 


PROSTATIC  RESORPTION  &■  RESECTION— Stern 


October,  1936 


and  its  contraindications  should  be  well  established 
in  order  that  it  may  find  its  rightful  place  in  urolo- 
gic  surgery.  Resection  is  frequently  performed  in 
cases  of  early  prostatism  where  a  less  radical  pro- 
cedure is  known  to  suffice. 

Early  prostatism  when  treated  as  an  inflamma- 
tory process  in  which  permanent  tissue  changes 
have  not  yet  occurred  is  amenable  to  this  palliative 
measure.  Resorption  of  moderate  prostatic  enlarge- 
ments can  be  accomplished  by  the  method  here- 
with described.  This  procedure  is  all  that  is  indi- 
cated in  many  cases  of  moderate  middle-  and  later- 
al-lobe enlargement. 

The  method  is  also  valuable  as  a  preliminary 
measure  to  resection,  facilitating  the  operation  and 
robbing  it  of  its  unpleasant  sequelae. 

Bibliography 

1.  Stern,  M.:  The  Stem  Method  of  Prostatic  Resection. 
Urol.  &  Cut.  Rev.,  Jan.,  1933. 

2.  Idem:  Transurethral  Prostatic  Resection.  Southern 
Surgeon,  Jan.,  1933. 

3.  Idem:  Prostatic  Resorption:  A  New  Treatment  for 
Early  Prostatism  With  a  Presentation  of  New  Instru- 
ments and  New  Currents.     Scheduled  but  not  read. 

4.  KiRWTN,  T.  J.;  Types  of  Vesical  Neck  Obstructions 
Suited  to  Intra-urethral  Resection:  Advantages  of 
Treatment  by  the  Rotary  Prostatic  Resectoscope.  Am. 
Jour.  Surg.,  Jan.,  1933. 

5.  Smith,  C.  K.:  Description  and  Demonstration  of  Two- 
Stage  Prostatic  Resection.  Urol.  &  Cut.  Rev.,  Feb., 
1935. 


fairly  intensive  and  continued  without  interruption  for  18 
to  24  months,  irrespective  of  negative  tests.  Frequent  ob- 
servation for  another  three  years  is  imperative.  In  chronic 
or  late  syphilis  such  observation  is  for  the  lifetime  of  the 
patient. 

Syphilis  may  simulate  any  known  disease. 


Towards  the  Mh-lentum  in  SYPHn-OLOCY 
(W.   D.  Wheeler,  Boston,   in   Urol.  &  Cuta.    Rev.,   Sept.) 
The  clinical  appearance  of  the  chancre  does  not  always 
conform  to  the  textbook  description  and  is  secondary  in 
importance  to  the  darkfield  test. 

Local  application  of  antiseptics  should  never  be  used 
before  a  darkfield  test  is  made  as  these  remedies  may  de- 
stroy the  treponema  and  interfere  with  a  timely  diagnosis. 
Chancres  may  occur  anywhere  on  the  body.  I  have 
records  of  cases  where  chancres  occurred  on  the  eye  of 
one  man,  on  the  finger  of  another  when  bitten  during  a 
fist  flight,  on  both  nipples  of  a  woman,  on  a  tonsil,  on  a 
thigh  and,  in  numerous  cases,  on  the  lips.  The  chancre 
may  be  hidden  in  the  vagina  or  on  the  cervix.  .4ny  ulcer 
of  long  standing  should  be  examined  by  the  darkfield  test 
for  the  purpose  of  either  establishing  or  ruling  out  the 
presence  of  syphilis. 

It  is  generally  recognized  now  that  the  Wassermann  test 
is  not  adequate.  The  more  sensitive  Kahn  and  Hinton 
tests  will  show  the  presence  of  syphilis  where  the  Wasser- 
mann test  fails.  In  primar>-  syphilis  the  Wassermann  test 
is  usually  negative  in  the  first  4  to  6  weeks  and  the  Hinton 
test  the  first  2  to  4  weeks.  Similarly,  negative  blood  tests 
after  a  short  period  of  treatment  do  not  indicate  a  cure. 
Failure  to  remember  these  two  important  facts  still  con- 
stitute the  vast  number  of  errors  committed  by  the  non- 
syphilologist. 

Every  pregnant  woman  should  have  a  reliable,  sensitive 
blood  test  for  syphilis.  If  syphilitic,  the  expectant  mother 
should  be  treated  throughout  the  pregnancy.  The  child 
will  be  normal.  In  this  manner  congenital  and  hereditary 
syphilis  could  be  wiped  out  in  a  very  short  time. 

Treatment  of  primary  and  secondary  syphilis  should  be 


Choice  of  Ointment  Vehicles  in  Dermatology 
(Bernard   Fantus,  Chicago,  in  Jour.  A.   M.  A.,  Sept.   12th) 
In  dermatology  solubility  determines  whether  the  appli- 
cation will  stick,  the  surface  be  properly  covered  with  the 
application.     The  first  division,  therefore,  of  the  ointment 
vehicles  must  be  made  on  the  basis  of  affinity  into  lipo- 
tropic and  hydrotropic  applications.     The  former,  having 
fat    affinity,    include   ointments   and    cerates,   cling   to   the 
fatty  surface  of  the  skin,  and  are  indicated  as  long  as  the 
surface  is  relatively  intact  and  fatty.     When  the  epithelial 
layer  of  the  skin  is  lost,  as  in  case  of  an  ulcer  or  excoria- 
tion, or  the  surface  is  moist,  as  in  weeping  eczema,  a  prep- 
aration with  water  affinity  to  which  the  terms  paste  might 
be  applied,  is  likely  to  be  much  superior  to  a  lipotropic 
preparation.     Probably  the  next  most  important  basis  for 
division   rests  on   differences  in    melting    point,    and    the 
dividing  line  must   be  the   t.   of   the  skin   of   the   covered 
parts   of   the   body,   say,   98   F.      Fatty   applications  of^a 
melting  point  above  that   of  the  surface  of   the  skin  are 
known   as   cerates,   because  the   increase   in   melting   point 
was  formerly  secured  largely  by  the  presence  of  wax  (cera). 
Fatty  applications  with  a  melting  point  at  or  below  the  t. 
of  the  skin  are  known  as  ointments.     Simple  cerate  forms 
when  spread  on  gauze  or  linen  a  bland  protective  dressing 
for   surfaces    the    natural    protective    layer   of    which,   the 
epidermis,  is  deficient  or  defective  and  that  are  secreting 
but  little  fluid.     Rosin  cerate  is  somewhat  irritative.     Such 
an  irritative  dressing  is  superior  to  a  bland  protectant  when 
stimulation  to  healing  is  desired.    The  cell  proliferation  in- 
duced by  such  irritants  will  favor  the  growth  of  connective 
tissue  relatively  more  than  that  of  epithelium  and  thus  lead 
to  the  development  of  exuberant  granulations.     .As  a  gen- 
eral   proposition,    ointments    are    contraindicated    in    acute 
inflammatory  conditions  of  the  skin,  because,  by  inhibiting 
the  evaporation  of  sweat,  they  check  the  cooling  influence 
this  would  exert  and,  in  consequence,  induce  hyperemia  of 
the   skin.     An    exception   to    this   occurs   with   the   cream 
ointments,  in  which  the  heating  qualities  of  fat  are  antag- 
onized  by   the  water   incorporated  in   them   by   means  of 
emulsification.      The    cooling    sensation    produced    by    the 
evaporation  of  the  water,  when  such  ointments  are  applied 
to  the  skin,  has  given  them  the  name  of  cold  cream.    These 
emulsions  also  have  the  advantage  of  making  the  applica- 
tion more  suitable  to  relatively  moist  surfaces,  as  emulsified 
fat  clings  to  them  fairly  well.     Rose  water  ointment  is  a 
good  vehicle  for  ointments  against  itching.     For  moist  raw 
surfaces  a  paste,  e.  g.,  one  containing  tragacanth,  is  much 
more  likely  to  meet  the  indications  than  an  ointment.   Thus, 
for  the  treatment  of  an  acute  burn  of  Umited  extent,  after 
a   preliminan,-   application   of   a   compress   of   25   per  cent, 
magnesium   sulfate   solution,  a    1    per   cent,  gentian   violet 
paste  may  be  ordered.    The  tannic  acid  dressing,  life  saving 
in   extensive   burns,   is   not   desirable   for  those   of   limited 
extent,  as  the  surface  layer  of  cells  must  be  sacrified  to  its 
coagulant   action.     What   ointment   vehicle  is  chosen   may 
make  the  difference  between  success  and  failure. 


Psychology  is  a  required  course  in  the  2nd  and  3rd  of 
the  6  years  of  the  medical  course  at  the  University  of  Tor- 
onto. One  of  the  first-year  subjects  is  "The  Relation  of 
Science  to  Civilization." 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


521 


Maladjustment  as  a  Cause  of  Mental  Disease* 

David  C.  Wilson,  M.D.,  University,  Virginia 


IX  a  study  conducted  by  Geo.  K.  Brown  a 
spot  map  of  the  City  of  Charlottesville,  Vir- 
ginia, showed  that  cases  of  Mental  Disease, 
cases  of  Delinquency  and  cases  of  Feebleminded- 
ness occurred  in  the  same  situations.  In  other 
words,  there  were  five  points  of  low  economic 
level  and  in  these  areas  were  grouped  the  large 
majority  of  behavior  problems  and  abnormal  per- 
sonality reactions  arising  in  the  neighborhood.  This 
reiterates  the  often-stated  conclusion  that  crime 
and  mental  disease  spring  from  similar  sources,  so 
must  be  somewhat  similar  states.  One  often  speaks 
of  a  criminal  as  a  maladjusted  individual,  but  it 
is  more  difficult  to  conceive  of  the  chronic  invalid 
in  the  State  Hospital  as  such. 

It  is  axiomatic  to  state  that  life  calls  for  con- 
stant adjustments  of  one  kind  or  another;  that 
normal  persons  are  meeting  situations  new  and 
old  in  a  more  or  less  satisfactory  manner  constantly 
and  that  the  majority  of  people  may  be  called 
well  adjusted,  yet  when  an  attempt  is  made  to 
differentiate  a  good  adjustment  from  a  bad  strictly 
on  a  scientific  basis  there  are  many  difficulties. 
Each  cell  of  the  body  has  certain  conditions  it 
must  meet;  each  organ  has  particular  demands  for 
functioning,  but  when  the  whole  individual  unit  is 
considered  the  situations  are  comple.x,  the  responses 
multiple,  so  that  any  solution  is  relative. 

On  a  fundamental  basis,  however,  the  problem 
can  be  simplified.  There  is  always  a  situation,  a 
condition  or  stimulus  which  is  a  cause  for  action. 
Normally  this  stimulus  persists  until  it  is  satisfied 
by  some  goal  attained.  The  reaction  is  simply 
stimulus — action — satisfaction.  In  the  individual, 
however,  several  complications  may  occur.  In  the 
first  place,  the  stimulus  may  be  too  strong.  If  this 
is  so,  it  calls  into  play  certain  emergency  visceral 
changes,  called  an  emotion,  which  affects  the  ac- 
tion and  produces  a  condition  of  tension,  felt  in 
the  muscles  especially.  In  the  second  place  the 
action  may  be  thwarted  or  blocked  by  some  envi- 
ronmental obstacle,  by  some  personal  defect  or  by 
some  antagonistic  action  going  on  in  the  individual 
at  the  same  time.  Third,  the  individual  may  use 
some  method  of  overcoming  the  block  that  is  dan- 
gerous, because,  while  it  solves  temporarily,  it 
leads  on  to  habits  of  solving  which  become  a 
menace  in  themselves.  Finally,  the  solution  itself 
may  only  partially  satisfy  the  action  and  the  ten- 
sion produced  continues  reduced  only  in  part.  It 
is  possible,  therefore,  to  have  a  stimulus  or  motive 


too  strong,  an  obstacle  which  is  too  great,  a  mech- 
anism for  solving  that  is  potentially  dangerous  and, 
finally,  an  inadequate  solution. 

Nothing  illustrates  the  whole  field  of  response 
better  than  the  complications  that  may  arise  to 
the  simple  reaction  of  emptying  the  urinary  blad- 
der. The  bladder  may  get  too  full,  and  cause  pain 
and  even  paralysis  of  bladder  function.  The  social 
situation  may  obstruct,  causing  an  inner  tension 
of  marked  degree.  The  prostate  may  be  too  large. 
Then  a  catheter  may  be  used,  producing  infection 
or  even  suggest  a  form  of  masturbation.  Finally, 
the  viscus  may  not  be  entirely  emptied,  causing  a 
continuous  tension  state. 

In  considering  the  phenomenon  of  adjustment  it 
is  always  important  to  use  the  simplest  terms  and 
to  apply  as  much  as  possible  the  dictates  of,  so- 
called,  common  sense.  To  designate  motives  by 
means  of  mystic  or  hypothetical  ideas  obstructs 
understanding.  It  is  best  to  look  for  motives  that 
we  feel  and  know.  Certainly,  there  is  a  drive  to 
satisfy  organic  needs;  then  the  motive  to  master 
or  excel;  the  motive  to  obtain  social  approval 
and  with  it  the  more  negative  action  to  conform  to 
social  demands  in  order  to  escape  blame  or  criti- 
cism. The  sex  drive  is  certainly  real  and  it  is 
true  that  after  a  certain  procedure  has  become 
habitual  it  also  operates  as  a  motive.  One  might 
postulate  a  newspaper-reading  motive,  a  cigar- 
smoking  motive  and  a  golf-playing  motive.  Here 
activity  is  aroused  and  continues  until  the  stim- 
ulus is  removed. 

Also,  when  considering  the  obstacles  that  thwart 
no  mystery  is  needed.  Lack  of  money,  the  mores 
of  the  group,  the  pimples  on  the  face  or  the  wish 
to  please  the  mother  or  the  father  may  be  obstacle 
enough.  The  obstacle  is  often  unmodifiable  or 
may  be  beyond  clear  differentiation,  so  it  is  the 
mechanism  of  response  that  must  be  controlled. 
Here  again  the  experience  of  any  one  of  us  on 
meeting  a  difficulty  gives  the  clue  to  the  possibili- 
ties of  response.  Undoubtedly,  the  simplest  and 
most  satisfactory  response  to  a  task  is  to  attack 
it  at  once,  complete  it  and  then  to  proceed  as  be- 
fore. However,  there  are  many  other  forms  of 
response.  The  exposed  individual  may  run  away; 
he  may  be  paralyzed  with  fear;  he  may  persuade 
himself  that  the  task  does  not  exist;  he  may  fly 
into  a  rage;  he  may  feign  sleep;  he  may  become 
sick;  he  may  say  it  is  the  task  of  some  one  else; 
finally,  he  may  do  nothing,  remaining  in  a  worrying 


•Presented  by  invitation  to   the  Wake  County  Medical  Society,  Raleigh,  August  13th. 


S22 


MA  LA  D  JUST MENT— Wilson 


October,  1936 


State  of  indecision. 

The  reactions  to  difficulty  vary  with  each  indi- 
vidual and  are  almost  limitless  in  extent  and  com- 
plexity; but  here  again  habit  and  training  play 
their  part,  causing  the  individual  to  use  the  re- 
sponse again  and  again  that  he  has  once  found 
successful.  In  general,  methods  of  response  can 
be  classified  into  five  categories:  first,  those  char- 
acterized by  some  type  of  attack;  second,  those 
in  which  withdrawal  or  retreat  is  the  main  method; 
third,  those  characterized  by  ignoring  or  attempts 
at  forgetting;  fourth,  a  method  in  which  some 
bodily  ailment  is  used  as  a  form  of  defense;  and, 
fifth,  onei  when  no  action  is  carried  through  but 
there  is  a  persistent  state  of  vacillation.  Each 
type  of  response  in  some  cases  may  be  successful, 
but  if  the  stimulus  is  great  or  persistent  all  forms 
of  attack  except  the  straightforward  one  will  fail 
and  with  failure  results  some  form  of  maladjust- 
ment. If  the  maladjustment  persists  then  follows  a 
behavior  disorder  in  some  function  of  the  individ- 
ual. This  behavior  disorder  may  be  acute  and 
easily  solved  or  it  may  become  chronic  and  beyond 
solution.  A  great  number  of  the  ills  that  are 
brought  to  the  physician  are  of  this  type.  Certainly 
a  great  number  of  the  psychoneurotics  are  malad- 
justed individuals.  Persons  with  phobias  and  com- 
pulsions would  fall  into  this  class.  Stutterers,  peo- 
ple with  tics  and  cramps,  and  perhaps  the  so-called 
constitutional  psychopaths,  would  be  admitted  by 
every  one  to  have  such  a  difficulty.  These  dis- 
orders should  be  recognized  as  such  and  imme- 
diately the  physician  should  look  for  the  motive, 
make  note  of  the  obstacle,  recognize  the  inadequate 
substitute  response  and  attempt  to  rearrange  the 
factors  to  bring  about  a  satisfying  result.  The 
problems  are  often  clear-cut  and  solution  not  dif- 
ficult if  the  approach  is  made  with  the  understand- 
ing that  the  whole  individual  is  involved. 

Still,  it  is  hard  to  believe  that  the  disintegrated 
patient  in  the  State  Hospital  could  reach  that  con- 
dition because  of  some  blocked  motive  or  some 
thwarted  drive.  Yet,  in  the  State  Hospitals  are 
many  persons  who  first  demonstrated  only  a  simple 
maladjustment,  but  in  whom  the  reaction  became 
more  and  more  habitual  until,  caught  in  their  own 
trap,  they  become  helpless  slaves  to  a  substitute 
mechanism.  This  state  of  affairs  is  demonstrated 
by  the  man  who  uses  alcohol  as  a  method  of  flight 
until  finally  he  can  live  only  an  institutional  life. 
Again,  the  child  who  uses  phantasy  very  often  when 
facing  the  problems  of  adolescence  passes  on  into 
a  world  of  dreams,  where,  still  unsatisfied,  the 
personality  gradually  disintegrates. 

A  boy,  the  only  son  of  a  widow,  who  was  reared 
in  a  very  strict  and  very  religious  environment,  at 
the  age  of  fourteen  began  to  wash  his  hands  un- 


necessarily. He  has  since  visited  numerous  clinics 
for  study  and  treatment,  but  the  washing  of  the 
hands  and  the  emotional  tension  which  goes  with 
it  has  now  engulfed  his  whole  life  so  that  he  is 
able  to  live  only  in  an  institution.  Certainly,  at 
first,  this  was  only  a  problem  in  adjustment,  but 
the  reaction  became  fixed  and  non-reversible  and 
so  continued  through  the  years.  Often  the  intro- 
spective child  first  develops  a  pain  in  the  stomach, 
to  be  called  a  hysteric;  next  goes  into  a  depression, 
to  be  called  a  manic-depressive  and,  finally,  the 
personality  begins  to  break  up  and  the  case  is 
diagnosed  dementia  praecox. 

Why  the  reaction  becomes  fixed;  why  one  indi- 
vidual recovers  and  another  succumbs — these  are 
facts  that  are  unknown.  Yet  they  are  in  their 
action  no  more  mysterious  than  the  sudden  appear- 
ance of  chronic  arthritis  in  a  patient  who  has  had 
a  focus  of  infection  for  years;  nor  the  sudden  ap- 
pearance in  a  young  adult  of  a  chronic  progressive 
nephritis.  How  mysterious  it  is  when  a  slight  cold 
will  cause  decompensation  of  a  previously  compen- 
sated heart  to  such  a  degree  that  it  never  functions 
normally  again. 

It  is  true  that  in  the  understanding  of  chronic 
personality  disorders  there  are  many  factors  un- 
known, but  it  is  also  true  that  many  are  known. 
Certainly  it  is  time  to  recognize  and  use  what  is 
known.  Inadequate — or  shall  we  say  pathological? 
— types  of  response  to  difficulty  are  a  major  cause 
of  both  minor  and  major  forms  of  mental  disorders. 
They  are  problems  for  treatment  by  the  physician. 
He  should  be  trained  and  organized  for  their  care. 
It  is  true  that  a  person  with  a  gastric  neurosis  may 
have  gallstones  and  that  an  ovarian  cyst  may  be 
found  in  a  woman  with  a  sexual  maladjustment, 
but  how  much  more  important  it  is  to  solve  the 
personality  disorder  than  to  remove  the  diseased 
tissue. 

Finally,  we  can  conclude  that,  when  maladjust- 
ments are  recognized  by  the  medical  profession  as 
real  sources  of  danger  and  treated  consistently  with 
understanding,  many  forms  of  chronic  mental  dis- 
order will  be  prevented.  Needless  to  say,  many 
other  causes  exist  for  mental  disease,  some  known 
and  many  beyond  our  present  knowledge,  but  here 
is  one  source  that  can  be  attacked  with  hof>e  of 
reward  and  where  a  simple  approach  with  the  use 
of  what  is  actually  known  will  produce  farflung 
results. 


Primary  dysmenorrhea  (S.  L.  Israel,  Phila.,  Jour.  A. 
M.  A.,  May  16th)  is  a  disease  of  conflicting  theories.  Two 
forms  of  endocrine  therapy  have  been  proposed  in  such 
cases,  estrogenic  substance  and  urinary  gonadotropic  sub- 
stance. As  shown  in  the  present  study  of  39  patients, 
both  are  disappointing. 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


523 


Acute  Mesenteric  Adenitis — A  Filtrable-Virus 
Disease?* 


Charles  Stanley  White,  M.D.,  F.A.C.S.,  Washington,  D.  C. 
Department  of  Surgery,  School  of  Medicine,  The  George  Washington  University 


ACUTE  INFLA:MMATI0N  of  the  mesen- 
teric glands  has  not  been  recognized  as  a 
medical  or  surgical  entity;  but,  in  the  ab- 
sence of  many  desirable  data,  the  disease  or  symp- 
tom, as  the  case  may  be,  is  usually  designated  by 
those  few  who  have  described  it,  as  acute  mesen- 
teric adenitis.  This  is  not  to  be  confused  with  the 
tuberculous  adenitis  that  is  often  seen  as  a  part 
of  the  picture  of  tuberculosis  of  the  gastrointestinal 
tract  and  peritoneum. 

For  a  number  of  years  we  have  been  puzzled  by 
having  in  our  practice,  cases  which  appeared  to 
be  acute  appendicitis  clinically,  but  at  operation 
the  appendix  did  not  seem  pathologically  consistent 
with  the  clinical  picture.  To  be  sure,  the  appendix 
was  red,  but  never  gangrenous  nor  ruptured.  We 
found  a  small  quantity  of  clear  or  slightly  cloudy 
fluid  in  the  peritoneal  cavity  particularly  adjacent 
to  the  cecum.  The  cecum  and  small  bowel  were 
abnormal  only  in  the  congested  appearance  of  the 
vessels.  The  most  pronounced  pathologic  manifes- 
tation was  found  in  the  distal  three  feet  of  the 
mesentery  of  the  small  intestine.  Here  the  glands 
were  conspicuous  by  their  number  and  size.  Nor- 
mally, glands  can  neither  be  seen  nor  felt  in  this 
mesentery,  but  in  these  cases  of  acute  appendicitis, 
so-called,  the  glands  varied  in  diameter  from  1  to  3 
cm.,  were  firm,  distinct  pearly  gray  and  numbered 
from  three  to  a  dozen  or  more.  None  of  the  glands 
was  suppurating  or  gangrenous,  and  any  one  could 
be  easily  enucleated. 

Our  procedure  in  such  cases  was  to  remove  the 
appendix  and  wonder  what  was  the  relation  be- 
tween the  glands,  the  appendix,  and  clinical  signs 
and  symptoms.  All  of  the  patients  recovered  after 
two  or  three  days  of  declining  fever  and  no  drain- 
age was  employed  in  any  case. 

Several  times  we  have  removed  a  few  of  the 
mesenteric  glands  and  sent  them  to  laboratories 
for  study.  They  have  all  failed  to  develop  a 
growth  in  various  media  and  the  sections  have 
shown  lymphoid  hyperplasia  only.  They  were  defi- 
nitely not  tuberculous. 

During  the  year  1934  we  had  twelve  cases  as 
described  above,  which  we  have  labelled  acute 
mesenteric  adenitis.  We  have  had  but  four  cases 
since  January,  1935.  There  seems  to  be  a  seasonal 
periodicity  in  their  appearance,  not  unlike  an  epi- 


demic of  a  communicable  disease.  There  is  much 
information  to  be  desired  in  reference  to  the  cause 
and  diagnosis  of  this  disease,  but  at  the  present 
time  our  knowledge  is  fragmentary.  It  may  be 
possible  to  assemble  a  complete  account  of  the 
disease  if  the  various  internists  and  operators  add 
their  bits  to  what  we  have.  With  the  object  of 
stimulating  interest  in  this  subject,  we  are  detailing 
a  composite  case  and  bringing  up  to  date  all  of  the 
material  contributions  that  were  available  to  us. 

A  cross  section  of  the  cases  we  have  seen  would 
give  a  history  approximately  as  follows: 

A  child,  12  years  of  age,  without  previous  his- 
tory of  recent  illness,  gastrointestinal  disorder,  sore 
throat  or  exposure  to  contagious  disease,  is  dis- 
turbed by  abdominal  pain.  The  pain  is  rather 
severe,  constant,  but  not  colicy.  It  is  rather  gen- 
eral, but  more  marked  in  the  lower  than  the  upper 
abdomen.  Temperature  of  102  to  103  is  the  rule, 
with  corresponding  acceleration  of  the  pulse  and 
respiratory  rate.  Diarrhea  is  rarely  present,  con- 
stipation is  the  rule.  Nausea  is  present  in  nearly 
all  cases;  vomiting  has  not  been  persistent  and 
usually  ceases  after  the  stomach  is  entirely  emptied. 
Foul  vomitus  has  not  been  encountered. 

The  physical  examination  shows  a  slightly  dis- 
tended, tympanitic  abdomen,  generally  tender  and 
resistant  to  pressure.  While  tenderness  is  marked 
in  the  lower  right  quadrant  it  is  conspicuous  by 
its  presence  in  the  lower  left  quadrant.  The  abdo- 
men is  uniformly  distended,  but  not  to  an  extreme 
degree.  The  physical  examination  of  the  throat 
and  chest  has  been,  in  our  experience,  uniformly 
negative  for  gross  pathology. 

The  blood  counts  have  shown  for  the  most  part, 
moderate  leukocytosis — 8,000  to  14,000,  with  a 
high  percentage  of  polymorphonuclear  neutrophiles 
— 80  to  95  p>er  cent.  The  urine  shows  neither  pus 
cells  nor  albumin. 

With  such  a  history  of  an  illness  of  48  hours 
or  less  duration,  scarcely  any  diagnosis  other 
than  acute  appendicitis  can  be  entertained,  and 
the  patient  forthwith  is  admitted  to  a  hospital 
and  the  appendix  is  removed  without  delay.  With 
our  knowledge  of  the  fulminating  nature  of  appen- 
dicitis, especially  in  children,  any  treatment  other 
than  surgical  seems  untenable. 

At  the  operation,  as  we  have  stated  in  an  earlier 


•Presented  to  the  Tri-State  Medical  Association  of  the  Carollnaa 
la.  February  17th  and  18th. 


nd   Virginia,    meetlne  at   Columbia.    South   Caro- 


ACUTE  MESENTERIC  ADENITIS— White 


October,  1936 


paragraph,  the  appendix  appears  in  the  role  of  the 
innocent  bystander,  and  promptly  meets  the  usual 
fate  of  that  individual. 

Such  is  the  history  and  termination  of  these  cases 
as  we  have  seen  them,  and  there  is  something  de- 
cidedly unsatisfying  in  the  entire  performance,  in 
that;  first,  the  diagnosis  was  inaccurate;  second, 
it  is  very  possible  the  patient  would  have  recovered 
without  operation;  third,  the  pathology  remains 
unexplained;  and  fourth,  the  error  in  diagnosis  in 
all  probability  will  be  repeated  as  no  differential 
diagnosis  can  be  established  with  our  present  in- 
adequate data. 

We  have  found  a  number  of  references  to  this 
disease  (if  we  may  so  term  it  temporarily)  by  a 
score  or  more  of  contributors  to  the  literature  in 
this  country,  in  England  and  on  the  continent, 
'^iih-Qi-  no  one  has  traced  the  inciting  agent,  if  one 
exists.  A  possible  exception  may  be  made  in  the 
paper  of  Goldberg  and  Nathanson^  of  Chicago,  who 
reported  nineteen  cases  studied  rather  carefully. 
We  shall  consider  their  cases  later. 

Struthers"  of  Edinburgh  seems  to  have  been  the 
first  to  call  attention  to  this  disease;  this  was  in 
1921,  and  his  paper  was  "Mesenteric  Lymphade- 
nitis Simulating  Appendicitis."  He  leaned  to  tu- 
berculosis as  the  underlying  cause,  but  stated  this 
as  far  from  conclusive.  Three  of  the  four  cases 
reported  were  definitely  not  tuberculous. 

Leonard  Freeman^  of  Denver,  writing  on  this 
subject  in  1923,  had  satisfied  himself  that  the 
adenitis  is  due  to  absorption  from  the  intestinal 
canal,  and  he  further  suggested  that  it  follows  the 
ingestion  of  contaminated  milk  or  other  foods,  and 
he  offered  the  theory  that  it  is  of  a  tuberculous 
nature  of  a  strictly  bovine  type;  but  guinea  pig 
inoculations  were  not  convincing. 

Speese*  in  1929  devoted  considerable  space  to 
the  discussion  of  the  etiology  and  suggested: 

(a)  Stasis  of  fecal  current  with  increased  vir- 
ulence of  the  organism  in  the  ileum. 

(b)  Inflammatory  processes  with  abrasions  and 
small  abscesses  in  the  bowel  in  this  region, 
with  secondary  infection  of  the  glands. 

(c)  Ulcerations  in  Peyer's  patches,  with  sec- 
ondary gland  involvement. 

Wilensky  and  Hahn''  made  the  statement  in 
1926  that  the  mesenteric  lymph  nodes  of  the  ileum 
are  never  seen  in  the  usual  types  of  acute  appen- 
dicitis, and  as  the  appendix  was  not  involved  in 
their  cases  mesenteric  adenitis,  they  concluded 
there  is  no  clinical  relationship  between  the  two 
conditions. 

We  found  approximately  twenty  other  references 
to  the  subject,  all  very  much  of  the  same  tenor. 
Wagner  reported  a  case  due  to  trauma.  The  con- 
sensus of  opinion  is  overwhelmingly  against  a  tu- 


berculous invasion. 

Goldberg  and  Nathanson,i  in  an  analysis  of 
their  nineteen  cases,  concluded  that  the  disease  can 
be  laid  at  the  door  of  the  hemolytic  streptococcus 
because  the  organism  was  found  in  all  the  throats 
cultured — eight  out  of  nineteen — and  that  "the 
same  organism  has  been  isolated  from  a  small  per- 
centage of  the  nodes  removed  and  studied."  As 
such  a  finding  was  made  in  but  one  case,  this 
leaves  much  to  be  desired  in  fixing  the  causal  re- 
lationship. We  do  not  attach  much  importance  to 
the  presence  of  streptococci  in  the  throat  in  con- 
necting up  the  evidence.  Goldberg  and  Xathanson 
are  in  accord  with  practically  every  observer  in 
exonerating  the  appendix,  and  agree  with  the  gen- 
eral opinion  that  a  prompt  exploratory  operation 
should  be  done,  as  a  differential  diagnosis  is  quite 
impossible.  They  very  properly  take  the  stand 
that  this  is  a  safer  procedure  as  a  surgical  princi- 
ple than  to  treat  such  a  case  medically. 

Our  experience  has  been  interesting,  but  our 
results  have  been  rather  negative.  We  have  not 
consistently  found  an  organism,  and  the  microscop- 
ical sections  have  been  without  differential  features. 
We  can  state  that  it  is  not  tuberculous,  is  not  asso- 
ciated with  appendicitis,  nor  with  any  macroscopic 
characteristic  changes  in  the  intestine  or  mesen- 
tery that  offer  a  promising  clue.  But  this  is  not 
new. 

One  pathological  report  by  Dr.  Earl  B.  McKin- 
ley''  offers  a  ray  of  hope.  He  stated:  "The  lymph 
nodes  in  the  case  of  E.  E.  have  just  been  brought 
to  my  attention  and  upon  examination  I  find  no 
inclusion  bodies  in  any  of  the  cells  which  would 
be  pathognomonic  of  virus  infection,  such  as  influ- 
enza. However,  only  about  half  of  the  virus  dis- 
eases are  associated  with  inclusion  bodies  and  these 
have  never  been  described  as  yet  for  influenza. 
One  might  try  to  infect  ferrets  with  emulsions  of 
mesenteric  lymph  nodes  from  such  cases  as  this 
and  in  that  way  demonstrate  the  presence  of  the 
virus." 

It  requires  considerable  temerity  to  suggest 
poliomyelitis  or  any  other  virus  disease  as  a  cause 
of  mesenteric  adenitis,  in  view  of  our  incomplete 
study,  but  we  believe  it  is  entitled  to  consideration. 
Our  conception  of  poliomyelitis  has  changed  some- 
what in  recent  years;  and  while  it  may  not  gt 
into  the  symptomatology  of  mesenteric  adenitis, 
just  consider  for  a  moment  the  following  statement 
by  Burrows,'  in  a  paper  entitled  "Is  Poliomyelitis 
a  Disease  of  the  Lymphatic  System?": 

"It  seems  quite  evident,  therefore,  from  all  avail- 
able evidence  at  the  present  time,  that  the  primary 
lesions  of  the  poliomyelitis  are  not  in  the  central 
nervous  system.  Poliomyelitis  is  probably  a  mis- 
nomer as  it  is  applied  to  the  disease  as  a  whole. 


October,   1936 


ACVTE  MESENTERIC  ADENITIS— White 


525 


It  is  merely  a  complication  of  a  widespread  infec- 
tious disease.  The  disease  is  not  a  primary  disease 
of  the  central  nervous  system:  it  is  a  disease  of 
the  lymphatic  system  of  the  body.  The  lesion  is 
not  of  the  kind  in  which  pus  appears  early,  but 
.  ...  an  acute  hyperplastic  lymphadenitis.  .  .  . 
The  pathologic  picture  in  all  of  the  fatal  cases  was 
a  general  lymphoid  hypjerplasia  which  was  most 
marked  in  the  solitary  follicles  of  the  gastrointes- 
tinal tract,  Peyer's  patches  and  the  mesenteric 
lymph  nodes."  He  further  states:  "As  Leake 
clearly  pointed  out,  the  systemic  changes  that  are 
present  in  all  cases  are  fever,  headache  and  gastro- 
intestinal disturbances.  The  latter  disturbances 
which  have  been  noted  most  often  are  constipation 
and  slight  distention." 

The  other  probable  common  virus  disease  is  in- 
fluenza. We  hear  much  about  "gastrointestinal  flu" 
but  some  members  of  the  profession  are  skeptical 
of  its  e.xistence  and  believe  the  term  is  merely  a 
camouflage  for  our  ignorance.  The  majority  of 
country  physicians — and  we  still  believe  they  are 
the  keenest  observers — have  no  doubt  that  influ- 
enza of  the  gastrointestinal  tract  is  as  much  of  a 
medical  entity  as  pneumonia. 

The  pathology  of  influenza  is  not  definitely 
known  except  in  the  fatal  cases,  and  here  a  lung 
complicaion  usually  predominates.  We  certainly 
have  little  or  no  information  about  the  pathology  in 
the  gastrointestinal  tract. 

Earl  B.  McKinley"*  in  discussing  the  recent  St. 
Louis  epidemic  of  encephalitis  stated:  "A  study 
of  the  epidemiology  and  character  of  these  various 
epidemics  brings  to  mind  again  the  possibility  of 
their  relation  to  epidemic  influenza  of  probable 
filterable  virus  origin,  which,  in  some  epidemics, 
may  be  of  gastrointestinal  nature,  in  others,  upper 
respiratory,  and  possibly  in  others,  one  or  both  of 
these  clinical  pictures  with  the  predominating  ef- 
fects soon  after  onset  manifested  in  the  central 
nervous  system,  the  pathology  being  that  of  an 
encephalitis.  The  clinical  history  of  this  disease, 
the  lack  of  discovery  of  the  true  etiological  agent 
over  these  many  years,  permits  at  least  the  raising 
of  the  question  again  as  to  its  possible  specific  re- 
lation to  epidemic  influenza,  most  probably  caused 
by  an  ultramicroscopic  virus." 

We  admit  our  failure  to  discover  the  cause  of 
mesenteric  adenitis,  and  have  substituted  sugges- 
tions for  facts.  It  is  our  hope  that  we  and  others 
may  have  the  time  and  opportunity  to  write  the 
last  chapter,  based  on  further  laboratory  study. 

Bibliography 

1.  Goldberg,  S.  L.,  and  Nathanson,  I.  T.:     Am.  Jour. 
of  Surgery,  N.  Y.,  New  Series  xxv,  no.   1,  .^5-40,   1934. 

2.  Struihers,  J.  W.:     Edinburgh  Med.  Jour.,  New  Series 
XXVII,  p.  22,  1921. 


3.  Freeman,  L.:     Surg.,  Gyn.  &  Obs.,  Chicago,  xxxvn,  p. 
149,    1923. 

4.  Speese,  J.:     Penn.  Med.  Jour.,  p.  225,  1929. 

5.  WiLENSKY,  A.  O.,  and  Hahn,  L.  J.:  Annals  of  Surgery, 
Lx.xxni,  p.  812,  1926. 

6.  McKiNi-EY,  E.  B.r     Personal  communication. 

7.  Burrows,  M.  T.:     Archives  of  Int.  Med.,  xLvm,  no.  1, 
33-50,   1931. 

8.  McKiNLEY,   E.    B.:      Proc.   Soc.   for   Exp.   Biology    & 
Medicine,  xxxi,  297-299,   1933. 

Discussion 

Dr.  T.  C.  Bost,  Charlotte: 

Gentlemen,  this  is  the  type  of  work  or  type  of  paper 
that  gets  us  somewhere,  that  advances  medicine.  It  is  a 
very  easy  thing  to  follow  a  blazed  trail.  Of  course,  if 
you  hit  the  right  road,  all  very  well;  if  not,  it  is  necessary 
to  try  to  get  on  the  right  road,  just  as  Dr.  White  has 
done  here.  He  apparently  has  shown,  step  by  step:  that 
tuberculosis  has  nothing  to  do  with  this  condition;  that 
so-called  auto-intoxication  or  absorption  of  toxins  does 
not  produce  it;  that  the  appendx  is  nothing  more  than  a 
disinterested  bystander,  as  he  expressed  it,  and,  in  the 
event  some  fellow  has  been  in  there  and  removed  the 
appendix,  it  is  not  even  there;  that  infections  of  the  nose 
and  throat  are  to  blame  is  not  proved,  because  the  infec- 
tive organism  (or  any  other  organism,  for  that  matter) 
has  not  been  found  except  once  by  Goldberg,  and  that  one 
discovery  does  not  prove  anything. 

As  Dr.  White  points  out,  it  is  wellnigh  impossible  to 
make  a  satisfactory  differential  diagnosis.  Then,  too,  this 
disease  seems  to  occur  chiefly  in  children,  and  I  am  con- 
vinced we  have  a  rather  high  percentage  of  atypical  cases 
of  appendicitis  in  children.  We  all  know  that  it  is  difficult 
or  impossible  to  make  this  differential  diagnosis,  and 
that  it  is  dangerous  to  procrastinate  because  of  the  possi- 
bility of  an  acute  fulminating  appendicitis.  Then,  opera- 
tion clears  up  the  diagnosis,  and  does  not  seem  to  do  any 
particular  harm.  In  fact,  Goldberg  goes  so  far  as  to  say 
that  the  patients  are  certainly  not  set  back  or  done  any 
harm  by  the  operation,  and  that  they  may  be  actually 
benefited  by  exposing  these  glands  to  the  air,  causing  a 
hyperemia,  just  as  cases  of  tuberculous  peritonitis  seem 
to  be  benefited  oftentimes  by  simply  opening  them  up  to 
the  air. 

Dr.  White's  work  here  has  done  something  else.  It  has 
ruled  out,  or  at  least  should  tend  to  rule  out,  the  fear  of 
removing  these  glands.  A  number  of  writers  have  advised 
strongly  against  their  removal,  for  fear  of  producing  a 
widespread  peritonitis.  His  work  has  shown  the  absence 
of  cultures  on  different  media.  That  being  true,  it  would 
seem  to  me  there  would  be  little  danger  in  removing  these 
glands  for  section,  and  it  seems  that  the  work  could  go 
on  unhampered  and  that  it  would  rule  out  the  possibility 
of  peritonitis. 

Then,  too,  it  is  possible  to  find  out  something  about 
other  possible  disease.  For  example,  in  the  case  of  a 
young  man  now  under  observation,  the  pathologist  gave 
me  a  report,  very  much  to  my  surprise,  that  it  was  sug- 
gestive of  an  early  Hodgkin's  disease. 

This  is  all  very  interesting,  and  I  think  Dr.  White  has 
done  a  very  valuable  piece  of  research  work  here. 

Dr.  James  R.  Young,  Anderson,  S.  C: 

In  the  last  twenty  years  I  have  had  possibly  a  dozen 
cases  like  those  Dr.  White  reported.  I  have  been  to  many 
medical  meetings,  and  I  have  never  heard  this  matter  dis- 
cussed as  delightfully  as  it  was  discussed  by  him.  I  have 
operated  on  all  of  these  cases  I  have  seen  but  two.  First, 
as   to   the   operation,   there   is  always   a   little    more   ileus 


526 


ACUTE  MESENTERIC  ADENITIS— White 


October,  1936 


than  you  would  expect  from  a  case  of  appendicitis.  There 
is  early  distention.  In  my  cases  it  has  been  rather  constant 
that  these  children  have  a  little  more  distention  than  you 
would  expect  them  to  have  in  a  case  of  appendicitis. 
From  my  observation  of  the  gut,  it  is  weakened.  It  does 
not  go  up  into  the  jejunum.  This  might  be  due  to  the 
virus  that  the  doctor  mentioned. 

I  have  had  two  cases  of  this  type;  at  least,  I  so  diag- 
nosed them.  There  are  two  or  three  symptoms  that  I 
think  might  be  mentioned.  Such  patients  have  had  appen- 
dicitis symptoms,  plus.  The  plus  is  headache,  backache 
and  some  malaise.  Now,  headache  is  not  a  common  symp- 
tom in  appendicitis,  nor  is  backache.  I  believe  if  we  are 
careful  in  our  diagnosis  we  shall  find  more  of  these  cases. 
In  all  my  cases  the  patients  got  well  in  about  a  week.  All 
those  things  fit  into  the  theory  that  Dr.  White  offers.  I 
am  glad  to  have  heard  the  paper. 

Dr.  R.  B.  Davis,  Greensboro: 

Certainly  Dr.  White  has  brought  to  our  attention  an 
important  abdominal  condition.  I  want  to  make  a  plea 
to  those  general  practitioners  who  are  seeing  a  large  num- 
ber of  cases  not  to  feel  too  bad  should  the  surgeon  happen 
to  disagree  with  you  when  the  patient  arrives  in  the  hos- 
pital. There  has  been  a  great  deal  said  about  fear.  I 
know  of  no  situation  that  would  make  for  a  better  feeling 
between  the  general  practitioner  and  the  specialist  than 
the  elimination  of  fear — fear  that  the  surgeon  will  not 
confirm  your  diagnosis,  or  that  he  will  make  a  different 
diagnosis.  Those  of  us  who  have  been  on  both  sides  of 
the  seesaw  can  speak  very  feelingly  on  this  matter.  You 
go  down  twenty  miles  from  town  at  two  o'clock  in  the 
morning  to  see  some  poor  man,  woman  or  child,  and  you 
think  that  person  should  go  to  the  hospital,  though  you 
feel  undecided  whether  that  patient  should  be  operated  on 
or  not ;  but  you  know  good  and  well  that  unless  you  put 
something  definite  before  the  family  you  will  get  nothing 
done:  then  you  use  the  weapon  of  fear  by  telling  the 
patient  he  must  go  to  the  hospital  and  have  an  operation 
for  appendicitis.  When  the  patient  goes  to  the  hospital, 
the  surgeon  has  to  either  agree  or  disagree.  If  he  agrees, 
and  the  patient  dies,  the  people  may  go  back  home  igno- 
rant, but  the  surgeon  may  not  rest  quite  so  comfortably. 
So,  if  the  surgeon  does  disagree  with  the  diagnosis  made, 
let  us  hope  that  our  diagnosis  made  at  home,  without  the 
facilities  of  a  laboratory  and  without  the  added  knowl- 
edge that  possibly  can  come  from  the  specialist,  let  us  call 
those  tentative  diagnoses  and  not  final  diagnoses. 

The  condition  that  Dr.  White  has  described  has  caused 
me  a  lot  of  worry.  My  first  real  experience  with  it  came 
in  1925,  when  the  superintendent  of  our  hospital  called 
me  at  four  in  the  morning  to  see  his  little  girl,  three-and- 
a-half  years  old,  who  had  been  taken  acutely  ill  in  the 
night.  We  had  four  or  five  consultants,  we  operated  on 
her  about  eleven  o'clock,  and  that  afternoon  she  died. 
Probably  she  would  have  died  anyway;  but  from  that  time 
until  now  I  have  been  fearful  of  failing  to  recognize 
mesenteric  adenitis.  I  somewhat  differ  from  Dr.  Bost  in 
believing  that  operation  does  not  hurt  and  may  help.  I 
do  not  believe  that  an  anesthetic  in  any  acute  infection 
helps  the  patient.  It  behooves  the  general  practitioner  not 
to  lay  down  too  hard-and-fast  a  Hne  for  the  surgeon  to 
walk  when  the  patient  gets  to  the  hospital ;  and  the  stir- 
geon  should  be  the  kind  of  person  who,  should  he  have 
to  disagree,  will  bear  it  in  mind,  and  let  it  be  known, 
that  he  takes  it  into  due  consideration,  that,  at  the  time 
and  under  the  circumstances  of  the  family  doctor  making 
the  diagnosis,  it  is  unlikely  that  a  surgeon  would  have 
done  any  better.  There  are  men  sitting  here  this  morning 
who   have   lost  the  support   of   a   number  of  practitioners 


over  a  period  of  years  because  they  dared  to  differ  in  the 
diagnosis.  To  those  surgeons  I  take  off  my  hat,  and  I  am 
quite  sure  that  when  the  race  is  run  they  will  wear  a 
white  cap  in  the  land  to  come,  as  they  have  in  the  operat- 
ing room  in  this  land,  and  I  hope  those  men  will  enter  the 
surgical  heaven  of  the  future.  I  have  one  son  who  con- 
templates studying  medicine,  and  I  shall  be  highly  pleased 
if  he  first  becomes  a  good  family  doctor,  and  thereafter, 
if  he  wants  to  specialize,  let  him  become  that  type  of 
specialist  who  dares  to  follow  his  convictions. 
Dr.  WiiiiA^c  .\lla^-,  Charlotte: 

I  just  want  to  ask  one  question,  and  that  is  whether 
anybody  ever  looks  for  worms  these  days.  Apparently 
these  are  belly  troubles  in  children,  and  that  is  where 
worms  belong,  in  the  bellies  of  children. 

Dr.  White,  closing: 

I  wish  to  thank  the  gentlemen  who  have  taken  part  in 
this  discussion  and  I  am  particularly  impressed  by  the  re- 
marks of  Dr.  Young  who  mentioned  headache  and  back- 
ache as  being  possible  clues  and  differential  signs  between 
mesenteric  adenitis  and  appendicitis. 

Until  we  are  able  to  differentiate  the  two  conditions,  it 
would  seem  that  an  operation  would  be  the  course  to  pur- 
sue. The  mortality  from  surgery  would  be  less  than  the 
mortality  that  follows  an  error  in  diagnosis. 

I  am  satisfied  that  these  cases  are  not  infrequent  and 
observations  will  be  made  from  time  to  time  that  will  en- 
able us,  eventually,  to  properly  classify  the  disease. 


Liver  Failure 
(G.  2.   Williams,  Denver,  in  Col.    Med.,   Sept.) 

Many  of  the  unexplained  postoperative  deaths  with  high 
fever  and  prostration  are  due  to  liver  failure. 

The  syndromes  are  divided  into  3  classes:  a)  those  in 
which  there  is  a  sudden  onset  with  high  fever,  coma  and 
rapid  death,  without  signs  of  uremia;  at  necropsy,  only 
necrosis  of  liver  cells  is  found;  b)  those  in  which  there  is  a 
similar  picture  with  later  onset  and  longer  duration,  with 
more  gradual  increase  in  symptoms  including  signs  of  ure- 
mia before  death ;  autopsy  discloses  liver  damage  of  vary- 
ing degree  accompanied  by  degeneration  of  renal  tubule 
cells;  c)  those  cases  in  which  slowly  increasing  exhaustion, 
muscular  weakness,  subnormal  t.  and  decreasing  b.  p.  prog- 
ress to  terminal  vascular  collapse,  coma  and  prostration. 
Necropsy  findings  may  be  slight,  but  usually  show  some 
ante-mortem  change  of  the  liver  cells,  if  not  definite  necro- 
sis. 

Liver  deaths  also  occur  in  many  organic  diseases  of 
chronic  debilitating  nature,  acute  toxemias,  liver  trauma, 
and  certain  drug  poisonings. 


Carcinoma  or  the  Stomach 

(Dr.   Gatewood,  Chicago,  in  Jl.   Indiana   State   Med.  Assn., 

Sept.) 

Cancer  of  the  stomach  is  the  most  frequent  cause  of 
cancer  deaths;  50%  of  500  consecutive  cases  of  gastric 
carcinoma  entering  the  Presbyterian  Hospital  were  diag- 
nosed as  inoperable.  At  least  3/5ths  begin  near  enough  to 
the  pylorus  to  make  them  probably  resectable. 

The  symptoms  are  varied,  but  this  very  fact  should  be 
a  warning  to  the  alert  physician.  X-ray  examination  by 
an  expert  is  the  most  reliable  aid  to  early  diagnosis. 


Pain  in  the  Back  or  ExTREiiiTiES,  definitely  described 
as  bone  pain,  has  been  the  major  symptom  [of  hyperpara- 
thyroidism] in  the  majority  of  cases  both  early  and  late 
in  the  disease. — Parsons. 


Pure  hypothyroid  obesity  is  an  uncommon  condition. 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Backache* 


D.  W.  Holt,  A.B.,  M.D.,  F.A.C.P.,  Greensboro,  North  Carolina 


WHILE  a  student  in  medical  college,  and 
later  a  resident  physician,  under  the 
teaching  and  leadership  of  the  noted 
physician,  author  and  beloved  teacher,  the  late  Dr. 
Thomas  INIcCrae,  I  was  impressed  with  the  way 
he  emphasized  the  subject,  Backache.  Well  do  I 
remember  how  he  tried  to  impress  upon  us  the 
importance  of  a  careful  and  painstaking  history 
and  examination  in  these  cases,  and  emphasized 
over  and  over  again  how  important  it  was  to  find 
the  cause  of  the  condition  before  instituting  medi- 
cal treatment  or  foolishly  referring  the  case  to  a 
surgeon,  gynecologist  or  orthopedist  for  some  need- 
less operative  procedure  from  which  the  unfortu- 
nate patient  would  receive  no  benefit  whatever,  and 
oftentimes  suffer  grave  injury. 

I  did  not  realize  at  that  time  just  how  important 
his  sound  advice  was,  nor  why  he  deemed  it  so 
necessary  to  repeat  so  frequently  and  forcefully. 
However,  since  I  have  seen  so  many  of  these  un- 
fortunate victims  who  have  been  needlessly  oper- 
ated upon,  with  no  relief,  who  could  have  been  re- 
lieved by  some  simple  treatment,  it  has  become 
clear  to  me  why  he  tried  so  diligently  to  impress 
upon  us  the  importance  of  a  careful  history  and  a 
proper  diagnosis  as  to  the  etiology  of  backache. 

Backache  may  arise  from  a  great  number  of 
conditions  which  may  be  coexistent  in  the  same 
individual,  therefore,  in  an  analysis  from  an  etiolo- 
gic  standpoint  it  is  necessary  to  proceed  with  the 
utmost  caution.  It  has  taken  a  long  time  for  med- 
icine to  arrive  at  this  conclusion,  and  there  have 
been  many  steps  in  the  development  of  the  opin- 
ion. When  gynecology  first  developed  as  a  spe- 
cialty, it  was  believed  that  pelvic  conditions  were 
the  chief  cause  of  backache.  The  view  changed 
only  when  it  became  known  that  relief  did  not 
often  follow  the  suspensions  and  other  gynecologic 
surgical  procedures,  and  that  men  were  also  liable 
to  backache.  .At  that  time,  probably  little  was 
known  as  to  the  etiology  of  lumbago  or  sciatica  or 
of  the  role  the  prostate  gland  plays  in  causing  back- 
ache. When  the  pendulum  swung  to  the  other  side, 
the  gynecologists  became  more  conservative.  In- 
deed, Dr.  Howard  Kelly,  back  in  the  90"s  con- 
stantly cautioned  his  students  not  to  promise  relief 
from  backache  in  the  presence  of  inflammatory 
conditions,  or  in  marked  retroversions;  and  well 
also  do  I  recall  how  Dr.  P.  Brooke  Bland,  in  Phil- 
adelphia, also  tried  to  impress  upon  us  in  my  stu- 


dent days,  that  simple  uncomplicated  retroversion 
was  not  a  cause  of  backache,  and  I  often  think  of 
his  saying,  "Any  physician  who  tells  a  woman  that 
an  operation  for  simple  retroversion  will  relieve  her 
backache,  certainly  does  not  know  the  nerve  sup- 
ply of  a  woman's  pelvis." 

With  the  greatly  increased  attention  to  focal  in- 
fections, many  other  causes  for  backache  have  been 
recognized.  Many  men  in  authority  have  stressed 
the  importance  of  teeth,  tonsils,  sinuses  of  the  head, 
appendix,  gallbladder,  prostate,  seminal  vesicles  and 
female  pelvic  organs  as  chief  sites  of  focal  infec- 
tions. The  bacteriologic  work  of  Rosenow  and 
Dick  has  given  this  theory  a  reasonable  amount  of 
corroboration,  and  the  fact  has  been  established 
that  backache,  with  or  without  disturbance  of  pos- 
ture, may  well  be  evidence  of  infection. 

There  are  certain  fundamental  conditions  that 
attend  any  investigation  of  backache.  We  realize 
the  fact  that  bad  posture  is  more  common  in  wo- 
men. Ordinarily  women  do  not  stand  as  correctly 
as  men.  They  normally  slouch  and  put  overstrain 
on  the  posture  musculature.  They  have  a  high  pro- 
portion of  flat  feet,  since  they  choose  shoes  that 
are  governed  by  style  and  not  by  the  needs  of  the 
wearer. 

The  importance  of  fatigue  is  not  sufficiently  em- 
phasized. Fatigue  alone  may  be  responsible  for 
backache.  Because  in  nearly  all  gynecological  dis- 
eases complaint  is  made  of  backache,  it  seems  rea- 
sonable to  assume  that  fatigue  must  be  shared  with 
static  as  well  as  with  the  pelvic  conditions. 

Cystitis  usually  causes  a  definite  backache.  Back- 
ache follows  in  a  number  of  cases  in  which  the 
tubes  have  been  removed  or  ligated,  and  oftentimes 
we  have  wondered  whether  or  not  because  of  any 
ovarian  adhesions  or  other  pelvic  pathology.  Of 
course,  I  do  not  want  it  to  be  understood  that  we 
must  not  pay  especial  attention  to  all  pelvic  in- 
flammatory conditions  and  the  role  which  they  play 
in  the  production  of  backache — such  as  cervicitis, 
pelvic  congestion,  endocervicitis  and  some  degrees 
of  posterior  parametritis. 

Endocervicitis  of  varying  degrees  is  frequently 
found  postpartum  and  should  be  cured  before  the 
patient  is  discharged. 

Low  backache  is  a  complaint  which  brings  many 
patients  to  a  physician.  The  conviction  seems 
deeply  rooted  in  the  minds  of  the  laity  that  back- 
ache and  "womb  trouble"  are  synonymous;  and  that 


BACKACHE— Holt 


October,   1936 


low  abdominal  pain  means  ovary  trouble.  It  has 
been  stated  by  noted  authorities  that  practically  one 
patient  in  five  visits  a  physician  because  of  back- 
ache. Physicians  have  now  recognized  that  there 
are  other  explanations  for  low  backache  than  de- 
rangements of  the  pelvic  organs. 

The  condition  in  the  pelvis  which  has  been 
blamed  perhaps  more  than  any  other  for  causing 
backache  is  uterine  retrodisplacement.  To  the  lay 
mind,  a  tipped  womb  means  a  backache;  but  obser- 
vations disclose  a  large  number  of  backward  dis- 
placements without  any  symptoms  whatever,  unless 
it  is  very  thoughtlessly — and  oftentimes  I  fear  for 
the  sake  of  pecuniary  reward — mentioned  to  the 
unfortunate  patient.  It  becomes  necessary  to  ex- 
plain why  backache  is  present  in  only  certain  cases 
of  retrodisplacement.  Something  beyond  the  the- 
ory has  been  advanced  that  circulatory  disturbances 
in  the  broad  ligaments  perhaps,  or  the  uterus  itself, 
accompany  the  abnormal  position,  and  that  it  is 
this  circulatory  disturbance  which  causes  the  back- 
ache. This  reasoning  may  be  correct,  but  it  is 
noted  that  backache  is  not  consistently  existent  in 
the  pelvic  inflammations;  obviously  in  these  cases 
the  circulatory  disturbances  are  marked.  Twenty- 
five  years  ago,  we  are  told,  the  uterosacral  liga- 
ments entered  the  picture  frequently,  but  today 
one  hardly  hears  them  mentioned.  Pressure  is  the 
basis  of  another  explanation.  The  adherent  retro- 
version with  pathology  in  the  appendages  might 
seem  to  be  one  which  would  most  likely  produce 
this  pressure,  but  backache  is  not  a  common  symp- 
tom of  pelvic  inflammation.  One  can  but  remem- 
ber the  extreme  degrees  of  prolapse  one  encounters, 
with  complaints  limited  to  "it  comes  outside,"  to 
realize  that  the  msre  excursion  of  the  uterus  from 
its  normal  position  is  not,  in  itself,  sufficient  to 
produce  the  symptom  under  discussion.  One  noted 
gynecologist  states  that  in  the  backache  cases,  an 
accompanying  retrodisplacement  was  disclosed  in 
only  11  per  cent,  of  his  cases.  Practically,  then, 
a  retrodisplacement  will  be  found  in  only  one  of 
ten  backache  cases.  Unfortunately,  many  patients 
seek  our  assistance  for  this  symptom  and  the  easy 
assumption  that  demonstrable  pelvic  abnormality 
is,  in  itself,  sufficient  explanation,  leads,  as  the 
next  step,  to  treatment,  especially  surgical  treat- 
ment. Unfortunately,  again,  it  is  common  experi- 
ence that  such  treatment  is  not  always  justified  by 
gratifying  results. 

With  the  realization,  then,  that  backache  may  be 
present  in  one  patient  with  certain  pelvic  abnor- 
malities, and  absent  in  another  with  more  or  less 
identical  pathology,  it  becomes  apparent  that  more 
light  is  required  on  this  subject  before  the  part 
the  pelvis  plays  in  the  production  of  this  symptom 
can  be  accurately  appraised.    Let  us  approach  it. 


then,  from  another  angle  and  consider  the  symptom 
itself,  devoting  our  attention  to  the  simple  observa- 
tion of  these  backache  cases.  Many  of  them  are 
of  duration  measuring  over  months  and  years.  In 
the  greater  number  of  cases  the  symptom  is  worse 
after  exertion,  especially  towards  night,  with  relief 
after  lying  down.  In  a  much  smaller  but  very 
definite  group  the  back  aches  only  when  in  bed. 
The  backache  existing  both  day  and  night  in  equal 
intensity  is  infrequent.  In  another  small  group  the 
symptom  is  felt  when  first  getting  up  in  the  morn- 
ing; in  still  another  comfort  is  greatest  after  sitting 
any  length  of  time.  One  is  struck  by  the  frequency 
with  which  these  women  patients  date  their  dis- 
ability back  to  childbirth. 

We  have  also  observed  that  patients  who  describe 
a  backache  after  exertion  also  complain  of  low 
abdominal  discomfort  or  pain  in  one  or  the  other 
lower  quadrant,  sometimes  sharp  and  fleeting,  some- 
times dull  and  persistent.  They  have  usually  had 
these  pains  for  a  long  time,  and  the  pains  also 
usually  disappear  when  the  patient  lies  down. 
Flatulency  is  a  common  accompanying  complaint; 
vomiting  is  infrequent.  The  patients  have  rarely 
been  confined  to  bed  with  an  acute  attack  of  either 
abdominal  pain  or  backache — except  always  time 
devoted  to  surgery  for  so-called  chronic  appendi- 
citis or  for  the  suspension  operation  so  many  have 
had.  They  have  hollow  backs,  i.e.,  well  marked 
anterior  lumbar  curves,  and  there  is  usually  definite 
relaxation  of  the  abdominal  walls;  they  often  are 
round  shouldered,  apt  to  be  undernourished,  and 
they  generally  convey  the  impression  that  the  busi- 
ness of  living  is  almost  beyond  their  capability. 
The  patients  whose  backaches  are  worse  or  only 
at  night,  present  an  entirely  different  picture.  They 
are  apt  to  be  overweight,  short  and  thick;  they 
have  no  lumbar  curves,  but  a  flat  square  back  with 
markedly  restricted  motions  in  all  directions,  a 
restriction  obviously  anatomical.  As  these  groups 
of  backache  patients  in  numbers  file  before  a  phy- 
sician for  examination,  though  his  judgment  may 
be  warped  by  a  predilection  for  some  specialty,  he 
cannot  help  but  realize  that  this  symptom  in  the 
great  majority  of  cases  has  much  to  do  with  motion, 
position  and  posture.  The  largest  group  has  no 
hesitancy  in  saying  that  the  bed  affords  complete 
relief.  Certain  motions  such  as  bending,  lifting, 
sweeping  and  other  household  duties  aggravate  the 
pain. 

We  also  note  that  a  great  majority  of  these  wo- 
men with  backache  do  housework — evidence  in  it- 
self conclusive,  for  the  majority  of  women  still  do 
housework.  Also,  factory  efficiencj'  has  not  yet 
been  introduced  into  the  kitchen,  where  one  hears 
little  of  fatigue  and  faulty  position,  of  muscle 
strain  or  wasted  motion,  though  we  have  seen  the 


October,   1936 


BACKACHE— Holt 


S29 


faint  beginnings  of  attention  to  this  in  the  "yard- 
high"  sink  advertisements. 

To  put  it  another  way,  the  gynecologist,  the  in- 
ternist or  the  surgeon  often  finds  himself  con- 
fronted by  functional  postural  defects  in  the  broad 
use  of  that  term.  We  may  then  retire  gracefully 
in  favor  of  the  orthopedist,  or  we  may  indulge  his 
curiosity  and  justify  it  by  the  argument  that  a 
given  case,  with  some  pelvic  abnormality  on  the 
one  hand  and  a  common  postural  defect  on  the 
other,  is  as  much  our  responsibility  as  the  ortho- 
pedist's. A  decision  is  to  be  made  as  to  where 
one  condition  begins  and  the  other  leaves  off  in  the 
production  of  this  backache. 

The  gross  anatomical  back  defects,  the  backs 
with  definite  pathology,  do  not  often  appear  in 
this  group;  they  have  long  since  come  under  the 
care  of  the  orthopedist.  Occasionally  the  gynecolo- 
gist finds  a  chronic  back  pain,  dated  from  some 
accident  or  injury  supposedly  causing  uterine  dis- 
placement: curiously,  this  particular  type  is  almost 
invariably  an  industrial  or  medico-legal  case.  In 
a  general  way  also,  these  patients  with  only  slight 
postural  deviation  have  a  maximum  of  discomfort 
and  a  minimum  of  pathology.  In  studying  these 
cases,  one  can  readily  see  that  they  furnish  a  num- 
ber called  chronic  appendicitis,  meaning  a  pain 
in  the  right  lower  quadrant,  which  has  as  its  chief 
characteristic  chronicity;  and  sadly  but  truly  also, 
this  same  condition  many  times  sends  patients  to 
the  gynecologist  with  a  self-achieved  diagnosis  of 
ovary  trouble. 

Palpation  of  this  type  of  abdomen  shows  relaxa- 
tion, a  distended  and  sometimes  tender  cecum, 
usualU'  at  the  pelvic  brim;  usually  a  palpable  sig- 
moid, also  usually  tender;  frequently  a  palpable 
liver  edge,  and  occasionally  a  floating  kidney.  Here 
again,  if  an  operation  has  been  done,  one  may  be 
surprised  at  the  frequency  with  which  these  pa- 
tients discuss  the  post-operative  adhesions.  It 
seems  that  this  is  a  sort  of  defense  mechanism. 
They  seem  to  want  to  seek  a  legitimate  justifica- 
tion for  their  continued  symptom,  lest  they  find 
themselves  catalogued  as  neurotic.  As  has  already 
been  indicated,  the  beginning  of  symptoms  in  many 
of  these  patients  dates  back  to  childbirth.  It  is 
easy  for  them  to  think  that  their  troubles  are  the 
direct  effect  of  childbearing,  or  some  operation 
which  they  have  had  to  undergo  for  their  backache 
which  was  never  relieved;  and  too,  it  is  this  type 
of  patient  that  furnishes  a  field  ripe  to  the  harvest 
for  those  operators  who  promise  relief  with  a  cervi- 
cal repair  or  a  suspension  of  the  uterus.  Granting 
that  such  may  be  the  answer  in  a  small  group  of 
cases,  it  is  still  easy  to  appreciate  another  sequence 
of  events  in  the  case  that  is  essentially  a  postural 
fault. 


If  the  adult  patient  could  only  be  taught  to  stand 
and  walk  correctly;  if  by  regulated  exercises  mus- 
cle tone  could  be  brought  to  normal;  if  with  a  ges- 
ture the  improper  and  fatiguing  apparatus  of 
housework  and  other  kinds  of  work  could  be  re- 
moved; if  the  height  of  all  patients  could  be  stand- 
ardized, as  well  as  sinks  and  tables,  a  cure  for  this 
housewife  backache  would  doubtless  ensue.  This 
ideal,  of  course,  is  impossible  of  attainment.  Even 
learning  correct  posture  by  systematic  exercising  is 
not  always  practicable.  The  majority  of  these  pa- 
tients do  not  have  the  time  nor  the  patience  to 
devote  to  a  long-drawn-out  course  of  treatment. 
It- becomes  necessary  to  short-cut  in  a  search  for 
relief,  and  oftentimes  a  corset,  in  the  case  of  a 
woman's  backache,  is  more  or  less  a  permanent 
part  of  her  wearing  apparel.  The  generation  which 
has  discarded  corsets  along  with  most  of  its  other 
clothing,  has  not  yet  lived  long  enough  to  come 
within  the  confines  of  the  group  under  discussion. 
If  the  corset  is  properly  cut  and  fitted,  and  worn 
correctly,  it  will  accomplish  for  most  of  these  cases 
the  results  we  desire.  It  is  a  practical  method  to 
obtain  a  result.  Details  can  be  attended  to  by  a 
competent  corsetiere.  Fitting  well  and  worn  propy- 
erly,  these  corsets  and  abdominal  supporters  give 
sufficient  support  to  relieve  muscle  strain  and  sub- 
sequent pain  in  the  lumbar  back,  and  by  holding 
up  the  abdomen  they  lessen  materially  that  group  of 
symptoms  due  primarily  to  ptosed  bowel  and  ab- 
dominal muscle  strain.  Proper  corseting  will  take 
care  of  a  very  considerable  number  of  these  cases, 
enough  to  warrant  it  a  standard  first  procedure  for 
the  backache  which  comes  to  us.  It  takes  care  of 
practically  that  whole  group  which  has  its  symp- 
toms with  exertion  and  its  relief  on  lying  down. 
A  reasonable  proportion  of  these  backaches  felt 
only  in  bed  are  relieved  by  a  proper  corset  worn 
in  the  daytime;  others  of  this  group  are  benefited 
by  procedures  which  tend  to  minimize  the  ex- 
treme flexion  these  rigid  backs  are  subjected  to  in 
beds  with  soft  mattresses  and  relaxed  springs. 
When,  in  a  case  seemingly  belonging  to  the  pos- 
tural group  relief  is  not  gotten  at  once  from 
proper  corset  or  supporters,  before  accepting  de- 
monstrable pelvic  pathology  as  a  probable  cause, 
we  must  consider  the  possibility  of  a  true  arthritic 
condition,  this  to  include  also  that  intangible  of 
intangibles,  sacro-iliac  pain.  I  have  found  that  the 
knee-chest  position  over  a  period  of  several  weeks 
is  a  valuable  addition  to  the  treatment  of  the  ab- 
dominal asjiects  of  these  cases.  With  the  correc- 
tion of  the  postural  fault,  and  excluding  arthritis 
by  x-ray  study,  the  backache  persisting,  one  is 
reasonably  justified  to  proceed  on  the  theory  that 
some  definite  pelvic  pathology  is  its  cause. 

We  have  noted  that  surgeons  generally  now  in- 


BACKACHE— Holt 


October,   1936 


sist  upon  some  kind  of  a  surgical  corset  after  ab- 
dominal operations.  It  is  a  reasonable  question 
whether  the  relief  some  patients  have  after  sus- 
pension operations  may  not  in  a  large  part  be  due 
to  this  corset  rather  than  the  operation.  A  suffi- 
cient number  of  cases  have  been  observed  to  have 
recurrent  symptoms  after  operative  treatment,  when 
their  special  corsets  are  worn  out,  to  prove  this  is 
a  fact  in  certain  cases  at  least. 


The  Nervous  Patient  in  the  General  Praciice  of 
Medicine 

(F.  J.  Hirschboeck,  Duluth.  Minn.,  in  Wise.  Med.  Jl., 
Sept.) 
Because  of  his  inherent  weakness,  it  is  difficult  for  the 
nervous  person  to  adapt  himself  to  environmental  influ- 
ences. It  is  easier  for  him  and  more  satisfying  to  his  ego 
to  have  the  environmental  milieu  modified  to  suit  his 
weaknesses  rather  than  that  he  constantly  adjust  himself, 
a  process  in  which  he  usually  fails.  This  failure  of  adjust- 
ment to  difficult  situations  is  one  of  the  chief  reasons  for 
a  nervous  person's  dissatisfaction  with  his  station  in  life, 
and  his  occupational,  marital  and  social  responsibilities. 
These  relatively  simple  behavior  disturbances  are  not  as 
obvious  as  the  more  serious  psychoneuroses  and  borderline 
states  and  the  nature  and  background  of  the  difficulty  is 
oftentimes  hidden  by  the  smoke  screen  of  subjective  symp- 
toms or  deliberate  denial. 

One  of  the  characteristics  is  fatigability  leading  to  a 
lowering  of  energy  that  is  conducive  to  lassitude  and  a 
foe  to  happiness.  This  is  frequently  related  to  undue 
anxiety,  to  sleeplessness,  to  an  unhappy  choice  of  occupa- 
tion, marital  infelicity,  a  fear  of  illness,  etc.  The  patient 
is  no  longer  filled  with  the  joy  of  living  and  becomes  self- 
centered,  introspective,  self-analytic;  fear  is  usually  asso- 
ciated— fear  of  death,  dishonor,  disease,  or  depreciation — 
and  colors  the  clinical  picture  with  anxieties,  phobias  and 
obsessions,  and  very  commonly  a  localization  of  mental 
projections  in  the  cardiovascular,  the  gastrointestinal,  or 
the  genitourinary  system,  as  the  case  may  be.  One  must 
distinguish  among  the  patients  who  have  almost  complete 
psychic  symptoms,  those  who  may  have  coincident  physical 
illness  as  well,  and  finally  those  physically  afflicted  who 
have,  as  a  consequence  of  their  illness  or  in  association 
therewith,  a  superimposition  of  psychic  elements. 

In  our  tendency  to  make  an  indirect  diagnosis  of  a 
neurosis  only  after  an  extensive  and  expensive  diagnostic 
procedure  we  do  not  heed  sufficiently  the  symptomatic 
ensemble  of  the  neurotic,  which  in  itself  is  so  characteris- 
tic! However,  a  direct  diagnosis  of  a  neurosis  is  not 
justifiable  unless  a  positive  psychic  cause  for  this  diagnosis 
can  be  established. 

The  constant  repetition  of  symptoms  to  their  friends 
and  relatives,  ultimately  leading  to  an  indifference  on  the 
part  of  the  hearers,  leads  the  patient  to  an  indulgence  in 
hyperbole  in  his  recital. 

Headaches  on  the  vertex,  band-like  or  pressure  head- 
aches, occipital  pain,  tired  feeling,  variability  in  disposition, 
globus  hystericus,  air  hunger  and  gas  belching,  cardiovas- 
cular and  gastrointestinal  neuroses  are  the  most  numerous 
of  somatic  complaints.  Many  patients  with  heart  symp- 
toms date  an  aggravation  of  their  condition  to  a  physician's 
diagnosis  of  heart  disease  erroneously  made. 

As  to  diagnosis  of  organic  or  functional  disease  in 
the  gastrointestinal  tract;  if  the  diagnosis  is  difficult  or 
elusive,  there  is  usually  sufficient  time  so  that  a  more  ex- 
haustive evaluation  of  the  symptom  complex  can  be  made. 


Clinicai,  Application  of  Venous  Pressure  Measurement 

(H.  H.  Hussey,  Washington,  in   Med.  An.  D.  C,  Aug.) 

The  apparatus  consists  of  a  20-gauge  needle  and  a  2  c.c. 
syringe  having  a  sidearm  to  which  a  calibrated  glass  meas- 
uring tube  is  connected  by  means  of  rubber  tubing  of  the 
size  of  a  14  F.  catheter.  The  other  end  of  the  glass  tube 
is  connected  by  means  of  another  short  piece  of  rubber 
tubing  to  a  glass  reservoir  of  any  description.  The  entire 
apparatus  can  be  sterilized  by  boiling.  Physiologic  salt 
solution  is  placed  in  the  reservoir  and  allowed  to  fill  the 
set,  which  is  then  ready  to  use.  The  patient  is  placed  in 
supine  position,  a  vein  is  selected  in  one  of  the  antecubital 
fossae,  and  the  needle  is  introduced  into  the  vain  as  usual. 
The  plunger  of  the  syringe  is  drawn  back  allowmg  saline 
to  run  through  the  sidearm  into  the  syringe  and  thence 
into  the  vein.  Next,  the  reservoir  is  detached  from  the 
apparatus,  and  the  zero  point  of  the  calibrated  tube  is 
placed  on  a  plane  with  the  midaxillary  line  of  the  patient, 
approximately  level  with  the  right  atrium  of  the  heart. 
The  saline  will  continue  to  fall  in  the  glass  tube,  fluctuating 
somewhat  with  respiration,  and  stopping  at  a  point  which 
indicates  the  height  of  the  venous  blood  pressure  in  terms 
of  mm.  of  saline.  Using  this  technic  it  has  been  found 
that  normal  persons  have  a  peripheral  venous  blood  pres- 
sure of  40  to  120  mm.  of  saline. 

Right  ventricular  failure  always  causes  a  rise  in  venous 
pressure  above  normal,  and  this  rise  may  be  the  means  to 
the  diagnosis  of  heart  failure. 

Repeated  measurements  of  venous  pressure  in  patients 
with  congestive  heart  failure  are  useful  to  follow  the  clini- 
cal course  of  the  disease  and  have  prognostic  importance. 

High  venous  pressures  in  lobar  pneumonia  have  an  un- 
favorable prognostic  significance. 

Measurement  of  the  blood  pressure  in  the  peripheral 
veins  is  valuable  in  the  diagnosis  of  cardiac  compression 
and  is  helpful  in  estimating  the  efficacy  of  surgical  treat- 
ment in  this  condition. 

Venous  pressure  measurement  is  useful  in  the  diagnosis 
of  mediastinal  tumors  and  in  observing  the  response  of 
certain  types  to  roentgen-ray  therapy. 

Pleural  effusion  and  pneumothorax  do  not  affect  venous 
pressure  unless  they  are  sufficient  to  provoke  dyspnea. 
Measurement  of  venous  pressure  is  useful  in  the  regulation 
of  artificial  pneumothorax  therapy. 


Early  Diagnosis  of  Tumor  of  the  Brain 


A  review  of  the  initial  symptoms  and  early  course  of 
100  patients  with  tumor  of  the  brain  revealed  headache, 
mental  changes  and  aphasia  as  the  most  frequent  primary 
.'symptoms  in  patients  with  rapidly-growing  tumors;  these 
symptoms  were  severe  and  disabling,  attracting  the  early 
attention  of  the  patient  and  the  doctor. 

Convulsions  and  visual  disturbances  were  the  most  fre- 
quent primary  symptoms  in  patients  with  slow-growing 
tumor;  these  symptoms  were  usually  mild,  transitory,  and 
unaccompanied  by  other  symptoms. 

The  course  of  the  disease  was  frequently  characterized  by 
partial  or  complete  remissions  in  subjective  as  well  as  ob- 
jective symptoms. 

Papilledema  was  present  in  4S.  The  incidence  was  high 
in  those  cases  of  long  duration. 


In  Saint  Olaf's  Saga,  A.D.  1030  (Med.  Times,  Apri.)  is 
an  account  of  the  feeding  of  leeks  to  a  man  wounded  in 
the  body  to  ascertain  "if  the  wound  had  penetrated  the 
belly,  for  if  the  wound  had  gone  so  deep,  it  would  smell  of 
leek." 


October,   1036 


SOUTHERN  MEDICINE  AND  SURGERY 


Protamine   Insulin 

Harold  Glascock,  jr.,  M.D.,  Raleigh,  North  Carohna 
Mary  Elizabeth  Hospital 


THE  value  of  insulin  in  the  treatment  of 
diabetes  mellitus  is  well  established. 
However,  in  method  of  administration  and 
speed  of  action  it  leaves  so  much  to  be  desired  that 
many  investigators  have  been  working  toward  im- 
provement in  these  regards. 

The  most  successful  work  in  this  field  has  been 
done  by  Danes, ^  who  have  based  their  experiments 
upon  the  idea  of  combining  regular  insulin  with  a 
substance  only  sparingly  soluble  in  body  tissue 
fluids.  After  many  trials  they  found  a  simple  pro- 
tein of  the  protamine  group  to  be  the  most  suitable 
preparation.  Protamines  of  this  type  are  found  in 
the  ripe  sperm  of  fish.  They  are  strongly  basic 
and  are  non-coagulable  by  heat;  hence,  when  they 
combine  with  insulin  the  reaction  of  the  mixture 
approaches  that  of  the  body  fluids.  The  solubility 
of  the  insulin  is  thus  reduced.  Of  these  protamines, 
the  one  prepared  from  the  sperm  of  Salmo  iridhts 
was  found  to  have  the  most  prolonged  and  the  least 
harmful  effect. 

When  combined  with  regular  insulin,  protamine 
forms  a  white  flocculent  precipitate  which  is  fairly 
stable  and  which  remains  partially  in  suspension  for 
some  time,  though  having  a  tendency  to  chng  to 
the  sides  of  the  container  and  thus  interfere  with 
uniform  distribution  in  the  liquid.  To  overcome 
this  last  fault  and  to  increase  its  stability,  Eli  Lilly 
and  Company,  following  the  suggestion  of  Scott  and 
Fisher  of  Toronto,  have  added  zinc  and  calcium 
The  addition  of  calcium  produces  a  more  finely 
divided  precipitate  which  remains  longer  in  suspen- 
sion, is  more  stable  and  has  an  enhanced  insulin 
effect.  This  product,  when  injected  subcutaneously, 
is  only  slightly  soluble  in  body  fluids.  It  gradually 
breaks  down  so  that  its  best  effect  begins  to  be 
evident  in  about  six  hours  and  continues  for  24  to 
38  hours.  The  injection  of  large  doses  causes  no 
reaction.  The  area  of  injection  becomes  hard  but 
this  hardness  disappears  in  a  day  or  two. 

Through  the  courtesy  of  Mr.  Burwell  and  Dr. 
Peck  of  the  Lilly  Company  I  have  been  able  to 
obtain  some  of  the  insulin  protaminate  for  clinical 
purposes.  By  its  use  I  have  been  able  to  reduce 
the  number  of  injections  of  insulin  per  day,  yet 
maintain  the  patient's  blood  sugar  at  a  more  uni- 
form level,  close  to  the  normal.  As  can  be  seen 
from  the  chart  the  blood  sugar  is  low  in  the  morn- 
ing instead  of  high  as  with  regular  insulin.  Appar- 
ently it  is  a  non-injurious  agent  which  acts  uni- 
formly over  a  long  period  of  time. 


Case   Report 

.\  17-year-old  white  boy,  has  been  on  insulin  and  restrict- 
ed diet  since  the  discover\'  of  his  condition  in  1930.  For  a 
time  previous  to  admission  he  had  been  having  a  high- 
carbohydrate  diet  with  insulin  R2,  u  23-23-23.  His  histor\' 
includes  four  previous  admissions  to  the  hospital — three 
for  dietary  adjustment,  one  because  of  coma.  On  this 
admission,  July  6th  last,  there  was  no  complaint  and  phy- 
sical examination  was  entirely  negative:  the  purpose  was 
clinical  trial  of  protamine  insulin.  Without  delay  his  diet 
was  established  at  carbohydrate  ISO  Gm.,  protein  60  Gm., 
and  fat  110  Gm.,  with  insulin  R,  u  23-15-20  for  the  first 
day  and  u  23-15-17  for  the  second.  The  first  two  days 
were  used  as  a  control  period.  It  can  be  seen  from  the 
chart  that  though  the  blood  sugar  varied  considerably 
during  this  period,  the  urine  remained  sugar-free  or  practi- 
cally so.  The  third  day  after  admission  insulin  P,  u  40 
and  insulin  R,  u  10  were  ordered  and  the  greater  part  of 
his  carbohydrates  given  at  the  noon  and  evening  meals, 
after  the  method  of  Sprague  et  a!J  The  following  day 
the  dose  was  increased  to  insulin  P,  u  45  and  insulin  R, 
u  IS,  and  again  on  the  11th  to  insulin  P,  u  SO  and  insulin 
R,  u  10.  July  12th  the  protamine  insulin  began  to  mani- 
fest its  effect.  The  blood  sugar  remained  down  and  the 
urine  became  practically  sugar-free.  From  then  until  July 
ISth  the  patient  remained  in  good  balance;  however,  July 
16th  the  supply  of  insulin  P  was  insufficient  and  was  re- 
plenished a  few  hours  later  so  that  the  patient  received 
two  doses  of  insulin  P  on  this  day.  On  July  18th  the 
patient's  food  was  reduced  because  he  claimed  that  he 
could  not  eat  all  of  his  C  150  diet.  Final  diet  was  carbo- 
hydrate 127  Gm.,  protein  60  Gm.,  fat  85  Gm.— totaling 
1513  calories  per  24  hours.  The  insulin  dose  was  reduced 
somewhat  out  of  proportion  to  the  reduction  in  carbohy- 
drate in  the  diet.  As  a  consequence,  on  July  IQth  blood 
sugar  was  again  found  to  be  at  higher  levels  and  sugar 
appeared  in  the  urine.  To  counteract  this  a  small  dose  of 
insulin  R  was  administered  in  the  afternoon.  The  following 
day  the  insulin  P  dose  was  raised  to  u  60.  The  patient's 
control  promptly  improved  and  remained  so  until  his 
discharge  on  July  23rd. 

From  the  chart  it  can  be  seen  that  the  patient  was  under 
better  control  when  on  protamine  insulin  than  when  on 
regular  insulin ;  that  the  blood  sugar  not  only  varied  less 
but  remained  at  a  lower  level.  Best  of  all,  the  number  of 
doses  per  day  was  reduced.  Since  discharge  the  patient 
has  been  able  to  carry  out  the  technique  of  the  use  of  the 
new  insulin  without  difficulty.  Attempts  will  be  made  in 
the  near  future  to  reduce  the  dose  of  regular  insulin  and 
perhaps  to  maintain  him  on  insulin  P  alone. 

Technique. — The  new  product  was  received  from 
the  manufacturer  in  two  vials,  one  containing  4 
c.c.  of  u  50  insulin,  the  other  1  c.c.  of  protamine 
insulin  buffered  with  sodium  phosphate  by  means 
of  a  sterile  syringe  so  that  the  resulting  mixture 
was  5  c.c.  of  u  40  protamine  insulinate.  Each 
morning  while  using  insulin  P  the  patient  took  the 
dose  of  insulin  R  in  the  left  arm  from  the  regular 
insulin  syringe  and  the  insulin  P  in  the  right  arm 
from  a  separate  syringe.     The  patient  was  thor- 


PROTAMINE  INSULIN— Glascock 


I 


October,  1935 


Chart  showing  case  during  period  in  hospital.  Blood-sugar  determinations  were  done  on  venous 
blood  by  the  method  of  Folin.  Examinations  for  sugar  in  urine  were  done  with  Benedict's 
solution.     O  is  used  to  indicate  blue  color;  1-plus,  green;  2-plus,   orange;   3-plus,   brick  red. 


I 


oughly  instructed  in  the  advantages  of  the  new 
product  as  well  as  its  dangers,  and  the  proper  tech- 
nique for  its  use. 

Summary 

1.  A  case  is  reported  of  the  use  of  protamine 
insulin  in  a  young  diabetic. 

2.  It  was  found  that  the  new  product  acted 
over  a  long  period  of  time,  and  was  non-injurious 
to  the  patient. 

3.  It  was  also  found  that  the  number  of  doses 
of  insulin  could  be  reduced  and  that  the  diabetic 
balance  could  be  better  maintained. 

1.  Hagedorn.  H.  C.  Jensen.  B.  Norman,  Krarup,  N.  B., 
and  Wodstrup.  I.:  Protamine  Insullnate.  J.  A.  M.  A., 
106:177.   Jan.,   1936. 


3.  Sprague.  R.  O...  Blum.  B.  B..,  Osterberg,  A.  E., 
Kepler,  E.  J.,  and  Wilder.  R.  M.:  CUnical  Observations 
with  Insulin  Protamine  Compound.  J.  A.  M.  A.,  106: 
1701,  May,  1936. 


The  Wish  to  Fall  III 
(E.  D.  Bond,  Philadelphia,  in  JI.Lan.,  July) 
There  is  a  curious  feeling  in  many  of  us  (especially  in 
the  conscientious)  that  it  is  wrong  to  rest.  Work,  is  praise- 
worthy ;  fatigue  is  admirable ;  rest  is  wrong,  recreation  is 
wrong.  It  has  been  observed  that  .Americans  think  that 
a  man  in  motion  is  morally  better  than  one  who  is  sitting 
down.  Only  when  you  are  sick,  is  it  at  all  right  to  rest. 
The  late  Clarence  Day  wrote  this  poem: 

In  Eastern  lands  the  holiest  gents 
Are  those  who  live  at  least  expense; 
They  barely  spealc,  they  seelv  release 
From  active  life  in  prayer  and  peace; 
But  in  the  Western  Hemisphere 
A  saint  must  reach  the  public  e3,r 
And  dust  about  and  shout  and  bustle. 
Combining  holiness  and   hustle. 
It  is  more  important  for  the  physician  to  be  able  to  dis- 
cuss individual  cases  with  a  psychiatrist  than  it  is  for  the 
patient  to  see  the  psychiatrist.    There  are  some  conversion 
symptoms  which  should  not  be  disturbed. 

The   physician,   in   doing   physical   examinations,   should 
guard   his  words   and   the   e.xpression   of   his   face   against 


suggesting  that  there  may  be  physical  lesions.  When  defi- 
nite lesions  exist  there  is  no  objction  to  telling  the  patient 
about  them.  It  is  the  doubtful  diagnosis  which  does  dam- 
age. 

.\void  analytic  terms:  instead  of  saying  "mother-fixation" 
speak  if  necessary  of  too  much  dependence  on  the  mother. 
Use  no  dream  interpretations.  ."Analysts  and  those  opposed 
to  analyists  unite  in  saying  that  half-way  analytic  proce- 
dures are  poor  treatment.  Do  not  tell  a  patient  to  express 
himself;  loosen  his  inhibitions. 

The  physician  should  learn  to  use  the  psychiatric  inter- 
view simply  and  harmlessly,  letting  the  patient  talk  fully 
and  freely  for  an  hour,  offering  few  Interruptions,  but 
some  understanding  and  encouragement.  If  the  physician 
can  show  the  patient  that  he  is  stating  a  personal  variation 
of  a  universal  problem  it  may  be  something  that  the 
patient  very  much  needs. 

A  very  general  statement  of  the  role  of  the  autonomic 
apparatus  sometimes  relieves  dread  of  organic  illness  and 
makes  it  easier  to  face  the  fact  that  disturbed  emotions 
have  physical  effects  which  are  painful  enough  but  tem- 
porary and  often  harmless. 

Common-sense  methods  may  remove  enough  of  the  load 
to  let  the  patient  get  along. 

Causes  foe  Failure  in  the  Treatmext  of  Diabetes 
(R.   W.   Finley,   Cleveland,  in   Ohio   State    Med.   Jl.,  Sept.) 

Give  him  a  written  diet  of  the  foods  he  is  to  eat  and 
the  amounts  of  each,  and  divide  the  diet  into  3  meals  for 
him.  Have  him  measure  his  diet  by  the  teaspoon,  table- 
spoon and  S-ounce  kitchen  measuring  cup.  This  method  is 
as  accurate  for  all  clinical  purposes  as  weighing  by  scale. 
By  its  use  the  patient  teaches  himself  in  terms  of  common 
table  silverware  how  to  estimate  most  of  his  food  portions 
in  his  own  home,  and,  therefore,  is  not  so  likely  to  jeel 
branded  when  dining  away  from  home.  Moreover,  errors 
arising  from  variation  in  food  composition  are  equally  con- 
stant with  I'oer  weighing  or  measuring;  100  gms.  of  peas, 
for  instance,  whether  weighed  on  a  scale  or  measured  by 
the  half  cup,  will  var>'  in  carbohydrate  content  by  5  to  8 
gms.  depending  upon  whether  a  small,  immature  or  a  large, 
mature  pea  is  chosen ;  and  for  practical  purposes  the  dif- 
ference is  negUgible. 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Apparent  Indications   for  Lumbosacral  Fusion  in  Low 
Back  Disorders* 

O.  L.  :Miller,  M.D.,  Charlotte,  North  Carolhia 


DUE  to  constantly  improving  x-ray  technique 
and  clinical  studies,  some  orderly  under- 
standing of  low  back  pathology  is  emerg- 
ing in  spite  of  the  complexity  of  the  subject. 

It  appears  that  some  type  of  inherent,  congenital 
weakness  or  anomaly  in  the  osseous  structures  of 
the  lumbosacral  area  is  the  underlying  cause  of  a 
majority  of  low  back  derangements.  These  defects 
may  be  present  and  give  no  symptoms  nor  concern 
in  a  young  person  whose  muscles  are  in  good  tone 
and  whose  epiphyses  are  immature  or  have  recent- 
ly matured  but  may  contribute  to  disabilities 
found  principally  in  middle  or  later  life. 

During  recent  years,  evidently  due  to  our  great 
industrial  expansion  and  the  introduction  of  the 
automobile,  our  cases  of  back  injuries  and  com- 
plaints have  become  serious  clinical  and  medico- 
legal problems. 

Diagnosis  in  low  back  injuries  is  difficult  even 
under  the  most  favorable  conditions  and  this  diffi- 
culty has  led  in  many  instances  to  a  suspicion 
that  no  real  pathology  was  present  and  that  ma- 
lingering was  at  the  bottom  of  the  complaint. 
While  the  latter  is  probably  true  in  some  cases, 
such  a  conclusion  should  not  be  arrived  at  without 
careful  examination  and  the  elimination  of  all  pos- 
sible causative  factors  of  genuine  back  disorders. 
We  can  quite  easily  be  unfair  in  calling  a  patient 
a  malingerer  when  some  vague  low  back  pathology 
is  really  present. 

The  two  regions  most  often  affected  in  low  back 
injuries,  or  in  chronic  back  complaints  of  other 
kinds,  are  the  lumbosacral  and  sacroiliac  joints. 
Both  these  regions  may  be  the  seat  of  pathology, 
the  result  of  many  different  contributing  causes. 
There  is  no  positive  differentiation,  by  physical 
examination,  between  lumbosacral  anomalies  and 
so-called  sacroiliac  strain.  The  results  of  surgical 
treatment  indicate  that  when  there  is  no  definite 
sacroiliac  abnormality  visible  in  the  x-ray  film, 
the  lumbosacral  rather  than  the  sacroiliac  joints 
mu.t  be  suspected  as  the  source  of  symptoms. 

The  weight  of  the  trunk  with  its  upper  append- 
ages is  transmitted  to  the  pelvis  through  the  lumbo- 
sacral articulation  and  Goldthwaite  states  that  fully 
one-half  the  motions  of  the  trunk  below  the  lower 
dorsal  region  is  made  in  this  articulation.  We 
have,  then,  a  joint  which  must  combine  unusual 
strength   with   freedom  of   motion,   and   this   joint 


is  located  in  the  body  at  a  point  of  great  stress 
and  is  beset  by  many  anomalous  and  developmen- 
tal variations.  George,  of  Boston,  stated  that  35 
per  cent,  of  all  spines  examined  by  x-rays  in  his 
laboratory  for  any  purpose  showed  congenital  ab- 
normalities in  the  lumbosacral  region.  Our  prob- 
lem is  to  know  the  normal,  or  the  approximate  nor- 
mal, in  the  low  back  and  to  arrive  at  some  con- 
sistent clinical  and  x-ray  findings  in  studies  on 
patients  presenting  themselves  for  examination  be- 
cause of  complaints  in  this  area. 
Sacroiliac  Strains 

The  sacroiliac  joints  are  large,  fairly  stable  and 
very  well  secured  by  ligaments  and  muscles.  While 
occasionally  strained  or  sprained,  they  are  not  the 
source  of  so  much  pathology  as  the  neighboring 
lumbosacral  joint.  Certainly  many  sins  have  been 
committed  in  the  medico-legal  field  in  the  name  of 
the  sacroiliac  joint. 

Acute  sacroiliac  sprain,  like  all  low  back  sprain, 
can  be  best  handled  by  having  the  patient  confined 
to  bed  on  a  firm  mattress  until  symptoms  disap- 
pear. Local  heat,  massage  and  adhesive  strapping 
are  to  be  used  and  more  secure  fixation  if  indi- 
cated. 

Chronic  sacroiliac  sprains  with  referred  sciatica 
sometimes  respond  kindly  to  manipulation  under 
anesthesia  followed  by  a  period  of  local  heat,  mas- 
sage and  graduated  exercises. 

Intractable  sacroiliac  derangements  can  be  cured 
by  surgical  fusion  of  the  joint  involved. 

Lumbosacral  Strain  and  Assocmted  Anomalies 
The  normal  lumbosacral  area  is  difficult  to  de- 
fine. The  best  classification  of  the  area  is  made 
by  considering  it  as  mechanically  sound  or  un- 
sound, stable  or  unstable.  The  stability  of  the 
lumbosacral  area  depends  largely  on  the  lumbo- 
sacral arch  articulations.  The  most  stable  backs 
are  those  with  facets  such  as  are  described  by  an- 
atomists as  normal — those  called  by  Ferguson, 
roentgenologist  of  the  New  York  Orthopedic  Hos- 
pital, the  internal-external  type.  Normal  joints  are 
in  the  sagittal  plane  and  in  an  anteroposterior 
roentgenogram  they  are  well  defined.  One  seems 
to  be  looking  directly  into  them.  The  lumbosacral 
facets  vary  from  the  apparently  secure,  well-wedged 
normal  type  just  described  to  the  apparently  in- 
secure or  transverse  type.  Instability  of  the  spine 
may  be  contributed  to  by  the  presence  of  bilateral 


•Pre.'if-ntcd  t'l  the  Surgical  SeitiDii  of  the  .M.-dieul  .Society    ot    the    State    of   North    Carohna,    meetinR   at    Asheville, 


LOW  BACK  DISORDERS— Miller 


October,  1936 


-Asymmetrical  or  congenitally  insecure  facets  are  seen  in  many  films  taken  of  the  lumbo- 
sacral junction  and  contribute  to  low  back  strains  and  derangement. 


anteroposterior  facets  or  unilateral  facets — one 
normal  internal-external  and  one  anteroposterior. 
These  latter  are  considered  to  be  the  worst  type 
of  facets  as  any  undue  strain  must  put  disturbing 
stress  on  one  or  the  other  of  these  joints  since 
they  do  not  operate  in  the  same  plane.  Some  sig- 
nificance must  then  be  attached  to  the  finding  of 
abnormal  facets  between  the  lumbar  spine  and  the 
sacrum.  The  hope  of  maintaining  or  recovering 
muscular  compensation  in  the  presence  of  these 
anomalies  is  uncertain. 


Sacral  Inclin.4tion" 
An  unstable  lumbosacral  junction  may  be  found 
alone  or  associated  with  some  other  anomaly.  In 
some  cases  the  center  of  gravity,  as  calculated  to 
fall  along  a  line  through  the  center  of  the  3rd  lum- 
bar vertebra,  passes  anterior  to  the  sacrum,  some- 
times as  much  as  two  inches.  Just  in  proportion 
as  this  line  falls  anterior  to  the  sacrum  is  the  weight 
not  borne  b}'  superimposed  bone,  but  sustained  by 
muscles  and  ligaments,  and  this  is  conducive  to 
strain.     The  normal  adult  sacral  angle  has  been 


October,   1936 


LOW  BACK  DISORDERS— Miller 


a 


F.Jr  2. 


Fig.  II — Sacral  inclination  is  considered  within  the  normal  when  it  measures  to  be  within  28  to 
40°  from  the  horizontal.  In  a  thoroughly  competent  back  a  vertical  line  through  the 
centre  of  the  bodv  of  the  third  lumbar  vertebra  should  touch  the  sacrum. 


estimated  to  be  38  \  According  to  Ferguson,  when 
this  angle  is  42 "  the  stresses  are  a  menace,  and 
when  the  angle  is  above  SO'  the  stresses  are  severe. 
As  the  sacral  angle  increases,  the  stresses  at  the 
lumbosacral  joint  increase.  The  phenomenon  of 
an  increased  sacral  angle  is  rather  constant  in 
chronic  back  strain  and  some  interpretation  must 
be  placed  on  this  finding. 

Prkspondylolisthesis 
I'respondylglisthesis  is  a  defect  in  the  lamina 


at  or  near  its  junction  with  the  pedicle.  It  is  a 
failure  of  union  between  the  anterior  and  posterior 
elements  of  a  vertebra.  The  condition  is  fairly 
common.  It  is  not  always  attended  with  symptoms 
of  decompensation  but  is  a  potentiality  of  acute 
traumatic  instability  at  any  time.  Prespondylolis- 
thesis  is  usually  visible  in  a  lateral  x-ray  film;  it 
may  be  seen  in  an  anteroposterior  view,  but  it  is 
best  outlined  in  a  45°  view  of  the  lumbosacral 


LOW  BACK  DISORDERS—Milkr 


October,  1936 


tikl^ 


Fig.  Ill — Illustrating  pathological  sacral  inclination.  A  vertical  line  through  the  body  of  the  third 
lumbar  vertebra  will  fall  anterior  to  the  sacrum.  Both  phenomena  are  e\'idence  cf 
actual  or  potential  lumbosacral  strain. 


Spoxdvlolisthesis 
Spondylolisthesis  is  the  dislocation  forward  of 
a  lumbar  vertebra.  This  displacement  usually  fol- 
lows already  existing  prespondylolisthesis.  From 
any  ordinary  trauma  to  the  low  back,  the  body  of 
a  lumbar  vertebra  with  insecure  fastenings  to  its 
neural  arch  may  slide  forward  in  varying  degrees 
on  the  vertebra  below.  This  is  most  frequently 
observed  at  the  fifth  lumbar  vertebra.  Cases  of 
spondylolisthesis  have  been  obser\-ed  without  anv 


history  of  trauma. 

The  diagnosis  of  spondylolisthesis  is  best  made 
by  means  of  a  clear  lateral  .x-ray  film  of  the  lumbo- 
sacral area.  Clinically,  lumbar  lordosis  is  exagger- 
ated, there  is  prominence  of  the  spine  of  the  fifth 
lumbar  vertebra  and  a  depression  may  be  felt  just 
above  it.  When  spondylolisthesis  exists  the  back 
is  subject  to  continuous  strain  and  is  unfit  for 
heavy  duty  unless  the  spine  is  surgically  fused, 
thus  bridging  this  defect.     Belts  and  braces  may 


October.   1936 


LOW  BACK  DISORDERS— Miller 


S37 


/w-^^y 


fig.  IV — Prespondylolisthesis  if  usually  found  as  a  congenital  condition,  though  it  may  result  from 
trauma.    Such  a  defective  vertebra  may  easily  dislocate  forward  on  the  one  below. 


be  used  as  protecting  supports   but  they  are  not 
curative. 

Transition' .\L  X'ertebra 
One  of  the  common  anomalies  is  the  transitional 
vertebra.  It  partakes  of  the  characteristics  of  a 
lumbar  and  sacral  vertebra  and  is  sometimes  termed 
the  sixth  lumbar  or  the  first  sacral.  The  transi- 
tional formation  may  be  present  on  one  or  both 
sides  in  any  degree  from  slight  enlargement  of  the 
transverse  process  to  pseudarthrosis  or  fusion  of 
the  transverse  process  to  the  sacral  wing.  When 
this  anomaly  is  symptomatic,  radiation  of  pain  may 


be  bilateral  or  unilateral.  Pain  may  occur  on  the 
side  of  or  opposite  to  the  anomaly,  if  the  anomaly 
is  unilateral.  This  usually  means  that  variations 
in  the  lumbosacral  facets  are  a  part  of  the  picture 
of  instability  and  play  a  part  in  the  symptom  syn- 
drome. If  the  pseudarthrosis  develops  into  a 
chronic  traumatic  arthritis,  the  false  joint  should 
either  be  resected  or  the  entire  lumbosacral  junction 
fused.  An  x-ray  taken  at  a  45°  angle  will  demon- 
strate whether  or  not  a  transverse  process  contacts 
laterally.  A  flat  anteroposterior  view  is  not  truly 
diagnostic  in  this  respect,  as  the  parts  may  overlie 


538 


LOW  BACK  DISORDERS— Miller 


October,   1936 


Fig.  V — Illustrating  a  case  of  spondylolisthesis  where  the  fifth  lumbar  is  displaced  sharply  forward 
on  the  sacrum.  A  fusion  operation  has  been  done  to  strengthen  the  spine  at  site  of 
defect. 


instead  of  impinge. 

Impinging  Spinous  Processes 
One  will  occasionally  see  impinging  spinous  proc- 
esses give  rise  to  pain.  In  such  cases  there  develops 
a  bursal  mass  of  fibrous  tissues  between  the  pos- 
terior tips  of  the  spines.  Chronic  irritation  and 
contusion  gradually  develop  and  varying  degrees 
of  disturbance  and  pain  follow.  I  have  seen  a 
number  of  these  cases  and  have  operated  on  four 
with  complete  relief  of  symptoms.     The  operation 


is  free  resection  of  contacting  points  between  the 
adjacent  spines. 

Posterior  Displacement 
Posterior  displacement  of  the  fifth  lumbar  ver- 
tebra on  the  sacrum  sometimes  occurs.  On  hyper- 
extension  of  the  spine  in  the  presence  of  undue 
mobility  of  the  fifth  lumbar  vertebra  the  body 
rides  backward,  and  on  flexion,  instead  of  gliding 
forward  again,  it  may  merely  tilt  on  the  posterior 
margin  of  the  sacrum.    The  diagnosis  can  be  made 


October,   IP36 


LOW  BACK  DISORDERS— Miller 


S39 


\ 


fyj.-  ^ 


Fig.  VI — A  transitional  vertebra,   partaking   of   the   characteristics  of  both   a   lumbar  and   sacral 
segment,  is  occasionally  the  source  of  low  back  pain  {see  text). 


only  by  absolutely  accufate  lateral  x-ray  filins. 
Some  students  consider  posterior  displacement  of 
the  fifth  lumbar  vertebra  one  of  the  commonest 
of  the  significant  lumbosacral  anomalies  and  one 
very  often  associated  with  symptoms.  The  back- 
ward displacement  of  the  fifth  lumbar  vertebra 
may  be  reduced  by  hyperextension  followed  by 
gradual  flexion  of  the  spine  while  traction  is  ex- 
erted on  the  pelvis.  However,  only  surgical  fusion 
of  the  area  will  control  this  condition  after  it  be- 
comes a  chronic  disturbance  since  the  faulty  me- 
chanics allowing  undue  motion  of  the  fifth  lumbar 
vertebra  still  exists. 

Spina  Bifida  Occulta 
Spina  bifida  occulta  is  observed  at  intervals  in 
x-ray  examination  of  the  low  spine.  It  is  not 
thought  to  have  much  significance  as  compared 
with  other  anomalies  mentioned  where  definite 
weight-bearing  occurs.  In  spina  bifida  occulta 
there  is  absence  of  bone  along  the  neural  arch 
where  ordinarily  some  supporting  spinal  ligaments 


are  attached   and  hence  some  weakness  exists  at 

the  site,  but  it  is  not  the  usual  source  of  backache. 

Fractures 

Fractures  of  transverse  processes  in  the  lumbar 
spine  are  rather  common  in  back  injuries.  One 
may  see  an  isolated  crack  or  a  series  of  processes 
fractured  and  sharply  detached.  Definite  diagno- 
sis can  be  made  from  well  taken  x-ray  pictures. 
These  fractures  are  often  missed  in  poorly  taken 
pictures  without  sufficient  contrast  between  the 
verse  process  of  the  fifth  lumbar  vertebra.  One  must 
be  on  the  alert  for  it  in  the  examination  of  any 
and  the  congenital  anomaly  or  failure  of  fusion  of 
the  transverse  process  to  the  body.  Light,  snug- 
fitting  body  plaster  jackets  make  the  best  dressing 
for  these  injuries.  They  will  heal  in  a  few  weeks 
by  osseous  or  fibrous  union  and  permanent  dis- 
ability rarely  follows. 

A  more  disabling  injury  is  fracture  of  the  trans- 
verse process  of  the  fifth  lumbar  vertebra.  One 
must  be  on  the  alert  for  it  in  examination  of  any 


S40 


LOW  BACK  DISORDERS— Miller 


October,  1936 


Fig.  VII — Where  insecure  facets  exist  between  the  last  lumbar  vertebra  and  the  sacrum,  the  lum- 
bar spine  may  displace  backward  on  the  sacrum.  This  is  sometimes  attended  by  a 
snapping  experience  and  is  followed  by  low  back  pain  and  sciatica.  Nerve  roots  mnay 
be  pinched  in  the  displacement. 


traumatized  back.  To  this  process  are  attached 
masses  of  stabilizing  ligaments  tying  the  fifth  lum- 
bar vertebra  to  the  sacruin,  wing  of  the  ilium  and 
the  spine  above.  The  intervertebral  foramina  be- 
tween the  fifth  lumbar  vertebra  and  the  sacrum  are 
adjacent,  the  sacral  plexus  passes  anteriorly  and 
much  displacement  of  the  fracture  fragments  is 
reflected  in  neurological  symptoms. 

Cases  where   fracture   of  the   transverse  process 
of  the  fifth  lumbar  vertebra  occurs  should  be  im- 


mobilized in  snug-fitting  plaster  spicas  and  pro- 
tection continued  with  the  patient  in  recumbency 
for  from  eight  to  ten  weeks  at  least.  Any  com- 
promise with  complete  fixation  here  allows  motion 
at  the  site  of  injury,  contributes  to  poor  union  of 
the  fracture,  local  reaction  with  chronic  irritation 
and  weakness,  sciatica  and  a  long  period  of  dis- 
ability. When  the  patient  is  allowed  to  get  up, 
protection  with  a  strong  belt  should  be  continued 
for  several  months. 


Ortober,   1936 


LOW  BACK  DISORDERS— Miller 


541 


URE     OF 
EDICLE    AT 

FACET. 


/=/>    ^ 


f;i,'.  VIII — In  lew  br.ck  injrrics  Hnc  "cracli"  fractures  comelimes  occur  tliroii-,'li  the  laminae  and 
pedicle;.     Tlu^e  friictures  may  involve  the  joints  and  cause  chronic  back  distress. 


Fractures  in  the  low  back  occurring  frequently 
rnd  of  uns.xplainable  chronicity,  are  ths  finj  cracks 
llirougli  articular  facets,  through  th;  pedicles  and 
lam'nae,  particularly  of  the  fifth  lumbar  vertebra. 
This  is  an  important  reason  why  alertness  should 
be  emphasized  in  examinations  of  acute  low  back 
sprains.  To  locate  these  fractures  the  best  of  x-ray 
detail  is  required  and  often  the  use  of  stereoscopic 
films.  Finding  these  isolated  fractures,  the  patient 
should  be  hospitalized  and  his  back  immobilized  in 
a  snug-fitting  spica  jacket.  This  protection  should 
be  continued  in  the  same  spirit  with  which  one 
would  treat  a  fractured  femur.  To  strap  such  a 
back  and  let  the  patient  go  along  starts  the  first 
stage  of  chronic  and  intractable  back  complaint 
which  may  never  be  relieved,  or  if  relieved  only 
at  the  exfiense  of  later  surgical  fusion. 
Fusion  Operations 

Lumbosacral   and   sacroiliac    fusion    operations 


are  rather  exacting  surgical  procedures  an:l  th~ 
paiient  snould  be  made  to  appreciate  this  fact  be- 
fore such  surgery  is  undertaken.  When  a  diagnosis 
is  made,  which  in  the  surgeon's  opinion  may  be 
leading  up  to  proposed  surgical  fusion  of  joints 
in  the  low  back,  it  is  well  to  try  various  so-called 
conservative  measures  in  treatment  before  asking 
the  subject  to  submit  to  operation.  Under  con- 
servative management  certain  unexplainable  recov- 
ery may  ensue,  giving  the  patient  relief,  thereby 
permitting  him  to  forego  the  ordeal  of  a  major 
operation. 

If,  on  the  other  hand,  after  a  reasonable  period 
of  protection  of  a  painful  low  back  by  means  of 
jackets,  braces,  etc.,  no  reasonable  relief  has  been 
experienced  and  all  x-ray  and  clinical  evidence 
continues  to  point  to  a  defect  ordinarily  amenable 
to  operation,  then  operation  should  be  resorted  to 
in  spite  of  its  exactions  and  the  six-  to  twelve- 


LOW   BACK  DISORDERS— Miller 


October,   1036 


months  convalescence. 

The  series  of  cases  in  which  I  have  done  lumbo- 
sacral or  sacroiliac  fusions  is  reported  as  my  ex- 
perience with  this  surgery.  In  the  light  of  results 
to  date  my  feeling  is  that  we  have  been  somewhat 
too  conservative  toward  offering  these  fusion  oper- 
ations. 

There  is,  however,  the  feeling  in  certain  quar- 
ters that,  in  some  parts  of  the  country,  this  surgery 
has  been  too  freely  resorted  to.  Most  of  the  large 
insurance  companies,  and  industrial  commissions 
in  some  states  have  concluded  that  poor  and  costly 
surgical  results  have  been  rather  commonly  seen 
after  low  back  operations. 

In  spite  of  this  it  is  well  known,  and  well  taught 
in  some  centers,  that  surgical  fusion  is  indicated  in 
the  presence  of  certain  definitely  demonstrated  low 
back  pathology,  and  we  must  assume  that  any  dis- 
favor with  which  the  operative  work  is  viewed  re- 
sults from  doing  the  surgery  where  it  was  not  indi- 
cated or  employing  poor  technique,  or  from  both. 

I  do  know  we  have  patients  in  private  practice 
benefiting  greatly  from  surgery  on  the  low  back. 
They  experience  the  discomfort  and  inconvenience 
necessarily  attending  it,  pay  the  cost,  and  evaluate 
it  fairly.  They  have  no  financial  or  psychological 
reason  to  do  otherwise.  If,  then,  we  see  the  same 
pathology  in  compensation  cases,  do  the  same 
operation  for  its  relief  and  carry  out  similar  con- 
valescent care,  we  should  expect  proportionately 
the  same  end-results.  In  our  surgical  work  we 
must  interpret  for  insurance  companies  the  clinical 
results,  since  they  pay  for  much  of  it  under  com- 
pensation laws,  and  recommend  it  in  cases  where 
it  seems  indicated.  We  must  interpret  to  industrial 
commissioners  our  end-results,  realizing  that  every 
case  is  a  law  unto  itself,  but  at  the  same  time  rec- 
ognizing that  all  things  being  tentatively  equal  the 
surgeon  should  expect  the  same  end-results  in  a 
given  case  whether  done  with  or  without  benefit  of 
compensation.  Our  best  yardstick  then  for  rating 
disability  after  operations  in  cases  of  low  back 
injuries  is  our  conclusion  arrived  at  on  cases  han- 
dled in  private  practice  rather  than  under  compen- 
sation where  some  psychological  influences,  it 
seems,  must  be  reckoned  with. 

No  attempt  has  been  made  here  to  outline  the 
details  of  the  technique  in  the  fusion  operation.  It 
has  been  my  e.xperience  that  these  patients  need 
eight  to  ten  weeks  in  recumbency  following  oper- 
ation and  are  best  splinted  by  means  of  plaster 
spica  jackets.  The  low  back  should  be  protected 
by  a  jacket  when  the  patient  becomes  ambulatory 
and  this  will  ordinarily  be  worn  for  four  to  six 
months,  after  which  a  snug-fitting  belt  should  give 
ample  protection.  The  patients  do  not  seem  to 
e.xperience  maximum  benefit   from  operation  until 


a  year  to  a  year-and-a-half  afterward.  By  this 
time  strong  bony  consolidation  should  have  taken 
place,  if  the  fusion  has  been  complete,  and  com- 
pensation for  the  original  defect  with  a  stronger, 
more  serviceable  back  will  have  resulted. 

Analysis  of  Cases 
Patients  having  operation  between  1928-1935: 

Males  ' 

Females  !■♦ 

Total   — 2 1 


■  of  patients: 

Youngest  

Oldest    

Average  

gnoses: 

Chronic  lumbosacral  strain  

Spondylolisthesis  _ 

Prespondylolisthesis  with  back  strain  

Unstable  5th  lumbar  with  associated  fractures- 
Sacroiliac    derangement    


Total   

Chiej  symptoms: 

Chronic  low  back  pain  — 

Pain  in  low  back  and  sciatica 


Total    — -. 

Type  of  operation: 

Lumbosacral   fusion 
Sacroiliac  fusion  


14 

7 


Total 


21 


Results: 

Able   to    carry   on   former   occupation   with   com- 
fort   __ 14 

Decidedly  improved  7 


Total 


21 


Conclusion:  Pain,  instability  and  disability  at 
the  lumbosacral  junction  not  relieved  by  conserv- 
ative treatment,  such  as  a  period  of  rest  in  bed 
on  a  firm  mattress  followed  by  protecting  jackets 
and  physiotherapy  or,  if  relieved  by  these  measures, 
found  to  recur  on  minor  provocation,  should  have 
an  operation  for  lumbosacral  fusion. 

Bibliography 

Dickson,  F.  D.:  Low  back  injuries  with  particular  ref- 
erence to  the  part  played  by  congenital  abnormalities. 
Okla.  State  Med.  Jour.,  1932,  25:415. 

Ferguson,  A.  B.:  The  clinical  and  roentgenographic  in- 
terpretation of  lumbosacral  anomalies.  Radiology,  1934,  22: 
54S. 


Vital  Statistics  and  Sickness  Insurance 
(ivied.    Econ.   Dept.  of  Jl.  A.   M.   A.,  Aug.   15th) 

Only  one  South  American  country,  Chile,  has  a  system 
of  compulsory  sickness  insurance.  This  country  had  a 
death  rate  of  26.8  in  1934  as  compared  with  11.8  in  Argen- 
tina and  of  10  in  Uruguay,  in  neither  of  which  countries  is 
there  an  insurance  system. 

In  Santiago,  Chile,  with  a  system  of  compulsory  insur- 
ance there  were  244  deaths  per  thousand  of  infants  under 
1  year.  Buenos  Aires  in  Argentina,  with  no  insurance,  had 
63. 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


S43 


DEPARTMENTS 


INTERNAL  MEDICINE 

Paul  H.  Ringer,  A.B.,  M.D.,  F.A.C.P.,  Editor 
Asheville,  N.  C. 


Pernicious  Anemia 

There  are  probably  no  two  diseases  the  treat- 
ment of  which  has  been  more  revolutionized  in  the 
last  decade  than  diabetes  and  pernicious  anemia. 
The  introduction  of  insulin  initiated  a  new  era  for 
the  diabetic,  and  the  discovery  of  the  potent  frac- 
tion of  liver  did  the  same  for  the  individual  suffer- 
ing from  p>ernicious  anemia,  the  treatment  of  which 
prior  to  that  time  had  been  most  unsatisfactory. 

Dr.  Cyrus  C.  Sturgis,  Professor  of  Medicine  at 
.\nn  Arbor,  Michigan,  has  an  interesting  summary 
in  the  September  number  of  Annals  oj  Internal 
Medicine,  entitled:  "The  Present  Status  of  Per- 
nicious Anemia;  Experience  with  600  Cases  Over 
Eight  Years."  Dr.  Sturgis  says  it  is  not  his  pur- 
pose to  present  new  and  detailed  data  but  to  give 
a  number  of  conclusions  dealing  with  some  aspects 
of  the  etiology,  diagnosis,  prognosis  and  treatment 
of  the  disease. 

W.  B.  Castle  and  his  collaborators  have  estab- 
lished definitely  that  "the  cause  of  the  anemia  is  a 
lack,  or  diminished  amount,  of  an  unidentified, 
enzyme-like  substance,  which  is  secreted  by  the 
mucosa  of  the  stomach.  This  has  been  called  the 
intrinsic  factor  which  functions  normally  to  control 
the  rate  of  red  blood  cell  production  in  the  bone 
marrow."  With  a  decrease  in  this  substance  the 
rate  of  blood  production  lessens  and  anemia  ensues. 

Dr.  Sturgis'  paper  does  not  pretend  to  deal  par- 
ticularly with  the  diagnosis  of  pernicious  anemia, 
but  he  emphasizes  the  fact  that  in  not  one  of  his 
600  cases  was  free  hydrochloric  acid  present  in  the 
gastric  secretion.  He  concludes:  "An  achlorhy- 
dria,  therefore,  is  essential  to  the  diagnosis  of  true 
.'\ddisonian  anemia,  and  the  presence  of  this  acid 
in  the  gastric  secretion  practically  eliminates  it 
from  consideration  as  a  diagnostic  possibility." 

Dr.  Sturgis  also  emphasizes  the  fact  that  an  im- 
portant diagnostic  point  in  addition  to  the  usual 
symptoms  of  any  anemia  is  numbness  and  tingling 
of  the  hands  and  feet.  This  may  be  the  initial 
symptom  of  pernicious  anemia;  but  if  it  is  not,  it 
occurs  at  some  time  during  the  course  of  the  dis- 
ease in  90  per  cent,  of  the  patients.  Recurrent 
glossitis,  long  recognized  as  a  symptom  of  perni- 
cious anemia,  occurred  in  two-thirds  of  Dr.  Sturgis' 
patients.  Evaluation  of  the  various  methods  of 
treatment  is  the  heart  of  Dr.  Sturgis'  paper.  He 
says: 


"A  sufficient  period  has  now  elapsed  to  permit  a  state- 
ment concerning  the  efficacy  of  various  types  of  treatment. 
The  different  therapeutic  agents  which  have  been  used  are 
raw  or  cooked  liver,  liver  extract  and  Ventrlculln  and  liver 
and  stomach  combinations  for  oral  use,  and  liver  extract 
for  Intramuscular  or  Intravenous  injections.  From  our 
experience,  It  can  be  said  that  any  one  of  these  forms  of 
treatment  can  usually  control  the  anemia  of  pernicious 
anemia  if  sufficient  quantities  are  given.  It  is  our  opinion, 
however,  after  giving  thousands  of  treatments  over  a  period 
of  several  years,  that  the  ideal  form  of  therapy  is  the 
intramuscular  Injection  of  liver  extract.  It  has  the  follow- 
ing advantages: 

1.  Gram  per  gram  of  liver,  it  is  many  times  more  ef- 
fective parenterally  than  It  is  by  mouth.  *  *  * 

2.  Local  or  general  reactions  have  not  been  observed 
following  its  use.  When  liver  extract  is  given  intravenously 
it  is  highly  effective,  but  following  about  10  per  cent,  of 
the  Injections  there  is  a  disagreeable  reaction  characterized 
by  a  chill,  fever,  and  often  nausea  and  vomiting.  This 
type  of  reaction  is  not  seen  following  intramuscular  injec- 
tions. *  *  * 

3.  Another  advantage  is  that  the  intramuscular  injection 
eliminates  all  problems  of  utilization  of  the  product  through 
incomplete  absorption  from  the  gastrointestinal  tract  and 
also  that  of  inadequate  storage  in  the  body.  *  *  * 

4.  The  treatment  by  intramuscular  injection  is  regarded 
by  most  of  our  patients  as  the  most  convenient  form  of 
therapy  as  the  blood  may  be  maintained  at  a  normal  level 
by  one  injection  weekly  and  ordinarily  no  other  medication 
is  required." 

Dr.  Sturgis  brings  up  the  question  as  to  what 
should  be  the  ideal  dosage  of  intramuscular  liver 
extract.  This  question,  of  course,  cannot  be  an- 
swered categorically  because,  pernicious  anemia  be- 
ing looked  upon  as  a  deficiency  disease,  the  defi- 
ciency will  not  be  equal  in  every  case.  Further- 
more, the  various  liver  extracts  on  the  market  vary 
enormously  in  the  amount  of  active  principles  con- 
tained. For  example,  one  manufacturer  states  that 
1  c.c.  is  derived  from  100  c.c.  of  liver,  whereas  an- 
other states  that  2  c.c.  are  derived  from  10  grams 
of  liver.  Dr.  Sturgis  advises:  "(1)  Give  a  variety 
of  liver  extract  which  is  clinically  tested,  (2)  use 
the  dose  advised  by  the  manufacturer,  (3)  control 
the  dosage  by  making  frequent  red  blood  cell 
counts." 

The  last  admonition  is  exceedingly  important, 
for  it  really  shows  the  results  of  treatment,  the 
object  of  which  is  to  keep  the  red  blood  cells  be- 
tween 4,000,000  and  5,000,000  per  cu.  mm. 

In  answer  to  the  question  whether  it  is  possible 
to  maintain  the  blood  of  a  patient  with  pernicious 
anemia  within  normal  limits  indefinitely  and  the 
individual  be  kept  in  good  health  so  that  he  can 
live  out  his  normal  span  of  life,  Dr.  Sturgis  feels 
that  he  probably  can — provided:  (1)  extensive 
cord  lesions  are  not  present  when  treatment  is  be- 
gun; (2)  an  adequate  amount  of  potent  anti-per- 
nicious material  is  given,  which  requires  the  closest 
cooperation  between  physician  and  patient,  because 
the  patient  must  appreciate  that  the  treatment  sim- 


SOUTHERN  MEDICINE  AND  SURGERY 


October,   1936 


ply  controls  the  disease  and  does  not  eliminate  its 
cause.  The  physician,  on  the  other  hand,  must 
realize  that  the  patient  must  remain  under  his  ob- 
servation more  or  less  continuously  for  an  indefinite 
period. 

Dr.  Sturgis  feels  that  perhaps  the  most  important 
therapeutic  problem  in  the  field  of  pernicious  ane- 
mia is  the  management  of  the  spinal  cord  changes. 
He  says: 

"It  is  well  recognized  that  the  pathologic  changes  in  the 
central  nervous  system,  which  occur  as  a  complication  in 
a  fair  proportion  of  patients  with  pernicious  anemia,  con- 
sist of  actual  degeneration  of  nerve  fibers  in  the  posterior 
and  lateral  columns  of  the  cord  which  results  in  an  ataxia 
with  var>'ing  degrees  of  spastic  paraplegia.  As  the  process 
develops,  there  is  a  loss  of  control  of  the  sphincter  of  the 
bladder  with  retention  of  urine,  a  resultant  cystitis,  and, 
if  the  condition  progresses,  an  ascending  pyelitis,  with  ab- 
scesses of  the  kidney,  septicemia,  bronchopneumonia  and 
death.  While  anti-pernicious  anemia  therapy  produces 
striking  effects  as  far  as  the  blood  is  concerned,  the  results 
attained  in  treating  the  central  nen-ous  system  lesions  are 
controversial.  It  has  been  our  experience  that  there  is 
often  striking  subjective  improvement  but  that  objective 
evidences  of  this  occur  in  only  a  small  percentage  of  the 
patients.  On  the  other  hand,  patients  have  been  observed 
who  have  made  an  unbelievable  recover,-.  One  woman 
of  61,  with  red  blood  cell  count  of  1,000,000  per  cu.  mm., 
who  was  confined  to  bed  with  a  well  advanced  combined 
degeneration  of  the  cord,  intense  infection  of  the  urinary 
tract,  extensive  decubitus  ulcers,  and  incontinence  of  urine 
and  feces,  is  now  able  to  walk  unassisted  and  does  all  of 
her  own  housework  including  the  family  washing.  This 
improvement  has  been  maintained  over  a  period  of  four 
years. 

The  question  has  been  asked,  whether,  if  a  patient  with 
pernicious  anemia  who  has  no  evidence  of  cord  changes 
is  treated  in  such  a  manner  that  the  blood  is  maintained 
at  a  high  normal  for  an  indefinite  period,  cord  changes 
are  likely  to  develop.  The  opinion  of  most  observers  is  that 
this  is  unlikely,  although  it  must  be  admitted  that  this 
question  must  remain  unanswered  until  sufficient  time  has 
elapsed  to  give  the  facts  for  a  statement  which  is  based  on 
observation  over  a  long  period  of  years.  In  our  group  of 
patients  this  has  not  occurred  in  a  single  patient  during  a 
period  of  eight  years. 

The  present  treatment  of  the  cord  changes,  in  addition 
to  the  management  of  the  urinary  infection  and  decubitus 
ulcers  which  may  be  present,  is  not  complicated.  It  con- 
sists (1)  in  administering  treatment  which  will  cause  the 
blood  to  return  to  a  high  level  of  normal  and  maintaining 
it  there  indefinitely.  (2)  Physiotherapy,  which  consists 
mainly  in  active  motion  produced  by  the  patient's  attempts 
to  walk  when  supported  by  attendants.  (3)  Re-education 
in  co-ordination  of  the  muscles  of  the  legs,  and  teaching 
the  patient  to  use  his  eyes  in  guiding  his  walking  attempts, 
as  the  sense  of  motion  and  position  of  his  legs  is,  of  course, 
usually  destroyed  by  the  lesions  in  the  posterior  columns 
of  the  cord." 

During  the  period  of  eight  years,  slightly  over 
10  per  cent,  of  Dr.  Sturgis'  600  patients  died  and 
approximately  one-half  of  these  succumbed  to  com- 
plications associated  with  lesions  of  the  central 
nervous  system.  However,  almost  all  of  this  group 
either  had  advanced  cord  lesions  when  they  were 


first  observed  or  failed  to  carry  out  the  treatment 
as  directed.  Furthermore,  many  of  them  were 
treated  before  the  parenteral  method  of  administer- 
ing liver  was  available. 

"The  remaining  one-half  of  the  fatal  cases  died  of  a 
variety  of  diseases  which  are  not  uncommon  causes  of 
death  in  this  age  group  and  the  fatal  conditions  can  only 
be  regarded  as  having  a  coincidental  association  with  per- 
nicious anemia.  The  most  common  causes  of  death  in  this 
group  were  cardiac  disease,  hypertension  and  apople.xy, 
operations  and  accidents,  pneumonia  and  malignancy.  It  is 
interesting  to  note  that  apparently  none  of  these  patients 
died  of  anc'mia  per  se,  as  their  red  blood  cell  counts  were 
not  reduced  to  a  seriously  low  level  when  they  were  last 
observed." 

Dr.  Sturgis'  pap>er  is  interesting,  well  boiled  down 
and  gives  to  the  man  who  sees  but  an  occasional 
case  of  pernicious  anemia  a  panoramic  view  of  the 
situation  and  very  definite  ideas  as  to  how  the 
condition  should  be  treated.  This  paper,  from  the 
pen  of  one  whose  position  has  given  him  unusual 
opportunities  for  vast  e.xperience  and  whose  ability 
iias  well  qualified  him  for  making  valuable  clinical 
observations  and  deductions,  is  one  of  the  most 
valuable  typ>es  of  publication  that  we  medical  men 
are  priviliged  to  read. 


-S.    M.    &    S.- 


SURGERY 

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


The  Use  and  the  Abuse  of  the  Abdominal 
Retr.^ctor 

The  abdominal  cavity  is  filled  with  viscera  so 
that  in  it  metal  retractors  are  necessary  to  prop- 
erly expose  the  operative  field  through  the  incision. 
That  they  are  useful  is  freely  admitted,  that  they 
may  be  greatly  abused  is  not  generally  appreci- 
ated. Because  of  its  tactile  sense  and  softness 
were  it  of  proper  shape  to  give  exposure  without 
obstructing  the  surgeon's  view  the  gloved  human 
hand  would  be  the  ideal  retractor. 

Retractors  are  made  of  steel  for  they  must  have 
maximum  strength  with  minimum  mass,  they  must 
occupy  minimum  space  to  give  maximum  exposure. 
Although  boilable  and  easily  sterilized,  a  steel  re- 
tractor is  hard  and  unyielding.  It  may  cause  dam- 
age to  the  viscera  or  to  the  tissues  of  the  abdom^jj 
inal  wall  when  pressure  from  it  is  too  great  or  to# 
prolonged.  ■ 

Hand  retractors  are  made  angulated  so  that  re- 
traction of  the  viscera  is  made  by  the  blade,  of 
varying  size  and  shape,  which  is  controlled  by  a 
handle  outside  the  wound.  The  assistant  or  nurse 
who  holds  the  retractor  little  appreciates  the  in- 
creased pressure  that  is  made  upon  the  viscera  by  ■ 
the  blade  through  leverage  from  the  handle.  That 
irreparable  damage  may  result  from  it  is  proved 
by  an  experience  of  the  writer  who,  by  fortunate 


October.   1P36 


SOUTHERN  MEDICINE  AND  SURGERY 


chance,  found  and  successfully  sutured  a  hole  in 
the  terminal  ileum  resulting  from  a  loop  of  the  gut 
having  been  caught  between  the  blade  of  the  re- 
tractor and  the  crest  of  the  ilium.  Were  the  pa- 
tient not  held  by  leather  wristlets  and  a  belt  around 
the  table  his  body  might  be  moved  on  the  table 
by  the  pull  thoughtlessly  exerted  by  a  strong-armed 
assistant  through  the  retractor.  When  in  difficult 
cases  two  hand  retractors  are  used  on  the  same 
side  of  the  wound  care  must  be  taken  that  the 
intestine  be  not  pinched  between  the  two  blades. 

The  self-retaining  retractor  is  made  so  that  when 
adjusted  in  the  wound  continuous  retraction  may 
be  indefinitely  maintained  by  a  set-screw.  Its  use 
automatically  frees  an  assistant's  hand  on  each  side 
for  other  work.  To  offset  this  it  has  the  disad- 
vantage of  not  being  as  flexible  as  the  hand  re- 
tractor in  adjustment  to  meet  the  frequently  vary- 
ing needs  at  operation.  Injury  to  tissue  depends 
upon  both  the  degree  and  the  duration  of  retrac- 
tion. Although  the  surgeon  is  sure  that  when  set 
the  retractor  will  not  vary  he  forgets  that  the  con- 
stant prolonged  force  exerted  by  it  on  the  tissue 
may  itself  be  harmful. 

No  matter  which  type  of  retractor  is  used  the 
surgeon  should  supervise  its  placing  and  its  adjust- 
ment. Whenever  possible  the  intestines  and  the  vis- 
cera should  be  packed  out  of  the  operative  field  by 
warm  moist  pads  before  retraction  is  made.  When 
possible  the  viscera  to  be  retracted  should  be  pro- 
tected with  pads  so  that  the  retractor  blades  do  not 
come  into  direct  contact  with  them.  A  retractor 
should  be  used  only  with  sufficient  force  to  give 
adequate  exposure.  W'hen  the  need  for  exposure 
has  passed,  forcible  retraction  should  stop.  Due 
care  must  be  taken  that  the  intestine  be  not  pinch- 
ed between  the  retractor  blade  and  the  bony  pel- 
vis. 

Gentleness  in  handling  tissue  is  a  fine  art  which 
is  richly  rewarded  by  smoothness  and  sureness  of 
convalescence.  When  paralytic  ileus  follows  a  clean 
laparotomy  it  is  most  often  from  visceral  trauma. 
Crippling  adhesions  after  clean  laparotomy  are  also 
from  trauma.  Rough  retraction  is  a  common  cause 
of  trauma  preventable  by  the  exercise  of  a  little 
care.  The  kind  of  work  the  surgeon  has  done  in 
the  abdomen  is  often  graphically  shown  at  subse- 
quent laparotomy.  After  the  master  there  is  an 
absence  or  a  minimum  of  adhesions;  after  the  tyro 
the  viscera  are  often  so  fixed  by  scarring  that  in 
spite  of  all  treatment  the  patient  is  permanently 
invalided. 


CLINICAL  PSYCHIATRY 


Attitudes  Toward  Psychiatry 
Claude  A.  Boseman,  M.D.,  Editor,  Pinebluff,  N.  C. 
In  beginning  a  department  in  this  Journal  de- 
voted to  Clinical  Psychiatry  I  deem  it  fitting  and 
proper  first  to  pay  my  respects  to  that  other  editor 
of  a  department,  that  brilliant  psychiatrist.  Dr. 
James  K.  Hall  of  Richmond.  As  a  psychiatrist,  a 
thinker,  and  an  author  Dr.  Hall  has  few  peers. 
For  years  he  has  been  as  a  voice  crying  in  the 
wilderness  in  behalf  of  the  mentally  sick  in  Vir- 
ginia and  the  Carolinas — indeed  the  whole  South — 
and  the  effect  of  his  courageous  leadership  is  ines- 
timable. His  work  and  his  writing  in  behalf  of 
that  most  neglected  class  of  pathological  humanity 
was  pioneering  in  these  states,  far-reaching  in  ef- 
fect and  endless  in  result.  These  things  are  well 
known  to  all  readers  of  this  Journal.  It  is  of  the 
man  that  I  would  speak  at  this  time.  He  is  not 
only  a  great  psychiatrist  but  a  loving,  helpful  friend 
to  his  patients.  He  is  not  only  a  brilliant  intellect 
but  a  kindly  advisor  to  any  in  need.  He 
is  not  only  a  leader  but  a  stimulator  of  leadership. 
His  work  in  psychiatry  will  live  on  and  increase 
in  usefulness  but  his  chief  monument  is  in  the 
hearts  of  his  friends.  And  so  aware  of  my  own 
limitations,  in  humility  because  of  my  lesser  ex- 
perience, and  in  deep  admiration  of  a  great  teacher 
and  a  beloved  friend,  I  begin  this  department  on 
Clinical  Psychiatry  with  this  expression  of  appre- 
ciation and  esteem  for  Dr.  Hall. 


It  is  reported  that  Public  Service  Commission  of  N.  Y. 
State  has  ruled  that  residence  telephone  rates  apply  to 
doctors  office  phones  of  doctors  whose  offices  are  in  their 
residences.  This  may  well  be  worth  consideration  in  other 
States. 


One  of  the  important  aspects,  if  not  the  most 
important  aspect,  in  approaching  any  field  of  learn- 
ing or  any  line  of  work  is  the  attitude  with  which 
one  approaches  it.  If  a  man  goes  out  to  dig  a 
ditch  feeling  that  this  work  is  unsuited  to  him, 
that  it  is  beneath  his  dignity  or  above  his  ability, 
one  can  be  very  sure  that  he  will  dig  a  very  poor 
ditch.  If  a  man  goes  to  an  opera  feeling  that  his 
clothes  are  uncomfortable,  that  he  is  going  merely 
because  it  is  considered  proper  and  that  he  will  not 
enjoy  it,  it  is  very  certain  that  the  most  dramatic 
of  Wagnerian  performances  will  hold  little  of 
beauty,  or  drama,  or  musical  appeal  for  him.  The 
attitude  of  approach  has  much  to  do  with  the  out- 
come. And  so  it  is  as  the  general  practitioner  of 
medicine  approaches  a  psychiatric  illness.  If  his 
attitude  is  one  of  an  open  mind,  of  a  friendly  in- 
terest and  a  willingness  to  learn  and  to  help,  he 
will  likely  achieve  much.  Too  often  this  is  not  the 
case.  Many  doctors  view  psychiatry,  psychiatrists 
and  the  psychiatric  patient  askance,  with  slight 
disdain,  if  not  with  actual  hostility. 

Nervous  patients  or  the  mentally  sick  are  gen- 
erally objects  of  amusement,  or  fear,  to  the  general 


546 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


public,  and  the  doctor  too  often  falls  in  line.  We 
laugh  at  the  mentally  ill  or  we  feel  afraid  of  them. 
We  do  not  laugh,  however,  at  the  deformities  of  a 
paralytic,  or  feel  afraid  of  the  pneumonia  patient 
raving  in  a  wild  delirium.  However,  both  types 
are  sick  people.  Too  often  the  mentally  sick  are 
termed  insane,  or  mad,  or  nuts,  depending  on  our 
degree  of  culture.  The  attitude  toward  the  psych- 
iatric patient  is  generally  that  of  disgust,  dislike, 
or  at  least  open  disdain.  Doctors  as  well  as  lay- 
men often  assume  this  attitude. 

That  psychiatrists  err  in  this  respect  also  at 
times,  I  do  not  deny.  During  medical  school  days 
there  is  hardly  a  single  student  who  thinks  he  will 
go  into  psychiatry  as  a  life  work.  Most  plan  to 
be  surgeons;  probably  psychiatry  is  at  the  bottom 
of  the  list.  After  finishing  school  many  finding 
their  funds  exhausted,  look  around  for  a  paying 
job  for  a  year  or  two,  and  become  members  of  the 
staff  of  mental  hospitals  because  there  is  assured 
a  salary.  They  find  that  they  like  the  work  much 
better  than  anticipated,  they  become  interested 
and  find  the  patients  likeable,  and  often  they  stay 
on  year  after  year  intending  to  leave  soon.  They 
still  feel,  however,  a  sense  of  inferiority  as  a  hang- 
over from  medical  school  days  and  rather  prefer 
not  to  tell  their  friends  about  their  work.  They 
are  slightly  ashamed  of  it  and  prefer  not  to  think 
of  themselves  as  psychiatrists.  That  this  attitude 
is  childish  is  evident.  I  have  known  several  doc- 
tors with  this  attitude  which  they  held  on  to  merely 
as  the  result  of  preconceived  notions. 

And  something  of  this  same  attitude  I  have  no- 
ticed in  residents  in  a  large  psychiatric  clinic  in  a 
University  hospital.  They  felt  a  definite  sense  of 
inferiority  in  relation  to  the  residents  in  other  de- 
partments. They  excused  their  course  on  the 
grounds  that  they  intended  to  be  professors  of 
psychiatry,  not  mere  psychiatrists  in  humbler  as- 
pects. No  state  hospital  work  for  them.  They 
felt  that  psychiatry  must  needs  apologize  for  being. 

Of  course  the  general  practitioner  could  not  be 
blamed  for  a  similar  attitude  if  some  psychiatrists 
themselves  hold  such  attitudes  toward  their  own 
field  of  activity.  Many  and  varied  are  the  com- 
plexes and  emotional  biases  that  enter  into  this 
strange  phenomenon.  The  primitive  view  that  the 
mentally  ill  are  possessed  of  devils  holds  in  some 
quarters.  That  the  neurotic  patient  is  shamming 
or  quitting  on  the  job  holds  in  others.  Many  doc- 
tors feel  that  they  know  nothing  of  psychiatric 
phenomena  or  mental  mechanisms  and  what  they 
do  not  know  lies  outside  their  sphere,  hence  outside 
the  field  of  medicine. 

This  is  by  no  means  the  whole  story,  however. 
Many  physicians  view  the  psychiatric  aspect  as 
the  most  fascinating  part  of  medicine.    Many  phy- 


sicians are  aware  that  the  psychiatric  ills  of  man- 
kind make  up  a  large  percentage  of  the  total  ill- 
nesses. All  thoughtful  physicians  are  cognizant  of 
the  fact  that  every  somatic  illness  has  its  mental 
aspect — that  there  can  be  no  separation  of  mind 
and  body  in  this  total  personality  of  ours. 

And  further,  the  astute  physician  is  aware  that 
the  apparently  purely  mental  illnesses  are  within 
his  province,  and  something  to  which  he  must  min- 
ister if  he  is  to  live  to  the  fullest  his  ideal  of  the 
true  physician.  The  mentally  ill  patient  turns  first 
to  his  family  physician.  Too  often  the  patient  has 
no  idea  what  the  trouble  may  be;  and  after  he 
finds  that  the  trouble  is  nervous  or  mental  the  pa- 
tient often  finds  that  insufficient  funds  prevent  his 
treatment  by  a  psychiatrist  in  a  private  hospital, 
and  the  unfortunate  feeling  that  a  stigma  attaches 
to  treatment  in  State  hospitals  and  their  overcrowd- 
ed condition  prevent  his  seeking  relief  there.  Hence 
the  family  physician  is  more  or  less  forced  to  do 
whatever  he  can  for  this  psychiatric  patient.  If 
his  attitude  is  that  the  whole  trouble  is  imaginary, 
the  patient  begins  at  once  the  round  of  all  the 
various  quacks  that  pretend  to  treat  every  possible 
ailment  of  man. 

If,  on  the  other  hand,  the  family  physician  ap- 
proaches the  problem  in  an  attitude  of  sympathy, 
listens  calmly  to  all  the  patient's  story,  and  offers 
what  suggestions  he  can,  the  patient  will  feel  that 
at  least  he  has  a  friend  to  whom  he  can  talk.  If 
this  attitude  is  persisted  in,  much  can  be  done  in 
the  amelioration  of  the  illness.  Oftentimes  the  pa- 
tient is  benefited  merely  by  telling  his  whole  story 
in  all  its  various  ramifications.  An  attitude  of 
patience  and  unhurried  calm  encourages  this. 

The  alcoholic,  the  drug  addict,  the  obsessional 
compulsive  neurotic,  the  hysterical,  the  neurasthe- 
nic are  all  sick  people  and  as  such  must  come 
within  the  sphere  of  the  family  physician.  The 
more  severe  forms  of  mental  illnesses,  such  as  the 
nianic-depressive  psychoses,  the  schizophrenias,  the 
anteriosclerotic  and  the  senile,  all  come  early  under 
the  observation  of  the  family  physician,  and  it  is 
he  who  must  gauge  the  severity  of  the  illness  and 
advise  hospital  treatment  if  it  be  necessary.  At 
least  he  must  hear  the  story  in  all  its  details  to 
determine  this. 

Toward  psychiatric  patients  and  psychiatric  ills 
we  ask  the  same  attitude  that  all  true  physicians 
in  every  clime  and  time  have  toward  the  patient 
and  toward  the  illness — no  matter  what  the  cause, 
no  matter  what  the  manifestation,  no  matter  what 
the  outcome.  Various  thoughtful  physicians  at 
various  times  and  places  have  written  or  spoken  of 
what  this  attitude  is.  In  his  beautiful  essay  en- 
titled "The  :Master-Word  in  ^Medicine,"  Dr.  Wil- 
liam Osier  says: 


October,   10J6 


SOUTHERN  MEDICINE  AND  SURGERY 


S47 


"-  -  -  To  you  is  given  the  harder  task  of  illustrating 
with  your  lives  the  Hippocratic  standards  of  Learning,  of 
Sagacity,  of  Humanity  and  of  Probity.  Of  learning,  that 
you  may  apply  in  your  practise  the  best  that  is  known  in 
our  art,  and  that  with  the  increase  in  your  knowledge  there 
may  be  an  increase  in  that  priceless  endowment  of  sagacity 
so  that  to  all,  ever>'where,  skilled  succour  may  come  in  the 
hour  of  need.  Of  a  humanity,  that  will  show  in  your  daily 
life  tenderness  and  consideration  to  the  weak,  infinite  pity 
to  the  suffering,  and  broad  charity  to  all.  Of  a  probity, 
that  will  make  you  under  all  circumstances  true  to  your- 
selves, true  to  your  high  calling,  and  true  to  your  fellow 
man."  ; 

With  such  an  attitude  on  the  part  of  the  general 
practitioner  of  medicine,  the  future  of  psychiatry  is 
assured. 


CARDIOLOGY 

Clyde  M.  Gilmore,  A.B.,  M.D.,  Editor,  Greensboro,  N.  C. 


Two  Questions  in  Coronary  Disease 
(Concluded) 
Continuing  the  questions  discussed  in  this  de- 
partment in  last  month's  issue  we  wish  to  give  the 
opinions  of  some  of  the  Carolina  physicians  inter- 
ested in  this  phase  of  medicine. 
The  Questions: 

1.  What  to  tell  the  patient  with  coronary  sclero- 
sis, angina  or  occlusion  and  when.  Should  the 
patient  be  taken  into  our  confidence  or  is  the 
knowledge  of  the  seriousness  of  the  lesion  a  lia- 
bility for  him?  Should  we  tell  the  patient  when 
we  have  concluded  that  the  end  is  near  or  that 
there  is  no  hope  of  improvement? 

2.  What  to  do  about  focal  infection  in  the  cor- 
onary occlusion,  advanced  coronary  sclerosis,  an- 
L'ina  of  effort  or  decompensation?  If  found  to 
have  definite  infections  in  the  tonsils,  teeth,  sin- 
uses or  gallbladder,  should  they  be  removed  as  in 
other  patients,  the  patient  not  being  critically  ill? 
Some  of  us  do  not  feel  that  these  patients  live  long 

■  enough  to  justify  the  danger,  suffering  and  expense 
attendant  on  the  measures  necessary  to  eliminate 
focal  infection.  Yet,  it  appears  that  the  majority 
of  such  patients  are  subjected  to  removal  of  foci 
of  infection.  Does  this  prolong  the  life  of  a  pa- 
itient  with  coronary  sclerosis?  Does  it  prevent  fur- 
ther damage? 

The  Answers: 
Dr.  P.  W.  Flagge,  High  Point: 

"No.  1.  It  has  been  my  habit,  excent  imder  cir- 
cumstances where  the  family  ha-  requested  in  ad- 
ivance  that  I  do  not  follow  my  routine,  to  acquaint 
jthe  patient  frankly  with  his  condition.  I  have 
'found,  if  tact  and  judgment  are  used  in  approaching 
this  matter,  that  it  can  be  done  with  no  more  men- 
tal shock  to  him  than  advising  him  he  has  lost  a 


leg  by  amputation  or  suffered  any  other  grave  crises 
in  his  life.  It  does  not  appear  clear  to  me  that  a 
man  can  take  proper  care  of  a  crippled  heart  until 
he  is  apprised  of  the  situation  and  the  reason  for 
his  conduct.  It  seems  to  me  that  it  is  far  less  dan- 
gerous for  such  a  man  to  know  his  condition  than 
it  is  for  him  to  go  on  under  a  delusion  and  subject 
his  heart  to  the  strain  of  exercise  and  work  that 
he  is  inclined  to  indulge  in  without  a  proper  under- 
standing of  the  facts.  I  do  not  feel  that  we  can 
formulate  any  hard  and  fast  rule,  or  indeed  have 
any  rule  at  all,  as  to  advising  patients  of  their 
approaching  demise.  In  the  first  place  this  con- 
clusion is  very  hard  to  reach  and  is  often  in  error. 
In  the  interest  of  his  family,  friends  and  business 
associates,  it  is  always  fair,  at  some  time  during 
the  progress  of  his  illness,  to  advise  him  that  his 
business  affairs  should  be  set  in  shape  to  meet  a 
possible  crisis,  leaving  the  matter  as  indefinite  as 
that,  but  insisting  upon  carrying  out  the  advice  in 
the  interest  of  those  he  loves  or  should  protect." 

"No.  2.  In  the  younger  patient  of  this  group 
it  is  good  management  to  consider  the  re- 
moval of  the  foci  of  infection,  provided  the  attacks 
have  not  been  frequent  or  severe  and  decompen- 
sation does  not  exist  and  is  not  imminent.  Such 
procedure  must,  of  necessity,  be  very  guarded  and 
gradually  instituted.  The  advisability  is,  to  some 
extent,  dependent  upon  a  gravity  of  a  surgical 
procedure.  In  the  older  of  cases,  where  cardiac 
symptoms  and  the  foci  of  infection  have  existed 
over  a  long  period,  any  major  surgical  procedure 
for  the  relief  of  the  foci  of  infection  often  carries 
with  it  more  risk  than  prospects  of  improvement 
of  the  patient's  condition." 
Dr.  W.  B.  Winlaw,  Rocky  Mount: 

"No.  1.  I  usually  take  time  and  explain  to  my 
patient,  when  I  am  sure  of  the  diagnosis,  that  he 
has  some  hardening  of  his  coronaries,  as  most  of 
his  or  her  age  have,  and  that  a  spasm  gives  the 
pain  known  as  angina;  then  go  into  the  things 
we  want  to  do  to  get  rid  of  it,  if  possible.  Definite 
gallbladder  disease,  or  kidney  stone,  diseased  ton- 
sils or  teeth  shown  by  x-ray  examination  to  be 
abscessed  should  b  ■  removed.  In  20  per  cent,  of 
cases  of  definite  coronary  sclerotic  disease  in  a 
series  that  I  studied,  gallbladder  disease  was  prov- 
ed by  x-ray  examination  and  electrocardiogram. 
Relief  of  the  gallbladder  symptoms  and  removal 
of  the  infection  by  operation  surely  makes  far  more 
coniruii  and  should  tend  to  slow  up  the  sclerosis. 

"If  they  survive  the  hard  initial  spell  of  an  oc- 
clusion, they  may  have  a  chance  to  get  over  it,  so 
I  do  not  believe  in  telling  them  but  explain  the 
possibility  to  the  family.  If  they  have  stood  first 
shock  and  after  a  few  days  appear  that  they  can- 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


not  make  it,  I  try  to  learn  about  their  business, 
will,  etc.,  and  if  necessary  explain  that  we  do  not 
expect  another  attack,  but  if  one  has  any  business 
affairs  to  get  straightened  it  would  be  a  sound 
business  plan  as  none  of  us  can  ever  tell  what  may 
happen.  I  never  tell  my  patients  there  is  no  hope 
for  improvement.  If  there  isn't  they  probably 
know,  if  conscious,  and,  too,  they  may  fool  us.  I 
think  it  is  well  to  tell  the  family  there  is  'very  little 
hope';  but  I  like  to  encourage  the  patient.  It 
helps  most  of  them,  at  least  to  rest  better. 

"No.  2.  I  do  not  think  any  recent  coronary 
occlusion  case,  until  well  compensated  at  least, 
should  be  bothered  by  removing  any  focus  of  in- 
fection, or  any  case  of  effort  or  decompensation 
angina  until  several  weeks  (at  least  six)  bed  rest 
with  compensation  restored.  After  compensation 
and  rest  I  think  they  can  stand  the  removal,  as  a 
rule,  of  a  very  definite  focus  of  infection  and,  al- 
though it  may  not  be  the  cause  of  the  condition, 
it  will  tend  to  help  any  patient's  general  improve- 
ment, especially  in  those  under  50  years  of  age. 

"I  have  seen  cases  in  patients  between  the  ages 
of  30  and  45  who  were  developing  h3rpertension 
and  coronary  sclerosis  come  to  a  standstill  or  im- 
prove after  removal  of  a  real  infection.  It  may 
have  been  other  measures  as  rest,  diet,  reduced 
weight,  or  the  mental  satisfaction  to  them  that  'we 
have  removed  the  cause,  now  take  care  of  your- 
self.' " 
Dr.  F.  R.  Taylor,  High  Point: 

"No.  1.  My  attitude  is  that  the  patient  should 
be  told  the  truth  as  nearly  as  possible,  as  gently, 
yet  as  clearly  as  it  can  be  done.  I  say  'as  nearly 
as  possible,'  because  it  is  difficult  to  estimate  the 
real  danger.  My  own  practice  is  somewhat  as  fol- 
lows: 

"In  cases  with  anginal  attacks  resulting  from  ef- 
fort, with  or  without  obvious  sclerosis: 

"Here  I  take  some  time  to  go  into  detail.  I  tell 
the  patient  frankly  that  he  has  angina  pectoris, 
and  that  this  is  a  very  uncertain  condition,  one 
in  which  a  definite  prognosis  can  not  be  given.  1 
try  to  state  facts,  emphasize  the  indispensability  of 
rest,  and  then  dwell  at  some  length  on  the  more 
optimistic  cases.  Much,  however,  depends  on  the 
individual.  /  never  tell  a  patient  with  angina  that 
there  is  nothing  wrong  and  to  forget  it — that  is  vir- 
tually malpractice  jrom  my  viewpoint.  However, 
the  fearful  patient  must  be  told  gently  and  skill- 
fully. The  'rhinoceros-hide'  patient  needs  different 
treatment.  This  type  brags  that  nothing  can  stop 
him  and  ridicules  any  advice  to  rest  or  slow  down. 
I  deliberately  try  to  put  the  fear  of  death  into 
him,  for  just  as  'The  fear  of  the  Lord  is  the  be- 
ginning of  wisdom,'  so  is  a  healthy  fear  of  death 


to  such  a  patient.  I  tell  him  that  no  life  insurance 
company  in  the  world  wants  to  do  business  with 
him  because  he  may  drop  dead  any  moment,  and 
cite  cases  illustrating  the  point. 

"Occasionally  one  sees  a  patient  crumple  under 
the  news  and  it  may  even  kill  him.  Much  more 
often,  however,  I  believe  that  the  strain  of  uncer- 
tainty and  an  attitude  of  saying  nothing  on  the 
part  of  the  doctor  kills  patients.  Chronic  anxiety 
is  bad  for  coronary  disease,  and  no  certainty  of 
diagnosis  is  as  bad,  as  a  rule,  as  uncertainty.  I 
am  somewhat  of  a  neurotic  type,  susceptible  to 
anxiety,  and  I  well  recall  how  as  a  boy  of  15,  I 
suffered  untold  agony  over  the  family  and  the  doc- 
tor whispering  about  me  outside  my  room.  This 
anxiety  lasted  about  a  week,  until  in  a  lucky  mo- 
ment I  overheard  the  words  'typhoid  fever.'  I 
demanded  at  once  to  know  if  I  had  typhoid  and 
was  told  I  had.  From  that  time  on  I  was  immense- 
ly relieved.  I  knew  what  I  had  to  face  and  wai 
satisfied  and  could  get  the  rest  I  required  to  live. 
Moreover,  in  coronary  disease,  as  in  tuberculosis, 
no  intelligent  person  is  going  to  limit  his  activity 
as  he  should  without  a  good  reason  for  doing  so. 
Adjusting  one's  activities  for  life  is  not  a  thing 
most  of  us  would  do  because  of  categorical  orders 
without  reasons  given 

"In  cases  of  coronary  thrombosis.  Here  the  pa- 
tient is  usually  acutely  ill,  not  only  with  pain,  but 
with  great  prostration,  and  he  is  often  too  weak  to 
be  much  interested  in  what  is  going  on.  Unless  he 
demands  an  explanation  I  simply  tell  him  he  has 
had  a  severe  attack  that  necessitates  absolute  rest, 
and  that  I  want  to  study  his  case  further  before 
expressing  an  opinion  as  to  just  what  the  attack 
means.  However,  if  he  reacts,  reasonably  soon  I 
tell  him  his  condition  and  show  him  that  many 
patients  recover  completely  if  only  they  take  the 
essential  rest. 

"******  In  my  practice,  with  the  vast  ma- 
jority of  my  patients  (and  I  think  it  true  of  human 
nature  in  general),  uncertainty  places  a  greater 
strain  on  a  patient  than  even  a  more  or  less  dire 
certainty.  I  think  the  medical  profession  has 
erred  in  assuming  too  great  a  lack  of  intelligence 
in  the  average  patient.  People  are  already  thinking 
about  these  dire  problems  before  they  come  to  the 

"No.  2.  Removal  of  focal  infection  seems  to  me 
to  be  entirely  an  individual  matter  based  on  the 
patient's  condition.  No  one  wants  to  operate  on 
focal  infection  in  a  patient  in  collapse  from  cor- 
onary occlusion.  One  should  certainly  wait  until 
a  reasonable  period  has  elapsed  (at  least  8  weeks 
after  thrombosis  of  anterior  coronary,  6  weeks  after 
thrombosis  of  posterior  branch)  and  until  the  pa- 
tient has  reacted.    *  *  *  *    if  great  hypertension, 


October,   1Q36 


SOUTHERN  MEDICINE  AND  SURGERY 


it  may  be  well  to  remove  all  foci  as  a  noble  experi- 
ment that  may  do  no  good  and  may  work  wonders. 
If  the  focus  is  in  the  gallbladder,  I  advise  operation 
if  possible  because  gallbladder  infection  causes  gas 
and  gas  may  cause  anginal  attacks,  in  a  patient  so 
predisposed.  ******  Heart  patients  stand 
surgery  better  than  we  used  to  think.  Needless  to 
say,  have  a  good  surgeon  with  the  very  best  meth- 
ods of  anesthesia  and  avoidance  of  shock.  If  den- 
tistry, take  a  barbiturate  before  novocain  as  an 
antidote  to  the  severe  palpitation  sometimes  set  up 
either  by  the  adrenalin  usually  with  it  or  occasion- 
ally by  the  novocain  itself.  Every  case  must  be 
judged  on  its  own  merits.  I  would  not  advise  oper- 
ation without  very  definite  evidence  of  a  pretty 
severe  focal  infection." 
Dr.  William  Allan,  Charlotte: 

"No.  1.  //  the  patient  insists  on  prognosis,  al- 
ways tell  him  the  truth. 

"No.  2.  The  jocal  injection  racket  has  about 
played  out.  It  has  never  had  any  place  in  Chronic 
Hypertensive  Cardiovascular  Disease." 

Summary — -It  appears  that  most  of  the  men  feel 
that  the  patient  should  be  told  his  condition,  cer- 
tainly when  his  condition  will  permit.  Most  agree 
that  definite  focal  infection  should  be  removed.  My 
own  feeling  is  that  the  patient  should  be  told  the 
truth  clearly  and  frankly  as  soon  as  he  is  over 
the  shock  of  his  first  attack.  With  the  possible 
exception  of  gallbladder  disease  I  do  not  believe 
that  the  removal  of  focal  infection  has  any  influ- 
ence on  the  course  of  this  type  of  heart  disease 
although  it  is  conceded  that  allied  conditions  often 
justify  the  removal  of  teeth  and  tonsils  in  the  cor- 
onary patient. 

S.    M.    &   S. 

THERAPEUTICS 

For  this  issue,  ].  A.  Shaw,  M.D.,  Fayetteville,  N.  C. 


One  of  the  Pediatric  Problems  of  N.  C. 

A  short  time  ago  a  doctor  wrote  me  and  the  last 
paragraph  of  his  letter  was  to  this  effect:  I  hate 
to  send  you  such  cases,  but  I  am  able  to  keep  the 
babies  well  in  the  families  of  those  with  some  fair 
amount  of  worldly  goods,  but  in  the  poorer  classes 
I  am  not  so  successful.  I  believe  the  pediatric 
problem  in  North  Carolina  is  poverty. 

Hand  in  hand  with  the  problem  as  described 
above,  in  my  opinion,  would  go  ignorance  and  care- 
lessness. After  a  few  years'  experience  in  the  east- 
ern part  of  the  State,  I  have  come  to  the  conclusion 
that  gastrointestinal  diseases  constitute  the  bulk  of 
the  real  sick  babies  and  infants  that  we  have  in 
the  summer  months,  and  I  believe  it  is  safe  to  say 
that  a  large  percentage  of  these  come  from  families 
that  are  really  unable   financially,   due   to   small 


wages  and  large  families,  to  give  their  babies  the 
proper  hygienic  surroundings. 

It  is  usually  assumed  that  when  one  makes  a 
criticism  he  should  have  something  to  offer  in  the 
way  of  improvement  of  the  condition,  but  in  this 
case  it  is  hard  to  be  specific.  The  poor  we  have 
with  us  always,  and  carelessness  and  ignorance  will 
always  be  here;  but  it  might  be  possible,  with  the 
proper  cooperation,  to  a  certain  degree  to  remedy 
all  these  evils.  Any  measure  instituted  for  any  one 
of  these  would  help  the  other. 

Last  summer  the  people  of  the  State  became 
concerned  about  poliomyelitis  and  in  every  home 
it  was  discussed.  This  was  accomplished  by  the 
untiring  efforts  of  the  N.  C.  State  Board  of  Health, 
aided  by  the  medical  profession  throughout  the 
State  and  the  publicity  given  the  disease  through 
the  State  press.  It  was  remarkable  how  people  in 
all  walks  of  life  could  discuss  the  disease,  and  how 
they  tried  to  cooperate  in  the  prevention  of  its 
spread.  Recently  the  Federal  Government  has 
given  to  the  State  some  money  to  be  used  in  child 
welfare  and  prenatal  work.  My  only  suggestion 
would  be,  with  the  Health  Department  as  a  head 
and  with  the  medical  profession  cooperating  more 
fully,  to  inaugurate  an  educational  program  where- 
by hygiene  could  be  taught  the  people  in  North 
Carolina  with  especial  reference  to  the  gastrointes- 
tinal diseases.  A  law  requiring  the  screening  of  all 
rented  homes  might  work  a  hardship  on  the  prop- 
erty owner,  but  certainly  would  be  a  blessing  to 
the  renter.  A  government  project  to  screen  the 
homes  of  those  owning  their  homes  and  unable  to 
provide  screen  might  do  a  great  deal  of  good. 

I  do  not  believe  it  is  necessary  to  try  to  prove 
the  need  of  something  to  reduce  the  mortality  and 
morbidity  in  this  State  from  colitis.  I  am  almost 
afraid  that  in  the  eastern  part  of  the  State  we  rele- 
gate it  to  the  same  category  with  a  common  cold. 
The  difference  is  that  of  the  common  cold  we  know 
little;  but  we  know  that  a  baby  brought  up  on 
almost  any  diet  under  almost  any  condition,  if 
reared  in  even  fair  hygienic  surroundings,  is  not 
likely  to  suffer  from  enterocolitis,  so  it  seems  wrong 
that  more  cannot  be  done  to  check  the  deaths  from 
this  cause.  I  realize  that  the  screening  of  homes, 
supplying  of  milk  and  other  nutritional  needs  will 
not  solve  the  problem  unless  the  people  are  better 
instructed  and  are  willing  to  make  some  effort 
themselves  to  help. 

The  strict  enforcement  by  the  city  and  county 
authorities  of  existing  laws  directed  to  health  con- 
ditions, and  more  centralization  of  power  in  the 
State  Board  of  Health  and  less  in  the  county  boards 
might  or  might  not  be  advantageous.  Certainly  I 
think  a  practical  course,  one  for  grammar  school 
and  one  for  high  school,  both  required  and  taught 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


in  every  school  in  the  State,  would  be  a  step  to- 
ward general  education  on  hygiene.  Such  courses 
should  be  supervised  by  physicians  and  when  pos- 
sible, given  by  them.  Such  a  course  might  be  slow 
in  bringing  results  but  in  the  end  would  pay  health 
dividends. 


Frederick  R.  Taylor,  M.D.,  F.A.C.P.,  High  Point,  N.  C. 

The  New  Epitome  of  the  U.  S.  Pharmacopeia 

AND  National  Formulary 

This  handy  little  60-cent  volume,  just  out, 
should  be  in  every  physician's  library.  It  is  put 
out  by  the  A  .M.  A.  and  gives  the  basic  essentials 
of  the  larger  volumes  of  which  it  is  an  epitome. 
Not  only  preparations  and  doses  are  given  but  sol- 
ubilities, occasional  comments,  etc.  The  solubility 
of  a  preparation  is  often  important  to  know  and 
very  difficult  to  remember.  The  volume  will  fit 
unobtrusively  in  a  pocket  of  a  coat  or  medical  bag, 
or  can  be  kept  on  one's  desk  where  a  larger  vol- 
ume might  be  in  the  way.  There  are  numerous 
tables  of  weights  and  measures,  equivalents  in  dif- 
ferent systems,  as  metric-English,  centigrade-Fah- 
renheit. For  many  years  the  National  Formulary 
has  been  both  a  standard  list  and  a  standing  joke, 
the  latter  because  of  the  large  number  of  inert 
obsolute  drugs  it  contained.  It  has  been  given  a 
much-needed  drastic  purge,  thus  eliminating  a  large 
number  of  doubtful  or  useless  old-timers,  and  while 
there  is  still  room  for  improvement,  the  present  re- 
vision seems  the  best  and  most  thorough  within  the 
knowledge  of  the  author. 

We  have  discovered  two  formula  changes,  as  fol- 
lows: 

The  Odontalgicum  of  N.  F.  V.  consisted  of  phenol  in 
oil  of  cinnamon  and  methyl  salicylate;  that  of  N.  F.  VI  is 
chlorbutanol  in  oil  of  cloves. 

The  Unguentum  of  U.  S.  P.  X  was  yellow  wax  and  ben- 
zoinated  lard;  that  of  U.  S.  P.  XI  is  white  petrolatum, 
wool  fat  and  white  wax. 

Many  preparations  have  had  their  names  chang- 
ed and,  although  little  confusion  will  result  from 
continuing  to  use  the  old  term,  it  is  well  to  recog- 
nize the  change. 

Some  25  preparations  have  been  shifted  without 
change  of  name  from  U.  S.  P.  X.  to  N.  F.  VI; 
one  from  N.  F.  V  to  U.  S.  P.  XI  (Sodii  Perboras). 
More  than  20  U.  S.  P.  X  preparations,  from  troches 
of  tannic  acid  to  tincture  of  zingiber  do  not  ap- 
pear in  the  U.  S.  P.  XI  or  N.  F.  VI;  and  about  240 
N.  F.  V  preparations  have  been  deleted — a  fact  that 
is  noted  with  gratification  and  encouragement. 

Among  the  half-hundred  preparations  which 
have  been  added  to  U.  S.  P.  XI  are:  Acriflavina 
Antitoxinum  Scarlatinae  Streptococcicum,  Calcii 
Creosotas,  Calcii  Gluconas,  Carbo  Activatus 
Ephedrina,  Ergosterol  Irradiati,  Erythritylis  Tetra 
nitras  Dilutus,  Ferri  et  Ammonii  Citrates  Virides 


Fluorescein  Solubile,  Histaminae  Phosphas,  Tinc- 
tura  lodi  Mitis,  Merbaphenum,  Oleum  lodatum, 
Oleum  Morrhuae  Non-destearinatum,  Parathyroid- 
eum.  Serum  Antimeningicoccicum,  Liquor  Sodii 
Hypochloritis,  Toxinum  Diphthericum  Detoxica- 
tum,  Toxinum  Diphthericum  Diagnosticum,  Toxi- 
num Scarlatinae  Streptococcum,  Tryparsamidum, 
Tuberculinum  Pristinum,  Vaccinum  Rabies,  Vac- 
cinum  Typhosum  and  Vaccinum  Typho-paratypho- 
sum. 

Nearly  120  new  preparations  have  been  added  to 
NF.  VI.  Among  these  are  noted  Elixir  Iso-alco- 
holicum.  Elixir  Aminopyrinae,  Ammonii  lodidum, 
Aqua  Redestillata,  Brucinae  Sulfas,  Calamus,  Tinc- 
tura  Cannabis,  Corpus  Luteum,  Ampullae  Epine- 
phinae  Hydrochloridi,  Ampullae  Hydrargyri  Sali- 
cylatis,  Methylrosanilinum,  Ovarium,  Phenol  Cam- 
phoratum,  Pituitarium  Anterior,  Ampullae  Pitui- 
tarii  Posterioris,  Pituitarium  Totum,  Unguentum 
Picis  Carbonis,  Procainae  Hydrochloridi,  Prunus 
Cerasus,  Salvia,  and  Suprarenalum. 

The  whole  book  may  be  had  for  60  cents  sent  to 
the  American  Medical  Association,  535  N.  Dear- 
born Street,  Chicago. 


Epinephrin  by  Inhalation 


The  nozzle  of  the  atomizer  is  placed  just  within  the  open 
mouth,  and  the  patient  inhales  deeply  while  creating  a 
spray.  The  amount  of  inhalation  necessary  for  relief  varies 
for  each  patient  and  depends  on  the  severity  of  the  symp- 
toms and  the  manner  in  which  the  atomizer  is  manipulated. 
There  is  a  wide  margin  of  tolerance  before  any  unusual 
reactions  occur.  For  use  with  children  unable  to  co-operate 
in  the  use  of  the  hand  atomizer  a  special  apparatus  was 
devised. 

Failure  to  obtain  initial  relief  is  usually  due  to  improper 
manipulation  of  the  atomizer  or  to  poorly  constructed  in- 
struments. Severe  paroxysms  require  exposure,  at  times, 
intermittently,  for  a  period  of  IS  to  30  minutes  before 
reUef  is  obtained.  The  ideal  routine  in  such  cases  is  the 
administration  of  hypodermic  epinephrine  to  obtain  initial 
relaxation.  This  is  followed  by  the  use  of  the  inhalation 
procedure  on  experiencing  the  least  suggestion  of  a  return 
of  symptoms. 

With  the  average  patient,  the  physiologic  effect  occurs 
more  rapidly  after  inhalation  of  the  1:100  solution  than 
with  hypodermic  injection;  rarely  is  it  any  slower.  Inha- 
lation is  infrequently  accompanied  by  any  of  the  dis- 
agreeable side-effects  of  subcutaneously  administered  epine- 
phrine. 


There  are  two  valuable  adjuncts  in  the  treatment 
OF  VALVULAR  DISEASE — iroti  and  strychnia.  When  anemia  is 
a  marked  feature  iron  should  be  given  in  full  doses.  In 
some  instances  of  failing  compensation  this  is  the  only 
medicine  needed  to  restore  the  balance.  Arsenic  is  occa- 
sionally an  excellent  substitute,  and  one  or  other  of  them 
should  be  administered  in  all  instances  of  heart  trouble 
when  pallor  is  present.  Strychnia  is  a  heart  tonic  of  very 
great  value.  Alcoholic  stimulants  in  moderation  are  occa- 
sionally useful,  especially  in  tiding  over  a  period  of  acute 
cardiac  weakness. — Osier. 


October,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


SSI 


HOSPITALS 

R    B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  firfitor,  Greensboro.N.  C. 


P  The  Best  Advertisement 

It  is  a  well  known  fact  that  the  American  people 
believe  in  advertising.  It  has  been  said  by  one 
large  firm  that  an  American  will  believe  anything 
if  it  is  told  him  often  enough. 

It  is  unfortunate  that  some  hospital  administra- 
tors and  nurses  look  upon  visitors  as  necessary 
evils  without  which  patients  can  not  be  expected 
to  come  to  the  hospital,  when  in  reality  the  visitors 
are  the  best  advertising  medium  that  the  hospital 
has.  This  contact  is  equally  as  effective  as  the 
satisfied  patient,  possibly  more  so. 

There  are  many  visitors  who  come  in  the  hos- 
pitals to  see  one  patient.  It  is  the  writer's  opinion 
that  it  would  be  fair  to  estimate  that  each  hospital 
patient  staying  the  average  II  to  13  days  will  have 
12  visitors.  This  means  12  contacts  between  pros- 
pective patients  and  the  hospitals'  staff. 

From  the  time  the  visitor  approaches  the  infor- 
mation desk  until  the  time  he  leaves  he  should  be 
considered  the  guest  of  the  hospital.  At  no  time 
should  any  employee  consider  him  a  nuisance,  or 
in  any  way  show  a  disposition  of  indifference  to 
him.  I  know  of  no  finer  way  for  the  nursing  staff 
to  show  their  loyalty  to  the  institution  in  which 
they  are  working  than  to  be  courteous,  polite,  sym- 
pathetic and  kind  to  the  visitors  in  their  institu- 
tion. 

In  the  absence  of  positive  evidence  to  the  con- 
trary, it  should  be  assumed  that  the  visitor  is  al- 
ways right  in  his  or  her  requests  and  demands. 
Almost  never  are  visitors  as  careful  about  the  linen 
on  the  patient's  bed,  the  scarfs  on  the  bedside  table 
or  dresser,  and  about  the  floor  and  its  covering  as 
they  should  be.  They  often  drop  cigarette  ashes 
or  lighted  cigarettes  where  they  will  do  harm.  They 
frequently  turn  water  or  medicine  over  on  the 
dresser  or  bedside  table,  and  almost  invariably  in- 
sist upon  sitting  upon  the  patient's  bed.  However, 
these  are  minor  errors  of  etiquette  when  compared 
with  the  way  some  nurses  treat  these  guests.  The 
laundry  and  vacuum  cleaner  can  wipe  away'  many 
of  the  results  of  errors  of  the  visitors,  while  in- 
jured feelings  heal  slowly,  and  the  opportunity  to 
apply  healing  balm  may  never  present  itself.  There- 
after the  injured  guest  carries  an  unfriendly  feeling 
towards  the  hospital  and  the  nurses,  and  this  is 
the  worse  kind  of  advertising  any  institution  can 
get. 

The  author  of  this  article  wishes  to  make  an 
earnest  plea  to  all  employees  of  all  hospitals  every- 
where, whether  large  or  small,  to  be  kind  and  con- 
siderate in  their  individual  treatment  of  guests  of 


their  hospital.  This  treatment  should  be  tactfully 
given  and  in  all  sincerity,  keeping  in  mind  that  a 
kind  work  softly  spoken,  in  the  language  that  is 
best  understood,  to  the  visitor  to  whom  one  is 
talking  is  a  far-reaching  service  that  will  never  be 
forgotten  as  long  as  that  person  lives. 


PEDIATRICS 

G.  W.  KuTSCHER,  M.D.,  F.A.A.P.,  Editor,  AshevUle,  N.  C.  ■ 


Roaring  Gap  Meeting 
Dr.  Leroy  Butler,  Winston-Salem,  was  host  to 
the  N.  C.  Pediatric  Society  at  Roaring  Gap  Chil- 
dren's Hospital  September  5  th  and  6th.  The  guest 
speaker  Dr.  Jos.  Brenneman,  of  Chicago,  talked 
on  Abdominal  Pain.  This  particular  discussion  on 
appendicitis  is  recommended  to  every  physician 
who  is  interested  in  reducing  the  rising  mortality 
rate  in  this  disease.  More  complete  reference  to 
his  attitude  regarding  appendicitis  in  children  will 
be  found  in  the  August,  1935,  issue  of  Journal  of 
Pediatrics. 

In  congenital  atresia  of  the  esophagus,  air  in  the 
stomach  is  a  common  finding  rather  than  an  un- 
heard-of sign.  The  air  reaches  the  stomach  through 
the  distal  end  of  the  esophagus  which  is  connected 
with  the  lungs  instead  of  the  upper  end  of  the 
esophagus.  The  prognosis  is  hopeless,  these  chil- 
dren seldom  living  beyond  the  second  week  of  life. 
The  baby  with  pyloric  stenosis  is  contented  in 
contrast  to  the  irritable  crying  baby  with  a  spastic 
pylorus.  The  tumor  in  the  stenosis  case  should  be 
paluable  in  90  per  cent,  of  cases,  provided  patience 
and  touch  are  adequately  utilized.  At  times  a 
differential  diagnosis  between  pylorospasm  and  py- 
loric stenosis  is  impossible. 

Congenital  atresia  of  the  duodenum  is  not  a  dif- 
ficult diagnosis;  it  demands  immediate  operation 
once  the  diagnosis  is  made.  As  evaporated  milk 
goes  through  the  stomach  without  the  formation  of 
curds,  it  should  be  tried  for  24  hours  in  every  case 
of  suspected  duodenal  atresia  because  there  may  be 
a  very  small  opening  that  would  not  admit  curds, 
but  may  allow  liquids  to  pass. 

The  walls  of  a  Meckel's  diverticulum  contain 
gastric  mucosa  or  even  pancreatic  tissue,  making 
ulcer  formation  rather  common.  Perforation  or 
hemorrhage  may  arise  from  this  area.  Hemorrhage 
may  be  severe  without  blood  being  passed  by 
bowel.  One  diagnostic  sign  of  Meckel's  diverticu- 
lum is  painless,  repeated  bleeding  from  the  bowel. 
In  these  cases  the  blood  in  the  intestinal  canal  clots, 
in  contradistinction  to  the  unclotted  blood  in  in- 
tussusception. 

The  diagnosis  in  intussusception  may  be  easy  or 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


difficult.  A  digital  rectal  examination  is  always 
indicated.  On  the  withdrawn  finger  is  usually 
found  a  jelly-like  substance  which  is  almost  path- 
ognomonic of  intussusception. 

A  commonly  overlooked  cause  of  distention  in 
the  newborn  is  the  failure  of  the  anal  canal  to 
completely  open,  a  thin  membrane  remaining 
stretched  from  side  to  side  of  the  canal.  Gas  ac- 
cumulates proximally,  but  the  distended  coils  go 
down  as  an  automobile  tire  that  has  been  punc- 
tured, when  the  finger  is  passed  into  the  anus  and 
the  membrane  ruptured,  and  all  is  well.  A  spastic 
sphincter  muscle  remains  spastic  after  being  tem- 
porarily opened  by  the  examining  finger.  In  this 
membranous  condition  once  the  finger  is  passed 
the  condition  is  cured. 

The  appendix  is  such  a  small  organ  to  cause  such 
a  lot  of  trouble.  The  speaker  doubted  that  simple 
appendicitis  causes  much  pain.  The  severe  pain  is 
usually  the  result  of  some  complication.  The  same 
holds  true  he  believes  of  high  fever  and  acute  gen- 
eralized tenderness.  The  mother  does  not  call  the 
doctor  because  the  pain  is  not  severe  and  there  is 
not  much  fever.  The  prognosis  is  dependent  more 
upon  the  alertness  of  the  parents  than  any  other 
factor.  The  use  of  cathartics  was  scored;  it  seems 
that  it  is  thought  advisable  by  parents  and  even 
some  physicians  in  Chicago  to  first  try  a  cathartic 
for  every  pain  in  the  abdomen.  Dr.  Brenneman's 
experience  has  plainly  demonstrated  the  folly  of 
such  treatment. 

The  close  relationship  between  an  acute  attack 
of  appendicitis  and  a  preceding  attack  of  tonsillitis 
was  pointed  out  very  plainly.  On  the  other  hand 
the  pain  in  the  abdomen  may  not  be  anything  more 
than  the  pain  associated  with  tonsillitis.  The  two 
conditions,  appendicitis  and  tonsillitis,  may  coexist. 
Tenderness  seems  more  important  in  making  the 
diagnosis  than  pain.  I  think  it  cannot  be  empha- 
sized too  heavily  that  the  one  important  sign  of 
early  appendicitis  is  tenderness  at  one  point  in  the 
proper  clinical  setting.  It  is  not  pathognomonic, 
however.  Dr.  Brenneman  pointed  out  on  several 
occasions  that  it  was  the  exception  that  proved  the 
rule,  in  order  that  his  statements  might  not  be 
taken  too  literally.  He  likewise  feels  that  more 
than  50  per  cent,  of  cases  of  appendicitis  in  chil- 
dren have  a  preceding  infection  behind  them. 

Dr.  Brenneman's  talk  was  frequently  interspers- 
ed with  his  witty  remarks.  His  audience  insisted 
that  he  continue  and  allowed  him  to  finally  stop 
only  out  of  respect  to  his  vocal  cords.  One  state- 
ment that  he  made  established  his  attitude  regard- 
ing the  promiscuous  use  of  blood  transfusions.  He 
told  us  of  a  child  that  was  desperately  ill  of  sev- 
eral conditions  and  as  part  of  the  treatment  a  trans- 
fusion was  used.    The  child  died  (not  as  a  result 


of  the  transfusion),  and  Dr.  Brenneman  said  most 
facetiously  that  it  was  the  only  case  he  knew  of 
in  which  a  transfusion  had  failed  to  cure  the  pa- 
tient. 

S.    M.    &  S. 

Breast  Feedino 
{III.  Med.  Jl.,  Sept.) 

Clifford  Grulee. — Breast  feeding  does  protect  children 
against  infection,  infection  in  general,  not  any  one  type 
of  infection.  Respiratory,  gastrointestinal  or  unclassified 
infections  are  all  equally  affected  in  a  general  way  by 
breast  feeding. 

H  .C.  Niblack. — Attending  physicians  we  hold  strictly 
responsible  for  keeping  the  babies  under  their  direction 
breast  fed.  We  cannot  check  every  baby  registered,  but 
we  can  check  the  deaths.  //  a  baby  dies  and  it  is  found 
not  to  have  been  breast  fed,  we  want  to  know  why;  if  that 
baby  had  been  taken  off  the  breast,  we  want  to  know  the 
indication. 

The  infants'  records  are  kept  on  colored  charts;  the 
yellow  indicating  the  breast-fed  babies  and  blue,  artificially 
fed.  We  expect  a  file  to  be  predominantly  yellow;  if 
there  are  too  many  blues,  we  expect  an  explanation.  When 
these  matters  are  taken  up  with  the  attending  physicians, 
their  argument  is:  "The  baby  was  put  on  a  bottle  in  the 
hospital  and  so  discharged ;  when  the  baby  is  registered  he 
is  already  in  the  habit  of  having  a  bottle,  and  the  mother 
of  giving  it."  Overcoming  the  bottle  habit  of  these  two 
individuals  is  difficult. 

Too  many  babies  are  being  discharged  from  the  hospitals 
on  unnecessary  bottle  feedings.  In  many  instances  giving 
these  feedings  is  a  matter  of  nursery  routine ;  formula  num- 
ber 1,  2  or  3  being  given  to  the  infant  at  the  discretion  of 
the  nursing  staff.  The  physician  must  personally  assume 
the  responsibility  of  directing  the  feeding  of  the  new-boms 
and  determine  the  policy  of  the  hospital  regarding  the  pro- 
cedure. There  has  been  too  much  stress  on  the  idea  that 
there  must  not  be  an  initial  loss  in  weight ;  this  unjustifiable 
fear  is  responsible  for  many  artificially-fed  infants. 

A  year  ago  we  made  a  city-wide  survey  of  the  breast 
feeding  situation  from  the  standpoint  of  hospitals.  The 
lowest  hospital  was  one  whose  clientele  is  from  the  wealth- 
iest class.  One  physician  casually  remarked  that  the  women 
delivered  in  his  hospital  did  not  want  to  nurse  their  babies, 
so  the  babies  were  put  on  bottle  feedings  by  the  staff  be- 
fore they  were  discharged. 

The  more  prosperous  mother  is  confused.  She  picks  up 
any  one  of  the  popular  magazines,  especially  the  women's 
publications,  and  from  the  pages  there  smiles  out  at  her 
those  superbly  beautiful  and  healthy  babies,  "the  result" 
of  various  artificial  feedings.  She  wants  a  baby  just  like 
that,  right  away.  She  also  has  noticed  that  her  friends  are 
having  seemingly  easy  time  with  their  babies  on  bottle 
feedings.  Then  she  starts  in  to  convince  her  physician  that 
she  cannot  possibly  nurse  her  baby — and  too  often  succeeds. 

There  is  no  better  stimulation  for  a  mother's  breast  than 
a  hungry  baby.  If  he  is  hungry,  he  will  nurse,  and  if  he 
is  getting  even  a  small  amount  he  will  keep  at  it,  and  if 
he  keeps  at  it  the  milk  will  come.  The  difficulty  has  been 
that  we  have  weakened  before  the  breast  attained  sufficient 
productive  capacity  to  support  the  baby. 

We  are  teaching  our  nurses  the  best  method  of  supple- 
menting the  baby's  efforts  in  developing  and  maintaining  a 
breast  milk  supply.  Certainly  manual  expression  is  best. 
There  is  no  pump  that  compares  with  it  in  simplicity  and 
effectiveness. 

If  we,  who  are  responsible,  namely,  physicians,  nurses, 
and  hospitals,  present  a  united  front,  we  shall  get  these 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


553 


mothers  in  a  frame  of  mind  that  they  will  not  only  want 
to  nurse  their  babies  but  will  believe  that  they  can — and 
will. 

s.  M.  &  e. 

PHARMACY 

W.  L.  Moose,  Ph.G.,  Editor,  Asheville,  N.  C. 


Some  Changes  in  U.  S.  P.  and  N.  F. 

On  June  1st  two  new  standards  for  medicinals 
became  effective:  the  U  .S.  P.  XI  which  is  be- 
coming with  each  revision  more  a  book  of  simple 
preparations,  the  scope  of  which  is  dependent 
upon  the  therapeutic  usefulness;  the  N.  F.  VI 
which  contains  those  simple  preparations  and  com- 
pounds for  which  there  is  sufficient  prescription  de- 
mand for  a  legal  standard. 

With  each  revision  there  are  many  changes  in 
the  nomenclature  of  the  articles  included.  Some 
removed  from  the  U.  S.  P.  to  the  N.  F.  and  from 
the  N.  F.  to  the  U.  S.  P.  and  some  dropped  com- 
pletely. 

A  new  plan  of  the  U.  S.  P.  is  inclusion  of  the 
structural  formula  of  organic  chemicals. 

Percentage  solutions  are  defined.  For  solution 
of  solids  in  a  liquid  the  weight  in  volume  (w/v) 
is  selected,  i.e.,  for  a  1%  solution  in  1  oz.,  4yi 
grains  are  dissolved  in  sufficient  of  the  solvent  to 
make  one  fluid  ounce.  Percentage  solutions  of 
fluids  are  volume  in  volume. 

There  is  also  described  an  official  medicine  drop- 
per. The  dropper  shall  have  at  its  delivery  end  an 
external  diameter  of  3  mm.  and  adjusted  to  deliver 
20  drops  of  distilled  water  that  shall  weigh  1  Gm. 
at  15°  C.  A  tolerance  of  10%  above  or  below  is 
allowed. 

There  are  standards  set  for  Vitamins  A  and  D 
together  with  methods  of  assay.  Methods  for 
standardization  of  products  used  in  the  treatment 
of  pernicious  anemia  are  provided  for  by  the  estab- 
lishment of  the  U.  S.  P.  antianemia  Preparations 
Advisory  Board  which  shall  set  standards  for  this 
type  product. 

The  Pharmacopjeal  Committee  will  issue  at  inter- 
vals new  standards  as  better  information  is  ob- 
tained, probably  every  year. 

Some  of  the  more  commonly  used  pharmaceuti- 
cals have  been  given  new  titles,  in  most  instances 
very  similar  to  the  old.  A  few  examples:  Acet- 
phenitidin  is  now  Acetophenitidin ;  Chloramine  is 
now  Chloramine  T;  Compound  Solution  of  Cresol 
is  now  Saponated  Solution  of  Cresol;  Iron  and 
Ammonium  Citrate  is  now  Iron  and  Ammonium 
Citrates;  Pituitary  is  now  Posterior  Pituitary. 

Many  other  changes  will  be  noticed  in  the  U.  S. 
P.  brought  up  to  date.  The  N.  F.  VI  has  in  it 
many  new  articles,  some  of  which  will  be  discussed 


later. 

Note. — A  good  deal  of  the  matter  in  this  article  had 
come  in  from  Dr.  F.  R.  Taylor  and  been  set  up  for  this 

issue. — /.  M.  N. 

S.   M.   *;  6. 

The   Treatment   of   Trichophytosis    Interdigitaxis 
(L.  N.   Elson,  New  Orleans,   in   Urol.  &  Cuta.   Rev.,  Oct.) 

The  treatment  consists:  1)  in  moistening  with  clean 
water  the  skin  around  the  affected  toes  and  the  toes  next 
to  them;  2)  in  sprinkling  between  and  around  the  toes  a 
small  quantity  of  sodium  perborate;  3)  in  slightly  mois- 
tening the  perborate  and  leaving  it  exposed  to  the  air  for 
5  minutes;  then  4)  with  a  wet  gloved  finger  in  slowly  and 
gently  rubbing  it  in  and  adding  gradually  small  quantities 
of  water  until  it  is  all  washed  away.  The  gentle,  2-  to  3- 
minute  friction  has  the  best  effect.  The  first  treatment 
should  be  an  office  procedure.  Then  the  patient  should  be 
instructed  to  supplement  the  treatment  with  frequent 
sprinkling  with  dry  talcum  powder  (no  admixture  of  rice 
powder  or  orris  root).  Any  of  the  bismuth  salts  (best  of 
all,  bismuth  formic  iodide)  or  precipitated  chalk.  Itching 
often  is  intense  for  a  few  minutes.  ReUef  after  is  really 
spectacular. 

The  treatment  should  be  repeated  if  and  when  the  itch- 
ing comes  back,  once  a  day  or  once  a  week.  As  a  rule  2 
to  4  treatments  complete  a  cure.  Observe  hygienic  meas- 
ures as  to  change  of  socks  and  sterilizing  the  bed  clothes. 

An  infallible  prescription  for  the  secondary  or  pustular 
stage  is  this: 

R 

Phenolis  Liquefacti  10  drops. 

Balsam  Peruvianae, 

Calcii  Carbonatis  Precipitatis, 

Zinci  Oxidi,  of  each,  one  dram, 

Petrolati  (no  lard)   q.s.  one  ounce. 

M.  Sig.:     Apply  twice  daily. 

No  soap  on  the  affected  parts  except  occasionally  mild 
castile.  For  the  most  part  he  should  apply  the  ointment  on 
top  of  the  former  application  In  the  morning  after  anoint- 
ing, the  patient  may  sprinkle  on  top  a  good  bit  of  talcum 
powder  to  lessen  the  soiling  of  the  footwear. 

The  procedure  is  continued  until  after  the  toes  and  foot 
are  completely  well. 

Tertiary  stage  of  painful  ulceration  and  excoriation  of 
of  the  skin  and  disseminated  foci  of  necrosis  of  subcutane- 
ous tissues. 

R 

Zinc  Sulph.  2  drams. 

Olei  Menth.  Pip.  10  drops 

.^lumini  Sulph  6  drams. 

Acidi  Borici  3  ounces. 

M.  Sig.:  Teaspoonful  to  glass  (8  ounces)  of  warm  wa- 
ter.   Apply  every  8  hours. 

Instruct  the  patient  to  saturate  pads  of  gauze  or  cotton 
with  this  solution  and  apply  all  around  the  toes  and  af- 
fected parts  of  foot  and  keep  these  pads  saturated  by  fre- 
quently adding  some  of  the  same  warm  solution.  After  8 
hours  the  pads  are  changed  and  a  fresh  solution  used. 
This  should  be  kept  up  for  a  few  days,  then  there  should 
be  a  few  hours'  intermission  between  applications  with 
exposure  of  the  foot  to  the  open  air  and,  for  short  periods, 
to  the  sunshine. 

When  the  epithelization  is  complete,  the  treatment  is  dis- 
continued. If  a  few  purulent  spots  persist  apply  the  oint- 
ment as  in  the  second  stage. 


Your  Druggist:     Ask  him  to  advise  against  taking  pur- 
gatives in  the  presence  of  pain  in  the  belly. 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  103 


GENERAL  PRACTICE 

WncoATB  M.  JoBKtOM,  M.D.,  Editor,  Winston-Salem,  N.  C. 


read  it.  It  is  the  greatest  novel  I  have  read  in  a 
decade.  After  reading  it,  almost  any  other  story 
would  have  fallen  flat. 


The  Doctor, 
by  Mary  Roberts  Rinehart  (Farrar  and  Rinehart, 
New  York,  $2)  does  not  measure  up  to  the  stand- 
ard set  by  that  talented  lady.  It  portrays  the 
struggle  for  professional  success  of  a  brilliant  young 
doctor,  beginning  with  the  end  of  his  hospital  res- 
idency in  1910  and  ending  soon  after  the  World 
War.  Like  all  of  her  stories,  there  are  no  breaks 
in  medical  technique,  and  it  gives  to  the  layman  a 
graphic  picture  of  the  sacrificial  life  a  conscientious 
doctor  must  lead — the  long  working  hours,  the  loss 
of  sleep,  the  irregular  meals  and  the  enormous 
amount  of  gratis  work  to  be  done. 

It  seems  to  me,  however,  that  the  hero,  Noel 
(Chris)  Arden  is  entirely  too  idealistic  and  im- 
practical to  be  natural.  To  begin  with,  he  engaged 
an  office  and  living  quarters  in  the  slovenly  home 
of  a  typical  "poor  white  trash"  family.  He  spurn- 
ed the  love  of  Miss  Beverly  Lewis,  the  only  daugh- 
ter of  the  town  millionaire,  because  her  father's 
money  was  tainted,  although  he  was  madly  in  love 
with  her — as  if  she,  poor  thing,  could  help  her 
father's  cupidity.  He  married  Katie  Walters,  the 
shallow-pated  daughter  of  his  landlord  and  land- 
lady, after  they  both  had  died,  because  he  did  not 
know  how  else  to  get  rid  of  her;  and  ever  after  she 
was  a  millstone  around  his  neck.  Service  in  the 
World  War  gave  him  a  little  vacation  from  her, 
but  when  he  returned  he  found  her  worse  than 
ever — extravagant,  social-climbing,  liquor-drinking, 
a  typical  post-war-era  product. 

Their  marriage  ended  in  divorce  after  Katie,  in 
a  half-drunken  rage,  wrecked  one  of  her  cars  with 
him  in  it  and  thought  he  could  no  longer  make 
money  for  her  because  the  right  musculo-spiral 
nerve  was  cut.  The  story  ended  rather  melodra- 
matically. Beverly,  now  a  widow — came  back 
to  him  and  asked  him  to  marry  her.  He  refused, 
thinking  his  career  was  ended.  Soon  afterwards, 
however,  the  nerve,  which  had  been  sutured,  once 
more  came  to  life,  and  he  rushed  back  to  her,  arriv- 
ing just  in  time  to  find  her  almost  dead  after  an 
operation  for  ruptured  duodenal  ulcer — and  to  re- 
vive her  by  his  presence  and  the  assurance  of  his 
love.  It  is  to  be  presumed  that  they  lived  happily 
ever  thereafter — though,  with  his  genius  for  saying 
and  doing  the  wrong  thing,  I  doubt  it. 

Perhaps  one  reason  I  found  this  tale  so  disap- 
pointing was  that  I  had  just  finished  Gone  With 
the  Wind,  by  Margaret  Mitchell  (Macmillan,  $3— 
and  worth  more) .  There  is  a  story  that  is  destined 
to  take  its  place  with  the  world's  classics.  Doubt- 
less most  of  you  have  heard  of  it,  and  many  have 


Screw  Worm  Intfestation 
(W.    R.   Wallace,   Chester,  in  Jl.   S.   C.    Med.   Assn.,  Sept.) 

This  worm  does  not  bur>-  itself  completely  in  the  tissue 
and  therefore  it  is  very  seldom  that  enlargement  or  cutting 
is  necessary.  The  blunt  rear  end  remains  in  contact  with 
air,  as  the  breathing  apparatus  is  situated  there  and  appears 
as  two  brownish  plates.  The  worms  lie  usually  side  by 
side,  somewhat  like  cavities  in  honeycomb.  There  seems 
to  be  a  slight  rotary  motion  as  the  worms  busy  themselves 
with  their  destructive  feeding. 

The  symptoms  are  so  characteristic  that  when  this  con- 
dition is  placed  on  your  ever  increasing  hst  of  probable 
diagnoses,  a  correct  diagnosis  is  very  easy.  In  easily  ac- 
cessible wounds  the  worms  are  readily  seen.  In  the  nasal 
cavity  when  they  develop  rather  high  up  the  view  may  be 
obscured  by  partially  dried  secretion.  After  a  cleansing 
solution  the  nasal  speculum  brings  them  well  in  view. 

The  treatment  consists  of  mopping  away  the  secretions 
with  gauze  or  cotton,  cleansing  with  pero.xide  of  hydrogen 
and  irrigating  with  boric  acid  solution  or  1:2000  potassium 
permanganate.  This  is  done  to  reduce  the  disagreeable 
odor  and  to  remove  the  secretions  which  attract  the  flies 
and  encourage  another  deposit  of  eggs.  The  wound  is  light- 
ly packed  with  gauze  saturated  with  benzol  so  that  the 
fumes  are  inhaled  by  the  insects. 

Discussion:  Dr.  Jas.  A.  Hayne,  Columbia: 

In  this  State  we  have  no  record  of  having  fatal 
infestation  of  a  human  being  by  screw-worm  larvae  before 
last  year.  Characteristic  of  the  screw-worm  blow-fly  is  it 
has  a  red  head  and  three  white  stripes  on  its  back.  It  will 
lay  its  eggs  whenever  it  can  find  blood.  This  fly  lays  its 
eggs  rapidly;  they  hatch  within  4  hours,  under  favorable 
circumstances  and  develop  a  screw  worm. 

The  prevention  of  screw-worm  infestation  is  simple. 
Paint  fresh  wounds  with  pine  oil.  The  odor  of  the  pine 
oil  repels  the  fly. 

s.  M.  &  s. 

The  Variable  Ausculatory  Signs  of  Pulmonary  Cavities 

(R.    A.     Bendove,    New    York    City,    in    Radiologic    Rev., 
Sept.) 

In  3S0  cases  of  pulmonary  cavities  studied  at  hospitals, 
I  found  that  246  lack  most,  if  not  all,  of  the  classic  aus- 
cuhatory  signs  of  cavitation.  However,  these  findings  in 
no  way  disparage  the  diagnostic  importance  of  the  steth- 
oscope, but  merely  point  to  the  necessity  of  revising  ac- 
cepted physical  signs  of  cavities  and  their  probable  mech- 
anism. Whereas  pectoriloquy  and  amphoric  breathing  may 
be  heard  over  an  old  fibroid  lesion  which  is  of  little  clinical 
significance,  ver\-  scanty  signs  may  be  elicited  over  an 
active  pulmonary  cavity.  Of  the  246  cases  which  lacked 
cavernous  breathing,  36  revealed  no  inkling  of  the  pres- 
ence of  any  pulmonary  lesion,  but  the  rest  of  the  cases 
manifested  certain  helpful  adventitious  signs. 

Of  350  cases  of  pulmonary-  cavities,  only  104  (29.7%) 
exhibited  cavernous  breathing;  33  (9.4%)  gave  no  inkling 
whatsoever  as  to  the  presence  of  a  pulmonary  lesion;  177 
(50.6%)  lacked  the  cavernous  sound  but  manifested  their 
presence  through  other  adventitious  signs,  and  36  (10.3%) 
were  intermediate,  i.e.,  at  times  were  absolutely  silent  to 
auscultation  and  at  other  times  revealed  themselves  by  cer- 
tain stethoscopic  signs. 

The  most  significant  and  common  signs  of  early  cavi- 
tation are  modified  breath  sounds  and  localized  coarse  rales 


I 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


SS5 


heard  on  ordmar>'  inspiration.  Such  cavities  have,  as  a 
rule,  soft  and  yielding  walls  which  are  easily  amenable  to 
coUapse  therapy.  Cavernous  breathing  generally  indicates 
an  older  cavity,  be  it  tuberculous,  or  non-tuberculous  with 
fibrosed  rigid  walls  which  render  it  refractory  to  medical 
treatment;  only  radical  surgery  is  able  to  close  completely 
such  a  cavity.  The  absolutely  mute  cavities  can  be  diag- 
nosed only  by  roentgenology ;  they  are  the  least  frequent 
and  usually  have  a  fair  prognosis. 


RADIOLOGY 

Wright  Clabison,  M.D.,  and  Allen  Bakiek,  M.D., 
Editors,  Petersburg,  Va. 


Has  Iso-Iodeikon  or  Diodrast  Any  Therapeu- 
tic Value? 

In  September,  1929,  one  of  us  (W.  C.)  exam- 
ined the  gallbladder  of  a  60-year-old  man  follow- 
ing the  intravenous  administration  of  tetiothalein 
sodium  (iso-iodeikon),  and  since  the  gallbladder 
shadow  was  extremely  faint,  the  patient  was  re- 
quested to  return  in  a  few  days  for  reexamination. 
He  did  not  appear  at  the  appointed  hour  and  a 
phone  call  brought  forth  the  declaration  that  the 
medicine  (iso-iodeikon)  had  greatly  relieved  his 
indigestion,  gas  and  other  disagreeable  symptoms, 
and,  therefore,  he  did  not  think  it  necessary  to 
repeat  the  injection. 

Since  having  this  experience,  we  have  questioned 
a  number  of  patients  about  any  relief  of  symptoms 
they  may  have  experienced  following  the  adminis- 
tration of  iso-iodeikon  and  many  have  claimed 
some  improvement  in  their  symptoms;  but  most  of 
these  patients  were  treated  by  their  respective  fam- 
ily physicians  immediately  following  the  adminis- 
tration of  iso-iodeikon  by  us  (for  purposes  of  ex- 
amination) and  we  can  draw  no  definite  conclusions 
from  these  cases. 

Nickel*  made  a  careful  study  of  the  effect  of 
tetiothalein  sodium  on  bacteria  and  reported  that 
it  has  a  decided  bacteriostatic  action  on  staphy- 
lococcus albus  and  on  the  various  forms  of  strep- 
tococci usually  associated  with  infections  of  human 
beings. 

Kirklin-  has  reported  an  amelioration  of  symp- 
toms of  gallbladder  disease  following  the  adminis- 
tration of  tetiothalein  sodium. 

Since  tetiothalein  sodium,  administered  to  a  pa- 
tient, comes  in  direct  contact  with  every  active  liver 
cell  and  bile  duct,  and  since  the  preparation  con- 
tains a  fairly  large  percentage  of  chemically  com- 
bined iodine,  it  seems  logical  to  believe  that  its 
proper  administration,  over  a  sufficient  length  of 
time,  may  prove  beneficial  in  the  treatment  of 
certain  infections  of  the  biliary  tract. 

A  similar  assumption  is  logical  as  to  the  possi- 
bility  of   some  effect   on   urinary   infections   from 


the  use  of  the  various  contrast  media  used  by 
radiologists  in  intravenous  pyelography.  These 
preparations  are  excreted  almost  entirely  by  the 
kidneys  and  all  of  them  contain  a  relatively  high 
percentage  of  chemically  combined  iodine.  With 
these  possibilities  in  mind,  we  have  recently  ques- 
tioned certain  patients  as  to  any  relief  of  urinary 
symptoms  following  the  intravenous  injection  of 
these  preparations  in  cases  sent  to  us  for  intra- 
venous pyelography.  Two  patients  seem  to  have 
been  benefited,  but  it  is  quite  possible  that  other 
factors  may  have  contributed  to  the  results  in 
these  cases;  however,  only  one  injection  was  made 
in  each  case  and  we  have  not  attempted  seriously 
to  treat  these  cases  by  repeated  injections  of  these 
preparations. 

The  earlier  contrast  preparations  used  in  intra- 
venous pyelography  were  quite  irritating  and  caus- 
ed moderately  severe  reactions  in  some  patients, 
but  those  now  in  popular  use  by  radiologists  are 
practically  non-irritating.  It  would  seem  unwise, 
however,  to  give  large  doses  or  to  prolong  unduly 
the  administration  of  even  the  more  modern  prep- 
arations in  cases  with  relatively  poor  kidney  func- 
tion. 

The  administration  of  large  doses  of  iso-iodeikon 
in  cases  of  jaundice  is  contraindicated  and  the  pro- 
longed administration  of  the  preparation  in  any 
condition  may  eventually  prove  to  be  a  burden  to 
the  liver.  With  these  exceptions,  however,  iso- 
iodeikon  is  a  reasonably  safe  preparation  to  ad- 
minister either  orally  or  intravenously. 

The  value  of  iso-iodeikon  in  the  treatment  of 
gallbladder  conditions  and  of  the  various  contrast 
media  in  the  treatment  of  urinary  infections  must 
be  determined  by  further  trial.  Our  experiences 
are  mentioned  here  only  in  the  hope  of  stimulating 
others  to  try  out  these  preparations  therapeutically, 
with  great  caution  and  in  cases  in  which  the  chance 
of  doing  harm  is  minimal.  In  this  way,  their  ther- 
apeutic value,  or  lack  of  value,  may  be  more  accu- 
rately determined. 

References 

1.  Nickel,  A.  C:  Tetiothalein  Sodium-N.  N.  R.  as  an 
Antiseptic  and  a  Germicide  of  the  Biliary  Tract.  Jl. 
of  Pharmac.  and  Exp.  Ther.,  37,  359-366,  Nov.,  1929. 

2.  KiRKLiN,  B.  R.:  Discussion  of  article  by  Allen  C. 
Nickel.  Proceedings  of  the  Staff  Meetings  of  the  Mayo 
Clinic,  4,  178-179,  1929. 


Identification  of  the  Cancer  Ceil 
(W.  C.  MacCarty,  Rochester,  Minn.,  in  Jl.  A.  M.  A., 
Sept.  12th) 
Are  we  recognizing  cancer  early?  In  1918  I  began  a 
series  of  observations  to  determine  just  what  effect  cancer 
campaigns  were  having  on  the  sizes  of  cancers  being  re- 
moved surgically.  These  figures  have  not  changed  appre- 
ciably over  a  period  of  14  years.  There  has  been  little  or 
no  change  in  the  average  size  or  percentage  of  those  hav- 
ing glandular  involvement  in  this  same  period. 


556 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


The  pathologist  technical  methods  of  study  of  tissues 
have  changed  little  since  the  time  of  Virchow.  Medical 
students  today  rarely  if  ever  see  unfixed  tissues;  they  get 
their  knowledge  from  the  same  type  of  microscopic  sec- 
tions that  were  looked  at  by  students  40  years  ago. 

In  1907  I  began  the  study  of  fresh,  unfixed,  unembedded, 
surgically  removed  tissues  with  and  without  stains.  It 
was  not  ver>-  long  before  I  recognised  that  cancer  cells 
were  not  irregular  in  shape  and  size  or  even  pyknotic  as 
described  in  textbooks;  neither  did  they  contain  asym- 
metrical mitotic  figures.  Living  and  unfixed  and  unem- 
bedded fresh  cancer  cells  were  found  to  be  beautifully 
ovoidal  or  spheroidal  and  to  contain  one  or  more  large 
nucleoli,  which  are  rarely  visible  in  fixed  and  embedded 
postmortem  material.  The  nucleoli  were  much  larger  in 
such  maUgnant  cells  than  in  reparative  regenerative  cells 
with  which  they  might  be  confused  with  low  powers  of 
the  microscope. 

The  nucleoli  of  cancer  cells  are  much  larger  than  those 
in  any  other  condition  of  cells  of  a  given  tissue.  Patholo- 
gists must  study  perfectly  fresh  tissues  without  embedding 
if  they  expect  to  recognize  cancer  before  it  reaches  the 
late  stage  of  being  recognized  with  the  low  powers  of  the 
microscope. 

Wherever  the  ratios  have  been  studied  the  malignant 
cells  have  always  large  nucleoli  by  which  they  can  be 
identified  as  malignant  cells. 

Opinions  based  on  failure  to  confirm  these  facts  in  fixed 
tissues  that  are  not  fresh  and  not  embedded  are  not  only 
of  no  value  but  will  impede  progress  in  the  early  recogni- 
tion of  cancer. 

The  cancer  cell  has  identifying  characteristics.  Histology 
of  the  past  and  present  and  modem  cytology  are  two  very 
different  sciences  with  quite  different  technics  requiring  a 
somewhat  different  training,  yet  to  be  recognized  by  gen- 
eral pathologists  and  taught  by  them  to  modem  medical 
students. 

Until  medical  students  are  taught  this  newer  method,  we 
cannot  expect  cancer  to  be  recognized  early. 


UROLOGY 

Robert  W.  McKay,  M.D.,  Editor,  Charlotte,  N.  C. 


Concerning  Urethral  Strictures 
Urethral  strictures  are  caused  by  scar  tissue 
replacing  the  normal,  elastic  spongy  corpus  spongi- 
osum which  surrounds  the  penile  portion  of  the 
urethra.  The  inciting  cause  may  be  infection  (gon- 
ococcal or  non-specific),  traumatic  (rupture  of  the 
urethra  from  any  cause,  laceration  by  instruments, 
or  injection  of  strong  chemicals).  The  general 
practitioner  as  well  as  the  urologist  is  sadly  fa- 
miliar with  the  so-called  filiform  urethral  stricture. 
We  see  very  few  filiform  strictures  at  the  present 
time  in  comparison  with  former  days,  yet  a  few 
such  cases  produce  enough  trouble  to  last  the  aver- 
age doctor  a  lifetime.  They  occur  in  the  ignorant 
classes  through  neglect  or  self-treatment,  the  patient 
in  such  cases  waiting  until  the  scar  tissue  surround- 
ing the  urethra  has  contracted  down  to  such  a 
point  that  only  a  whalebone  filiform  will  pass 
through.    The  final  attack  of  acute  retention  usually 


has  its  unfortunate  termination,  in  our  sad  ex- 
perience, about  two  or  three  o'clock  in  the  morn- 
ing, the  patient  having  had  previous  difficulty  in 
urinating  for  about  two  days.  Those  of  us  practic- 
ing in  the  South  see  many  cases  among  the  igno- 
rant Negroes  who  have,  as  is  well  known,  a  natural 
propensity  to  keloid  formation. 

The  so-called  loose  stricture  which  usually  pro- 
duces the  much-written-about  morning  drop  or  gout 
militaire  does  not  present  many  difficulties.  It  is 
quite  simple  to  cocainize  the  urethra  and  pass  in- 
creasingly large-size  sounds.  The  passage  of  sounds 
in  such  cases  will  break  up  the  scar  tissue,  afford 
free  drainage  of  the  urethra  and  the  morning  drop 
disappears. 

The  filiform  stricture,  however,  presents  a  very 
acute  problem  and  is  often  mishandled.  It  is  quite 
a  mistake  when  a  urethral  instrument  is  passed  and 
encounters  such  a  condition  to  forcibly  try  to  dis- 
tend the  urethral  canal.  If  a  slight  amount  of 
pressure  does  not  cause  the  instrument  to  pass 
through  the  strictured  portion  it  should  be  imme- 
diately withdrawn  and  a  filiform  should  be  inserted 
as  a  guide,  followed  by  a  hollow  instrument  which 
acts  as  both  dilator  and  catheter.  If  force  has 
previously  been  used,  flaps  of  mucous  membrane 
are  torn  away  from  the  distal  portion  of  the  stric- 
ture and  forced  down  into  the  pin-point  opening. 
In  this  manner,  if  previous  force  has  been  used  in 
sounding,  the  hole  through  which  the  filiform  should 
pass  is  already  closed  with  a  flap  of  mucous  mem- 
brane and  affords  quite  a  problem  indeed. 

There  are  certain  practical  points  of  technique  in 
getting  through  filiform  urethral  strictures  which  we 
wish  to  bring  before  those  who  are  not  already 
acquainted  with  their  use. 

The  filiform  itself  should  be  of  the  female  type 
in  which  the  steel  portion  of  the  instrument  is 
screwed  into  the  filiform  instead  of  the  filiform 
being  screwed  into  the  steel  instrument,  for  the 
latter  type  is  more  subject  to  breakage  at  the  stric- 
ture, leaving  the  filiform  in  situ  in  the  urethra 
much  to  the  consternation  of  the  operator.  The 
end  of  the  filiform  should  not  be  too  large  but 
should  taper  and  not  be  too  flexible  for  very  often 
to  the  uninitiated  instead  of  passing  through  the 
stricture  the  filiform  will  buckle  and  curl  up  in  the 
urethra  and  if  a  follower  is  passed  under  such  con- 
ditions the  urethra  will  be  severely  traumatized. 
To  prevent  this  occurring,  after  passing  the  filiform, 
the  end  should  be  released;  if  it  is  in  the  bladder 
it  will  stay  in  situ.  If  it  is  not  through  the  stric- 
ture, the  curled-up  portion  will  act  as  a  spring  and 
force  the  filiform  slowly  out  of  the  end  of  the  penis. 
In  very  tight  filiform  strictures  sometimes  it  is  im- 
possible to  immediately  pass  anything  at  all  through 
the  stricture.    In  such  cases  we  have  found  it  often 


October,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


effective  to  pass  not  one  but  as  many  as  three  or 
four  filiforms.  By  doing  this  the  filiforms  act  as  a 
splint  one  against  the  other  and  prevent  buckling. 
If  there  are  false  passages  present  (produced  by 
former  traumatic  instrumentation)  some  of  the  fili- 
forms will  fill  up  the  false  passages  and  allow  the 
one  which  hits  the  aperture  of  the  stricture  itself 
to  pass.  When  using  this  technique  one  should  move 
the  filiforms  in  sequence,  first  trying  one  then  the 
other.  Under  such  conditions  also  it  is  sometimes 
helpful  to  gently  fill  the  urethra  with  sterile  olive 
oil  so  as  to  balloon  out  that  portion  which  lies  in 
front  of  the  stricture.  In  this  way  a  cid  dc  sac  is 
formed  with  the  stricture  lying  at  its  bottom.  It 
also  helps  with  the  lubrication. 

In  cases  in  which  nothing  could  be  passed  we 
have  seen  some  individuals  employ  olive  oil  and 
an  anesthetic  and  by  forcing  this  solution  through 
the  stricture  dilate  it  by  hydraulic  pressure.  We 
also  have  the  sad  recoUection  of  two  young  indi- 
viduals who  suddenly  passed  away  under  such  treat- 
ment. It  must  not  be  forgotten  that  where  the 
corpus  spongiosum  joins  the  stricture  it  is  quite 
easy  to  tear  it,  and  if  this  is  done  fluid  injected 
under  pressure  can  be  forcibly  thrown  into  the 
blood  stream;  and,  unquestionably  the  two  indi- 
viduals who  passed  away  died  of  oil  emboli.  It  is 
also  not  to  be  forgotten  that  all  strictures  are  in- 
fected and  it  is  quite  easy  through  using  too  much 
force  or  injecting  solutions  to  force  infection  into 
the  blood  stream  and  cause  the  so-called  urethral 
chills  (transitory  bacteremias)  which  are  so  dis- 
tressing. In  some  instances  where  the  stricture  was 
so  tight  that  we  feared  to  dilate  with  a  steel  in- 
strument, a  filiform  ureteral  catheter  has  been 
passed  into  the  bladder  and  the  bladder  allowed 
to  empty  itself  either  by  aspirating  the  ureteral 
catheter  with  a  glass  syringe  and  needle  or  allow- 
ing it  to  decompress  itself  drop  by  drop.  We  are 
often  amused  by  advice  from  others  of  the  pro- 
fession that  the  simple  way  to  pass  a  filiform  is  to 
insert  an  endoscope,  view  the  opening  in  the  stric- 
ture and  actually  catheterize  it  with  the  filiform  as 
one  would  do  a  ureter.  The  unfortunate  part  about 
this  procedure  is  that  most  general  practitioners 
do  not  have  an  endoscope  and  fewer  still  know 
how  to  properly  use  one.  We  have  tried  this  pro- 
cedure repeatedly  and  have  never  been  able  to 
pass  a  filiform  in  this  manner  in  any  patient  in 
which  we  could  not  pass  one  by  filling  the  urethra 
with  multiple  filiforms.  Filiform  strictures  should 
not  be  dilated  at  the  first  sitting  above  a  No.  14 
or  No.  16  F.  If  possible,  after  dilating  them  up 
to  this  calibre,  a  small  urethral  catheter  should  be 
introduced  into  the  bladder.  If  this  is  allowed  to 
remain  in  the  urethra  for  forty-eight  hours,  on 
withdrawing  it  the  operator  will  be  very  much  sur- 


prised to  find  that  the  scar  tissue  of  the  stricture 
has  been  greatly  softened  and  he  is  now  able  to 
dilate  it  usually  to  No.  18  or  No.  20  F.  with  very 
little  reaction. 

In  these  modern  times  with  a  local  hospital  at 
the  disposal  of  the  vast  majority  of  modern  doctors 
we  think  it  ine.xcusable  to  do  a  suprapubic  puncture 
with  trocar.  After  all  attempts  at  passing  a  fili- 
form have  failed  it  is  much  beter  to  take  the  patient 
to  the  hospital  and  do  a  small  midline  suprapubic 
incision.  The  peritoneum  will  be  found  to  have 
been  pushed  up  by  the  distended  bladder  and  it  is 
a  simple  matter  to  make  a  stab  wound  and  insert 
a  suprapubic  DePezzer  catheter.  In  doing  this  the 
operator  should  not  forget  that  if  the  bladder  is 
greatly  distended  the  urine  should  be  evacuated 
slowly,  as  occasionally  if  the  patient  is  already. in 
bad  condition  the  sudden  release  of  a  large  amount 
of  urine  will  produce  profound  shock.  We  occa- 
sionally see  such  cases  in  which  the  perineal  type 
of  operation  has  been  tried.  To  those  perfectly 
familiar  with  the  anatomy  of  the  perineum  and  who 
are  accustomed  to  doing  perineal  surgery  it  is  not 
difficult,  but  to  those  who  are  not  perfectly  familiar 
with  the  perineum  the  suprapubic  route  affords 
many  less  dangers. 

In  strictures  which  have  progressed  to  peri- 
urethral abscess  formation,  rupture  of  the  urethra 
and  extravasation  of  urine,  wide  incisions  should 
be  made  in  the  extravasated  areas  and  the  bladder 
should  always  in  such  cases  be  drained.  No  at- 
tempt should  be  made  to  reestablish  the  urethral 
canal  until  the  slough  caused  by  the  extravasation 
has  separated  and  the  wounds  have  acquired  a 
healthy  appearance. 

Internal  urethrotomies  done  by  the  sliding  knife 
of  Maisonneuve  are  not  as  simple  as  they  appear 
to  be  and  should  seldom  be  employed.  Most  stric- 
tures can  be  dilated  by  use  of  an  indwelling  cathe- 
ter up  to  any  calibre  desired.  If  the  stricture  band 
is  severed  by  the  sliding  knife,  at  the  point  of 
severance  scar  tissue  will  again  make  its  appearance 
and  the  urethra  will  have  to  be  subsequently  dilated 
anyway.  The  dangers  of  postoperative  hemorrhage 
and  septicemia  are  greatly  enhanced  by  the  use  of 
this  operative  technique,  and,  in  our  opinion,  it 
should  not  be  employed  except  in  very  exceptional 
cases.  A  patient  who  has  had  a  filiform  stricture 
should  report  to  his  doctor  every  sLx  months  any- 
way. 

A  few  years  ago  we  performed  quite  a  few  opera- 
tions for  reestabllshment  of  the  urethral  canal 
where  it  was  obliterated  by  long  strictured  areas 
by  perineal  section,  passing  a  sound  down  to  the 
point  of  stricture,  opening  the  urethra  at  the  point 
of  the  sound,  at  the  same  time  dividing  the  stric- 
tured area  and  dissecting  out  the  scar  tissue,  leaving 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


a  strip  of  mucous  membrane  behind.  The  bulbous 
portion  of  the  urethra  was  then  picked  up  and  a 
No.  16  catheter  passed  through  the  meatus  of  the 
urethra  down  the  canal  and  into  the  bladder  in 
such  a  manner  that  it  lay  against  the  strip  of  mu- 
cous membrane  that  was  formerly  the  urethra.  The 
loose  tissues  were  then  brought  over  this  catheter 
with  a  running  continuous  suture  of  No.  1  chromic 
catgut.  The  catheter  was  allowed  to  remain  in 
place  for  ten  days.  At  the  end  of  this  period  it 
was  changed  and  a  new  catheter  inserted  and  al- 
lowed to  stay  in  a  week  more.  At  the  expiration 
of  this  time  the  strip  of  mucous  membrane  left  be- 
hind would  completely  encircle  the  catheter  and 
thus  one  would  have  a  new  urethral  canal. 

Such  an  operation  is  entirely  workable  in  an  ed- 
ucated person,  but  the  crux  of  the  matter  lies  in 
the  fact  that  educated  upper  classes  do  not  allow 
themselves  to  have  obliterations  of  portions  of  the 
urethra.  Most  of  the  morons  on  whom  this  oper- 
ation was  done  voided  all  right  for  two  or  three 
months,  never  came  back  for  subsequent  dilata- 
tions, and  finally  returned  four  or  five  months  later 
at  which  time  they  illustrated  perfectly  the  quo- 
tation "the  latter  end  is  become  worse  with  them 
than  the  first."  In  some  of  these  individuals 
after  one  or  two  such  sad  experiences  we  have 
ended  up  by  bringing  the  urethra  out  into  the 
perineum  and  comforting  the  patient  by  telling 
him  it  was  better  to  void  sitting  down  than  not  to 
void  at  all. 

After  a  few  years  of  experience  in  dealing  with 
the  surgical  treatment  of  strictures  we  are  reminded 
of  the  old  maxim  that  we  were  taught  as  students 
that  frequently  "the  operation  should  be  fitted  to 
the  individual  and  not  the  individual  fitted  to  the 
operation." 

Some  time  ago  we  were  sitting  in  at  the  hearing 
of  an  industrial  commission.  The  case  which  came 
up  previous  to  the  one  in  which  we  were  inter- 
ested concerned  a  young  man  who  had  been  in  an 
automobile  wreck  and  fractured  his  pelvis  with  a 
traumatic  severance  of  the  urethra.  The  physician 
who  had  handled  his  case  apparently  had  done  an 
excellent  job  as  the  patient  was  able  to  void,  al- 
though his  stream  was  small  and  he  required  inter- 
mittent dilatation.  The  question  came  up  as  to 
whether  or  not  the  individual  was  permanently 
disabled  and  we  were  surprised  to  hear  opinions 
stating  that  since  he  could  void  all  right  and  the 
continuity  of  the  urethra  had  been  established  he 
was  fit  and  ready  for  work.  In  our  experience 
traumatic  ruptures  of  the  urethra,  with  their  fre- 
quent post-traumatic  stricture  formation,  probably 
are  the  most  difficult  of  all  to  permanent  cure. 

.^t  the  point  of  rupture,  whether  or  not  the 
urethra  has  been  surgically  anastomosed,  an  im- 


mense amount  of  scar  tissue  formation  takes  place. 
When  this  scar  tissue  contracts  the  stricture  is 
formed  and  because  of  the  anatomy  of  the  parts 
it  generally  lies  immediately  against  the  external 
urinary  sphincter.  Such  strictures  are  very  dense 
when  allowed  to  contract  down  to  pin-point  size; 
they  are  extremely  difficult  to  treat  instrumentally, 
and  frequently  require  care  the  rest  of  the  patient's 
life. 

Almost  the  same  may  be  said  of  those  unfortu- 
nate individuals  who,  from  ignorance,  fear  or 
drunken  befuddlement,  fill  their  urethras  with 
iodine,  lysol,  strong  mixtures  of  potassium  perman- 
ganate, or  other  caustic  chemicals  as  a  prophylactic 
measure.  Such  individuals  swap  a  short  symbiosis 
with  the  naughty  gonococcus  for  a  life  of  contin- 
uous misery.  The  mucous  membrane  of  the  urethra 
is  destroyed  in  its  entirety  and  the  whole  lining  is 
passed  as  a  cast  and  in  its  place  contracting  scar 
tissue  causes  almost  a  complete  atresia  of  the 
whole  canal.  Such  patients  are  doomed  to  inter- 
mittent dilatations  the  rest  of  their  lives  if  they 
wish  to  void  through  the  penile  meatus. 

The  keystone  of  the  treatment  of  strictures  of 
the  urethra  is  unquestionably  patience  and  pity- 
first  of  all  for  and  wth  the  ignorance  of  the  types 
of  individuals  who  allow  these  strictures  to  be- 
come filiform.  The  average  physician  certainly 
should  pray  for  more  of  it,  especially  at  three 
o'clock  in  the  morning  in  dealing  with  charity 
cases.  Secondly,  patience  in  spending  an  hour  or 
more  in  gently  attempting  to  get  the  first  filiform 
by,  for  very  frequently  if  one  has  patience  and 
perseverance  he  will  pass  a  filiform  after  many, 
many  attempts.  After  the  filiform  is  passed  into  the 
bladder  the  battle  is  won — until  the  patient  allows 
it  to  contract  down  again  through  his  neglect,  at 
which  time  more  patience  and  pity  and  filiforms 
will  have  to  be  expended. 


Premature  Ejaculations 
(J.  L.  Pritcher,  Los  Angeles,  in  Urol.  &  Cuta.  Rev.,  Oct.) 

All  organic  lesions  and  endocrine  deficiencies  should  be 
taken  care  of.  The  patient  -must  be  reassured  that  the 
condition  can  be  helped.  Common  sense  and  some  knowl- 
edge of  psychotherapy  will  suffice  in  the  average  case. 

By  far  the  largest  group  of  cases  yields  negative  findings 
disclosing  only  one  thing — ^hypersensitivity. 

The  plan  of  treatment  in  this  last  group  is:  The  frenum 
is  sectioned  or  the  patient  is  circumcised.  The  verumon- 
tanum  is  treated  once  a  week  with  pure  phenol  through 
the  endoscope  or  panendoscope,  for  six  weeks.  The  urethra 
is  fiUed  every  day  or  every  other  day  with  a  solution  of 
nupercain  1  to  230,  retained  for  10  to  15  minutes.  .\ 
jelly  containing  0.5%  of  nupercain  can  be  used  with  the 
same  benefit.  Passing  of  a  sound  even  in  the  absence  of 
a  stricture  will  be  found  helpful.  Relaxed  and  soft  pros- 
tates without  any  pus  should  have  massage  twice  a  week. 

To  desensitize  the  integument  of  the  phallus  the  best 
results  were  obtained  with  a  proprietar>'  jelly   containing 


October,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


SS9 


a  cocaine  derivative  with  some  other  sedatives.  This  jelly 
is  applied  5  to  10  minutes  before  coitus  to  the  mcatal  por- 
tion of  the  glans  and  to  the  frenum. 

Atropin  by  mouth,  alone,  or  in  combination  with  styp- 
ticin  is  beneficial  as  it  diminishes  secretion  of  the  vesicles. 
Calcium  should  be  given  even  when  the  blood  calcium  is 
within  normal  limits. 


OBSTETRICS 

Henry  J.  Lancston,  M.D.,  Editor,  Danville,  Va. 


Sqipiified  Obstetric  Care 
(E.   D.  Plass,  Iowa  City,  in  The   Diplomate,  Feb.) 

Within  the  past  several  years  obstetric  literature  gener- 
ally has  tended  to  the  discussion  of  rare  complications,  to 
the  description  of  new  and  compUcated  diagnostic  and 
therapeutic  developments,  and  to  the  glorification  of  oper- 
ative delivery  under  standardized  hospital  conditions,  to 
the  confusion  of  the  majority  of  practitioners  who  must  of 
necessity  dehver  women  in  their  homes. 

Pregnancy  is  a  physiologic  process,  even  though  there 
is  a  closer  than  usual  approach  to  the  pathologic,  and 
there  is  little  need  for  marked  deviation  from  the  usual 
standards  of  reasonable  living.  Too  great  emphasis  upon 
the  establishment  of  a  new  routine  serves  to  set  the  preg- 
nant woman  apart  and  to  aggravate  the  neurotic  tendencies 
which  are  present  in  all  of  us. 

There  is  no  reason  for  proscribing  meats ;  we  have  for 
some  time  given  high-protein  diets  to  those  toxemic  patients 
who  have  no  evidence  of  chronic  nephritis  and  to  those 
with  hypochromic  anemia,  and  with  gratifying  results. 

The  vagina  is  normally  protected  by  its  own  peculiar 
bacterial  flora,  which  develop  an  acidity  strong  enough  to 
kill  the  usual  pyogenic  bacteria  in  from  a  few  hours  to 
three  days.  /(  is  thus  evident  that  the  chief  probkm  which 
confronts  the  physician  is  to  do  as  little  harm  as  possible. 

If  it  be  admitted  that  any  invasion  of  the  birth  canal 
carries  a  certain  risk,  it  becomes  clear  that  the  simplest 
possible  routine  should  be  the  best.  It  has  been  established 
by  controlled  experiments  that  delivery  without  any  peri- 
neal preparation  is  safe.  By  many  years  of  clinical  trial 
it  has  been  demonstrated  that  a  very  simple  procedure  is 
adequate.  The  pubic  hairs  are  clipped  with  scissors  or 
regulation  clippers  in  order  to  avoid  the  discomfort  which 
may  ensue  after  delivery  from  clotting  of  the  discharges. 
Shaving  has  been  discontinued  because  the  lathering  and 
subsequent  cleansing  offer  the  opportunity  for  contaminated 
material  to  be  carried  into  the  birth  canal.  The  average 
nurse  or  physician  cannot  shave  this  area  without  produc- 
ing small  cuts  and  abrasions,  which  may  become  infected. 
The  cut  hairs  are  brushed  off  with  a  square  of  clean  gauze, 
but  no  soap  and  water  are  permitted.  Following  the 
clipping,  2%  aqueous  mercurochrome  solution  is  sprayed 
from  an  atomizer  over  the  perineal  region,  the  lower  abdo- 
men, and  the  inner  aspects  of  the  thighs.  While  the  anti- 
septic effect  of  this  solution  may  be  debatable,  it  has 
proved  to  be  a  conscience-saver  and  its  psychic  effect  is 
good.  This  preparation  is  repeated  before  each  vaginal 
examination  and  again  just  before  delivery.  Spraying  is 
more  economical  than  painting  and  is  recommended  for 
that  reason. 

A  similar  dry  technic  is  employed  during  delivery.  Dry 
gauze  sponges  and  towels  are  used  but  no  antiseptic  solu- 
tions, on  the  basis  of  the  belief  that  they  offer  little,  if 
any,  real  protection  to  compensate  for  the  potential  danger 
involved  in  washing  contaminated  material  into  the  vagina. 
The  instillation  of  mild  antiseptics  into  the  vagina  duriUo 


labor  has  been  discarded  after  a  clinical  trial. 

Vaginal  examinations  under  sterile  precautions  are  made 
whenever  satisfactory  information  cannot  be  obtained  by 
the  other  procedures.  Relatively  little  experience  soon 
brings  considerable  precision  through  rectal  touch,  and 
there  is  no  good  evidence  to  show  that  this  form  of  exam- 
ination carries  any  risk  to  the  patient.  Sterile  precautions 
are  not  necessary  provided  the  thumb  is  kept  away  from 
the  introitus. 

Enemas  are  employed  whenever  rectal  examination  shows 
that  the  lower  bowel  contains  fecal  matter.  If  the  patient 
cannot  empty  the  bladder,  catherize  using  a  rubber  cathe- 
ter. Every  attention  is  given  to  seeing  that  the  parturient 
ingests  sufficient  fluid  and  easily  digestible  nourishment. 

As  analgesics,  after  an  experience  of  20  years,  I  prefer 
morphine  and  scopolamine. 

The  problem  of  anesthesia  for  home  dehvery  is  equally 
difficult,  with  chloroform  and  ether  competing  for  honors. 
The  former  is  still  generally  preferred  for  the  short  anes- 
thesia necessary  in  spontaneous  labor.  Among  the  newer 
methods  only  infiltration  and  block  anesthesia  with  novo- 
caine  or  some  similar  drug  have  any  reasonable  place  out- 
side of  hospital  practice. 

Spontaneous  labor  is  safest  generally  and  should  be  en- 
couraged, interference  being  employed  only  for  definite  and 
strict  indications.  The  modern  furore  for  "convenience" 
forceps  and  version  and  for  ill-advised  cesarean  section 
receives  no  support  from  the  critical  analyses  which  have 
been  made. 

Pituitary  extract  has  no  place  in  the  conduct  of  labor 
until  after  the  child  has  been  born.  The  third  stage  use  of 
pituitary  extract  does  not  consistently  hasten  placental  ex- 
pulsion or  reduce  bleeding. 

Immediately  after  delivery,  the  woman  requires  constant 
attention  for  at  least  one  hour  to  guard  against  excessive 
bleeding  from  uterine  atony.  The  size  of  the  uterus  should 
be  repeatedly  determined  by  abdominal  palpation,  and  any 
enlargement  should  be  met  with  vigorous  massage  until 
the  contained  clots  are  expelled.  This  may  also  reduce 
annoying  afterpains. 

After  24  hours  the  woman  is  encouraged  to  change  her 
position  frequently  and  it  is  better  for  her  to  remain  in 
bed  for  a  week  or  10  days.  After  the  second  or  third  day, 
systematic  exercise  should  be  directed  especially  at  the 
abdominal  muscles,  and  may  include  deep  breathing,  raising 
the  legs,  and  elevating  the  head  and  shoulders.  Each  day 
should  see  the  addition  of  some  new  feature.  At  the  end 
of  a  week,  the  knee-chest  position  is  assumed  for  increasing 
periods  each  day  until  it  is  maintained  for  IS  to  20  minutes 
twice  daily.  This  may  have  some  effect  upon  the  position 
of  the  uterus,  but  is  prescribed  because  it  alters  pelvic  cir- 
culation, prevents  congestion  and  improves  blood-vessel 
tone. 

••  A  full  diet  from  the  time  of  delivery,  with  supplemen- 
tary feedings  between  meals,  hastens  the  recovery  of 
strength.  The  use  of  leafy  vegetables  and  milk  is  encour- 
aged. Yeast  may  be  employed  to  augment  the  vitamin 
intake. 

Wait  3  days  before  evacuating  the  bowel  with  a  simple 
enema  or  cathartic.  Plain  mineral  oil  is  preferable  to  the 
continued  use  of  any  other  cathartic  agent. 

The  perineum  is  kept  reasonably  clean  by  washing  once 
or  twice  a  day  with  soap,  water  and  washcloth,  without 
any  antiseptics.  Within  3  days  after  delivery  the  patient 
ordinarily  takes  her  own  bath,  as  a  part  of  her  daily  exer- 
cise, and  also  cleanses  the  vulval  region.  The  more  exten- 
sive the  laceration  and  repair  the  more  effective  this  let- 
alone  care  is.  The  vulval  pad  has  everything  to  condemn 
and  nothing  to  commend  it.  A  saner  procedure  consists  in 


S60 


SOUTHERN  MEDICINE  AND  SURGERY 


October,   1936 


placing  an  absorbent  pad  under  the  buttocks  and  replacing 
it  when  soiled.  Such  pads  are  easUy  made  from  cotton 
with  a  newspaper  back  and  are  inexpensive.  When  the 
patient  is  out  of  bed,  the  usual  T-binder  and  vulval  pads 
are  employed,  but  by  this  time  the  wound  has  healed  and 
no  harm  is  done. 

The  nipples  may  be  covered  with  a  square  of  gauze  held 
in  place  by  strips  of  adhesive  or  a  binder.  No  other  atten- 
tion is  given  unless  an  abnormality  appears.  Overdistended 
breasts  are  treated  by  support  and  analgesics,  but  rarely 
by  pumping,  since  removing  the  milk  merely  stimulates  the 
secretion  of  more.  Milk  fever  is  not  an  entity.  Cracked 
nipples  demand  rest.  The  baby  should  be  fed  from  the 
bottle  for  at  least  4S  hours  while  distention  of  the  breasts 
is  relieved  by  occasional  pumping.  The  milk  thus  obtained 
can  be  supplemented  by  a  formula  to  provide  sufficient 
nourishment.  Heat  and  light  as  suppUed  by  an  electric 
bulb  apparently  hasten  the  healing.  In  more  stubborn 
cases,  recourse  may  be  had  to  silver  nitrate  solution  or 
stick,  but  this  is  rarely  necessary.  When  nursing  is  re- 
sumed, a  nipple  shield  reduces  trauma  to  the  recently  healed 
area.  To  dr\'  up  the  breasts,  for  any  reason,  the  simplest 
and  quickest  procedure  is  to  stop  nursing  abruptly,  bind 
the  breasts  tightly  to  the  chest  wall  with  muslin  bandages, 
and  provide  analgesics  for  the  relief  of  pain.  The  period 
of  discomfort  is  not  lessened  by  inducing  watery  stools 
through  the  repeated  administration  of  saline  cathartics 
nor  by  reducing  the  fluid  intake.  Pumping,  stripping,  and 
massaging  the  breasts  only  prolong  the  process  and  are  not 
advisable. 

For  mastitis  support  the  breasts,  apply  ice  caps  con- 
stantly. Unless  the  t.  falls  to  normal  within  48  hours,  it 
is  probable  that  suppuration  has  occurred.  Another  sig- 
nificant sign  of  breast  abscess  is  demonstrable  edema  of 
the  overlying  skin.  Pus  should  be  evacuated  under  general 
anesthesia,  which  permits  digital  exploration  of  all  the  ab- 
scess pockets. 

S.   M.    &   S. 

PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 
Pitt  County  Health  Officer 


cember  31st,  1935,  are:  Colorado,  Connecticut, 
Idaho,  Illinois,  Indiana,  Nebraska,  Nevada,  New 
Hampshire,  New  Jersey,  North  Dakota,  Pennsyl- 
vania, Rhode  Island,  South  Dakota,  Vermont,  Wis- 
consin and  Wyoming. 

It  seems  almost  incredible  that  the  rural  popula- 
tion in  sixteen  States  is  still  without  a  whole-time 
health  service.  Of  course,  the  public  health  move- 
ment in  the  United  States  is  new.  Guilford  County, 
North  Carolina,  was,  I  believe,  the  first  county  in 
the  United  States  to  have  a  whole-time  rural  health 
unit.  (This  unit,  I  understand,  was  organized  in 
1911.)  But  the  movement  has  passed  the  experi- 
mental stage  and  it  is  difficult  to  see  why  it  is  not 
embraced  by  all  States  and  counties,  even  the 
poorer  ones. 


Rural  He.\lth  Service  in  the  United  States* 
The  South  leads  the  nation  in  the  matter  of 
Rural  Health  Service.  Delaware,  Maryland  and 
New  Mexico  lead  all  the  other  States  in  the  per- 
centage of  rural  population  having  whole-time 
health  service;  all  counties  in  these  States  having 
this  service. 

From  January  1st  to  December  31st,  1935,  in 
the  whole  country  88  whole-time  health  units  were 
established  and  17  discontinued — a  net  gain  of  71 
units  in  that  year. 

A  comparison  of  North  Carolina  with  South  Car- 
olina and  Virginia  is  of  interest:  on  January  1st, 
1935,  North  Carolina  had  41  units:  South  Carolina 
li  and  Virginia  17:  on  December  31st.  North  Car- 
olina had  53,  South  Carolina  had  2i,  and  Virginia 
had  40.  The  percentage  of  population  in  these 
States  having  whole-time  health  units  is:  North 
Carolina,  63.1;  South  Carolina.  61;  Virginia,  49.8. 
States  having  no  whole-time  rural  health  units  De- 


HUMAN  BEHAVIOR 

Ja^us  K.  Hall,  M.D.,  Editor,  Richmond,  Va. 


•From  V.  S.  Public  Health  Reports. 


Odysseyixg  in  the  Mountains 
Water  and  life  are  both  abundant  but  they  are 
not  evenly  and  generously  distributed.  I  wonder 
how  much  we  know  about  them.  They  seem  to 
be  related.  I  doubt  if  life  can  exist  without  water. 
I  can  think  of  no  useful  purpose  that  water  could 
serve  in  a  dead  world.  Most  of  us  have  a  whole- 
some fear  of  a  large  body  of  water,  and  for  un- 
usual quantities  of  it,  especially  when  it  is  dis- 
turbed. But  some  things  are  more  impressive  by 
their  absence  than  by  their  presence.  That  is  true 
of  water.  What  can  be  more  dreadful  than  a  con- 
tinuing drought? 

In  and  about  Richmond  there  has  been  only  an 
occasional  shower  of  rain  since  last  spring.  In  con- 
sequence, the  crops  and  the  gardens  are  almost  a 
failure,  the  pastures  are  parched,  and  many  of  the 
shrubs  and  smaller  trees  are  dying.  The  surface 
of  the  earth  is  parched  by  long-continued  heat,  and 
the  vegetable  world  persistently  prays  for  relief 
from  inspissation. 

When  I  drove  into  North  Carolina  along  United 
States  Highway  Number  One  on  September  21st, 
I  looked  upon  green  fields,  splendid  crops,  and 
pastures  so  luxuriant  that  I  could  appreciate  the 
feeling  of  the  Psalmist  in  his  instinctive  desire  to 
revel  in  all  the  greenery  by  lying  down  in  it  and 
inviting  his  soul  back  to  tranquillity.  There  is 
something  comforting  and  stabilizing  afforded  by 
close  contact  with  the  earth.  Do  we  realize  that? 
In  the  city  even  our  feet  are  kept  from  contact  with 
the  earth.  The  companion-piece  to  the  twenty- 
third  Psalm  is  Grass,  a  majestic  tribute  to  the 
almost  universal  sustainer  of  life,  by  John  J.  In- 
galls,  once  United  States  Senator  from  Kansas. 

I  am  not  surprised  that  the  President  was  lately 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


untroubled  by  the  downpour  of  rain  upon  his  open 
car  as  he  journe3ed  from  Asheville  down  to  Char- 
lotte. He  had  recently  traveled  through  several 
arid  Western  States.  The  rain  that  came  down 
upon  him  in  North  Carolina,  and  the  grass-carpet- 
ed hills  and  mountains  upon  which  he  feasted  his 
vision,  must  have  evoked  a  song  of  thanksgiving 
from  his  heart  and  turned  him  to  comforting  con- 
templation of  the  pastoral  Psalm. 

In  the  President  is  often  concentrated  the  might 
of  a  mighty  jjeople.  Through  him  they  can  do 
many  things.  He  can  move  the  still  water  and 
obstruct  the  moving  water,  but  not  even  the  Presi- 
dent can  cause  it  to  rain.  God  keeps,  and  will 
keep,  I  doubt  not,  that  power  in  His  own  hands. 

I  wonder  if  we  do  not  measure  most  impressively 
by  contrast.  I  can  easily  remember  piedmont 
North  Carolina  for  half  a  century,  but  the  region 
seems  to  me  to  be  greener,  more  luxuriantly  so 
this  summer,  than  ever  before  within  my  memory. 
I  write  in  jMorganton  on  the  morning  of  September 
25th.  Here  I  spent  the  night  of  the  twenty-first 
and  the  following  day.  On  the  twenty-third  I  at- 
tended in  Asheville  the  meeting  of  the  Tenth  Dis- 
trict JNIedical  Society.  The  entire  assemblage  were 
guests  of  Dr.  Mark  and  Dr.  Ray  Griffin  in  their 
spacious  and  splendid  institution  at  Appalachian 
Hall.  A  good  deal  has  been  written  about  the 
effect  of  environment  upon  the  individual,  but  no 
scientist  has  verbalized  the  effect  so  succinctly  and 
so  powerfully  as  the  Psalmist.  In  the  twenty-third 
Psalm  the  sight  of  the  green  pastures  invited  the 
shepherd  to  lie  down  and  to  be  at  ease  upon  the 
green  grass,  and  to  restore  his  soul  to  its  former 
peace.  And  the  one  hundred  and  twenty-first  Psalm 
opens  with  a  tribute  to  the  majesty  and  the  strength 
of  the  hills:  I  will  lift  up  mine  eyes  unto  the  hills, 
from  whence  cometh  my  help.  Who  can  look  out 
upon  a  massive  mountain  range,  without  feeling 
inspired  and  strengthened? 

Several  years  ago  I  attended  a  meeting  of  the 
Tenth  District  Society  at  Black  Mountain.  Dr. 
Abel  presided  over  that  session.  I  saluted  him 
again  on  day  before  yesterday.  He  remains  large 
in  body  and  busy  in  mind.  At  the  meeting  at 
Black  Mountain  I  read  a  brief  paper  about  de- 
mentia praecox.  A  doctor  said  to  me  afterwards 
that  it  was  the  gloomiest  paper  he  had  ever  heard 
read.  I  surprised  him  by  thanking  him  for  the 
tribute  to  my  production.  I  told  him  that  we 
know  nothing  about  dementia  praecox,  not  even 
what  it  is,  except  a  universal  scourge,  and  that  if 
I  had  succeeded  only  in  causing  him  to  realize 
what  an  affliction  the  disease  constitutes  I  had  been 
compensated  for  my  journey. 

The  meeting  of  the  Tenth  District  on  day  before 
Xouapisajd  aq;  japun  Xiq;ooms  pauoipunj  j^BpjajsaX 


of  Dr.  A.  J.  Jervey,  of  Tryon.  But  the  immortal, 
spiritual  imprint  of  Charleston  must  be  upon  the 
soul  of  all  the  Jerveys.  All  that  I  have  ever  known 
have  tinctured  with  their  innate  gentility  the  com- 
munities in  which  they  have  lived,  but  I  have 
always  wondered  when  they  are  going  back  to 
Charleston,  where  they  must  all  spiritually  belong. 

Within  recent  years  I  have  had  the  good  fortune 
to  attend  a  meeting  in  most  of  the  Districts  of 
North  Carolina.  I  know  no  better  nor  more  useful 
medical  meetings.  I  have  said  that  before,  but  I 
do  not  mind  saying  it  again.  The  meetings  are 
well  attended,  both  in  numbers  and  in  the  attention 
given  the  papers  and  their  discussions.  I  go  to 
the  meetings  when  I  can,  largely  for  selfish  rea- 
sons— to  learn  something  about  medicine.  The 
doctors  in  North  Carolina  are  professionally  alert 
and  adventurous  and  courageous.  They  are  insist- 
ent that  their  patients  have  the  best  that  medicine 
has  to  offer — whether  their  patients  be  paupers  or 
plutocrats.  The  most  spirited  discussion  at  the 
meeting  was  provoked  by  Dr.  Sams,  of  Marshall, 
a  Hippocratic  Hercules,  about  the  predicament  of 
the  indigent  sick.  And  I  inferred  that  the  doctors 
are  going  to  insist  that  medicine  and  they  must 
be  stone  blind  to  those  stratifications  of  society 
caused  by  economic  differences,  but  keenly  alert 
to  the  ravages  and  the  dangers  of  disease  wherever 
it  exists.  And  that  is  the  right  notion,  of  course, 
for  sickness  in  the  community  affects  the  entire 
community  and  not  alone  the  individuals  who  are 
sick.  The  program  was  excellent,  and  it  was  not 
too  long.  But  even  though  it  was  short,  in  it  were 
included  discussions  of  endocrinology,  intestinal 
obstruction,  colic,  broken  bones,  cysts  of  the  mesen- 
tery, and  I  found  out  that  they  are  about  as  rare 
as  Christian  charity;  and  the  treatment  of  syphilis. 
Dr.  J.  P.  Rousseau,  of  Winston-Salem,  remains  a 
quiet,  self-effacing,  modest  gentleman,  in  a  rather 
hurried,  raucous,  and  self-assertive  and  aggressive 
world.  But  he  talked  to  us  in  such  a  way  about 
the  therapeutic  value  of  the  use  of  radiant  energy 
in  benign  lesions  of  the  female  pelvis  that  I  con- 
cluded he  must  know  as  much  about. that  as  Bill 
MacNider  knows  about  the  kidneys.  Were  it  pos- 
sible for  me  to  attend  six  or  eight  of  the  District 
Medical  meetings  in  North  Carolina  every  year  I 
should  be  more  competent  to  minister  to  my  sick 
folks. 

I  was  about  to  make  a  remark  about  the  North 
Carolina  physician,  but  I  staid  my  hand  a  little 
too  late.  I  doubt  if  two  such  goods  words  as  are 
embraced  in  the  noun  North  Carolina  should  be 
demoted  to  an  adjectival  function.  And  we  know, 
of  course,  all  of  us,  that  there  can  be  no  such  crea- 
ture as  a  composite  physician.  All  the  folks  in 
North   Carolina,  or  certainly   most  of   them,  are 


S62 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


highly  individualistic,  and  so  much  so,  to  be  sure, 
that  no  two  of  them  are  alike.  I  am  certain  that 
I  know  of  no  two  doctors  in  North  Carolina  whose 
professional  photographs  would  look  at  all  alike. 
No  physician  in  North  Carolina  or  elsewhere  re- 
sembles in  his  ratiocinations  Dr.  William  deBerniere 
MacNider.  But  his  thinking,  professional  and 
otherwise — and  he  is  always  thinking — is  no  more 
unique  nor  individualistic  than  that  of  his  kins- 
man and,  I  hope,  my  sweet  friend,  Dr.  Eugene 
Pierre  Mallett,  of  Hendersonville.  I  can  conceive 
of  no  one  less  concerned  about  matter  nor  more 
concerned  about  spirit.  My  soul  is  lifted  up  always 
even  by  brief  communion  with  him.  I  wish  my 
physical  habitat  were  more  proximate  to  his. 

Bless  him!  immortality  itself! — even  though  he 
did  make  the  momentary  mistake  of  assuming  that 
I  did  not  identify  his  somatic  structure.  Why  he 
brought  such  a  charge  against  me  I  cannot  imagine, 
for  he  looks  now  as  he  did  when  I  was  a  boy.  He 
tried  to  enable  me  to  grasp  how  long  he  had  prac- 
ticed medicine  by  telling  me  how  long  ago  he  had 
graduated,  but  age  does  nothing  to  him  but  allow 
him  to  accumulate  experiences.  He  is  as  much  a 
permanency  in  western  North  Carolina  as  the 
French  Broad  and  as  Mount  Mitchell.  You  know, 
of  course,  that  I  am  speaking  of  that  blithe  spirit, 
Dr.  Henry  Bascom  Weaver. 

The  drive  from  Morganton  to  Asheville  in  the 
early  afternoon,  with  a  momentary  halt  at  Black 
Mountain  for  lunch,  was  an  unalloyed  joy.  I  won- 
dered as  I  passed  it  why  the  Commission  is  build- 
ing the  State's  Tuberculosis  Sanatorium  right  out 
in  the  broiling  sun,  with  a  tree  nowhere  near.  I 
think  it  does  the  souls  as  well  as  the  bodies  of 
sick  people  good  to  look  out  upon  nearby  trees. 
And  there  are  more  forests  in  Buncombe  County 
than  there  are  clearings.  But  I  suppose  the  new 
Sanatorium  will  set  out  exotic  trees  all  around  it, 
and  that  within  a  generation  or  so  the  patients  will 
be  able  to  find  shade  without  remaining  indoors. 
But  what  do  I  know  about  tuberculosis?  A  hos- 
pital for  the  treatment  of  that  disease  may  be 
better  off  without  a  tree  near  it.  The  journey  down 
the  mountain  on  a  moonlight  night  is  a  magnifi- 
cent experience.  I  thought  of  the  splendid  engi- 
neering and  the  magnificent  construction  work  rep- 
resented by  that  highway.  Although  many  of  the 
curves  are  sharp,  and  many  of  the  drop-offs  are 
hundreds  of  feet  in  depth,  I  had  such  confidence 
in  the  guiding  skill  of  the  charioteer  that  I  thought 
of  the  other  world  only  when  I  looked  up  at  the 
full  moon  and  the  star-studded  sky.  Dr.  James 
W.  Vernon  drives  swiftly,  to  be  sure,  but  steadily 
and  safely,  and  he  exhibits  none  of  that  reckless- 
ness characteristic  of  the  late  Jehu,  the  son  of 
Nimshi,  whose   many  devotees  still   meet   us   and 


pass  us  on  the  highways  until  their  admissions 
to  hospitals  and  to  their  final  crypts.  But  none 
of  them  disturbed  the  steady  and  resolute  speed 
of  our  wheelman,  Dr.  Vernon.  The  same  doctor 
who  can  superintend  a  hospital,  serve  as  a  member 
of  the  Board  of  Medical  Examiners  of  his  State, 
and  also  as  Mayor  of  his  town,  can  hold  his  Ford 
firmly  on  the  highway,  whether  the  roadway  be 
straight  or  serpentine.  Both  his  wife  and  mine 
were  flattered  by  having  to  inform  one  or  two  of 
our  acquaintances  that  they  are  not  our  second 
wives. 

On  the  following  day  I  heard  rainfall  in  the 
early  morning  for  the  first  time  in  several  months. 
It  was  a  blessed  sound.  And  the  downpour  did 
not  deter  me  one  moment  from  driving  through  it 
over  into  Polk  County  to  spend  the  day  with  Miss 
Alaud  Coxe  at  Green  River  plantation.  There,  in 
the  midst  of  a  great  domain,  remote  from  Ruther- 
fordton  several  miles,  I  lived  for  a  few  hours  as  I 
should  love  to  live  the  remainder  of  my  days. 
Within  the  great  rambling  old  house  are  sweet  and 
dignified  reminders  of  other  days,  together  with  all 
the  comforts  of  the  present;  and  without  the  house 
are  boundless  forests,  occasional  fields,  quietness 
and  the  beauty  and  peace  of  God  and  a  stillness 
such  as  must  have  enfolded  the  earth  in  its  earliest 
days.  But  man's  passion  has  reached  even  into 
that  remote  region.  On  the  floor  of  the  great  living 
room  are  the  imprints  left  by  the  shoes  of  the  cav- 
alry horse  of  a  Federal  trooper  in  the  last  days  of 
the  Civil  War.  But  I  know  that  today's  peace 
and  serenity  at  Green  River  Plantation  would  fetch 
back  to  the  souls  of  the  worn  and  weary  the  res- 
toration that  the  shepherd  prayed  for  in  the  twenty- 
third  Psalm.  I  believe  I  know  more  than  one 
mortal  who  would  learn  to  know  again  the  mean- 
ing of  satisfaction  of  mind  and  serenity  of  soul  by 
a  sojourn  at  that  hospitable  old  plantation. 

In  returning  to  Morganton  through  Rutherford- 
ton — ancient  Gilbert  Town — I  recalled  that  the 
Over-the-mountain  Men  gathered  there  on  their 
way  to  King's  Mountain  to  dislodge  from  its  sum- 
mit Major  Patrick  Ferguson  and  his  British  and 
Tory  soldiers  during  the  Revolutionary  War.  The 
battle  lasted  only  a  few  hours  and  only  two  or 
three  thousand  soldiers  were  engaged  on  both  sides, 
but  Major  Ferguson  was  killed,  as  were  many  of 
his  soldiers,  and  all  the  others  were  captured.  That 
brief  but  brave  struggle  meant  the  end  of  British 
rule  in  the  Carolinas,  and  it  soon  made  Yorktown 
inevitable.  And  the  Mountain  Men  had  nothing 
but  their  squirrel  rifles  and  their  stout  hearts  and 
unconquerable  souls.  At  the  celebration  held  on 
the  little  mountain  a  century  and  a  half  after  that 
victory,  President  Hoover  delivered  the  memorial 
address.     But  the  prayer  made  on  the  same  occa- 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


sion  by  the  Rev.  Dr.  James  I.  Vance  is  equalled  in 
beauty  and  eloquence  and  dignity  and  majesty  and 
patriotism  only  by  Lincoln's  Gettysburg  address. 
All  school  children  in  the  United  States  should 
memorize  it.  I  am  sorry  to  hear  that  age  and 
poor  health  have  brought  about  Dr.  Vance's  re- 
tirement from  the  pulpit.  Some  of  his  ancestors 
used  their  squirrel  rifles  at  King's  Mountain.  On 
driving  from  Rutherfordton  to  Morganton  I  selected 
Road  181 — a  little-improved  red-dirt  road,  treach- 
erously slippery  in  places.  My  wife  chided  me  for 
not  returning  by  the  hard-surface  road  by  Marion. 
But  I  was  anxious  to  travel  over  the  dirt  road  be- 
cause I  had  been  told  that  the  Mountain  Men  had 
marched  from  beneath  the  Council  Oak  near  Mor- 
ganton to  Rutherfordton  over  that  very  road,  and 
I  think  several  sharp  skirmishes  were  fought  along 
the  route.  And  as  I  drove  through  Brindletown  I 
remembered  that  gold  was  mined  there  in  the  ear- 
liest days,  and  there  gold  is  still  washed  from  the 
mountain  sides.  Were  this  region  in  Virginia  me- 
tallic markers  all  along  the  roadside  would  be  tell- 
ing the  tourists  of  the  brave  days  of  old.  Near 
Morganton,  in  a  house  that  still  stands,  Zebulon 
Baird  Vance,  the  great  War-Governor,  married  his 
first  wife;  and  no  farther  distant,  out  on  the  Lenoir 
Road,  Woodrow  Wilson  spent  his  first  honeymoon 
in  the  home  of  the  bride's  school-days'  friend,  Mrs. 
Hamilton  Erwin.  But  the  passerby  is  not  arrested 
by  such  unexpected  information.  The  people  of 
North  Carolina  are  not  much  given  to  civic  retro- 
spection. Their  hearts  and  their  minds  are  upon 
the  future.  But  all  life  finds  ultimate  sustenance 
in  the  past,  which  is  not  dead,  but  everlastingly 
vital. 


-B.   M.   4   6.- 


ElGHTY-THREE     HiKES    IN    THE    BiG    SmOKIES    AND    HuRRIES 

B.4CK  TO  His  Steady  Job 
(Fniiii  a  Knoxville  Paper  of  Sept.   27th) 

Dr.  J.  L.  Thompson  (Med.  Col.  of  the  State  of  South 
Carolina,  class  ISSO)  was  hurrying  to  Columbia,  S.  C,  to 
get  back  to  his  clerical  job  at  the  State  Hospital  for  the 
Insane,  where  he  has  been  employed  for  the  past  SS  years. 

He  had  spent  an  active  two  weeks  vacation  here  during 
uh'''h  he  h'':cd  in  the  Smokies  2nd  took  in  Norris  Dam 
and  Clingman's  Dome.  He  visited  with  his  sister,  Mrs. 
J.  .\.  Killian,   1041   Luttrell  street. 

"We  tried  to  get  him  to  stay  over,  but  he  just  had  to  be 
back  at  work  Monday  morning,  and  would  not  have  been 
late  for  anything,"  Mrs.  Kilhan  said. 


-s.  M.  & 


REMOVAL  NOTICE 

The  Morse  Laboratories,  Inc.,  take  pk'asure  in  announc- 
ing to  the  medical  profession  the  removal  of  their  offices 
to  more  spacious  quarters  at  27  East  21st  Street,  New 
York  City. 


Surgical    Observations 

A  Column  Conducted  by 

The  Staff  or  the  Davis  Hospital 
Statesville,  N.  C. 


Cases  Illustrating  the  Differential  Diagno- 
sis OF  Right  Upper  Abdominal  Diseases 

For  many  years  persistent,  painless  jaundice 
which  increases  in  severity  has  been  considered  a 
strong  indication  of  cancer.  However,  so  often  do 
we  find  other  conditions  which  give  this  picture, 
that  we  have  come  to  the  conclusion  that  in  every 
case  presenting  these  symptoms  the  possible  bene- 
fits of  an  operation  should  be  considered.  Within 
the  past  few  weeks,  we  have  examined,  diagnosed 
and  operated  in  an  unusually  large  number  of  cases 
of  disease  of  the  gallbladder,  bile-ducts,  liver,  head 
of  pancreas  and  the  right  upper  abdomen  generally. 
Many  of  these  cases  are  exceedingly  instructive. 

One  was  that  of  a  man  just  under  seventy,  who 
came  in  complaining  of  painless  jaundice  persist- 
ing for  seven  months  and  gradually  increasing.  At 
times  he  had  felt  some  pain  in  the  upper  abdomen 
on  the  right  side,  but  it  had  never  been  severe 
enough  to  require  opiates.  Though  this  man  weigh- 
ed only  128  pounds,  he  was  moderately  well  nour- 
ished. Examination  sliowed  little  out  of  the  ordi- 
nary except  jaundice,  a  two-plus  albuminuria  and 
an  icterus  index  of  18,  which  later  went  up  to  30. 

After  the  proper  preliminary  treatment,  through 
a  high  right  rectus  incision  a  stone  in  the  common 
duct  was  removed  and  the  common  duct  and  hepatic 
ducts  explored.  No  other  stones  were  found.  The 
gallbladder  was  then  removed  and  a  T-tube  placed 
in  the  common  duct  and  left  in  for  a  considerable 
length  of  time. 

The  patient  stood  the  operation  all  right  and  left 
the  hospital  free  of  jaundice,  his  condition  improv- 
ed greatly  and  his  prospects  for  return  to  health 
are  good. 

It  has  been  considered  unusual  for  the  gallblad- 
der to  be  greatly  enlarged  from  obstruction  of  the 
common  duct  by  a  stone.  In  this  case,  the  gall- 
bladder was  greatly  distended  and  filled  with  dark 
biie.  Since  returning  home,  this  patient  has  re- 
j^otted  that  he  feels  all  right  and  is  able  to  do  a 
lillle  work — that  is,  he  is  able  to  go  about  and  look 
alter  his  affairs. 

Anot'ner  man  43  years  of  age  came  in  one  night 
suffering  with  intense  pain  in  the  lower  and  upper 
portion  of  the  right  abdomen.  The  white  blood 
count  was  up  considerably,  and  we  decided  it  was 
best  to  operate  immediately. 

On  opening  the  abdomen  through  a  high  right 
rectus  incision,  we  found  a  very  acutely  inflamed 


SOUTHERN  MEDICINE  AND  SURGERY 


October,   1936 


appendix  and  a  gallbladder  which  was  enormously 
enlarged,  tightly  distended  and  filled  with  whitish, 
mucoid  material.  A  ball-valve  stone  was  found  at 
the  junction  of  the  gallbladder  with  the  cystic  duct. 
Removal  of  the  stone  was  accomplished  without 
any  difficulty.  A  probe  was  passed  through  the 
cystic  into  the  common  duct  and  the  common  duct 
carefully  explored  down  to  the  duodenum.  No 
other  stones  were  found.  It  was  thought  advisable 
to  drain  the  gallbladder,  which  was  done.  He 
made  a  good  recovery  and  was  able  to  leave  the 
hospital  in  two  weeks.  He  is  doing  well  and  will 
doubtless  make  a  good  recovery.  One  interesting 
feature  in  this  case  was  that  the  appendix  was  very 
acutely  inflamed  and  was  sufficient  to  account  for 
many  of  the  symptoms.  However,  his  excruciating 
pain  probably  came  from  the  gallbladder  region. 

A  man  57  years  of  age  came  in  complaining  of 
great  pain  in  the  right  upper  abdomen,  with  white 
count  14,400 — pmns.  &3% — and  prostration  so  se- 
vere that  we  decided  to  operate  immediately. 

Through  a  high  right  rectus  incision  we  found 
that  one  large  stone  in  the  gallbladder,  the  head 
of  the  pancreas  swollen  and  all  the  structures  about 
the  common  duct  swollen  and  highly  inflamed. 
Evidently  he  had  an  acute  pancreatitis.  There  was 
also  moderate  hepatitis  and  considerable  cholang- 
itis. In  this  case  the  one  large  stone  was  removed 
and  the  gallbladder  drained.  The  patient  had  a 
rather  stormy  time  for  a  few  days,  but  is  now  on 
the  road  to  recovery.  The  pancreatic  disease  will 
probably  subside  as  it  is  evidently  not  cancerous. 

A  man  73  years  of  age  was  brought  in  complain- 
ing of  severe  more  or  less  continuous  pain  in  the 
region  of  the  stomach  and  right  upper  abdomen 
for  two  weeks.  Jaundice  was  pronounced,  icterus 
index  46.8. 

After  careful  preparation  a  high  right  rectus  in- 
cision disclosed  what  is  apparently  carcinoma  at 
the  head  of  the  pancreas  and  of  the  liver.  Drain- 
age of  the  gallbladder  is  giving  the  patient  consid- 
erable relief  and  will  doubtless  prolong  his  life. 

In  all  cases  where  there  is  an  obstruction  at  the 
lower  part  of  the  common  duct,  we  should  consider 
an  anastomosis  of  the  gallbladder  to  the  duodenum, 
or  possibly  in  some  cases  to  the  stomach.  An  an- 
astomosis to  the  duodenum,  however,  usually  gives 
more  satisfactory  results. 

A  man  68  years  of  age  was  recently  admitted 
suffering  from  jaundice  which  has  been  gradually 
increasing  for  the  past  six  or  seven  months.  He 
has  a  moderate  amount  of  right  upper  abdominal 
pain. 

This  patient  was  given  every  possible  preopera- 
tive treatment,  including  calcium  chloride  intra- 
venously and  blood  transfusions. 


Through  a  high  right  rectus  incision,  it  was 
found  there  was  a  carcinoma  of  the  liver  extending 
down  to  and  obstructing  the  hepatic  ducts.  The 
gallbladder  was  collapsed  and  there  was  no  appar- 
ent obstruction  along  the  course  of  the  common 
duct,  and  the  head  of  the  pancreas  was  apparently 
not  diseased. 

A  small  section  of  the  carcinoma  removed  for 
examination  was  found  to  be  primary  carcinoma 
of  the  liver,  of  the  liver-cell  type. 

Another  impressive  case  was  that  of  a  woman  60 
years  of  age  who  had  a  moderate  ascites.  It  was 
relieved  only  after  two  weeks  of  medical  treatment. 
When  the  ascites  was  relieved,  a  tumor  could  be 
felt  in  the  right  upper  abdomen,  which  was  evi- 
dently a  tightly  distended  gallbladder.  After  care- 
ful preparation,  though  a  high  right  rectus  incision 
it  was  found  that  the  gallbladder  was  greatly  en- 
larged and  was  full  of  thick,  dark  bile.  There  was 
no  obstruction  along  the  common  duct  and  no 
stones  could  be  palpated  in  the  cystic  or  common 
ducts.  The  head  of  the  pancreas  was  large  and 
smooth,  suggesting  a  simple  pancreatitis,  secondary 
to  the  cholecystitis.  The  liver  was  rather  dark 
and  indicated  a  definite  hepatitis.  This  patient  had 
a  cholecystostomy  and  is  improving  steadily.  There 
has  been  no  recurrence  of  the  ascites. 

Many  of  these  cases  did  not  consult  a  doctor 
until  the  symptoms  were  pronounced — either  severe 
pain  or  actual  jaundice. 

All  cases  of  this  type  should  have  careful  study. 
With  the  means  of  diagnoses  available,  an  accurate 
estimate  of  the  condition  present  is  usually  possi- 
ble. 

Because  of  the  fact  that  certain  cases  which  are 
apparently  malignant  and  incurable  at  examination 
may  turn  out  to  be  benign — such  cases  as  that  of 
the  man  who  had  the  large  common  duct  obstruc- 
tion from  calculus — it  is  advisable  to  operate  upon 
practically  all  patients  with  obstructive  jaundice 
if  their  physical  condition  will  permit.  This  will 
give  every  patient  a  chance  and  is  worth  while. 
Even  in  incurable  cases  a  cholecystostomy  may 
give  a  great  deal  of  relief  for  the  time  being  and 
prolong  the  patient's  life.  Where  advisable  an 
anastomosis  between  the  gallbladder  and  the  duode- 
num, or  between  the  gallbladder  and  stomach  may 
be  the  means  of  prolonging  a  patient's  life  and 
making  more  comfortable  the  remaining  months  of 
life. 


-S.   M.   &  S.- 


CiRRHOSis  OF  THE  LivER  is  fairly  common  in  China  where 
the  people  are  too  poor  to  drink  alcohol. 

Slow  Wound  Healing. — Think  of  diabetes  and  syph- 
ilis. 

Some  diarrheas  are  due  to  allergic  conditions;  some 
others  to  too  much  thyroid  secretion. 


October,  1936  SOUTHERN  MEDICINE  AND  SURGERY 


4.  '     *  * .  .  .^.  .  .     . .  .     . .J, 

if:  President's  Page  t 

t  Tri-State  Medical  Association  of  the  Carolinas  and  Virginia  i 


To  Members  oj  the  Tri-State  Association: 

Because  of  a  personal  hospital  and  surgical  experience  this  summer  and  the 
subsequent  rush  to  catch  up  with  work  after  recovery  your  President  has  given  little 
time  or  thought  to  his  duties  in  the  past  few  months.  Now  that  my  administrative 
year  is  just  half  gone  I  am  beginning  an  intensive  drive  to  increase  the  membership 
of  the  Association  rather  than  wait  until  just  before  the  next  annual  meeting  ii> 
February  to  start  action. 

There  are  some  few  energetic  and  very  loyal  members  who  can  always  be  de- 
pended upon  to  give  of  their  time  and  efforts  but  this  is  an  appeal  to  EVERY  MEM- 
BER to  do  his  utmost  to  gain  at  least  one  new  member  during  the  drive.  A  personal 
letter  will  soon  go  out  to  each  member  carrying  an  application  blank  and  a  list  of 
non-members  in  his  vicinity  and  every  man  is  urged  and  expected  to  sign  up  one  or 
more  (there  is  no  limit!) 

It  is  not  necessary  for  me  to  call  to  your  attention  the  advantages  offered  by 
membership  in  this  Association;  however,  I  do  not  want  you  to  overlook  two  im- 
portant and  interesting  facts:  First,  this  Association  has  always  endeavored  to  interest 
the  man  in  general  practice  particularly  and  the  programs  of  its  meetings  have  been 
arranged  accordingly;  second,  the  Association  publishes  the  most  interesting  and 
the  most  practical  journal  from  the  standpoint  of  the  man  in  general  practice  that  I 
know  of  or  have  seen.    These  two  arguments  alone  should  gain  many  new  members. 

May  I  count  on  you  to  secure  one  or  more  new  affiliates. 

Faithfully  yours, 

DOUGLAS  JEiVNINGS. 


SOUTHERN  MEDICINE  AND  SURGERY 


October,   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.  Nohthington,  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 
Eye,  Ear  and  Throat  Hospital  Group .Charlotte,  N.  C. 

Orthopedic   Surgery 

O.  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 —  I 

Internal    Medicine 

P.  H.  Ringer,  M.D...  _ -  Asheville,  N.  C. 

Surgery 

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

Obstetrics 

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 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 


_.Asheville,  N.  C. 


W.  Lee  Moose,  Ph.G. 

Cardiology 

Clyde  M.  Gilmore,  A.B.,  M.D Greensboro,  N.  C. 

Public  Health 

N.  Thos.  Ennett,  M.D - Greenville,  N.  C. 

Radiology 

Allen  Bakker,  M.D I  Petersburg,  Va. 

Wright  Clarkson,  M.D. ) 

Therapeutic* 

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

Clinical   Psychiatry 
C.  A.  BosEMAN,  M.D. Pinebluff,  N.  C. 


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. 


Not  Another  Mouse  Even  From  That 
Mountain 

This  journal  is  of  the  opinion  that  doctors  may 
well  stop  talking  and  writing  in  answer  to  those 
eager  to  make  of  the  Practice  of  Medicine  a  Gov- 
ernmental Bureau  and  of  every  Doctor  of  Medicine 
a  political  hireling.  To  be  strictly  accurate,  the 
program  does  not  contemplate  hiring  all  doctors, 
but  only  those  who  bask  in  the  smiles  of  politi- 
cians: the  rest  of  us  may  sweep  streets,  go  on  relief 
or  jump  in  the  river — accordingly  as  mood  inclines 
or  opportunity  offers. 

However,  it  may  be  that  a  final  barrage  is  in 
order.  Anyhow,  the  New  York  State  Medical  Jour- 
nal for  this  month  carries  an  editorial  which  should 
silence  the  few  remaining  vociferous  proponents  of 
medical  care  at  so  much  (or  so  little)  per  week, 
and  at  the  hands  of  political  appointees. 

This  New  York  champion  of  the  best  interests  of 
society  at  large  and  its  doctors  offers  little  that  is 
new  in  the  way  of  argument;  rather  it  selects  from 
the  best  of  the  reasons  offered  and  presents  them 
with  rare  concentrated  effectiveness.  That  it  is 
imperatively  necessary  that  society  be  made  up 
largely  of  those  who  are  neither  rich  nor  poor  is 
obvious;  but  we  would  remind  that  some  of  the 
stoutest  champions  of  individualism  in  the  open, 
behind  closed  doors  become  the  niftiest  arrangers 
of  strangling  combines. 

The  Editor  investigates  the  trend  of  youth  to- 
ward occupations  over  many  centuries  and  finds 
that  when  adventurous  careers  were  to  be  antici- 
pated only  in  the  Church,  brilliant  youth  gravi- 
tated to  the  Church;  and  that  so  it  was  later  when 
arms  offered  most,  and  still  later  when  commer- 
cial pursuits  promised  most — capacity  and  rapacity 
would  be  served.  A  proper  tribute  is  paid  to  the 
developments  in  medicine  by  individualistic  en- 
deavor, some  of  the  brilliant  minds  being  attracted 
to  medicine  as  a  iield  offering  employment  con- 
genial to  young  men  of  ability  and  desiring  to 
remain  their  own  masters. 

We  are  told  that  the  country's  educators  should 
ponder  the  problem  that  will  confront  them  if  the 
advocates  of  compulsory  health  insurance  have 
their  way,  and  the  question  is  asked: 

"What  type  of  youth  would  be  attracted  to  a 
medical  career?" 

Our  own  opinion  on  this  subject  was  expressed 
in  a  meeting  of  our  county  medical  society  nearly 
four  years  ago;  and  neither  the  few  earnest  zealots 
nor  the  many  paid  propagandists  have  shaken  the 
conviction  that: 

We  have  not  the  least  doubt  that  under  this  sys- 
tem it  would  be  so  impossible  for  a  doctor  to  re- 
tain a  vestige  of  self-respect  that,  within  ten  years 


October.   1936 


SOXJTHERN  MEDICINE  AND  SURGERY 


S6r 


of  its  inauguration,  a  better  class  of  students  would 
be  attracted  to  barbering  or  paper-hanging  than  to 
medicine. 

Instead  of  being  the  first,  the  doctor's  should  be 
the  last  job  to  be  Socialized.  It  would  not  be  too 
much  to  expect  of  Countries  in  which  everyone  else 
is  paid  a  salary  by  the  State,  that,  after  a  few  years 
of  experience,  the  practice  of  medicine  would  be 
restored  to  a  fee  basis,  not  in  the  interest  of  the 
doctors,  but  in  the  interest  of  the  whole  people. 
Why?  Because  (to  repeat  reasons  we  gave  four 
years  ago) : 

The  engineer,  the  postman,  the  lawyer,  the 
plumber,  the  preacher,  the  carpenter,  the  teacher, 
the  merchant,  the  policeman,  the  public  health  of- 
ficial— everybody  but  the  doctor — does  his  work 
on  regular  schedule.  Only  the  doctor  can  be  or- 
dered about  by  every  Tom,  Dick  and  Harry  who 
is,  thinks  he  is,  or  pretends  to  be  ill.  Considerable 
protection  is  afforded  the  doctor  by  the  fact  that 
his  services  are  charged  for.  The  only  other  pro- 
tection the  doctor  has  under  our  present  system, 
when  he  has  every  reason  to  believe  his  attendance 
is  not  needed,  and  yet  it  is  insisted  on,  is  to  suggest 
that  another  doctor  be  called.  Both  these  protec- 
tions would  be  swept  away  were  the  Committee's 
plan  to  be  put  into  effect. 

We  have,  and  will  maintain,  a  lower  death  rate 
and  a  lower  morbidity  rate  than  any  country  hav- 
ing compulsory  health  insurance;  and  we  will  re- 
fuse to  follow  in  the  footsteps  of  thoe  countries 
which  have,  in  the  name  of  health  care,  put  a  pre- 
mium on  malingering  and  promoted  the  will  to  be 
sick.  We  shall  continue  to  encourage  the  will  to 
be  well. 

E.  A.  Filene,  of  Boston,  is  (or  was)  one  of  the 
largest  contributors  to  the  fund  collected  to  force 
on  us  medical  care  at  so  much  per  week;  but  when 
Mr.  Filene's  own  person  needed  medical  care  in 
Russia,  where  medical  care  is  supplied  at  so  much 
per  week,  he  had  a  doctor  in  private  practice  come 
by  airplane  from  Germany  to  take  care  of  him. 
Man  is  made  a  little  lower  than  the  angels,  but 
still  a  little! 

He  who  runs  may  read — and  will  read. 

We  all  have  long  been  familiar  with  the  fact  that 
death  and  sickness  rates  in  our  own  country  are 
much  lower  than  in  any  country  in  which  plans 
such  as  are  being  urged  upon  us  are  in  operation; 
but  not  so  generally  known  is  the  fact  that  three 
South  American  countries  provide  the  most  startling 
contrast  and  argument  against  the  proposed  change. 

Chile,  with  a  system  of  compulsory  sickness  in- 
surance, had  a  death  rate  of  26.8  in  1934  (the  lat- 
est year  for  which  complete  returns  are  available) 
as  compared  with  11.8  in  Argentina  and  of  10  in 


Uruguay,  in  neither  of  which  countries  is  there  an 
insurance  system. 

In  the  Capital  of  Chile,  with  a  system  of  compul- 
sory insurance  there  were  244  deaths  per  thousand 
of  infants  under  1  year,  while  the  Argentine  Capi- 
tal, with  insurance,  had  63. 

Chile  and  .\rgentina  lie  side  by  side  for  more 
than  2,000  miles.  Both  export  a  great  deal  more 
than  they  import,  which  means  that  neither  is  a 
poor  country.  There  is  no  difference  of  conse- 
quence in  kind  of  population. 

W^e  said  in  these  columns  in  February,  1930,  and 
we  maintain: 

That  the  cost  of  adequate  medical  care  in  this 
section  of  the  country  does  not  constitute  a  prob- 
lem of  consequence;  that  95  per  cent,  of  our  pop- 
ulation are  better  satisfied  in  their  relations  with 
their  doctors  than  they  are  in  their  relations  with 
their  landlords,  their  grocers,  their  coal  dealers,  their 
clothiers,  their  preachers,  or  the  teachers  of  their 
children;  that  medical  practice  in  these  parts,  far 
from  being  chaotic,  is  well  organized,  and  medical 
service  is  freely  available;  that  the  times,  medi- 
cally speaking,  demand  no  God-saking;  that  the 
false  and  abusive  representations  being  broadcast 
should  be  answered  by  practicing  physicians;  that 
all  speaking  or  writing  on  the  subject  should  let  it 
be  known  for  whom  they  speak. 


Two  Hundred  Yeaes  But  as  a  Single  Day 
A  brother  of  the  editor,  engaged  in  historical 
research  for  the  Government  with  headquarters  at 
Washington's  Birthplace,  contributes  an  advertis- 
ing notice  as  carried  in  The  Virginia  Gazette,  issue 
of  August  2Sth  to  September  1st,  1738,  Williams- 
burg, Virginia: 

"Mr.  Parks, 

Pray  insert  this  in  your  next  Paper.  I  have  some  Knowl- 
edge in  Herbs,  and  if  any  Person  will  be  so  good  to  inform 
me  in  one  of  your  Gazettes,  the  true  Cause  and  Nature  of 
Cancer,  I  will  discover  an  Herb,  the  Virtue  of  which  is  so 
great,  that  it  will  alone  cure  the  most  violent  Cancer  that 
Mortal  can  be  afflicted  with.  I  am  willing  to  help  my 
Fellow  Creatures;  and  for  that  Reason  desire  you'll  oblige 
him  Who  is 

Sir,  Your  humble  Servant, 

Silvias." 

Any  of  us  could  put  his  hand  on  a  Silvius  eager 
to  delude  and  prey  on  those  who  have,  or  can  be 
persuaded  that  they  have,  cancer;  and  how  famil- 
iar is  the  pious  profession  of  willingness  to  help 
Fellow  Creatures! 

The  phrasing  is  a  bit  archaic;  for  instance,  the 
use  of  discover  to  mean  removing — for  a  price — 
the  cover  from  his  secret;  but  the  callous  appeal 
to  pathetic  credulity  is  such  as  is  being  made  every 
day  over  all  the  territory  in  which  The  Virginia 
Gazette  circulated,  and  everywhere  else. 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


Our  Brush-up  Course 

Participation  in  this  year's  course  in  everyday 
medicine  given  by  Charlotte  doctors  September 
24th  to  26th  may  well  have  brought  to  mind,  "The 
more  the  merrier,  but  the  fewer  the  better  share.'' 
Although  there  were  not  quite  as  many  present  as 
were  expected,  there  was  a  good  turn-out,  and  the 
vray  these  stayed  throughout  gave  real  inspiration. 

When  it  was  too  late  to  change  the  time  for  the 
course  it  was  learned  that  two  District  meetings 
and  another  special  meeting  were  being  held  on 
conflicting  dates. 

The  features  were  instructive  and  well  presented 
and  it  is  certainly  no  disparagement  of  any  other 
to  say  that  Dr.  John  Peter  Munroe's  clinical  pre- 
sentation was  the  high  mark. 

Dr.  jNIunroe  says,  and  we  all  agree,  that  we  are 
going  to  have  a  Brush-up  Course  in  1937,  provid- 
ing even  more  clinical  discussions  of  whatever  sub- 
jects those  most  interested  will  choose  to  have  pre- 
sented. 


Obituary 


-S.    M.    &    S. — 


Duke's  Post  Graduate  Course  October  ISth 
TO  17th 

On  October  15th,  16th  and  17th  there  will  be 
given  at  Duke  Hospital  a  Post  Graduate  Course 
on  Diseases  of  the  Heart,  Circulation  and  Kidney 
after  the  order  of  the  one  given  last  year  on  Dis- 
eases of  the  Gastrointestinal  Tract.  Though  three 
thousand  invitations  were  sent  out  last  year,  many 
physicians  reported  that  they  would  have  attended 
the  course  but  did  not  receive  notice  of  it.  This 
journal  is  glad  of  the  opportunity  to  call  special 
attention  to  this  educational  feature  and  remind 
that  a  cordial  invitation  is  extended  to  all  physi- 
cians to  be  present  at  the  meeting. 

Among  the  speakers  who  will  participate  in  the 
program  are:  Dr.  W.  T.  Longcope  of  Baltimore, 
Dr.  Stewart  Roberts  of  Atlanta,  Dr.  Soma  Weiss 
of  Boston,  Dr.  William  Porter  of  Richmond,  Dr. 
Edwin  Wood  of  Charlottesville,  Dr.  Frank  N.  Wil- 
son of  Ann  Arbor,  Dr.  Herman  L.  Blumgart  of 
Boston,  Dr.  Charles  C.  Wolferth  of  Philadelphia, 
Dr.  Claude  Beck  of  Cleveland,  Dr.  James  C.  White 
of  Boston,  Dr.  ]\Iont  Reid  of  Cincinnati,  Dr.  Carl 
J.  Wiggers  of  Cleveland,  Dr.  William  deB.  Mac- 
Nider  of  Chapel  Hill,  Dr.  Hugh  Young  of  Balti- 
more, Dr.  W.  F.  Braasch  of  Rochester,  and  Dr. 
Louis  Hamman  of  Baltimore. 

The  excellence  of  the  course  given  last  year  would 
suffice  to  assure  that  any  doctor  who  attends  this 
year's  course  will  be  handsomely  repaid.  Those 
who  do  not  have  first-hand  information  about  1935 
course,  are  pointed  to  the  list  of  speakers  where 
will  be  found  names  of  many  of  the  ablest  and 
most  pleasing  and  popular  teachers  of  what  Med- 
icine can  do  for  mankind. 


Doctor  Eugene  Price  Graj 

"  'Gene"  Gray,  as  he  was  known  to  all  his  friends 
— for  we  loved  him  too  well  to  be  more  formal — 
answered  the  final  call  on  June  24th,  nearly  two 
years  after  he  had  been  so  disabled  by  a  severe 
coronary  thrombosis  as  to  have  to  abandon  his 
practice.  He  recovered  only  enough  strength  to 
move  around  among  his  friends,  until  a  cerebral 
hemorrhage — mercifully  a  swiftly  fatal  one — closed 
the  final  chapter  of  his  earthly  career. 

Gene's  patients  loved  him  with  a  whole-hearted 
devotion  that  is  all  too  rare  nowadays,  and  his 
colleagues  esteemed  him  just  as  highly.  His  sun- 
shiny nature,  unfailing  good  humor,  abundant  com- 
mon sense  and  magnetic  personality,  together  with 
his  splendid  professional  training,  made  him  one 
of  those  rare  individuals  of  whom  it  can  be  truly 
said,  "He  is  a  born  doctor."  Like  his  father,  who 
was  a  doctor  of  the  same  type,  he  thought  far 
more  of  the  patient  than  of  the  fee.  One  story 
is  quite  characteristic  of  him.  A  colleague  asked 
if  he  did  not  grow  tired  of  practicing  for  a  certain 
family  who  never  never  known  to  pay,  although 
the  head  of  it  had  a  good  income.  He  replied, 
"Well,  I  just  can't  go  back  on  them.  They  are  so 
loyal." 

The  memory  of  his  many  useful  years  of  prac- 
tice, and  the  cheerful  courage  with  which  he  met 
his  last  months  of  invalidism,  will  serve  as  an  in- 
spiration to  his  professional  friends  who  are  left 
to  carry  on. 

—WIN GATE  JOHNSON. 


S.    M.    &    S.- 


Doctor  DeWitt  Kluttz 

Dr.  DeWitt  Kluttz,  aged  47,  prominent  physi- 
cian and  associate  of  the  Tayloe  Hospital,  Wash- 
ington, Xorth  Carolina,  died  suddenly  at  his  sum- 
mer camp  nine  miles  below  Washington  September 
7th.    Death  was  caused  from  embolism. 

He  was  born  at  ]Monroe,  N.  C,  the  son  of  the 
late  Alex  W.  Kluttz  and  Alice  Jane  Walkupp  Kluttz 
of  Chester,  S.  C,  and  graduated  from  Davidson 
College,  later  receiving  the  Master  of  Arts  degree 
from  this  institution,  and  from  the  L'niversity  of 
Xorth  Carolina,  where  he  did  his  premedical  work. 
.\fter  graduation  in  medicine  from  the  L'niversity 
of  Pennsylvania  he  served  a  two-year  interneship 
at  the  Episcopal  Hospital  at  Philadelphia. 

He  did  special  work  at  Boston  in  1935,  specializ- 
ing in  x-ray  and  diagnostic  courses. 

From  his  student  days  at  Davidson  he  was  mark- 
ed as  a  leader.  Here  he  was  captain  of  the  foot- 
ball team  in  his  senior  year.  For  two  years  he 
taught  at  Woodberry  Forest,  specializing  in  athlet- 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


ics.  He  was  honored  by  his  profession  in  this  state 
and  served  as  president  of  the  Second  District 
Medical  Society  of  North  Carolina  and  was  a  mem- 
ber of  that  group's  advisory  committee;  president 
of  the  Beaufort  County  JNIedical  Society  and  was 
a  member  of  the  North  Carolina  X-ray  Society. 
At  the  time  of  his  death  he  was  a  Counsellor  of 
the  Tri-State  ^Medical  Association,  and  a  member 
of  the  Southern  and  of  the  American  Medical  Asso- 
ciations. He  had  served  as  vice-president  of  the 
Seaboard  Medical  Society  also. 

He  came  to  Washington  in  1919  and  was  asso- 
ciated with  the  late  Drs.  David  T.  Tayloe,  sr.,  and 
Joshua  Tayloe.  He  remained  here  for  five  years, 
leaving  to  enter  the  University  of  Pennsylvania  to 
take  post  graduate  x-ray  and  laboratory  work. 
After  completing  this  work  he  became  associated 
with  Dr.  Hugh  Smith,  of  Greenville,  S.  C. 

He  returned  to  Washington  in  1929,  again  asso- 
ciating himself  with  the  Tayloe  Hospital  Staff  as 
x-ray  specialist  and  diagnostician.  He  was  a  mem- 
ber of  the  Presbyterian  Church,  took  an  active  in- 
terest in  this  community  and  was  regarded  as  a 
leader  in  his  profession.  He  was  highly  regarded 
in  East  Carolina.  The  profession  and  our  staff 
have  lost  a  valuable  member,  and  we  have  lost  a 
good  friend. 

He  was  married  to  ]\Iiss  Annie  Stevens  of  York, 
S.  C,  who  survives  him,  and  two  brothers,  Lex 
Kluttz,  General  Secretary  Charlotte  Y.  M.  C.  A., 
and  Sam  W.  Kluttz  of  Chester,  S.  C. 

Funeral  services  were  conducted  from  the  home 
on  Washington  street  September  9th  by  the  Rev. 
Mr.  W.  D.  Mclnnis,  pastor  of  the  Presbyterian 
Church.  Fifty  graduate  and  student  nurses  of 
the  Tayloe  Hospital  attended  the  services  in  a 
body,  as  well  as  the  trustees  of  the  institution  and 
hundreds  of  physicians  and  friends  from  all  parts 
of  the  state  and  South  Carolina.  The  remains  were 
taken  to  the  home  of  relatives  at  Monroe,  N.  C, 
from  which  burial  took  place  the  following  day  in 
the  Monroe  cemetery. 

—JOHN  C.  and  JOSHUA  TA  YLOE. 

S.    M.    &    S. 

Academy  of  Physical  Medicine 

The  Academy  of  Physical  Medicine  will  hold  its  annual 
meeting  in  Boston,  at  the  Hotel  Statler  on  October  20th 
to  22nd. 

The  program  is  educational  in  character  and  contains 
symposia  and  reports  on  the  new  studies  and  clinical  devel- 
opments in  Physical  Medicine  presented  by  recognized  au- 
thorities in  the  various  fields  of  medicine  and  basic  sciences. 

An  elaborate  program  has  been  arranged  for  the  visiting 
ladies. 

All  members  of  the  medical  profession  are  cordially  in- 
vited to  attend.  A  program  will  be  mailed  on  request  of 
William  D,  McFee,  M.D.,  Chairman  Executive  Committee, 
41  Bay  State  Road,  Boston,  Mass.  Franklin  P.  Lowry, 
M.D.,  Secretary-Treasurer,  13  Washington  St.,  Newton, 
Mass. 


BOOK  REVIEWS 


DISEASES  OF  THE  AIR  AND  FOOD  PASSAGES  OF 
FOREIGN-BODY  ORIGIN,  by  Chevalier  Jackson,  M.D., 
Sc.D.,  F..\.C.S.,  LL.D.,  Professor  of  Bronchoscopy  and 
Esophagoscopy,  Temple  University,  and  Chevalier  L. 
Jackson,  A.B.,  M.D.,  M.Sc.  (Med.),  F.A.C.S.;  Professor  of 
Clinical  Bronchoscopy  and  Esophagoscopy,  Temple  Univer- 
sity. 094  pages  with  2,000  illustrations  including  3  plates 
in  colors.  Philadelphia  and  London:  W.  B.  Saunders  Com- 
pany. 1936.     Cloth,  S12.50  net. 

The  priority  and  the  expertness  of  the  senior 
author  account  for  the  enormous  number  of  cases 
which  form  the  basis  of  this  authoritative  work. 
The  authors  realize  that  this  information  will  not 
be  found  useful  by  those  practicing  their  own 
specialty  alone,  but  by  family  doctors  and  those  in 
many  other  special  lines  of  practice. 

Perhaps  in  no  other  branch  of  medicine  have  so 
great  advances  been  made  in  the  past  two  or  three 
decades,  and  the  name  Jackson  stands  for  the  best 
in  this  form  of  distress-relief  and  life-preservation. 


THE  RELIEF  OF  PAIN:  A  Handbook  of  Modern  An- 
algesia, by  Harold  Balme,  M.D.  (Durh.),  F.R.C.S.  (Eng.), 
D.P.H.  (Lond.),  Formerly  Professor  of  Surgery  and  Dean 
of  the  School  of  Medicine,  Cheelo  University,  China;  with 
an  introduction  by  Sir  E.  Farquhar  Buzzard,  Bt.  K.C.V.O., 
LL.D.  (Man.),  M.D.  (Oxon.),  F.R.C.P.,  Regius  Professor 
of  Medicine  in  the  University  of  Oxford.  President-elect 
of  the  British  Medical  .■\.';sociation,  1936-7.  P.  Blakislon's 
Son  &  Co.,  Inc.,  1012  Walnut  St.,  Philadelphia.  1936. 
$4.00. 

The  relief  of  pain  is  one  among  the  most  import- 
ant duties  of  a  doctor  and  one  among  the  most 
important  services  he  can  render  his  patient. 

In  this  book  are  gathered  together  the  experience 
of  many  years  and  valuable  writings  from  all  over 
the  world. 

First  to  be  considered  is  the  problem  of  pain, 
then  general  and  systemic  pain,  then  regional  pain, 
then  the  therapeutics  of  analgesia. 

Not  all  old  measures  of  relief  of  pain  are  re- 
jected, nor  all  new  ones  accepted. 

It  is  not  at  all  an  encouragement  to  palliative 
treatment  to  the  neglect  of  exact  diagnosis  and  the 
removal  of  causes.  It  is  a  book  that  will  prove  a 
boon  to  the  patients  of  doctors  who  concern  them- 
selves constantly  with  the  cure  and  the  comfort  of 
their  patients,  and  to  such  doctors. 


A  TEXTBOOK  OF  OBSTETRICS,  by  Edward  A. 
ScHirMANN,  A.B.,  M.D.,  F..\.C.S.,  Professor  of  Obstetrics, 
School  of  Medicine,  University  of  Pennsylvania;  Surgeon- 
in-Chief,  Kensington  Hospital  for  Women ;  Gynecologist 
and  Obstetrician  to  Philadelphia  General  and  Memorial 
Hospitals;  Obstetrician  to  Chestnut  Hill  Hospital;  Consult- 
ing Gynecologist  to  Frankford,  Jewish,  Burlington  County 
and  Rush  Hospitals.  780  pages  with  581  illustrations  on 
497  figures.  Philadelphia  and  London:  W.  B.  Saunders 
Company,  1936.     Cloth,  :f;6.50  net. 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


It  is  gratifying  to  see  a  modern  textbook  of  ob- 
stetrics of  less  than  800  pages  and  at  a  reasonable 
price.  Seeing  it  said  that  the  advances  of  the 
past  quarter-century  have  been  offset  by  unwise 
operative  efforts  inspired  by  these  advances  en- 
hances the  pleasing  foretaste.  It  would  seem  well 
to  leave  out  of  a  book  written  to  teach  obstetrics 
detailed  information  on  anatomy  and  physiology 
specially  involved,  and  to  confine  such  discussions 
to  pertinent  facts  of  recent  discovery.  However, 
the  author  sticks  to  his  subject:  he  does  not  wander 
off  into  a  labyrinth  in  which  author  and  reader  are 
lost  by  the  hour.  The  section  on  diagnosis  of  preg- 
nancy is  a  beautiful  illustration  of  a  just  balancing 
of  the  importance  and  applicability  of  bedside  and 
laboratory  tests;  and  that  on  the  management  of 
pregnancy  shows  a  balance  and  a  breadth  of  com- 
prehension of  the  multiplicity  of  factors  involved 
that  is  seldom  seen.  His  general  principles  for 
conducting  labor  are  admirable.  On  the  whole  the 
book  shows  grasps  of  the  subject  and  ability  to 
teach  it,  without  exaggeration  of  its  great  import- 
ance, without  assuming  that  the  whole  time  of  most 
doctors  can  be  taken  up  with  obstetrical  matters. 
s.  M.  &  s. 

Forty-one  years  ago — November  8th,  1895 — Wilhelm 
Konrad  Rontgen,  of  Wurzburg,  discovered  that  a  partially 
evacuated  glass  vessel,  through  which  an  electric  current 
of  about  10,000  volts  was  being  passed,  emitted  a  radiation 
which  could  penetrate  opaque  substances. 


NEWS  ITEMS 


Anal-  Sed 


Analgesic,   Sedative   and   Antipyretic 

Affords  relief  in  migraine,  headache,  sciatica  and 
neuralgia.  Rheumatic  symptoms  are  frequently  re- 
lieved by  a  few  doses. 

Description 
Contains   3^    grains   of   Amidopyrine,    J4    grain    of 
Caffeine  Hydrobromide  and  15  grains  of  Potassium 
Bromide  to  the  teaspoonful. 

Dosage 
The  usual  dose  ranges  from  one  to  two  teaspoonfuls 
in  a  little  water. 

How  Supplied 
In  pints  and  gallons  to  physicians  and  druggists. 


Burwell  L  Dunn  Company 


Manufacturing 
Established 


CHARLOTTE,  N.  C. 


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


The  Interjmationai,  College  of  Surgeons 

This  organization,  with  headquarters  at  Geneva,  Switzer- 
land, announces  that  it  will  hold  its  first  examination  for 
Membership  and  Fellowship  some  time  before  January  1st, 
1037.  In  the  United  States  the  examinations  will  be  held 
at  New  York  City,  Chicago,  Durham,  N.  C,  San  Francisco, 
San  Antonio,  Texas,  and  Rochester,  Minn.  A  surgeon  may 
become  a  member  if  he  is  over  30  years  of  age  and  passes 
the  required  examination,  which  consists  of  a  written  test, 
a  chnical  bedside  examination,  an  oral  test  and  operations 
on  the  cadaver.  The  written  examination  papers  will  be 
prepared  in  Geneva  and  the  same  questions  will  be  sub- 
mitted to  surgeons  in  every  country  in  the  world.  The 
examination  for  Fellowship  is  practically  the  same,  except 
that  an  applicant  may  receive  the  Specialty  Fellowship  in 
any  one  of  the  various  special  branches  of  surgery.  An 
applicant  for  Fellowship  must  be  over  40. 

Surgeons  in  the  United  States  desiring  to  take  either  ex- 
amination should  send  for  an  application  form  to  one  of 
the  following  Regents:  Dr.  Dean  Lewis  (National  Re- 
gent), Professor  of  Surgery,  Johns  Hopkins  University, 
Baltimore;  Dr.  John  Erdmann,  Professor  of  Surgery,  Co- 
lumbia University,  New  York;  Dr.  Deryl  Hart,  Professor 
of  Surgery,  Duke  University,  Durham;  Dr.  Frederick  G. 
Dyas,  Professor  of  Surgery,  University  of  Illinois,  Chicago; 
Dr.  E.  Eric  Larson,  Clinical  Professor  of  Surgery,  Univer- 
sity of  California,  Los  Angeles;  Dr.  A.  O.  Singleton,  Pro- 
fessor of  Surgery,  University  of  Texas,  Galveston. 

In  Canada  the  examination  wiU  be  held  in  Montreal 
and  Toronto.  Candidates  may  receive  examination  appli- 
cation forms  from  the  Dominion  Regent:  Dr.  E.  .i^rchibald. 
Professor  of  Surgery,  McGill  University,  Montreal;  or 
from  Dr.  D.  E.  Robertson,  Assistant  Professor  of  Surgery, 
University  of  Toronto,  or  Dr.  Charles  Vezina,  Professor  of 
Clinical  Surgery,  Laval  University,  Montreal. 

The  fee  for  the  examination  will  be  $250.00  and  the 
same  fee  will  be  required  of  applicants  in  Mexico,  Panama 
and  South  American  countries.  Eighty  per  cent,  of  the  fee 
will  be  returned  to  candidates  who  fail  to  pass  the  examina- 
tion. 

The  International  College  of  Surgeons  has  a  very  high 
standing  for  Membership  or  Fellowship.  About  300  of 
the  leading  surgeons  of  the  United  States  and  Canada  have 
been  appointed  Regents  and  it  is  the  earnest  desire  of  the 
College  to  stimulate  interest  among  the  best  men  in  sur- 
gery. It  is  the  hope  of  the  College  that  a  great  many  men 
will  apply  for  Fellowship  this  year. 


N.  C.  Surgical  Club 
Fifteen  surgeons  from  various  cities  in  North  Carolina 
gathered  in  Roanoke  Rapids  for  the  annual  meeting  of  the 
N.  C.  Surgical  Club.  Dr.  Bahnson  Weathers  was  host  on 
this  occasion,  the  meeting  being  held  at  his  home.  .A  buffet 
luncheon  was  served  at  noon,  and  the  afternoon  was  given 
over  to  business  and  to  discussions  pertaining  to  the  pro- 
fession. 


The  Third  Postgraduate  Course  in  Otolaryngology 
AND  Ophthalmology  wiU  be  held  at  the  University  of 
Virginia  the  last  week  in  October.  The  Otolaryngology 
dates  will  be  October  27th  and  2Sth,  and  the  course  will 
be  conducted  by  Dr.  Perry  Goldsmith  of  Toronto,  Dr. 
Gabriel  Tucker  of  Philadelphia,  Dr.  J.  R.  Richardson  of 
Boston,  and  Mr.  E.  B.  Burchell  of  New  York.  The  courses 
in  Ophthalmology  will  be  held  on  October  29th  and  30th, 
and   will   be   conducted   by   Drs.   Bernard   Samuels,   Webb 


October,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Eli  Lilly  and  Company 

FOUNDED      18  7  6 

!Makers  oj  !Mcdicinal  Products 


PULVULES   LEXTRON 

[Liver- StctiuKb  Concentrate  with  Jron  and 
Titamin  B.  £.iUy] 

RAPID  convalescence  from  many  debil- 
itating diseases  can  be  brought  about 
•  with  'Lextron'  when  secondary 
anemia  has  assumed  a  conspicuous  place  in 
the  clinical  picture.  On  'Lextron'  the  patient 
receives  all  the  materials  essential  for  blood 
regeneration. 

Pulvules  'Lextron'  (Liver-Stomach  Concen- 
trate with  Iron  and  Vitamin  B,  Lilly)  are 
supplied  in  bottles  of  84  and  500. 


Prompt  Atteution  Qiveu  to  Professional  Jncfuiries 

PRINCIPAL    OFFICES    AND    LABORATORIES.    INDIANAPOLIS,    INDIANA,    U.S.A. 


Please  Mention  THIS  JOURNAL  When  Writing  to  Advertisers 


572 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


Weeks,  John  Wheeler  and  J.  W.  White  of  New  York,  and 
Dr.  Harr\-  Gradle  of  Chicago.  The  fee  will  be  §15.00  for 
either  part  of  the  course  and  ?25.00  for  the  full  course. 
The  subjects  will  be  announced  later. 


The  Georgi.a  Pediatric  Society  meets  December  10th. 
Papers  will  be  read  in  the  afternoon  and  evening  sessions 
by  Dr.  John  A.  Toomey,  of  Reserve  University ;  Dr.  Julius 
H.  Hess,  of  the  University  of  Illinois;  Dr.  Henry  Helmholz, 
of  the  Mayo  Clinic;  and  Dr.  W.  A.  Mulherin  of  Augusta, 
assisted  by  Dr.  Alfred  Walker  of  Birmingham  and  Dr. 
Lesesne  Smith  of  Spartanburg. 

The  committee  is  anxious  for  you  to  attend,  and  prom- 
ises a  day  full  of  interest  and  instruction.  They  would 
appreciate  knowing  of  your  intention  to  be  present  at  this 
meeting. 


The  Southeastern  Branch  of  the  American  Urological 
Society  will  hold  its  annual  convention  at  Charlotte  De- 
cember 4th  and  Sth.  Dr.  Claude  B.  Squires  is  Chairman 
of  the  Arrangements  Committee  and  Dr.  Hamilton  McKay 
is  President-elect.  The  physicians  will  be  guests  at  a  ban- 
quet the  evening  of  December  4th  at  the  Charlotte  Coun- 
trv  Club.  The  business  sessions  will  be  held  at  Hotel 
Charlotte. 


The  Ninth  District  Medical  Society  held  its  annual 
meeting  at  Salisbury,  at  the  Country  Club  on  September 
24th.     Papers: 

Urinary  Hemorrhage,  Dr.  J.  W.  Frazier,  Salisbury;  Re- 
cent Concepts  of  Cardiovascular  Disease  with  Brief  Review 
of  2200  Cases,  Electrocardiographic  Records,  Dr.  J.  S.  Hol- 
brook,  Statesville;  The  Surgeon  and  Proctology,  Dr.  G.  F. 


ARTHRITIS 

Prompt  and 
Sustained 


Relief 


SUtPHOCEn 


THERAPEUTIC  ACTION 

Pain    checked,    reduction    in     swelling    hastened, 
joint  mobility  definitely  increased. 
Therapeutic  doses  produce  no  toxic  symptoms. 
Non-irritating,  painless  and  no  "protein  shock." 

FORMULA: 

A  5%  solution  of  Dipeptyl-Amino  Thiol.  Con- 
tains the  special  determinates  obtained  from  the 
protein  molecule  complex  and  organic  sulphur 
molecularly  combined  in  the  form  of  disulphide — 
S:S — and  sulphydry] — S  H — groups,  so  that  each 
2  c.c.  will  contain  the  equivalent  of  10  mgms.  of 
available  sulphur. 

.'WAILABLE:   in  2   c.c.  ampuls,  bo.xes  of   12,  25, 
100. 

'Write  for  complete  literature. 


HYPO-MEDICAL 


iiSO  BROADWAY  .  NEW  YORK.N.Y. 


Busby,  Salisbury;  Fractures  and  Emergency  Operations, 
Dr.  Edward  W.  Phifer,  Morganton ;  For  the  Good  of  the 
Profession,  Dr.  C.  F.  Strosnider,  Goldsboro,  N.  C,  Presi- 
dent North  Carolina  Medical  Society. 

At  the  banquet  held  at  6:30  Dr.  F.  B.  Marsh  served  as 
toastmaster  and  the  guest  speaker,  Mr.  R.  L.  Pope,  Thom- 
asville,  had  as  his  subject  A  Layman  Examines  the  Doc- 
tor. 

Officers  elected:  Dr.  Frank  B.  Marsh,  Salisbury,  Presi- 
dent; Dr.  R.  T.  Hamrick,  Hickory,  Vice  President;  Dr. 
J.  S.  Lewis,  Hickory,  Secretary-Treasurer;  and  Dr.  J.  D. 
Redwine,  Lexington,  Assistant  Secretary-Treasurer.  Hick- 
ory was  selected  for  the  1037  meeting. 

Miss  Hattie  Griffin  of  Goldsboro  and  Dr.  Alfred  G. 
Grunwell,  LI.  S.  N.,  were  married  at  noon  September  3rd, 
at  the  summer  home  of  the  bride's  father,  W.  H.  Griffin 
of  Goldsboro,  at  Black  Mountain.  Immediately  after  the 
luncheon  Dr.  and  Mrs.  Grunwell  left  for  a  wedding  trip. 
LTpon  their  return  they  will  be  at  their  home,  "Villa 
Bianca,"  in  Punta  Gorda,  Fla. 


The  regular  August  meeting  of  the  Wake  County  Med- 
ical Society  in  the  Auditorium  of  Dix  Hill  on  the  evening 
of  August  13th,  Dr.  I.  M.  Procter,  president,  in  the  chair. 

Dr.  David  C.  Wilson,  of  the  University  of  Virginia  Med- 
ical School,  spoke  on  Maladjustment  as  a  Cause  of  Mental 
Disease.  There  were  short  discussions  of,  and  questions 
asked  about,  the  paper  before  Dr.  Wilson  closed  his  part 
of  the  program  with  a  short  talk. 

Dr.  J.  W.  Ashby  made  a  motion  that  Dr.  Wilson  be 
asked  his  consent  that  his  paper  be  sent  to  Southern  Med- 
icine and  Surgery.  This  was  seconded  and  passed.  Dr. 
Wilson  turned  the  paper  over  to  the  secretary. 

The  secretary  read  a  letter  of  transfer  from  the  Edge- 
combe-Nash Medical  Society  in  the  case  of  Dr.  Roy  Nor- 
ton. Dr.  Gibson  made  the  motion  that  the  application  for 
transfer  be  received.  It  was  seconded  by  Dr.  Glascock, 
and  passed  unanimously  by  the  society ;  referred  to  the 
censorship  committee. 

/.  M.  Procter,  M.D.,  Pres. 

N.  H.  McLeod,  M.D.,  Sec.-Treas. 


Mecklenburg  Colinty  Medical  Society,  September 
15th,  Medical  Library,  S  o'clock,  the  meeting  in  the  nature 
of  a  Pediatric  Symposium.  Brief  case  reports  were  pre- 
sented by  the  several  pediatricians  of  the  city,  and  a  short 
paper  by  Dr.  J.  S.  Hunt  on:  "Raw  Apple  Diet  in  the 
Treatment  of  Pediatric  Diarrheas." 


Mecklenburg  Coltnty  Medical  Society,  October  6th, 
8  o'clock,  Medical  Library. 

Symposium  on  the  Heart:  Cardiac  Disorders  of  Child- 
hood, Dr.  J.  R.  Ashe;  The  Electrocardiogram  in  Cardiac 
Diagnosis,  Dr.  Ellas  Faison;  Cardiac  Dyspnea,  Dr.  L.  W. 
Kelly ;  The  Heart  in  Old  Age,  Dr.  J.  M.  Northington. 


The  newly-organized  Virginia  Neuro-Psychiatric  So- 
ciety held  its  first  meeting  at  Charlottesville,  September 
30th. 

Features  of  the  Program:  The  Relative  Effects  of  Dark- 
ness and  of  Occipital  Lesions  upon  an  Elevated  Maze 
Habit,  Mrs.  Cecile  B.  Finley;  Chronic  Meningitis  following 
Spinal  .Anesthesia,  Dr.  H.  Page  Newbill ;  Present  Status  of 
Immune  Reactions  in  Meningitis,  Dr.  W.  E.  Bray;  Discus- 
sion of  seven  cases  treated  by  Electropyrexia  in  Paresis, 
Dr.  James  King;  Psychoneurotic  Reactions,  Dr.  D.  C.  Wil- 
son ;  Clinical-Pathological  Conference  on  a  case  of  von 
Recklinghausen's  Disease  with  Bilateral  Eighth  Nerve  Tu- 
mors, Drs.  E.  P.  Lehman  and  Cash. 


October,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


S73 


Richmond  Academy  of  Medicine,  stated  meeting,  Sept. 
22nd,  8:30  p.  m.  Program:  Report  of  Unusual  Compli- 
cation in  Meckel's  Diverticulum,  Dr.  Charles  R.  Robins, 
sr. ;  Pregnancy  and  Labor  in  400  Unmarried  Primiparac, 
Dr.  William  Bickers,  discussion.  Dr.  Greer  Baughman;  Dif- 
ferential Diagnosis  in  Rheumatic  Arthritis  and  Gout,  Dr. 
E.  L.  Kellum,  discussion.  Dr.  Douglas  Chapman. 


From  Dr.  A.  E.  B.aker.  Charleston 

Describing  the  skin  as  a  reflecting  mirror  of  the  indi- 
vidual's general  health,  Dr.  John  M.  van  de  Erve,  Charles- 
ton skin  specialist,  on  Sept.  22nd  spoke  before  members 
of  the  Charleston  Rotary  Club  at  the  Francis  Marion 
Hotel  on  Skin  in  the  Modern  World.  The  physician  traced 
briefly  the  development  of  man  over  a  period  of  thousands 
of  years  to  his  modern  professional  and  industrial  life,  in 
which  he  said  "Man  has  locked  himself  into  the  dark 
damp  of  coal  mines,  into  the  dusty  and  dingy  cubicles  of 
commerce  and  has  given  up  much  of  his  previous  health- 
freedom."  "Slowly,"  he  said,  "His  life  has  become  more  ar- 
tificial until  now  he  lives  much  of  his  time  in  artificial  light 
ipstead  of  sun,  on  artificial  food  rich  in  concentrated  sweets 
instead  of  wholesome  coarse  food  and,  what  is  even  more 
important,  in  an  artificial  stew  of  nervousness."  The  skin 
is  exposed  to  insults  from  irritation  externally  and  inter- 
nally. All  employers  are  concerned  with  the  effects  of 
external  irritants — the  florist  so  sensitive  to  flowers  that  a 
change  of  occupation  is  necessary,  the  painter  who  devel- 
ops dermatitis.  The  second  problem  is  the  health  of  the 
individual.  The  mental  stress  and  strain,  and  the  physical 
activity  of  modern  life  exact  their  dues  from  the  health  of 
the  business  man.  Rest,  relaxation,  and  a  reasonably  quiet, 
well-ordered  life  is  the  answer  to  many  of  these  troubles. 
In  conclusion,  Dr.  van  de  Erve  said:  "May  Rotary  take 
its  part  in  providing  the  abundant  and  healthful  life  for 
all  of  us,  employers,  executives,  professionals,  w-ho  still  arc 
underprivileged  as  to  health  and  leisure," 

Dr.  Josiah  E.  Smith,  chairman  of  the  Charleston  housing 
authority,  is  back  in  the  city  after  a  two  months'  trip 
abroad.  Dr.  and  Mrs.  Smith,  their  four  children  and  the 
nurse  employed  in  Dr.  Smith's  office.  Miss  Nina  Allsbrook, 
returned  on  the  11th.  The  Smith  party  sailed  from  Nor- 
folk on  the  City  oj  Baltimore  and  returned  on  the  Presi- 
dent Harding,  landing  in  New  York. 

The  program  of  the  Southern  Tuberculosis  Conference 
and  the  Southern  Sanatorium  Association  which  meets  in 
Hot  Springs,  Ark.,  October  lst-3rd,  includes  four  speak- 
ers from  South  Carolina ;  Dr.  W.  Atmar  Smith,  Charleston, 
President  of  the  Southern  Sanatorium;  Dr.  J.  F.  Busch, 
Superintendent,  Greenville  County  Sanatorium;  Mrs.  D. 
McL.  McDonald,  Executive  Secretary,  South  Carolina  Tu- 
berculosis Association;  and  Charles  A.  Weinheimer,  Presi- 
dent of  the  Charleston  County  Tuberculosis  Association. 
The  conference  will  make  a  study  of  tuberculosis  infection 
among  the  various  social,  economic  and  race  groups  in  the 
South  and  the  method  most  effective  in  handling  the  dis- 
ease among  the  various  groups.  Emphasis  in  the  cHnical 
section  of  the  conference  will  be  put  on  the  diagnosis  and 
treatment  of  the  disease  among  the  Southern  mountaineers 
and  among  the  Negroes.  The  problem  of  finding  those 
afflicted  with  tuberculosis  while  disease  is.  in  its  earlier 
stages  will  be  discussed  from  the  standpoint  of  the  private 
physician,  the  public  health  official  and  the  local  tubercu- 
losis association,  with  special  emphasis  on  college  and  high 
school  students. 

The  Seventh  District  (S.  C.)  Medical  Association  held 
its  annual  meeting  at  Kingstrec  on  Sept.  17th.     Papers  were 


AN  OUTSTANDING  MEDICAL 
MEETING  —  the  Annual  Meet- 
ing of  the  Southern  Medical  Associa- 
tion in  Baltimore  in  mid  November. 
In  the  twelve  general  clinical  sessions, 
the  sixteen  sections,  the  six  independ- 
ent medical  societies  meeting  conjoint- 
ly, and  the  scientific  and  technical  ex- 
hibits, every  phase  of  medicine  and 
surgery  will  be  covered — the  last  word 
in  modern,  practical,  scientific  medicine 
and  surgery.  Addresses  and  papers  by 
distinguished  clinicians  not  only  from 
the  South,  but  from  all  over  the  United 
States. 

Regardless  of  what  any  physician  may 
be  interested  in,  regardless  of  how  gen- 
eral or  how  limited  his  interest,  there 
will  be  at  Baltimore  a  program  to  chal- 
lenge that  interest  and  make  it  worth 
while  for  him  to  attend. 

PVERY  PHYSICIAN  IN  THE 
■'— '  SOUTH  who  is  a  member  of  his 
state  and  county  medical  societies  can 
be  and  should  be  a  member  of  the 
Southern  Medical  Association.  The 
annual  dues  of  ^4.00  include  the  As- 
sociation's own  Journal  each  month, 
the  Southern  Medical  Journal  —  the 
equal  of  any,  better  than  many. 

SOUTHERN   MEDICAL   ASSOCIATION 

Empire  Building 
BIRMINGHAM,  ALABAMA 


SOUTHERN  MEDICINE  AND  SURGERY 


October,  1936 


The   Tulane   University  of  Louisiana 
GRADUATE  SCHOOL  of  MEDICINE 

Postgraduate  instruction  offered  in  all  branches  of  medicine. 

Special  Courses: 

Surgery,  Gynecology  and  Obstetrics — May  10  to  June  5,  1937. 
Tropical  Medicine  and  Parasitology — June  14  to  July  24,  1937. 

Courses  leading  to  a  higher  degree  are  also  given. 

A  bulletin  furnishing  detailed  information  may  be  obtained  upon  application  to 

THE  DEAN,  GRADUATE  SCHOOL  OF  MEDICINE 

1430  Tulane  Avenue,  New  Orleans,  La. 


read  by  Dr.  R.  C.  Bruce,  of  Greenville,  State  president; 
Drs.  Hal  M.  Davison  and  Frank  Boland,  of  .Atlanta;  Drs. 
Hamilton  McKay  and  O.  D.  Baxter,  of  Charlotte;  Dr. 
Robert  Wilson,  of  Charleston;  Dr.  Robert  E.  Seibels,  of 
Columbia;  Drs.  P.  E.  Huth  and  M.  E.  Parrish,  of  Sumter. 
The  guests  were  entertained  at  luncheon  by  the  Williams- 
burg County  Medical  Society. 

Dr.  Harry  E.  Rodgers,  native  of  Ravenel  and  former 
Charlestonian,  died  Sept.  13th  in  Albuquerque,  N.  M.  He 
was  born  June  7th,  1S96,  and  educated  in  the  Ravenel 
schools,  Porter  Military  .\cademy,  Clemson,  and  the  Col- 
lege of  Charleston.  For  eleven  months  he  served  overseas 
as  a  lieutenant  in  the  air  corps,  hiter  the  war,  he  com- 
pleted his  College  of  Charleston  courses  and,  in  1923,  was 
graduated  from  the  Medical  College  of  the  State  of  South 
Carolina.  He  served  an  interneship  at  St.  Francis  Xavier 
Infirmary  here  and  took  postgraduate  courses  in  Vienna. 
When  he  returned  from  .Austria,  he  began  practice  of  medi- 
cine in  the  New  Mexico  city  and  there  resided  until  his 
death. 

Miss  Hazel  Thomas  Baker  and  Dr.  Lebby  Barnard  King, 
of  James  Island  and  Charleston  were  married  Sept.  19th 
at  7  o'clock,  in  the  Presbyterian  Church,  the  ceremony  be- 
ing performed  by  The  Rev.  Mr.  W  .R.  Prichett. 


From  Dr.  L.  B.  McBrayer,  Southern  Pines 
The   Committee   of   the   State   Medical   Society   on  Post 
Graduate  Assembly  expects  to  hold  two  or  three  more  as- 
semblies in  different  parts  of  the  State  during  the  remainder 
of  the  year. 

The  .'\nnual  Brush-Up  course  held  at  Charlotte,  Septem- 
ber 24th  to  26th,  made  possible  by  Dr.  James  M.  North- 


Dl U  RBITAL 


VASODILATOR 
DIURETIC     •     SEDATIVE 

No  Barbital  Complications 


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3gr. 

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(  Calc.  Lact 
/  Hypertension  (any  cause) 
INDICATIONS      "^"."''"^S^card!'""'""  " 
(  Myocarditis 
AVAILABLE  J  In  tablets  at  all  drug  stares 


I  Oi! 


Write  for  literature  and  samples 


GRANT  CHEMICAL  COMPANY 

315  EAST  77th  STREET        •        •        NEW  YORK,  N.  Y. 


ington  and  his  Journal,  Southern  Medicine  and  Surgery, 
as  always,  was  a  very  interesting  and  instructive  post  grad- 
uate course. 

The  University  of  North  Carolina  is  presenting  a  Post 
Graduate  Course  in  the  Fourth  District  at  Goldsboro,  N. 
C.  This  will  be  held  once  a  week  for  six  weeks  in  the 
City  of  Goldsboro.  For  information  address  Mr.  R.  M. 
Grumman,  Director  Extension  Work,  University  of  North 
Carolina,  Chapel  Hill,  N.  C. 

.'Announcement  has  been  received  that  Duke  University 
will  repeat  its  Post  Graduate  Course  this  fall  of  one  after- 
noon and  evening  and  the  morning  and  afternoon  of  the 
next  day. 

At  the  recent  commencement  of  the  University  of  North 
Carolina  the  President  and  Faculty  conferred  the  LL.D. 
degree  on  Dr.  Paul  Pressly  McCain,  Supt.  of  the  State 
Sanatorium,  Sanatorium,  N.  C. 


Dr.  John  Knox, -of  Lumberton,  was  painfully  injured 
in  an  automobile  coUision  on  the  road  between  Lumber- 
ton  and  Maxton,  the  morning  of  September  26th.  The 
wreck  occurred  when  a  pick-up  type  truck  attempted  to 
pass  a  heavy  truck  that  was  traveling  behind  a  wagon  and 
was  unable  to  get  sufficient  clearance,  striking  the  rear 
right  side  of  Dr.  Knox's  car  and  causing  it  to  leave  the 
highway  and  strike  a  telephone  pole.  Dr.  Knox  was  un- 
conscious when  first  reached  but  soon  regained  conscious- 
ness and  was  able  to  walk  into  Thompson  Memorial  Hos- 
pital, to  which  he  was  taken.  .An  examination  made  at  the 
hospital  showed  that  he  had  no  broken  bones,  the  extent  of 
his  injuries  consisting  of  a  lacerated  upper  lip,  bruises  and 
cuts  to  his  forehead,  body  bruises  and  injuries  to  his  back 
and  left  knee. 

(Some  day  every  car  on  every  road  will  have  a  gover- 
and  then  trucks  (legal  speed  limit  30  mi.)  will  not 
"    ind  60.— Edr.) 


^ularly  l>etwe 


In  accordance  with  the  retirement  ruling  of  the  Board 
of  Trustees  of  the  University  of  North  Carolina,  Dr.  .Anna 
M.  Gove,  college  physician  and  head  of  the  medical  divi- 
sion of  the  department  of  health  of  North  Carolina  College 
for  Women,  is  retiring  from  that  position  and  is  being  suc- 
ceeded by  Dr.  Ruth  M.  Collings,  who  since  1925  has  been 
associate  physician  and  professor  of  hygiene. 


Dr.  Roshier  W.  Miller,  President  of  ihe  Richmcnd 
.Academy  of  Medicine,  presided  over  the  sessions  on  one 
of  the  days  of  the  3-day  Conference  on  Crime  held  at  the 
Jefferson  Hotel  September  27th  to  20th;  and  Dr.  O.  B. 
Darden  of  Westbrook  addressed  thge  session  on  The  P!iy- 
sician  and  the  Psychiatrist. 


I 


October,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


S7S 


Dr.  Douglas  VasderHoof,  Richmond,  was  elected  a 
director  of  the  National  Community  Chests  and  Councils, 
Inc.,  at  the  meeting  of  the  national  organization  in  Wash- 
ington, Sept.  19th. 


Dr.  VViLLi.Ajit  DE  Berniere  M.acNider,  of  the  School  of 
Medicine  of  the  University  of  North  Carolina,  lately  visited 
friends  in  Richmond. 


— S.    M.    &    S.- 


Dr.  John  Wyatt  Davis,  jr.,  of  Lynchburg,  Virginia,  and 
Miss  Clementene  Goode,  of  Utica,  Kentucky,  were  married 
in  Owensboro,  Kentucky,  August  20th. 


Dr.  Frederick  McCullock,  of  Lynchburg,  Virginia,  and 
Miss  Gertrude  Davis  Hancock,  of  Beaufort,  North  Caro- 
lina, August  29th. 


Dr.  Edward  Murdough  Ellerson,  of  Washington,  and 
Miss  Elsie  Boyd  Tucker,  of  Richmond,  were  married  on 
September  26th. 


Miss  Mildred  Crowder,  daughter  of  Mr.  and  Mrs.  Thom- 
as Steele  Crowder,  of  3600  Ann  street,  Richmond,  and  Dr. 
Edward  Grey  don  Pickles,  of  New  York,  at  S:30  o'clock  at 
the  Woodland  Heights  Baptist  Church,  Richmond.  The 
bride  is  a  graduate  of  Westhampton  College.  Dr.  Pickles 
is  a  graduate  of  Richmond  College.  Later  he  received  his 
Master's  and  Doctor's  degrees  from  the  University  of  Vir- 
ginia. He  is  now  doing  research  work  at  Rockefeller  In- 
stitute in  New  York. 

s.  M.  &  s. 

Deaths 


Dr.  Arthur  Van  Harlingen,  one  of  the  earliest  of  Amer- 
ican skin  specialists,  died  at  his  home  in  Bryn  Mawr,  Penn., 
September  23rd,  in  his  ninety-first  year.  Death  resulted 
from  a  stroke  suffered  two  weeks  ago.  He  was  a  classmate 
and  associate  of  the  late  Dr.  Louis  A.  Duhring,  the  first 
Professor  of  Dermatology  at  the  University  of  Pennsylva- 
nia Medical  College.  For  two  years  Dr.  van  Harlingen 
served  as  a  resident  physician  at  the  Philadelphia  and  Penn- 
sylvania Hospitals  and  then  began  practice  in  this  city. 
After  twelve  years  as  chief  of  the  skin  clinic  at  the  Uni- 
versity of  Pennsylvania  he  became  Professor  of  Dermatol- 
ogy at  the  Philadelphia  Polyclinic  Hospital,  lecturing  at  the 
same  time  at  Jefferson  Medical  College. 


Dr.  John  Moses  Maness,  SS   (N.  C.  Med.  Col.  '09),  of 
Hamlet,  died  September  25th,  after  three  weeks  of  illness. 


Dr.  Benjamin  Williams  Best,  75  (P.  &  S.,  Balto.,  '84), 
died  at  Clinic  Hospital  September  24th  from  injuries  suf- 
fered in  an  automobile  wreck  September  ISth. 


Dr.  Manfred  Call,  of  Richmond,  died  September  12th 
after  an  illness  of  many  weeks. 

For  a  few  years  after  his  graduation  Dr.  Call  was  asso- 
ciated with  Dr.  Ben  Johnston,  but  in  1905  he  determined 
to  specialize  in  the  field  of  diagnostic  work.  At  the  time 
of  his  death,  Dr.  Call  was  Professor  of  Clinical  Medicine 
in  the  Medical  College  of  Virginia,  a  chair  which  he  had 
filled  with  notable  success  for  many  years.  He  had  also 
served  the  college  as  dean  of  the  school  of  medicine  from 
1922  to  1929.     He  was  one  of  the  founders  of  the  Chil- 


dren's Memorial  Clinic  of  Richmond  and  was  treasurer  of 
Stuart  Circle  Hospital. 

His  students  remember  him  as  an  acute  and  diagnosti- 
cian, a  brilliant  lecturer  and  an  upright  and  forceful  man. 


Dr.  James  Morehead  Whitfield,  Richmond  coroner  for 
19  years  and  widely  known  chemist  and  to.xicologist,  died 
September  4th,  after  an  illness  of  several  months. 

Born  in  Jackson,  Miss.,  in  1S67,  Dr.  Whitfield  went  to 
Richmond  to  practice  his  profession  in  1893  and  quickly 
identified  himself  with  the  city. 

He  attended  Richmond  College  and  the  University  of 
Virginia,  graduating  from  the  University  with  the  degree 
of  Doctor  of  Medicine  in  1887. 

At  the  University  he  became  interested  in  chemistry 
under  the  instruction  of  Prof.  J.  W.  Mallett,  and  this 
study  engaged  his  entire  later  life. 

In  1890,  he  became  assistant  surgeon  in  the  United  States 
Navy  and  stayed  in  the  service  for  several  years.  During 
his  service  he  attended  wounded  Venezuelan  soldiers  under 
fire  at  La  Guiras  and  was  decorated  for  his  services. 

He  began  the  practice  of  his  profession  in  Manchester 
(South  Richmond)  in  1893.  Determined  to  devote  his  life 
to  the  study  of  chemistry,  he  abandoned  the  practice  of 
medicine  and  established  a  laboratory.  Then  in  1904  he 
entered  the  service  of  the  city  with  the  Board  of  Health 
and  in  1907  became  city  chemist,  a  position  he  relinquished 
in  1917  when  he  was  appointed  coroner. 

It  was  as  teacher  that  he  was  most  widely  known.  At 
the  Medical  College  of  Virginia  he  taught  Chemistry  and 
Medical  Jurisprudence,  Elemental  Chemistry  at  the  Vir- 
ginia Merchants'  Institute  and  for  a  while  Chemistry  at 
Richmond  College.  His  students  are  scattered  over  the 
world. 

A  physician  son.  Dr.  James  M.  Whitfield,  jr.,  is  the  only 
survivor  of  the  immediate  family. 


Dr.  J.  Wilton  Hope,  71,  till  his  retirement  three  years 
ago  one  of  Virginia's  leading  surgeons,  died  Sept.  3rd,  at 
his  home  in  Hampton. 


Dr.  J.  Ernest  Dowdy,  50,  native  of  Winston-Salem  and 
former  practicing  physician  there  for  many  years,  died 
Sept.  19th  at  a  hospital  in  Martinsville,  Va.  He  had  been 
in  declining  health  for  several  years.  Dr.  Dowdy  moved 
from  there  to  Sandy  Ridge  several  years  ago. 

F^OR 

PAIN 


The  majority  of  the  phy- 
sicians  in  the    Carolinas 
are  prescribing  our  new 
tablets 


AND 


751 


Analjeslc  and  Sedative     ^  ""'"♦s      5  parts       I  part 
Aspirin    Phenacetin   Caffein 


JTe  will  mail  professional  samples  regularly 
with  our  compliments  if  you  desire  them. 
Carolina    PhnrmaccutirnI    Co..    Clinton,    S.    C. 


1 


SOUTHERN  MEDICINE  AND  SURGERY 


October,   1936 


Our  Medical  Schools 


University  of  North  Carolina 

Dr.  \V.  McKira  Marriot,  '04,  has  resigned  as  Dean  of 
the  Washington  University  (St.  Louis)  School  of  Medicine 
to  become  on  July  1st  Dean  of  the  Medical  School  at  the 
University  of  California  and  Professor  in  Research  Medi- 
cine. Dr.  Marriot  had  been  at  the  St.  Louis  institution  as 
dean  since  1923,  but  had  been  a  faculty  member  there  in 
1910-14  and  1917-23. 

Dr.  Marriot,  one  of  the  University's  most  distinguished 
living  alumni,  has  written  many  scientific  articles,  especially 
in  the  field  of  pediatrics,  and  is  widely  known  for  his  re- 
searches in  lactic-acid  milk  and  evaporated-milk  feeding. 
Before  specializing  in  pediatrics.  Dr.  Marriot  engaged  for 
many  years  in  research  in  biological  chemistry. 

The  Washington  University  Medical  School  doubled  its 
endowment  during  Dr.  Marriot's  administration  and  many 
additions  were  made  to  its  physical  plant.  In  addition  to 
his  connection  with  the  University  Dr.  Marriot  had  en- 
gaged in  active  practice  of  pediatrics  in  large  St.  Louis 
hospitals.  He  is  associated  with  many  medical  organiza- 
tions. 

Dr.  Marriott  received  the  B.S.  degree  at  Chapel  Hill  in 
1904,  the  M.D.  degree  at  Cornell  in  1910.  The  University 
of  Missouri  conferred  upon  him  an  honorary  degree  at  its 
last  commencement.  Dr.  Marriot  is  a  nephew  of  the  late 
Dr.  Gore,  Professor  of  Physics  at  Chapel  Hill. 

Dr.  A.  D.  Browne,  who  has  been  engaged  in  physical 
health  work  at  George  Peabody  College  at  Nashville,  Ten- 
nessee, will  next  year  become  Director  of  Physical  Educa- 
tion at  Louisiana  State  University. 

Dr.  M.  R.  Gibson  has  been  elected  Grand  Chef  de  Gare 
of  the  Raleigh  Voiture  of  the  40-and-8,  American  Legion 
Social  organization. 

Dr.  T.  W.  M.  Long,  Roanoke  Rapids,  North  Carolina, 
is  the  Democratic  nominee  of  his  senatorial  district.  He 
has  served  both  in  the  House  and  the  Senate  branches  of 
the  State  legislative  body. 

Dr.  J.  Norman  Harney,  a  native  of  Plymouth,  North 
Carolina,  has  moved  from  Tea  Neck,  New  Jersey,  to 
Greensboro,  North  Carolina,  where  he  will  continue  to 
practice  medicine. 

Dr.  William  W.  Bowling,  of  Durham,  and  Miss  Agnes 
Scott  Paulk,  of  Atlanta,  were  married  on  July  7th. 

Dr.  E.  V.  Moore  has  opened  an  office  at  Spindale. 

Dr.  J.  C.  Gunter,  Sanford,  recently  graduated  from  the 
Jefferson  Medical  College  of  Philadelphia,  is  serving  an 
interncship  at  Cooper  Hospital,  Camden,  New  Jersey. 

Dr.  Charles  A.  Glenn,  Gastonia,  recently  graduated  from 
the  Medical  College  of  the  State  of  South  Carolina  at 
Charleston,  is  serving  an  internship  in  Columbia. 


Medical  College  of  Virginia 

The  99th  session  opened  September  14th,  with  convoca- 
tion exercises  at  12:00  noon  at  Monumental  Church,  pre- 
ceded by  academic  procession  from  McGuire  Hall.  Mr. 
Eppa  Hunton,  IV,  member  of  the  executive  committee  of 
the  Board  of  Visitors,  made  the  convocation  address.  Oth- 
ers taking  part  were  Dr.  W.  T.  Sanger,  President  of  the 
College;  Mr.  L.  C.  Bird,  President  of  the  .'\lumni  Associa- 
tion ;  Mr.  Lewis  T.  Stoneburner,  President  of  the  Student 
Body;  Dr.  William  B.  Porter,  Professor  of  Medicine;  Dr. 
Harry  Bear,  Dean  of  the  School  of  Dentistry;  Mr.  Wort- 
ley  F.  Rudd,  Dean  of  the  School  of  Pharmacy;  Miss  Fran- 
ces Helen  Zeigler,  Dean  of  the  School  of  Nursing;  Mr.  J. 


R.  McCauley,  Secretary-Treasurer  of  the  College,  and  The 
Reverend  Mr.  George  Ossman,  who  gave  the  invocation. 
While  enrollment  figures  have  not  been  completed  it  is 
expected  that  more  than  650  students  will  be  in  attendance 
in  the  four  schools.  Dr.  J.  C.  Elsom,  a  graduate  of  the 
school  of  medicine  in  1886,  was  introduced  to  the  assembled 
body. 

Dr.  Lewis  E.  Jarrett,  superintendent  of  the  hospital  divi- 
sion, attended  the  annual  meeting  of  the  American 
Hospital  Association  in  Cleveland,  September  2Sth  to  Octo- 
ber 3rd.  Doctor  Jarrett  presided  over  the  Section  on 
Construction. 

Dr.  J.  H.  Wcatherby  has  been  appointed  research  asso- 
ciate in  pharmacology. 

Dr.  Harvey  B.  Haag,  Professor  of  Pharmacology,  will 
leave  shortly  to  visit  the  various  laboratories  of  the  medi- 
cal schools  in  the  Mid-West. 

Dr.  Wyndham  B.  Blanton,  Professor  of  History  of  Med- 
icine, has  been  appointed  one  of  the  editors  of  the  Annals 
of  Medical  History. 

Dr.  Lee  E.  Sutton,  jr..  Dean  of  the  School  of  Medicine, 
represented  the  college  at  the  Harvard  University  Ter- 
centenary Celebration  September  16th  to  ISth. 


Duke 

Duke  Research  Scholarship  to  Westinghouse  Worker 
(Westing:house    Technical   Press    Service) 

D.  Gordon  Sharp,  26,  of  Annandale,  N.  J.,  a  biophysi- 
cist  in  the  research  department  of  the  Westinghouse  Lamp 
Company,  Bloomfield,  N.  J.,  has  entered  Duke  University 
on  a  research  fellowship  for  a  Ph.D.  Degree  in  Physics. 
He  will  assist  Dr.  Deryl  Hart  on  operating  room  experi- 
ments with  the  new  device  which  kills  germs  in  the  air. 

Westinghouse  Memorial  Scholarships  were  established  at 
the  close  of  the  World  War  in  memory  of  employees  killed 
in  France.  Every  year  four  men  are  provided  with  schol- 
arships of  ?500  towards  a  college  education  of  either  engi- 
neering or  some  phase  of  science  with  the  privilege  of 
working  with  the  company  during  the  summers  and  enter- 
ing permanen  temploy  after  graduation.  Sons  of  employees 
or  employees  with  two  or  more  years  of  service  are  eligible 
for  the  scholarships. 

Mr.  Sharp  majored  m  Physics  at  Rutgers  University, 
\ew  Brunswick,  N.  J.,  and  was  graduated  with  a  B.S. 
Degree  in  1932.  Joining  the  research  staff  of  the  Westing- 
house Lamp  Company  upon  his  graduation,  he  was  en- 
gaged in  experimental  work  on  x-ray  tubes.  During  this 
time  he  invented  a  device  for  cooling  the  anodes  of  deep 
therapy  x-ray  tubes  with  oil. 

In  recent  years  he  has  been  serving  as  a  biophysicist, 
assisting  Dr.  Robert  F.  James  in  the  development  of  the 
Sterilamp*  for  the  sterilization  of  food  against  mold  spore 
and  of  the  air  in  operating  rooms  against  infectious  germs. 
In  connection  with  this  work  Mr.  Sharp  invented  a  rotary 
apparatus  which  uses  this  device  and  can  be  used  to  ster- 
ilize liquids,  such  as  serums,  so  that  they  will  remain  in 
the  sterile  state  until  used. 

Mr.  Sharp  will  study  for  his  Ph.D.  degree  in  physics  at 
Duke  University  where  Dr.  Hart  has  succeeded  in  steriliz- 
ing the  air  in  operating  rooms  by  the  use  of  Sterilamps.'* 

•Trademark. 


Medical  College  of  the  State  of  South  Carolina 

The  morning  of  Sept.  24th,  the  107th  session  of  the 
Medical  College  of  the  State  of  South  Carolina  began  with 
opening  evercises  in   the  college  auditorium.     Dr.   Robert 


Oaober,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


577 


Wilson,  Dean  of  the  college,  made  announcements  concern- 
ing the  work  of  the  coming  year.  Class  work  began  on 
the  2Sth  with  appro.ximately  170  students  attending.  Dr. 
Banov,  County  Health  Officer,  who  was  elected  Assistant 
Professor  of  Public  Health  at  the  end  of  the  last  session, 
sent  in  his  resignation  from  the  position  due  to  the  fact 
that  his  duties  as  health  officer  did  not  permit  the  extra 
work.  Six  additions  to  the  faculty  for  this  session  are: 
H.  D.  Bruner,  M.S.,  M.D.,  instructor  in  the  department  of 
physiology ;  Dr.  Walter  .\.  Stultz,  instructor  in  the  depart- 
ment of  anatomy;  Dr.  S.  L.  Lavin,  instructor  in  the  de- 
partment of  medicine;  Dr.  Wilbur  C.  Hunsinger,  teaching 
fellow  in  surgery ;  Dr.  J.  E.  Revely,  instructor  in  clinical 
pathology;  Dr.  Harold  Wood,  instructor  in  pathology. 


Common  Forms  of  Heart  Disease 

(Wm.    H.    Holmes,    Chicago,    in    Nor'wes.    Med.,    Mar.) 

At  least  95%tof  organic  heart  disease  is  the  result  of 
infection,  of  into.xication,  or  of  widespread  vascular  changes. 
Infection  is  by  far  the  most  important. 

Rheumatic  infection  is  regarded  as  caused  by  strepto- 
cocci, constitutes  40%  of  all  types  of  heart  disease;  in 
patients  under  20  years  of  age,  over  90%. 

Other  types  of  infection  are  syphilis  and  an  acute  or 
subacute  infection  of  the  valves  by  various  types  of  strep- 
tococci, and  occasionally  by  bacilli. 

The  mitral  valve  alone  is  affected  in  62%  of  all  cases; 
with  aortic  in  ii ;  aortic  alone  in  5. 

.•\lthough  rheumatic  infection  involves  all  the  structures 
of  the  heart,  its  worst  damage  is  evidenced  by  a  valvulitis. 

In  most  cases  of  serious  rheumatic  mitral  disease  one 
can  elicit  a  history  of  more  than  one  attack  of  rheumatic 
fever  or  of  some  equivalent  infection.  There  is  enlarge- 
ment to  the  right  and  upward  to  the  left  and  a  character- 
istic murmur  which  precedes  ventricular  systole. 

If  there  is  a  permanent  opening  of  the  mital  valve  the 
systolic  murmur  is  found  in  mitral  regurgitation  and  you 
may  feel  a  presystolic  thrill  in  the  mitral  region  in  an  area 
seldom  larger  than  a  silver  dollar;  not  essential  for  the 
diagnosis. 

The  murmurs  of  mitral  disease  are  by  no  means  as 
important  as  the  character  of  the  first  tone.  In  mitral 
stenosis  the  first  tone  has  a  peculiar  snapping  sound  which 
is  highly  characteristic,  whereas  in  a  regurgitation  the  first 
tone  is  absent. 

The  engorgement  of  the  left  auricle  is  followed  by  pul- 
monary congestion,  the  vessels  of  the  lungs  being  greatly 
engorged  so  that  on  auscultation  over  the  pulmonic  valve 
area  one  should  hear  a  loud  snapping  second  sound;  not 
infrequently  there  is  cough  over  a  period  of  years,  more 
and  more  productive  of  a  tenacious  mucoid  sputum.  Dus- 
kiness increases,  the  breathlessness  is  aggravated  and  diges- 
tive difficulties  make  their  appearance,  the  result  of  en- 
gorgement of  the  great  veins  of  the  abdominal  viscera 
and  particularly  the  liver.  Belching,  heartburn,  flatulence, 
disturbances  of  renal  function,  and  varicosities  develop  and 
finally  edema. 

The  patient  with  rheumatic  mitral  disease  having  once 
begun  to  show  symptoms  of  cardiac  failure,  and  particu- 
larly if  iibrillating,  will  require  digitalis  more  or  less  con- 
tinuously for  the  rest  of  his  life  to  keep  the  ventricular 
rhythm  as  slow  as  possible  without  giving  rise  to  the  unde- 
sirable digitalis  effects. 

Use  the  dry  leaf,  standardized  by  a  reputable  firm,  for 
use  before  the  expiration  of  a  specified  period  of  time. 
Dosage — 1  grain  for  every  10  lbs.  of  body  weight  within 
24  to  48  hours;  not  based  on  the  weight  of  a  patient  dur- 
ing an  edematous  stage,  because  under  these  circumstances 
a  person  who  normally  weighs  150  lbs.  may  weigh  180  or 


even  200  lbs. 

Give  50%  of  total  dose  at  once,  25%  in  6  hours  and 
the  remainder  in  two  6-hour  periods;  thereafter  from  1.5 
to  3  grains  daily.  High  blood  calcium  enhances  the  digi- 
talis effect ;  therefore,  one  may  give,  intramuscularly  or 
intravenously,  15  to  20  c.c.  of  10%  calcium  gluconate,  re- 
peating it  with  each  dose  of  digitalis.  If  given  intraven- 
ously inject  very  slowly. 

For  less  serious  degrees  1.5  to  3  grains  of  digitalis  for 
periods  of  10  days,  alternating  with  3  or  4  days  of  rest. 
Digitalis  is  the  most  important,  but  morphine  ranks  sec- 
ond. The  patient,  sitting  up  in  bed,  eyes  bulging,  lips 
dusky  and  convinced  that  every  breath  he  takes  will  be 
his  last,  can  be  relieved  more  quickly  by  morphine  than 
by  any  other  method.  One  should  not  hesitate  to  use 
morphine  because  of  any  fear  of  drug  addiction. 

The  heart  muscle  must  have  adequate  oxygen  and  glu- 
cose, or  progressive  failure  of  the  cardiac  muscle  is  inevi- 
table. In  congestive  failure  prompt  relief  may  be  had  by 
withdrawal  of  500  c.c.  of  blood;  venesection  cannot  be 
used  frequently. 

Podophyllin,  sodium  sulphate  or  magnesium  sulphate, 
sufficient  to  cause  several  watery  stools,  may  do  much 
good.  \  dyspneic  patient  may  be  exhausted  by  the  effort 
involved.  In  stupor  or  coma  the  absorption  of  small 
amounts  of  magnesium  may  aggravate  the  stupor.  The 
poisonous  effects  of  magnesium  are  controlled  at  once  by 
an  intravenous  injection  of  calcium. 

Salyrgan,  once  or  twice  a  week  intravenously,  1  to  2  c.c; 
ammonium  nitrate,  ammonium  chloride  or  calcium  chlo- 
ride 3  or  4  days  preceding  the  injection  of  mercury,  for 
an  adult  15  grains  from  4  to  6  times  a  day.  The  mercurial 
diuretics  should  not  be  given  to  patients  who  have  glom- 
erulonephritis. 

Aortic  insufficiency  on  a  syphilitic  basis  is  less  well  tol- 
erated than  aortic  disease  due  to  rheumatic  infection. 


INHALANT 

No.  77 

An  Ephedrine  Compound  used  as  an  inhalant 
and  spray,  in  infections,  congested  and  irritated 
conditions  of  the  nose  and  throat.  Relieves 
pain  and  congestion,  preventing  infection,  and 
promotes  sinus  ventilation  and  drainage  with- 
out irritation. 

Description 
Inhalant  No.  77  contains   Ephedrine,   Menthol, 
and  essentials  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 

Manujiw luring    <^^^^    I'liannacisls 


CHARLOTTE,  N.  C. 

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


SOUTHERN  MEDICINE  AND  SURGERY 


October,   1936 


IN     MEMORIAM 

Doctor  A.  W.  Knox 

In  the  passing  of  Augustus  Washington  Knox 
on  May  9th,  1936,  The  Raleigh  Academy  of  Med- 
icine lost  its  oldest  Fellow  in  point  of  years  and 
of  service.  He  joined  the  Academy  in  1877  and 
continued  his  fellowship  up  to  the  time  of  his 
death — a  period  of  59  years.  Although  the  Acad- 
emy was  eight  years  old  when  he  signed  the  roll, 
Dr.  Knox  early  became  one  of  its  leading  spirits 
and  none  was  more  ardent  and  loyal  in  his  attach- 
ment. In  his  turn  he  held  the  various  offices  more 
than  once  and  enjoyed  the  distinction  of  having 
been  president  for  a  longer  term  than  any  other 
Fellow  of  the  Academy.  From  the  date  of  the 
adoption  of  the  county  unit  organization  by  the 
American  Medical  Association  in  1903,  when  the 
.--Vcademy  agreed  to  meet  only  upon  the  call  of  the 
president,  up  to  1922  after  the  acceptance  of  a 
resolution  at  its  SOth  anniversary  to  assemble  quar- 
terly, Dr.  Knox  remained  as  president  throughout 
these  nineteen  years,  until  his  successor  was  elect- 
ed. He  rejoiced  in  his  fellowship  and  never  wa- 
vered in  his  allegiance. 

Dr.  Knox  was  no  ordinary  man.  ^Mentally  ac- 
tive, morally  supreme,  physically  powerful,  he  was 
endowed  with  professional  and  personal  talents 
which  made  him  respected  and  admired.  When 
he  came  to  Raleigh  in  1877  he  had  received  med- 
ical and  surgical  training  far  above  any  young  man 
of  his  time  in  this  vicinity.  His  graduation  from 
Bellevue  Hospital  Medical  College  of  New  York 
in  1874  was  followed  by  a  residency  of  two  years 
in  Bellevue  Hospital  and  one  year  in  the  W^oman's 
Hospital  of  Xew  York,  where  he  felt  the  influence 
of  the  great  J.  iNIarion  Sims,  who  had  just  retired, 
and  served  as  house  officer  to  the  celebrated  Em- 
met. It  was  but  natural,  therefore,  that  from  the 
beginning  Dr.  Knox  became  an  eminent  and  pro- 
gressive practitioner  of  medicine.  His  reputation 
was  not  only  local,  but  in  his  prime  he  was  well 
known  throughout  the  State  from  his  regular  at- 
tendance upon  the  meetings  of  the  State  iMedical 
Society.  By  this  organization  he  was  elected  a 
member  of  the  Board  of  Examiners  in  1884  and 
president  in  1902. 

Dr.  Knox's  natural  forte  was  surgery.  His  hos- 
pital experience  had  put  him  surgically  far  in  ad- 
vance of  his  colleagues,  so  that,  though  specializa- 
tion was  not  to  be  thought  of  at  that  period,  he 
began  at  once  to  do  most  of  the  surgical  operations 
in  this  section,  along  with  a  busy  general  practice. 
For  his  day  and  time  his  skill  as  a  surgeon  was 
noteworthy.  Thanks  to  his  service  under  Emmet 
l.e  excelled  in  plastic  gynecological  work;  while  he 
executed  amputations,  excisions,  fractures  and  dis- 
locations, and  traumatic  surgery  with  marked  suc- 
cess. 


erate,  often  sacrificing  the  time  element  to  the  exact 
mechanical  performance  of  the  operation.  But  he 
was  exceedingly  accurate  and  conscientiously  care- 
ful. He  was  never  known  to  trim  a  flap  after  an 
amputation,  for  he  worked  out  the  problem  before- 
hand, even  at  times  drawing  preoperative  diagrams 
which  he  followed  to  the  letter.  He  performed  at 
least  a  half-dozen  amputations  at  the  hip-joint  ac- 
cording to  his  modification  of  Wyeth's  method.  His 
skill  in  the  treatment  of  fractures  was  due  to  his 
meticulous  attention  to  every  detail  and  his  experi- 
ence in  handling  dislocations  of  the  hip-joint  was 
extraordinary.  His  records  show  five  such  cases 
(there  may  have  been  more)  all  reduced  so  pre- 
cisely and  easily  that  the  patients  suffered  no  re- 
actions and  practically  no  afterpain. 

His  early  experience  included  no  abdominal  oper- 
ations and  many  years  passed  before  he  essayed  to 
invade  this  region.  His  admission,  that  he  was 
"not  at  home  in  the  belly,"  was  that  of  a  conscien- 
tious man,  who  later  applied  himself  so  that  he 
became  proficient  in  operating  on  hernias,  abdom- 
inal tumors,  intestinal  obstructions,  etc.  He  was 
one  of  the  first  in  this  State  to  adopt  the  principles 
of  antisepsis  as  preached  by  Lister  and  finally  to 
adhere  strictly  to  the  rules  of  aseptic  surgery. 

The  character  of  this  man  was  his  crowning 
glory.  He  had  neither  guile  nor  dissimulation.  His 
life  was  an  open  book.  If  there  ever  was  a  man 
who  furnished  an  example  of  the  soul  of  honor. 
Dr.  Knox  was  that  man.  iMore  than  that,  he  could 
fulfill  the  saying:  "he  sweareth  to  his  own  hurt 
and  changeth  not."  Indeed,  he  would  lean  over 
backward  in  his  desire  to  be  scrupulously  honest. 
Frankness  was  second  nature  to  him.  "]Man  to 
man"  was  his  watchword.  Never  did  he  knowingly 
harm  a  single  soul,  nor  wish  to,  and  his  natural 
inclination  was  to  believe  good  of  every  one;  but 
let  him  discover  one  human  being  who,  he  thought, 
had  betrayed  a  trust  or  falsified  a  fellow  man,  and 
down  upon  that  one  came  his  thunderbolts  of  con- 
temptuous indignation  and  righteous  wrath.  He 
was  hard  and  relentless  on  the  unjust  and  unworthy, 
as  he  was  gentle  and  friendly  with  those  he  found 
faithful  and  true. 

Dr.  Knox  lived  to  an  advanced  age,  eighty-seven 
years  at  his  death,  which  occurred  three  days  after 
his  birthda}'.  Nine  years  ago,  when  he  retired  on 
the  SOth  anniversary  of  the  beginning  of  his  prac- 
tice, the  Raleigh  Academy  of  Medicine  honored 
itself  by  tendering  him  a  complimentary  dinner 
and  preventing  him  with  a  silver  loving  cup,  prop- 
erly engraved,  which  he  designated  shall  go  to  his 
i'rst  grandson  who  chooses  medicine  as  a  career. 
For  four  years  before  the  end  Dr.  Knox  was  a  bed- 
ridden invalid,  cheerful  and  contented,  illumined 
by  the  glow  of  a  well-spent  life.  "Virtue  is  its 
own  reward." 


Journal 

of 
SOUTHERN  MEDICINE   &   SURGERY 


Vol.  XCVIII  Charlotte,  N.  C,  November,  1936 


No.   11 


Goitre* 

John  Peter  Munroe,  AI.D.,  Charlotte,  North  Carolina 


IX  1913,  while  traveling  abroad  for  pleasure 
and  study  with  a  group  of  doctors,  one  was 
impressed  by  the  number  of  the  women  of 
Switzerland  who  had  goitre.  Every  clinic  showed 
one  or  more  cases  of  unusual  thyroid  development. 

About  ten  miles  from  the  City  of  Berne  there 
was  a  hospital  of  about  1500  beds  where  goitre 
was  treated  exclusively.  I  w'as  told  that  the  drink- 
ing water  came  from  the  snows  off  the  mountains, 
which  probably  lacked  some  mineral  necessary  to 
prevent  goitre. 

In  1917,  in  Cleveland,  a  committee  was  appoint- 
ed to  investigate  a  similar  condition  e.xisting  in  the 
Lake  regions  of  this  country.  They  reported  the 
lack  of  iodine  in  the  drinking  water  was  the  cause 
of  the  trouble.  Consequently  there  was  an  inten- 
sive treatment  started  of  iodine  tablets,  each  grains 
two,  to  be  taken  three  times  a  day,  for  two  weeks 
every  six  months.  About  1918  the  same  course 
was  instituted  in  Switzerland  and  the  results  have 
been  very  gratifying. 

Two  famous  clinics  of  this  country  have  made 
names  for  themselves  in  investigating  and  treating 
goitres,  namely,  IMayo  and  Crile  Clinics.  Several 
Charlotte  surgeons  have  devoted  special  attention 
to  goitre,  with  very  gratifying  results. 

In  1922  Crile  published  a  book.  The  Thyroid 
Gland,  and  in  his  introduction  he  stated  that  both 
theory  and  practice  would  be  constantly  subject 
to  revision  and  possibly  reversal  of  opinion. 

As  far  as  I  know,  his  views  have  not  been  chang- 
ed materially,  so  I  take  the  liberty  of  making  nota- 
tions from  his  book: 

(a)  "Endemic  goitre  is  a  geologic  deficiency  dis- 

ease, due  to  the  lack  of  iodine  in  the  or- 
ganism." 

(b)  "By  the  proper  administration  of  iodine  to 

the  pregnant  mother  and  to  the  child  up 
to  and  through  the  period  of  adolescence, 
endemic  goitre  may  be  prevented:  that  is 
to  say,  the  children  of  goitrous  regions  may 
be  goitre  free  as  are  the  children  of  the 


seashore." 

(c)  "After  the  twenty-fifth  year  of  age,  iodine 

exerts  little  or  no  beneficial  effects  on 
goitres." 

(d)  "By   the   proper   use   of   iodine   or    thyroid 

products  many  cases  of  quiescent  goitre, 
especially  of  the  adenomatous  type,  are 
converted  into  exophthalmic  goitre  or  hy- 
perthyroidism." 

(e)  "We  now  believe  that  the  so-called  hyper- 

thyroidism is  an  intracellular  acidosis 
which  is  overcome  by  restoring  the  normal 
acid-alkali  balance." 

(f)  "Any  case  up  to  the  beginning  of  dissolution 

is  operable,  or  may  be  made  operable  by 
a  short  period  of  active  treatment." 
"Classification  of  Pathologic  Disease  of  the  Thy- 
roid Gland,"  briefly: 

1.     Simple  goitre,  which  includes  the  hyperpla- 
sias of  the  gland  seen  at  puberty. 
Colloid  goitre. 
Adenoma  of  the  thyroid. 
Exophthalmic  goitre,  hyperthyroidism. 
5.     Myxedema,  hypothyroidism. 
"Adenoma   of   the  Thyroid" — is   manifested   by 
an  enlargement  of  the  gland  that  is  nodular  in  char- 
acter, single  or  multiple  and  varying  greatly  in  size. 
"Exophthalmic  Goitre" — The  cardinal  symptoms 
are: 

1.  ,  The  presence   of    an    enlarged    thyroid    or 

struma. 

2.  Exophthalmos. 

3.  Tremor. 

4.  Tachycardia. 

(Basal  metabolism  is  usually  high.) 
Eye  Signs — The  eye  signs  present  some  of  the 
most  characteristic  features  of  the  disease.  There 
is  a  noticeable  staring  expression  and  exophthal- 
mos, usually  bilateral,  but  occasionally  unilateral, 
present  in  a  large  proportion- of  the  cases.  There 
is  a  lagging  of  the  upper  lid  cm  looking  down. 
There    is    infrequent    winking    and    the    power    of 


2. 


4. 


•A  ffHlure  of  the  Charlutte  Brush-u])  Cuuri<e  in  Everyday  Medicine  of  Septemlier  21tli  U>  2(lth. 


GOITRE^Munroe 


November,   1P36 


convergence  is  often  decreased. 

Ulceration  of  the  Cornea  is  not  an  uncommon 
occurrence.  The  function  of  the  eyelids  as  protec- 
tors of  the  delicate  ocular  conjunctiva  being  dimin- 
ished and  the  lids  being  unable  to  close  over  the 
protruding  organ,  the  eyeball  is  exposed  day  and 
night. 

Swelling  of  the  Lids  is  a  common  occurrenc? 
and  patients  may  complain  bitterly  of  "pouches 
about  the  eye."  The  upper  lids  are  usually  in- 
volved, but  the  lower  ones  may  also  be  swollen. 

Bram  points  out  that  "Toxic  Adenoma  is  a  thy- 
roid condition,  giving  rise  to  constitutional  mani- 
festations, while  Exophthalmic  goitre  or  Graves' 
disease  is  a  constitutional  condition  giving  rise  to 
thyroid  manifestations."" 

DiFFERENTIAJ.    DIAGNOSIS 

Toxic  Adenoma 

"1.  There  is  a  family  history  of  goitre  in  30  per 
cent,  of  cases.  Xo  significant  history  of 
nervousness. 

2.  The  patient  is  usually  of  middle  age. 

3.  The  exciting  cause  is  unknown,  not  psychic 
trauma. 

4.  Tachycardia  is  not  marked;  it  is  somewhat 
ameliorated  by  sleep  and  digitalis. 

5.  Tremor  is  inconstant  and  is  somewhat  coars- 
er than  in  exophthalmic  goitre. 

6.  There  is  no  exophthalmos. 

7.  Iodine  therapy  may  result  in  marked  im- 
provement, but  it  may  aggravate  the  clinical 
symptoms. 

8.  Hypertension  is  common. 

9.  Thyroidectomy  is  conclusive  and  clinical 
recovery  is  complete  and  permanent." 

Exophthalmic    Goitre 
"1.  Usually  there  is  no  history  of  simple  goitre, 
but  a  family  history  of  nervousness,  exoph- 
thalmic goitre,  or  diabetes  is  common. 

2.  The  patient  is  usually  an  adolescent  or  young 
adult. 

3.  The  usual  exciting  cause  is  apparently  a 
psychic  trauma. 

4.  Tachycardia  is  marked,  not  tangibly  affect- 
ed by  sleep  and  digitalis. 

5.  Tremor  is  constant  and  finer  than  in  ade- 
noma. 

6.  Exophthalmos  is  common. 

7.  Iodine  therapy  usually  results  in  transient 
remission. 

8.  Hypotension  is  common. 

9.  Thyroidectomy  is  inconclusive:  perfect  oper- 
ative clinical  recovery  is  questionable." 

Treatment 

1 .  Radiologic 

2 .  Surgical 

3.  Medical. 


Radiologic  Treatment 

Crile  says  "The  pulse  rate  is  nearly  always  re- 
duced promptly;  usually  the  tremor  and  nervous 
symptoms  are  relieved  at  once;  the  body  weight 
begins  to  increase  immediately. 

There  is  a  divergence  of  opinion  regarding  the 
effect  upon  the  gland  itself,  as  the  experience  of 
different  writers  appears  to  have  varied  widely." 

Seymour  expresses  the  opinion  of  most  advocates 
of  the  x-ray  treatment  of  hyperthyroidism  in  his 
summary  of  its  advantages.  His  opinion  coincides 
with  the  opinions  of  our  excellent  radiologists  in 
Charlotte. 

1.  There  are  no  fatalities. 

2.  There  is  no  resulting  scar,  as  after  operation. 

3.  X-ray  treatment  does  not  interfere  with  the 
patient's  occupation. 

4.  It  is  painless  and  causes  very  little  inconveni- 
ence to  the  patient. 

SURGIC.AI. 

Mayo  and  Crile  agree  that  operation  is  the 
proper  treatment,  claiming  that  mortality  is  practi- 
cally eliminated  by  operation  and  the  hardening  of 
the  gland  by  x-rays  is  avoided. 

The  Rt.  Hon.  Lord  Horder,  of  London,  takes  a 
middle  ground  and  advises  partial  thyroidectomy 
besides  the  medical  treatment.  In  this  author's 
own  experience,  "the  operation  should  be  under- 
taken whenever  the  disease  remains  active  after  six 
months  of  carefully  supervised  medical  treatment, 
and  also  in  cases  which  relapse  in  spite  of  the  pa- 
tient's routine  of  life  being  adequately  controlled. 
The  operation  is  indicated  in  all  cases  in  which 
auricular  fibrillation  has  developed,  and  still  more 
when  signs  of  congestive  heart  failure  are  present, 
whether  the  cardiac  rhythm  be  so  affected  or  not. 
To  delay  when  any  of  these  three  criteria  have 
arrived,  is  to  lose  valuable  time  and  to  lessen  the 
benefit  which  may  otherwise  be  expected." 

Principles  of  Medical  Treatment  of  Exophthalmic 
Goitre 

Guiding  Principles;  There  are  several  captions 
under  which  the  principles  of  the  medical  treatment 
of  Graves'  disease  may  be  discussed;  (a)  Removal 
of  discoverable  infectious  foci,  (b)  a  varying  rest 
and  exercise  program  to  overcome  and  repair  the 
ravages  of  the  hyperactive  gland,  (c)  a  properly 
outlined  diet  and  baths,  (d)  the  use  of  medica- 
ments in  effort  to  eliminate  the  results  of  the  va- 
rious vicious  circles,  and  (e)  the  application  of 
psychotheraphy. 

Cooperation  of  the  Patient  is  second  only  to 
the  skill  of  the  physician.  The  details  of  the  treat- 
ment must  not  be  left  to  the  memory  of  the  family 
or  patient.  Everything  must  be  put  in  writing 
from  the  start. 

Rest  aims  at  the  correction  of  the  physical  and 


November,  1936 


GOITRE— Munroc 


S81 


mental  overalertness  characterizing  Graves'  dis- 
ease. Daily  program  for  meals,  rest  and  sleep  to 
be  written  out  for  the  patient. 

Though  not  imperative,  passive  exercise  may  in 
the  form  of  mechanical  vibration  to  back  of  neck, 
or  massage,  be  given  to  all  subjects  of  exophthal- 
mic goitre. 

Drugs — Quinine  hydrobromate  is  useful  solely 
in  combating  the  symptoms  of  the  hyperthyroid 
state,  particularly  when  this  is  a  constituent  of 
Graves'  syndrome.  The  administration  of  quinine 
hydrobromate  does  not  result  in  tangible  increase 
in  the  size  of  the  thyroid  gland. 

While  incautious  iodine  administration  may 
arouse  a  simple  goitre  into  toxicity,  such  is  not 
the  case  with  quinine  administration.  In  the  ab- 
sence of  extreme  sensitivity,  the  most  that  can 
occur  from  quinine  medication  is  transient  cincho- 
nism,  without  tangible  involvement  of  the  thyroid 
gland. 

In  the  average  case  of  hyperthyroidism,  espe- 
cially with  Graves'  syndrome,  the  beneficial  effects 
of  iodine  are  more  prompt  and  are  even  spectacular 
as  compared  with  those  of  quinine.  Iodine  results, 
however,  are  transient  in  the  usual  patient,  and 
are  followed  within  approximately  three  weeks  by 
cancellation  of  the  benefit.  Not  so  with  those 
from  quinine.  While  the  results  of  the  exhibi- 
tion of  quinine  are  more  tardy,  making  their  ap- 
pearance within  three  or  four  weeks  or  longer,  the 
effects  are  cumulative.  In  association  with  other 
appropriate  measures  quinine  medication  may  re- 
sult in  recovery  within  several  months  in  the  aver- 
age patient.  The  ideal  patient  for  iodine  adminis- 
tration is  of  middle  or  past  middle  age  who  has 
a  thyroid  that  is  either  normal  or  moderately  swol- 
len. 

In  exophthalmic  goitre,  a  combination  oj  quinine 
and  iodine,  each  grains  one,  was  given  three  times 
a  day,  and  the  results  were  compared  with  a  simi- 
lar series  in  which  quinine  was  the  only  drug  given, 
and  with  still  another  series  in  which  the  only  drug 
given  was  iodine.  It  was  evident  for  periods  of 
time  quinine  and  iodine  were  synergistic  one  with 
the  other.  In  other  words,  the  complementary  ef- 
fects of  iodine  with  quinine  expedited  and  intensi- 
fied the  beneficial  results.  Also,  in  combination 
quinine  and  iodine  produce  results  at  a  much  earlier 
date  in  the  average  case,  than  when  either  is  given 
alone.  The  combination  may  be  given  for  a  [jeriod 
of  two  weeks,  when  the  iodine  may  be  discontinued 
for  a  week  or  ten  days,  then  readministered  for 
a  like  period. 

In  Graves'  disease  the  quickening  of  all  bodily 
functions,  especially  those  of  the  brain,  peripheral 
nervous  system,  and  circulation,  and  above  all  in- 


somnia, cry  out  for  the  calming  influence  of  a  seda- 
tive. Of  all  the  sedatives  at  our  disposal  we  find 
the  barbiturates  most  serviceable  and  least  objec- 
tionable, barbital  or  phenobarbital  in  moderately 
large  doses. 

On  theoretic  grounds  the  premises  favoring 
ovarian  therapy  refer  chiefly  to  the  evidences  of 
ovarian  hypofunction  so  prevalent  in  subjects  of 
Graves'  disease. 

Patients  approaching  or  actually  in  severe  crisis 
and  incapable  of  retaining  food  because  of  nausea 
and  vomiting  and  those  with  considerably  diminish- 
ed carbohydrate  tolerance  or  with  complicating  dia- 
betes, in  which  overfeeding  is  both  a  necessity  and 
a  problem,  find  in  insulin  a  most  potent  and  at 
times  astonishing  measure  in  the  march  toward 
health. 

Digitalis,  though  not  to  be  used  in  the  manage- 
ment of  the  average  case,  is  of  distinct  value  for 
the  patient  with  congestive  heart  failure  and  in 
some  instances  of  persistent  auricular  fibrillation. 

CLINIC 

A  young  colored  woman,  aged  32,  school  teacher  and 
rather  above  the  average  in  intelligence,  eight  years  ago 
had  an  attack  somewhat  similar  to  the  present  one  but 
more  severe  and  of  longer  duration.  At  that  time  I  se- 
riously considered  operation  but  did  not  have  it  done  on 
account  of  mental  symptoms  present.  I  also  considered 
sending  her  to  the  State  Hospital,  but  fortunately  neither 
course  had  to  be  taken. 

After  being  under  my  care,  at  intervals,  for  a  year  she 
was  able  to  resume  teaching  and  has  not  missed  a  day 
from  her  work  until  the  present  time. 

She  not  only  taught  every  winter  but  attended  summer 
school  even,'  summer  and  this  past  winter  in  connection 
with  her  work  took  an  extension  course.  This  intensive 
mental  work  was  probably  a  causative  factor  in  bringing 
on  this  attack. 

The  latter  part  of  July,  1936,  I  had  no  hesitation  of 
making  my  diagnosis  of  exophthalmic  goitre,  by  reason  of 
the  cardinal  symptoms  present. 

I  did  have  a  hesitation  in  reporting  the  case  until  having 
made  a  basal  metabolism  test  this  morning,  when  I  find 
her  test  normal. 

I  attribute  her  rapid  recovery  to  the  intense  medical 
treatment,  namely: 

1.  Confined  absolutely  to  bed.     (No  visitors  allowed.) 

2.  Regulation  of  bowels. 

3.  Diet  (largely  confined  to  carbohydrates.) 

4.  Sedatives  to  relieve  intense  nervousness,  which  was 
followed  by  phenobarbital  and  quinine  hydrobro- 
mate. 

5.  Ovarian  pills  given  for  irregular  and  painful  menses. 
It  was  my  purpose  to  give  her  a  course  of  iodine  but 

she  responded  so  readily  to  the  medication  outlmed  that 
it  was  not  given,  but  a  good  tonic  for  her  general  condi- 
tion was  prescribed.  If  there  is  a  return  of  the  cardinal 
symptoms,  iodine  will  be  given  in  intermittent  courses  of 
2  or  3  weeks  each. 


Irr.\diated  eroosterol  has  given  good  results  in  the 
treatment  of  trichinosis  in  rabbits.  It  is  given  with  an 
idea  of  speeding  calcification  of  the  cysts. 


SOUTHERN  MEDICINE  AND  SURGERY 


November.   103o 


Peter  Francisco — Hyperpituitary  Patriot* 

Jas.  K.  Hall,  M.D.,  Richmond,  Virginia 


WARFARE  more  than  any  other  circum- 
stance tends  to  endow  mere  man  with 
immortality  and  to  fetch  forth  from 
hidden  obscurity  many  a  hamlet,  tavern,  grain- 
mill,  road  or  stream.  Two  great  armies  that  had 
wrestled  valiantly  with  each  other  for  four  tragic 
years  ceased  their  struggles  at  a  little  village  in 
the  hills  of  \'irginia  on  the  south  bank  of  the 
-Appomattox.  Eastward,  scarcely  more  than  a 
hundred  miles,  that  little  river,  now  become  a  nav- 
igable waterway,  joins  the  James.  At  this  conflu- 
ence even  in  early  colonial  days  the  little  town  was 
known  as  City  Point.  But  the  wharf  there  must 
have  been  kept  busy  as  the  great  plantations  of 
the  two  vallej's  sent  across  the  seas  the  products 
of  their  tillage  and  received  in  exchange  the  fab- 
rications of  the  old  world.  Had  not  one  of  the 
earliest  owners  of  that  area  been  so  attached  to 
his  plantation  City  Point  rather  than  Richmond 
might  have  become  the  new  capital  of  the  colony 
when  the  change  was  made  from  Williamsburg. 

Xo  other  rivers  in  North  America  have  been  so 
tragically  associated  with  warfare  as  the  Appomat- 
tox and  the  James.  Just  west  of  the  junction  on 
the  south  bank  of  the  James  flourished  for  a  brief 
three  or  four  years  the  town  of  Henricopolis.  Here, 
perhaps,  was  the  first  hospital  in  the  colonies,  and 
here  plans  were  made  for  the  first  university. 
Silently,  but  efficiently,  the  encircling  Indians 
wielded  the  tomahawk  and  applied  the  torch. 
Henricopolis  became  a  memory. 

The  contending  forces  in  the  Revolutionary 
struggle  pursued  each  other  'round  about  City 
Point,  but  the  Colony  of  Virginia  was  spared  a 
pitched  battle  until  Vorktown  was  reached.  In 
1812  British  soldiers  crossed  and  re-crossed  the 
James  and  the  Appomattox. 

At  City  Point  Grant  established  in  1864  the 
headquarters  of  his  invading  army:  there  Lincoln 
visited  him:  there  Mrs.  Lincoln  reprimanded  Mrs. 
Grant  for  presuming  to  remain  seated  in  the  pres- 
ence of  the  wife  of  the  President  of  the  LTnited 
States:  there  Grant's  father  visited  him,  and  was 
unable  to  understand  why  the  hides  of  the  govern- 
ment's slaughtered  beeves  could  not  be  turned  over 
to  him  for  use  in    his    tannerv:    near-bv    General 


•Presented  to  the  Tri-State  Jledical 
lina,  February  17th  and  ISth. 


L-iation  uf  the  Carolinas  and   Vir; 


Benjamin  F.  Butler  unfortunately  found  himself 
in  a  bottle  in  the  mouth  of  which  General  Beaure- 
gard had  placed  a  military  cork. 

On  a  June  day  in  1765  two  planters,  probably 
discussing  British  tyranny,  wondered  why  the  ves- 
sel had  turned  about  in  the  river  and  sailed  away 
instead  of  anchoring  at  the  wharf  at  City  Point. 
The  flag  at  the  mast-head  was  so  small  that  they 
could  not  identify  it.  They  walked  over  to  the 
little  four-  or  five-year-old  boy  left  on  the  dock 
by  members  of  the  crew.  The  little  boy's  clothing 
indicated  that  he  had  not  been  reared  in  want. 
His  suit,  though  worn  and  soiled,  had  lace  about 
the  cuffs  and  along  the  collar.  He  was  a  sturdy, 
manly  youngster:  dark  and  swarthy.  Their  greet- 
ings and  inquiries  evidently  fell  upon  ears  unfamil- 
iar with  the  English  tongue,  and  the  child's  prattle 
they  could  not  understand.  He  had  been  brought 
ashore  in  a  row-boat,  and  the  foreign  vessel  had 
immediately  turned  eastward  down  the  James. 

Other  citizens  became  interested  in  the  lonely 
little  boy.  For  a  week  or  more  he  was  quartered 
and  cared  for  in  a  room  in  a  building  nea;  the 
dock.  There  Judge  Anthony  Winston  of  Bucking- 
ham County,  who  had  come  down  to  meet  a  boat, 
saw  the  child  and  obtained  permission  to  take  him 
to  his  home.  Hunting  Towers.  But  the  foreign- 
born  lad  knew  no  words  in  the  English  language, 
and  it  was  many  months  before  he  could  talk  at 
all  about  himself.  Somewhere  across  the  sea — in 
Portugal?  in  Spain? — he  had  lived  in  a  great  man- 
sion and  had  played  with  his  little  sister  in  a  lovely 
garden.  She  and  his  beautiful  mother  hz  could 
remember  clearly;  his  father  only  vaguely.  In  the 
mansion  guests  were  assembling  for  a  dinner;  he 
and  his  little  sister,  by  a  display  of  candy,  cakes 
and  toys,  were  enticed  from  the  garden  gate.  Rough 
men  seized  them  and  ran  with  them.  But  his  sister 
struggled  and  cried  out  and  escaped.  He  was 
manacled,  blindfolded  and  gagged  and  carried 
aboard  a  ship.  After  a  long,  tempestuous  voyage 
he  was  discharged  at  City  Point.  His  name,  he 
thought  he  remembered,  was  Peter  Francisco.  On 
each  of  his  silver  shoe-buckles  were  two  large  let- 
ters, P.  F.  There  were  in  little  Peter  Francisco 
those  qualities  suggestive  of  gentle  blood  and  splen- 

meeting  at   Columbia.    South   Caro- 


♦Published  in  the  Annals  of   Medical    History,  New  Series.  "\"ol.  Vin.  Xo.  5,  September,  1936. 


I 


November,   1936 


PETER  FRAS'CISCO—HaU 


■■S83 


did  lineage.  He  was  winsome,  but  dignified  and 
self-reliant.  He  scampered  over  Judge  Winston's 
extensive  plantation;  he  hunted,  fished,  played  and 
familiarized  himself  with  the  details  of  plantation 
life.  But  there  is  little  evidence  that  any  effort 
was  made  by  his  benefactor  to  afford  him  educa- 
tional opportunities. 

Judge  Winston  was  the  maternal  uncle  of  Patrick 
Henry,  so  soon  to  become  the  tongue  of  the  Revo- 
lution. In  Hunting  Towers  the  rapidly  growing 
lad  listened  many  a  time  to  the  fiery  statesman's 
diatribes  against  the  British  government,  and  Peter 
became  one  of  Patrick  Henry's  warmest  admirers. 
At  the  seat  of  government  at  Williamsburg,  and 
at  the  convention  in  old  St.  John's  Church  in  Rich- 
mond, both  Judge  Winston  and  Peter  Francisco 
were  mightily  moved  by  Henry's  torrid  eloquence 
as  he  swayed  those  two  assemblages.  Though  per- 
haps only  fifteen  years  of  age,  in  1775  Peter  was  in 
structure  and  in  stature  more  than  a  grown  man. 
At  that  age  he  was  six  feet  six,  and  he  weighed  two 
hundred  and  sixty  fxjunds. 

Is  it  cause  for  wonder  that  he  felt  both  willing 
and  fit  to  join  Patrick  Henry's  military  command? 
But  he  yielded  reluctantly  to  Judge  Winston's 
counsel  to  wait  until  he  became  more  mature.  A 
year  later,  at  the  probable  age  of  sixteen,  the 
youthful  giant  became  a  soldier  of  the  American 
Revolution.  His  first  engagement  was  fought  on 
the  banks  of  the  Brandywine.  A  wound  disabled 
him,  and  he  recovered  in  the  home  of  a  Quaker. 
There  he  met  another  wounded  soldier,  the  young 
French  officer,  Lafayette,  scarcely  twenty  years  of 
age.  The  friendship  betwixt  the  unknown  private 
and  the  titled  foreigner,  begun  in  an  improvised 
hospital,  lasted  until  terminated  by  the  death  of 
Francisco  in  old  age. 

Peter  Francisco  participated  in  all  the  principal 
battles  from  Stony  Point  to  Savannah.  Although 
his  enlistment  had  been  preceded  by  no  military 
training,  he  instinctively  exhibited  high  military 
qualities  and  his  valorous  conduct  won  the  tiign 
approval  of  Washington  and  called  forth  the  out- 
spoken praise  of  Greene  and  Lafayette.  Greene 
and  Lafayette  were  not  only  his  superior  officers — 
they  were  his  admiring  friends.  And  that  is  all 
the  more  remarkable,  because  Francisco  was  only 
a  private.  He  had  declined  a  commission  because 
of  his  meagre  education. 

At  Stony  Point  Francisco  was  the  second  to 
scale  the  wall,  in  spite  of  a  nine-inch  bayonet  wound 
in  his  abdominal  wall.  At  Paulus  Hook  he  was 
again  wounded.  With  General  Gates  at  Camden, 
his  superhuman  strength  enabled  him  to  carry 
away  to  safety  an  eleven-hundred-pound  cannon 
after  the  horses  that  drew  it  had  all  been  killed. 
On   the  same   field   he  sent  a   bullet,   through   the 


heart  of  a  grenadier,  and  thereby  saved  the  life  of 
Colonel  Mayo.  A  little  later  he  saved  his  own 
life  with  a  bayonet  thrust  into  another  British 
soldier.  On  the  Guilford  Battle  Ground  near 
Greensboro  a  tall  monument  marks  the  place  where 
"Peter  Francisco,  a  giant  of  incredible  strength, 
killed  eleven  British  soldiers  with  his  own  broad 
sword,  and,  although  badly  wounded  by  a  bayonet, 
made  his  escape."  In  this  desperate  and  demon- 
iacal assault  it  is  recorded  that  Francisco,  with  his 
giant's  sword,  completely  bisected  a  British  soldier. 
Is  it  little  wonder  that  Lord  Cornwallis  turned  to 
the  coast,  in  search  of  the  British  fleet?  His  failure 
to  meet  it  at  Yorktown  placed  his  sword  in  Wash- 
ington's hand.  After  Guilford  Court  House,  where 
Francisco  was  again  badly  wounded,  he  was  again 
nursed  back  to  health,  as  at  Brandywine,  in  the 
home  of  a  Quaker.  Soon  afterwards,  at  Ben  Ward's 
Tavern  in  Amelia  County,  he  ran  into  Tarleton's 
command,  and  made  his  escape  by  the  most  desper- 
ate fighting. 

Immediately  after  Yorktown  Francisco  and  La- 
fayette came  together  to  Richmond.  As  they 
passed  old  St.  John's  Church,  in  which  by  his 
matchless  eloquence  Patrick  Henry  had  precipitated 
the  Revolution,  a  romantic  story-book  episode  oc- 
curred. A  lovely  sixteen-year-old  girl  tripped  just 
as  she  was  entering  her  carriage,  and  would  have 
fallen  but  for  the  steadying  hand  of  the  passing 
soldier.  Although  ]\Iajor  Anderson  respected  La- 
fayette's giant  friend,  and  admired  his  courage  and 
valour  on  the  field  of  battle,  he  could  not  give 
his  consent  to  the  marriage  of  his  daughter  Susan- 
nah to  one  so  illiterate  and  so  unsubstantially  en- 
dowed as  Peter  Francisco.  The  young  veteran 
went  to  work  to  make  a  fortune  and  he  went  to 
school  to  make  himself  culturally  fit  for  the  girl 
he  loved.  Slowly  parental  objection  subsided,  and 
in  178S  Peter  Francisco  and  Susannah  Anderson 
were  married.  She  became  the  mother  of  two  sons, 
only  one  of  whom  survived,  and  in  1790  she  died. 
In  1794  Catherine  Brooke  became  Peter's  second 
wife,  and  she  gave  birth  to  two  sons  and  two  daugh- 
ters, and  lived  until  1821.  Two  years  later  the  old 
hero,  probably  more  than  sixty  years  of  age,  be- 
came the  victim  of  the  charms  of  the  widow  of 
ISIajor  West.  She  bore  him  no  children,  but  sur- 
vived him  many  years.  But  after  two  years  of 
married  life  she  tired  of  the  country  and,  probably 
as  a  result  of  uxorial  proddings,  Peter  Francisco 
was  elected  Sergeant-at-Arms  of  the  General  As- 
sembly of  Virginia.  V'isitors  to  the  State  Capitol 
looked  upon  the  great  giant,  the  stories  of  whose 
deeds  of  arms,  incalculable  strength,  and  historic 
associations  had  made  him  almost  a  legendary  fig- 
ure. In  January,  18.M,  he  died,  and  as  the  General 
Assembly  was  then  in  session,  his  massive  remains 


584 


PETER  FRANCISCO— Hall 


November,  1936 


were  followed  to  old  Shockoe  Cemetery  by  all  the 
leading  officials  and  dignitaries  of  the  city  and  the 
state.  Four  years  later  his  companion-in-arms  and 
friend,  John  Marshall,  the  great  Chief  Justice,  was 
buried  near  him. 

Have  you  already  decided  that  the  young  war- 
rior's e.xhibition  of  elephantine  strength  was  either 
mythical,  or  the  result  of  the  excitement  and  the 
furor  of  battle?  After  Yorktown,  Peter  attended 
the  school  of  Mr.  McGraw,  a  hundred-and-ninety- 
pound  Gamaliel,  and  the  schoolmaster  testified  that 
his  pupil  many  a  time  held  his  teacher  on  the 
hand  of  one  outstretched  arm  as  if  he  had  been 
only  an  apple.  And  Mrs.  Willis  wrote  to  a  friend 
that  Peter  Francisco,  in  those  days  when  feats  of 
strength  were  common  rather  than  unusual,  held 
her  in  one  outstretched  hand  and  her  grown  friend 
in  the  other  hand  as  if  they  had  been  little  dolls. 
And  when  Mr.  Pamphlett  of  Kentucky  stopped  at 
Peter's  store  in  Buckingham  on  purpose  to  pick  a 
row  with  him,  Peter  pitched  the  Kentuckian  over 
a  four-foot  fence,  and  his  horse  immediately  after 
him,  to  the  astonishment  of  all  three  of  them. 
Called  to  a  boggy  meadow  in  the  pasture,  Peter 
picked  a  marooned  milch  cow  up  in  one  arm  and 
her  baby  calf  in  the  other,  and  carried  both  to  firm 
ground.  And  on  a  muddy  highway  in  midwinter 
Peter  suggested  to  the  driver  that  the  three  double 
teams  be  unhitched  from  the  heavily  loaded  and 
stalled  tobacco  wagon,  and  that  the  driver  guide 
the  wagon's  tongue.  Against  the  rear  of  the  wagon 
Peter  placed  his  Herculean  shoulders  and  dislodged 
the  wagon  that  six  mules  could  not  budge.  His 
great  size  and  his  superhuman  strength  persisted 
until  his  final  illness  fell  upon  him  at  the  age  of 
seventy-one.  Within  three  weeks  he  was  dead — 
of  some  intestinal? — abdominal? — trouble,  attrib- 
uted to  a  wound  received  in  battle.  But  do  you 
not  suppose  that  he  died  of  appendicitis,  as  Patrick 
Henry  had  done  thirty  years  before? 

It  is  both  plagiaristic  and  platitudinous  to  state 
that  what  has  been  is  that  which  is  and  which 
shall  be.  When  the  brothers  of  Joseph  fished  him 
out  of  a  pit  and  sold  him  to  passing  slave-traders 
they  probably  did  not  initiate  kidnaping.  But  the 
episode  left  its  imprint  upon  Egyptian,  Jewish  and 
world  history.  Kidnaping  and  ransoming,  slavery 
and  manumission  and  such  an  economic  depression 
as  that  with  which  Joseph  so  successfully  dealt  as 
food  dictator  has  continued  recurrently  to  this 
day.  Nor  is  the  human  giant  an  unusual  phenom- 
enon in  history.  Soon  after  the  dispersal  from  the 
Garden  the  children  of  Adam  and  Eve  encountered 
giants.  And  we  read  of  the  mighty  children  of 
Anak.  David,  the  shepherd  lad,  restored  the  morale 
of  the  terrified  army  of  Saul  by  giving  Goliath  of 
Gath  a  depressed  fracture  of  his  frontal  bone  by 


a  small  stone  hurled  from  a  sling-shot.  Goliath's 
skull  should  have  been  unusually  thick,  for  he  was 
probably  nine  feet  tall.  But  Og,  King  of  Bashan, 
was  probably  eleven  feet  tall.  We  know  nothing 
of  the  size  of  Samson,  but  even  after  Delilah  had 
deprived  him  of  his  character  and  had  probably 
sapped  him  of  much  of  his  strength,  he  was  able 
with  his  bare  arms  to  tear  down  the  temple  of  the 
Philistines  and  to  give  the  morticians  their  busiest 
day. 

Even  in  more  recent  times  there  are  evidences 
of  unusual  human  strength  and  endurance.  George 
Washington  would  not  occupy  his  place  in  history 
had  he  been  a  physical  weakling.  General  J.  E.  B. 
Stuart  was  probably  unacquainted  with  physical 
fatigue  or  fear.  And  the  great  bearded  Teutonic 
member  of  his  staff,  Heros  Von  Borcke.  was  of 
such  stature  that  he  had  to  use  as  his  mount  a 
draft  horse.  His  mighty  arm  and  his  sword  were 
of  such  length  that  no  Federal  cavalryman  could 
come  near  him.  General  Wade  Hampton,  who  suc- 
ceeded to  the  command  of  Stuart's  troops,  was  said 
to  be  the  strongest  man  in  the  Confederate  Army. 
Little  is  said  of  Stonewall  Jackson's  physical 
strength,  but  his  endurance  was  unusual.  Reti- 
cence and  relentlessness  dramatized  his  life  to  his 
own  people,  and  brought  terror  to  his  enemies. 
General  Hood  was  once  a  powerful  man  but  many 
wounds  lessened  his  vitality  and  persistent  pain 
probably  made  of  him  an  opium  addict.  Not 
Sherman  so  much  as  papaver  somniferum  probably 
overcame  him  in  Georgia.  Ewell  had  already  lost 
not  only  a  leg,  but  most  of  his  health,  when  placed 
at  the  head  of  the  Stonewall  Brigade.  And  Lee, 
even  before  Grant  struck  him  in  the  Wilderness  in 
the  spring  of  1864,  was  already  dying  of  cardiac 
degeneration.  Jefferson  Davis,  though  an  invalid, 
lasted  into  old  age.  He  lived  at  cross-purposes 
with  others  because  he  could  not  live  comfortably 
with  himself.  Was  the  trouble  ocular,  gastrointes- 
tinal, chronic  malaria,  glandular,  or  was  his  per- 
sonality that  of  a  psychopath?  The  South  paid 
dearly  for  his  poor  health. 

But  Peter  Francisco  fought  valiantly  and  suc- 
cessfully and  joyously  because  his  strength  and 
his  endurance  were  phenomenal  and  his  spirits  were 
high.  And  his  great  size  and  his  unusual  qualities 
were  made  possible  for  him  most  probably  by  a 
pituitary  gland  that  was  too  active  for  peace-time 
needs.  A  little  too  much  of  the  secretion  of  that 
gland — perhaps  only  the  fractional  part  of  a  drop 
each  week — gave  him  his  gigantism,  his  endurance, 
his  prowess,  his  boundless  energy  and  his  dauntless 
courage.  And  the  hypophyseal  overactivity  prob- 
ably awakened  into  livelier  functioning  the  other 
members  of  that  potent  chain  of  cellular  clusters — 
the  thyroid,  the  adrenals,  the  parathyroids  and  the 


November,  1936 


PETER  FRANCISCO— Hal! 


S8S 


gonads — so  that  Peter,  all  his  long  life,  was  kept 
busy  in  finding  wholesome  outlets  for  his  con- 
stantly accumulating  energ\-.  And  when  we  come 
to  know  more  about  the  hormones — of  the  music 
played  by  them  upon  the  human  keyboard;  of 
their  effects  upon  man's  emotions,  his  hopes,  his 
joys,  his  sorrows,  his  aspirations,  his  despairs,  his 
courage,  his  fears,  his  strength,  his  weakness — then 
we  may  read  history  more  intelligently  and  estimate 
the  makers  of  it  more  accurately. 

Discussion 
Dr.  R.  E.  Seibels,  Columbia: 

It  is  a  ver>'  special  pleasure,  in  the  midst  of  a  long 
scientific  program,  to  have  as  scholarly  and  delightful  a 
paper  as  this  one  Dr.  Hall  has  read.  All  of  us  who  know 
him,  whenever  we  see  his  name  on  a  program,  know  that 
we  are  going  to  have  a  special  treat,  not  only  in  the  literary 
content  of  his  paper  but  in  the  charm  of  his  personality, 
and  certainly  on  this  occasion  he  has  more  than  lived  up 
to  his  record. 

We  are  very  often  not  inclined  to  take  for  ourselves  the 
medicine  we  prescribe  for  our  patients — not  always  through 
lack  of  faith.  I  think  a  doctor  needs  recreation,  needs 
time  away  from  his  practice.  When  you  say  that  to  one 
of  your  friends,  the  answer  is:  "I  haven't  got  time."  An 
Englishman,  a  man  of  prominence,  came  to  this  country. 
The  reporters  saw  him  down  at  the  boat  when  he  was  em- 
barking to  return  home.  "Well,  what  do  you  think  of 
.America?"  they  asked.  He  said:  "When  I  came  over 
here,  I  was  told  to  use  the  subway,  instead  of  the  surface 
cars,  to  save  time.  I  saw  in  the  window  of  a  telegraph 
office  the  sign:  'Don't  write,  telegraph.  Save  time.'  Then 
I  was  told  to  use  the  long-distance  telephone,  to  save  time. 
What  do  you  Americans  do  with  the  time  you  save?" 

When  we  go  back  in  the  practice  of  medicine  we  find 
quite  a  number  of  men  in  the  profession  who  became  dis- 
tinguished in  other  lines — botanists,  soldiers,  and  what  not. 
I  should  like  to  say  a  few  words  about  a  doctor  in  Charles- 
ton who  came  to  this  country  in  1723,  Dr.  Thomas  Dale. 
He  very  quickly  distinguished  himself  in  the  practice  of 
medicine  in  a  community  in  which  medicine  was  well  prac- 
ticed. He  took  a  leading  part  in  the  fight  against  small- 
pox, a  disease  by  which  Charleston  was  ravaged  from  time 
to  time.  He  was  bitterly  opposed  to  inoculation ;  so  much 
so  that  when  Kirkpatrick  came  there  and  practiced  it,  in 
the  epidemic  of  "34  and  '35,  he  engaged  in  a  newspaper 
controversy  with  him.  He  translated  five  volumes  from 
the  Latin  and  French.  He  was  married  three  times.  To 
a  daughter  he  gave  a  house  on  Queen  street  which  is  still 
standing.  His  third  wife  was  a  Miss  Simmons,  and  his 
son  by  her,  Thomas  Simmons  Dale,  became  distinguished 
in  England.  In  addition  to  that,  he  wrote  the  prologue 
to  Colonel  Farquhar,  which  was  the  first  play  produced 
in  America.  He  became  assistant  justice  of  the  Supreme 
Court  and,  on  the  death  of  the  Chief  Justice,  served  as 
Chief  Justice  for  more  than  a  year.  He  was  an  eminent 
botanist  and  had  a  large  collection  of  plants,  which,  on 
his  death,  he  willed  to  Harvard.  So  here  we  have  a  phy- 
sician who,  in  addition  to  his  practice,  did  all  these  other 
things,  and  that  before  the  time-saving  devices  which  we 
now  have. 

It  was  a  great  pleasure  to  hear  Dr.  Hall's  paper. 

Dr.  W.  J.  Lackey,  Fallston,  N.  C: 

This  is  a  romantic  subject  which  Dr.  Hall  has  chosen. 
The  fact  that  a  gland  which  does  not  weigh  over  five  or 
ten   grains  can   bring   about  such   changes  is   rumantic   in 


itself.  Endocrinology  is  romantic,  and  I  wish  I  were  an 
endocrinologist. 

When  a  man  comes  in  to  consult  us  about  the  first 
thing  we  think  of  is,  how  is  the  stomach?,  how  is  the 
heart?  or  how  are  the  liver  and  the  kidneys?  There  are 
very  few  of  us  who  think  of  the  endocrine  glands.  The 
patients  will  tell  us  about  the  disturbances  of  the  heart 
and  stomach  and  liver;  they  know  about  them:  but  unfor- 
tunately they  will  not  tell  us  about  the  endocrine  glands. 
They  do  not  know  anything  about  them,  and  we  do  not 
know  much.  I  was  wondering  in  the  discussion  this  morn- 
ing about  viruses,  and  this  afternoon  in  the  discussion  of 
heart  massage,  if  there  is  not  some  way  in  which  we  can 
stimulate  those  endocrine  glands. 

Dr.  Hall's  paper  is  interesting  and  instructive.  I  should 
like  to  show  a  slide  or  two  and  give  the  concluding  chap- 
ter in  the  history  of  a  case  reported  at  the  meeting  of 
this  .\ssociation  at  Charlottesville  two  years  ago. 

This  is  a  Negro  boy  nineteen  years  of  age  who  was 
seven  feet  and  seven  inches  tall  at  that  time.  Notice  the 
enormous  length  of  the  arms  and  legs.  Here  is  a  picture 
of  the  skull.  Notice  the  enlarged  skuU.  I  thought  prob- 
ably he  had  a  tumor  of  the  pituitary.  Here  is  a  picture 
of  the  hands.    Notice  the  length  of  the  bones. 

This  boy  differed  from  the  case  Dr.  Hall  talked  about 
in  that  he  was  weak  and  could  not  walk  around  ver>- 
much.  He  would  get  up  and  down  like  an  old  person. 
He  was  not  strong.  His  appetite  was  fairly  good  all  the 
time;  he  did  not  have  an  excessive  appetite.  He  never 
suffered  any  pain  except  slight  headache.  He  never  was 
given  any  medicine  for  it.  His  health  was  good  on  up 
until  October,  1935,  when  he  became  suddenly  ill.  I  hap- 
pened to  be  out  of  town  and  did  not  get  to  see  him.  Ac- 
cording to  the  history  given  by  the  family,  he  began  to 
get  sleepy,  went  into  a  semicomatose  condition,  and  in  a 
few  days  died.  No  doctor  saw  him.  I  thought  the  history 
might  be  one  of  cerebral  hemorrhage;  possibly  the  pitui- 
tary tumor  there  caused  rupture  of  a  vessel.  This  boy 
was  normal  up  until  five  years  ago,  when  this  rapid  growth 
started.  I  shall  never  forget  the  first  time  I  saw  him.  I 
had  gone  to  see  his  sister  and  happened  to  see  this  colored 
boy  sitting  by  the  fire  with  his  big  feet  sticking  out.  He 
was  one  of  the  best  patients  I  ever  had. 

M.^jOR  A.  Moultrie  Bratlsford,  U.  S.  K.  Ret.,  Camden, 
S.  C. 

I  particularly  enjoyed  the  paper  by  Dr.  Hall.  It  was 
an  interesting  and  instructive  presentation  of  a  case  of 
hypersecretion  of  the  pituitary  gland  and,  in  like  manner, 
of  all  of  the  glands  of  internal  secretion  in  balanced  pro- 
portions. This  gave  Peter  Francisco  his  splendid  vitality, 
wonderful  size  and  marvelous  strength. 

In  the  army  we  are  very  much  interested  in.  the  glands 
of  internal  secretion.  Especially  is  this  true  in  regard  to 
the  air  service — a  calling  that  demands  the  highest  state 
of  physical  efficiency.  An  individual  should  be  stable  and 
well  balanced  when  he  comes  into  the  Aviation  branch  of 
the  service,  because  he  is  entering  a  Ufe  entirely  different — 
one  that  entails  the  most  exacting  calls  upon  all  of  his  fac- 
ulties. 

When  a  flyer  became  "stale,"  as  we  called  it  in  the  early 
days,  he  would  be  sent  away  from  the  field  for  a  rest  and 
change.  But,  in  many  cases,  upon  returning  to  duty, 
symptoms  of  inefficiency  would  recur.  We  considered  such 
pilots  suffering  from  chronic  nervous  exhaustion,  but  now 
we  suspect  them  of  possessing  malfunctioning  glands  of 
internal  secretion — especially  the  thyroid.  Such  individuals 
are  entitled  to  have  this  differentiation  completely  worked 
out.  If  malfunction  of  any  of  the  glands  is  discovered, 
these  men  are  considered  "damaged  goods"  so  far  as  flying 


S86 


PETER  FRANCISCO— Hall 


November.   1Q36 


is  concerned. 

It  is  extremely  important  to  detect  malfunction  of  glands 
at  the  time  of  the  initial  examination  of  applicants  for  the 
Air  Service,  otherwise  it  would  involve  not  only  eventually 
their  "cracking-up"  and  possible  death,  but  immense  ex- 
pense to  the  government  in  attempting  to  train  men  abso- 
lutely unfit  for  that  branch  of  the  service. 

Dr.  Jas.  M.  Northington,  Charlotte: 

I  have  a  special  interest — several  special  interests — in 
Peter  Francisco.  M\-  friend  Dr.  Hall  wrote  me  while  the 
program  was  in  the  making,  inquiring  if  I  knew  about 
Peter  Francisco.  I  responded  by  telling  him  I  was  brought 
up  not  very  far  from  where  Peter  was  brought  up,  and 
was  brought  up  on  the  tale  of  his  pitching  the  horse  and 
its  rider  over  the  fence.  So  I  have  a  kind  thought  for 
Peter. 

I  should  Uke  to  call  your  attention  a  little  further  to 
this  settlement  that  was  planned  at  Henricopolis,  the  City 
of  Henry,  on  the  James  River — or,  as  my  old  grandmother 
used  to  say,  the  Jeems.  So  far  as  I  know  it  was  the  first 
instance  in  the  world  of  a  hospital  and  a  university  being 
planned  on  such  a  scale.  So  many  acres  were  set  aside 
for  this  hospital  and  a  cow  was  provided  to  so  many  pa- 
tients, with  grazing  grounds  for  the  cows  and  other  grounds 
for  providing  sustenance  other  than  milk  for  the  patients — 
in  this  hospital  which  was  projected  in  1622.  What  ad- 
vanced thought  I  We  discover  some  little  thing,  and  we 
like  to  think  that  the  people  of  two  hundred  years  ago  or 
five  hundred  years  ago  never  heard  of  such  a  thing.  As 
the  Sage  of  Grace  Street,  Dr.  William  H.  Taylor,  used  to 
^ell  his  students:  "We  ask  in  our  pride,  What  would  the 
ancients  say  of  this?  and  if  they  could  reply,  often  they 
would  say  something  crushingly  uncomplimentary."  What 
we  call  progress  has  not  been  a  steady  climb  at  all. 

I  had  been  accustomed  to  hearing  and  talking  about 
Hippocrates,  and  about  five  years  ago  I  decided  I  would 
read  what  Hippocrates  actually  said.  I  was  astonished  to 
find  that  Hippocrates  was  probably  a  better  surgeon  than 
most  surgeons  today — except  as  to  abdominal  surgery ;  and 
this  largely  because  of  discoveries  in  which  surgeons  had 
no  part. 

Dr.  Hall  said  Peter  Francisco  was  probably  the  most 
distinguished  private  soldier.  1  ask  him  to  divide  honors 
with  John  Allen,  of  Mi^issippi,  who  goes  down  in  historj- 
as  Private  John  Allen  because  he  was  wont  to  say  he  was 
the  only  private  in  the  Confederate  Army,  but,  in  his  in- 
variably successful  campaigns  for  election  to  the  Congress, 
to  ask  all  ex-privates  to  vote  for  him,  all  ex-generals  to 
vote  for  his  opponent. 
Dr.  Carl  B.  Epps,  Sumter: 

I  was  very  much  interested  in  the  paper,  as  I  am  always 
interested  in  what  Dr.  Hall  presents.  He  has  been  for 
many  years  my  idea  of  the  real  Southern  gentleman  and 
scholar.  I  was  interested  in  this  story.  Some  of  you  may 
find  it  hard  to  believe  it.  I  can  accept  even  his  picking 
up  the  horse  and  the  rider  and  pitching  them  over  the 
fence.     I  can  accept  his  unhitching  the  six-horse  team  and 


himself  pushing  the  wagon  out  of  the  mud.  I  can  even 
accept  and  understand  how  Peter  Francisco  saved  the 
drowning  calf  and  the  drowning  cow.  What  I  want  to 
know  is  who  preserved  for  posterity  all  of  that  bull. 

Dr.  W.  C.  Ashworth,  Greensboro: 

Dr.  Hall  is  a  philosopher,  and  he  is  also  a  fine  historian. 
Since  we  have  a  monument  to  Peter  Francisco  in  Greens- 
boro, in  which  city  I  reside,  I  want  to  extend  to  you  an 
invitation  to  come  to  Greensboro  to  see  me  and  let  me 
take  you  over  to  the  battleground,  where  there  is  a  fine 
monument  to  Peter  Francisco. 

We  stick  too  much  to  our  medicine.  Dr.  Hall  is  a 
philosopher  and  a  historian  and  is  everything  that  makes 
up  a  real  man. 

Now,  when  any  of  you  come  over  to  Greensboro — as 
every  one  of  you  certainly  will — I  want  you  to  be  my 
guest  and  let  me  take  you  to  see  the  monument  to  Peter 
Francisco. 

Dr.  Hall,  closing: 

I  am  not  going  to  detain  you  any  longer.  I  want  to 
thank  the  gentlemen  who  discussed  the  paper,  and  I  want 
to  refer  my  good  friend  Dr.  Epps  to  a  ven,'  delightful  little 
volume  which  I  plagiarized  most  extensively — The  Roman- 
tic Record  of  Peter  Francisco,  A  Revolutionary  Soldier,  by 
Nannie  Francisco  Porter  and  Catherine  Albertson.  Both 
authors  are  great-granddaughters  of  Peter  Francisco.  Mrs. 
Porter  formerly  lived  in  Greensboro.  Her  son.  who  is  a 
great-great-grandson  of  Peter  Francisco,  lives  in  Raleigh. 
A  few  weeks  ago  I  went  to  the  State  Library  in  Rich- 
mond, searching  for  some  information,  and  there  I  met 
at  the  reading  desk  in  the  library,  by  chance,  Mrs.  Porter. 
I  did  not  know  she  lived  in  Richmond.  She  told  me  a 
good  many  things  about  her  great-grandfather. 

The  little  volume  does  not  tell  about  the  death  of  Peter 
Francisco  and  some  of  his  habits,  but  Mrs.  Porter  told 
me  that  he  lived  in  good  health  and  was  physically  and 
mentally  sound,  and  therefore  I  suppose  his  ductless  glands 
were  working  concordantly  all  his  life.  Dr.  Lackey's  pa- 
tient had  trouble,  I  suppose,  because  his  pituitary  gland 
went  ahead  of  the  others. 

Mrs.  Porter  told  me  that  Peter  Francisco  drank  little ; 
he  drank  only  wine  and  drank  that  moderately.  The  use 
of  wine  was  quite  common  at  that  time.  He  was  a  large 
eater.  He  had  a  good  mentality.  He  was  married  three 
times  and  had  six  children.  So  he  did  not  degenerate,  as 
so  many  of  these  individuals  do.  The  Pescuds,  in  Raleigh, 
are  direct  descendants  of  Peter  Francisco;  and  Mrs.  Porter 
told  me  that  a  great  many  of  his  descendants,  who  are 
scattered  all  over  the  United  States,  are  unusually  large. 

Of  course,  we  do  not  know  who  Peter  Francisco  really 
was ;  he  remains  a  myster.' ;  but  he  was  a  very  real  human 
being. 

References 

The  Romantic  Record  of  Peter  Francisco — .-1  Revolution- 
ary Soldier,  Nannie  Francisco  Porter,  author,  and  Cather- 
ine Fauntleroy  .■\lbertson,  co-author.  Printed  by  The  Mc- 
Clure  Company,  Inc.,  Staunton,  Virginia,  1020. 


^ 


_i3x_ 


Vv^^w*;.^^ 


November,  10.?6 


SOUTHERN  MEDICINE  AND  SURGERY 


5*7 


Mild  Hypothyroidism  in  Children* 

John  R.  Ashe,  ^NI.D.,  Charlotte,  North  Carolina 


IX  the  past  two  years  I  have  had  under  my 
care  10  children  whose  symptoms,  as  judged 
by  the  history,  clinical  findings — usually  in- 
cluding basal  metabolic  rate — and  the  therapeutic 
response  to  thyroid  extract,  were  best  explained 
by  varying  degrees  of  thyroid  deficiency. 

Our  textbooks  describe  conditions  of  total  or 
nearly  total  failure  of  function  of  the  thyroid  gland 
— cretinism  and  childhood  myxedema — in  such 
detail  that  there  should  never  be  any  difficulty  in 
our  recognizing  these  conditions  promptly;  but  the 
milder  types  of  thyroid  failure  are  usually  not 
mentioned  at  all  or  are  passed  over  with  brief  and 
indefinite  descriptions. 

The  medical  literature  of  the  past  five  years  con- 
tains a  number  of  articles  on  mild  hypothyroidism 
in  adults,  the  majority  of  these  emphasizing  its 
frequency,  its  many  and  varied  symptoms,  its  in- 
definite clinical  picture  often  leading  to  failure  of 
diagnosis,  and  the  gratifying,  at  times  spectacular, 
response  to  thyroid  medication.  In  this  five-year 
period,  with  the  exception  of  an  article  by  Cason 
on  mild  hypothyroidism  in  adolescent  girls  and  one 
by  Dorff  on  a  more  severe  degree  of  thyroid  defi- 
ciency, there  is  nothing  in  the  literature  on  this 
condition  in  children. 

In  the  21  years  of  my  pediatric  practice  in  Char- 
lotte I  have  seen  so  few  cretins  that  I  have  consid- 
ered this  condition  rare  in  our  vicinity,  but  the 
evidence  that  I  am  presenting  strongly  suggests 
that  milder  types  of  hypothyroidism  occur  with 
fair  frequency. 

I  am  briefly  reporting  six  cases,  each  of  which 
will  emphasize  some  particular  point.  None  of 
these  children  presented  any  of  the  signs  usually 
seen  in  cretinism.  Four  of  them  had  been  under 
my  care  since  birth,  one  since  six  months  of  age, 
and  one  since  his  third  year. 

Case  1. — A  girl,  aged  10  years,  had  graduated  from  my 
practice  and  I  was  called  back  in  desperation  because  I 
had  always  been  able  to  control  her  better  than  anyone 
else.  Her  home  environment  was  difficult  because  of  lack 
of  sympathy  from  a  father  who  had  never  been  sick  in 
hLs  life,  and  apprehensiveness  and  over-solicitude  on  the 
part  of  the  mother.  She  had  always  been  a  temperamental 
child,  rather  difficult  to  control.  Over  a  period  of  several 
weeks  she  had  been  rapidly  becoming  more  and  more  un- 
controllable and  had  reached  a  stage  of  depression  so  severe 
that  she  stayed  in  her  room,  usually  in  bed,  refusing  to 
go  to  school  or  to  have  anything  to  do  with  any  member 
of  her  family.  She  complained  of  vague  pains  in  the 
lower  abdomen  and  pelvic  region  and  had  been  examined 
by  a  competent  gynecologist  with  negative  findings.     She 

')f  the  Medical  Si 


also  complained  of  pains  over  her  heart  and  could  not  be 
convinced  that  she  did  not  have  heart  trouble.  She  ate 
very  poorly  and  refused  entirely  a  number  of  her  meals. 
She  was  a  most  unhappy-looking,  extremely  depressed  girl; 
but  physically  she  was  normal,  well  developed,  well  nour- 
ished, healthy-looking.  After  considerable  difficulty  a 
metabolism  test  was  done  and  the  reading  was  — 14%. 

She  was  put  on  yi  grain  of  thyroid  extract  twice  a  day, 
and  in  three  or  four  days  she  was  an  entirely  different  girl 
and  in  a  week  she  was  back  in  school,  behaving  normally 
toward  everyone  and  for  the  first  time  in  months  beginning 
to  show  some  interest  in  the  opposite  sex.  Ten  weeks  later 
her  metabohsm  rate  was  — 4.  She  continued  taking  thyroid 
for  nine  months  during  which  time  her  sisters  could  tell 
from  her  behavior  when  she  would  forget  to  take  her  dose. 
Metabohsm  reading  taken  six  months  after  treatment  had 
been  discontinued  was  -|-4. 

Since  the  beginning  of  thyroid  therapy  she  has  been  per- 
fectly normal  in  every  way.  This  girl  presented  all  three 
of  the  symptoms  which  have  been  most  helpful  in  suggest- 
ing the  presence  of  mild  hypothyroidism — altered  function 
of  brain,  undue  fatigue  and  indefinite  pains. 

Cason  reported  a  small  group  of  girls  from  13 
to  16  years  of  age  with  a  variety  of  behavior  prob- 
lems and  lowered  metabolic  rates  averaging  around 
— 20.  By  administration  of  sufficient  thyroid  ex- 
tract to  bring  their  rates  to  normal  these  girls  were 
rather  spectacularly  restored  to  normal  emotional 
states. 

Haywood  and  Woods  state  that  insufficient  thy- 
roid secretion  sometimes  shows  its  most  striking 
effect  through  malfunction  of  the  brain  cells.  The 
patient  may  become  depressed  and  apprehensive, 
thought  may  become  slow  and  body  movements  re- 
tarded. The  condition  is  easily  mistaken  for  a 
depressed  psychosis,  or  there  may  be  irritability 
and  excitement,  leading  to  a  diagnosis  of  mania. 

Hensel  states  that  hypothyroid  symptoms  may 
occur  at  any  time  of  life  but  are  particularly  com- 
mon at  puberty,  at  the  menopause,  during  and 
following  pregnancy,  and  in  the  convalescent  period 
following  infections,  particularly  influenza. 

Crile  and  associates  state  that  hypothyroidism 
may  be  the  cause  of  behavior  problems  in  children 
and  mention  startling  results  following  the  admin- 
istration of  small  doses  of  thyroid. 

It  is  well  known  that  the  thyroid  enlargement 
of  girls  at  puberty  is  often  associated  with  dimin- 
ished thyroid  activity,  and  some  recommend  treat- 
ment with  small  doses  of  thyroid  extract  in  addi- 
tion to  administration  of  iodine. 

Case  2. — This  boy,  aged  10  years,  of  most  neurotic  pa- 
rentage, had  given  difficulty  in  feeding  and  been  undernour- 
ished until  six  years  of  age.  Since  then  he  had  been  a 
healthy  child.     When  four  years  old  he  had  a  severe  frac- 

■  ciety  of  the  State  nl'  Xcirlh  Carolina,  nieetinp  at  AshevlUe, 


588 


MILD   HYPOTHYROIDISM— Ashe 


November,   1936 


ture  of  the  skull,  but  after  a  few  hours  of  mild  symptoms 
of  concussion,  this  caused  no  particular  trouble  except  that 
it  was  difficult  to  keep  him  in  bed  for  three  weeks.  He 
had  always  been  a  ver\-  nervous,  high-strung,  active  boy, 
controlled  with  some  difficulty.  During  the  first  four 
years  in  school  he  did  very  well.  In  his  fifth  year  he  be- 
came more  and  more  unmanageable,  both  at  home  and 
at  school,  and  the  principal  finally  informed  the  parents 
that  unless  something  were  done  he  would  have  to  be 
dropped.  He  had  become  emotionally  unstable,  crying  at 
the  sUghtest  provocation,  and  was  very  impertinent  and 
disagreeable.  Physically,  he  looked  well  and  was  entirely 
negative  on  examination.  His  basal  metabolic  rate  was 
—16. 

He  was  put  on  J/i  grain  of  thyroid  extract  twice  a  day, 
and  was  definitely  better  in  less  than  a  week,  much  happier 
at  home  and  behaving  much  better  in  school. 

With  this  boy  mUd  hypothyroidism  is  probably  not  the 
whole  story,  as  his  heredity  and  environment  certainly  are 
large  factors  in  his  psychic  makeup.  The  results  of  thy- 
roid therapy  are  obscured  to  a  considerable  extent  due  to 
the  fact  that  he  was  also  under  the  care  of  a  psychiatrist. 
His  case  is  included  in  this  report  because  his  evidence  of 
hypothyroidism  was  entirely  on  the  emotional  side. 

Case  3. — ^A  boy  aged  9  years,  with  past  history  negative 
except  for  a  thymic  attack  complicating  pertussis  at  two 
years  of  age,  treated  by  several  exposures  to  x-rays.  One 
year  ago  he  was  brought  to  me  because  for  several  weeks 
he  had  been  listless,  had  tired  easily,  had  not  done  well 
at  school,  and  had  become  emotionally  unstable,  crying 
for  the  sUghtest  cause.  He  also  complained  of  vague  pains 
in  the  muscles  of  his  legs.  Examination  was  entirely  neg- 
ative: height  was  S6J^  inches  and  his  weight  79%  pounds. 
Metabolic  rate  was  ■ — 33. 

He  was  put  on  %  grain  of  thyroid  twice  a  day  for  six 
months,  when  it  was  decreased  to  yi  grain  once  a  day. 
In  4  or  5  days  after  treatment  was  begun  he  was  feeling 
much  better,  all  of  his  symptoms  had  disappeared  and  he 
has  been  doing  well  ever  since.  MetaboUsm  test  repeated 
in  three  months  was  — 10.  He  now  feels  well  and  basal 
metabolic  rate  four  days  ago  was  +'.  Bone-age  studies, 
by  roentgen  ray,  show  normal  appearance  of  metacarpal 
ossification.  In  this  case  emotional  instability  was  the 
most  pronounced  symptom. 

This  boy  had  been  under  my  care  for  nine  years  and 
had  been  seen  frequently,  but  until  his  visit  a  year  ago 
there  had  never  been  any  reason  to  suspect  that  hypothy- 
roidism was  present.  When,  in  getting  up  this  report,  I 
called  his  mother  to  ask  her  some  questions  about  him,  she 
voluntarily  came  to  my  office  to  tell  me  how  happy  she 
and  her  husband  are  that  he  is  apparently  normal  in  every 
way  since  starting  small  doses  of  thyroid. 

Thyroid  medication  was  discontinued  at  the  end  of  one 
year  but  in  3  weeks  he  lapsed  into  exactly  his  former 
state  of  emotional  instability,  under  fatigability  and 
vague  pains  in  various  parts  of  his  body. 

Resumption  of  thyroid  resulted  in  the  same  happy  re- 
sponse obtained  in  the  beginning  and  he  now  feels  and 
acts  better  than  at  any  time  in  his  life. 

Case  4. — Girl,  aged  6  years,  had  always  been  well  and  I 
had  seen  her  infrequently.  The  father,  formerly  a  railroad 
fireman,  had  always  made  a  good  living  for  them,  but  had 
been  laid  off  for  three  years  and  had  finally  been  forced 
to  go  on  relief.  He  had  had  a  nervous  breakdown  and 
has  recently  been  found  to  be  a  mild  hypothyroid.  This 
child  was  brought  to  me  in  May,  1935,  because  of  increas- 
ing lack  of  energy  over  several  months.  She  had  reached 
the  point  that  it  was  difficult  to  keep  her  out  of  bed.  She 
would  get  up  at  the  usual  time  but  would  quickly  go  back 


to  bed.  She  would  not  go  out  of  the  house  and  would  not 
play  with  the  other  children.  She  had  a  very  poor  appe- 
tite, was  constipated,  and  complained  of  vague  pains  in  her 
legs.  In  my  office  she  was  listless  and  quiet  and  even  sit- 
ting in  a  chair  required  considerable  effort.  Examination 
was  entirely  negative.  Height  was  43  inches  and  weight 
3S  pounds,  slightly  underweight  but  not  under  height.  Her 
metabolic  rate  was  — 32. 

She  was  put  on  yi  grain  of  thyroid  extract  twice  a  day. 
In  four  or  five  days  all  her  symptoms  had  disappeared 
and  3^  months  later  treatment  was  discontinued  by  her 
parents  because  she  was  doing  well.  For  9  months,  she 
has  done  well.  This  year  she  was  put  in  school  and  in 
spite  of  a  very  severe  winter,  did  not  miss  a  day  and  led 
her  class.  She  is  now  energetic,  plays  out  doors  all  day 
long  and  looks  perfectly  well.  Metabolism  test  was  re- 
peated three  months  ago  and  was  — 12.  She  has  been 
doing  so  well,  however,  without  thyroid  administration 
that  we  have  been  letting  her  go  along  untreated.  There 
is  a  delay  of  about  a  year  in  her  bone  age  as  determined 
by  x-ray  four  days  ago.  The  centers  of  ossification  of  the 
trapezium  and  scaphoid,  which  normally  appear  at  five  to 
six  years,  are  not  yet  present.  It  is  my  intention  to  resume 
treatment  here  because  of  the  great  importance  of  the  thy- 
roid hormone  on  growth. 

This  chUd,  like  the  one  preceding,  was  within  eight  of 
the  metabolic  reading  usually  considered  as  indicating 
complete  absence  of  thyroid  activity ;  yet  there  was  nothing 
in  her  appearance  suggesting  cretinism,  and  thyroid  therapy 
for  a  few  weeks  changed  her  to  a  happy  active  child.  The 
chief  symptom  here  was  a  most  pronounced  lack  of  energy. 
Case  5. — This  boy,  aged  9  years,  had  frequent  upper- 
respiratory  infections  in  the  first  few  years  of  his  life, 
usually  attended  by  considerable  aching  of  legs.  When 
two  years  old  he  complained  for  several  months  of  pains 
over  his  sacral  region.  These  pains  occurred  in  the  day 
or  night,  and  had  no  relation  to  exercise.  At  that  time 
examination,  including  x-ray  of  pelvis,  was  negative  and 
the  pain  continued  for  several  months  in  spite  of  attempted 
immobilization.  In  January,  1935,  he  was  brought  to  me 
because  of  indefinite  pains  in  the  calf  of  his  left  leg.  Ex- 
amination was  negative.  He  was  referred  to  an  orthopedic 
surgeon  who  thought  that  the  pain  was  due  to  too  much 
pull  on  his  tendo  achillis.  Strain  was  taken  off  this  by 
padding  the  heel  of  his  shoe.  Two  months  later  he  re- 
turned because  he  had  gotton  no  relief  from  the  pain  in 
this  leg,  and  was  now  complaining  of  similar  pain  in  the 
other  calf.  He  had  always  been  a  quiet,  inactive  boy, 
preferring  to  stay  in  the  house  and  read  rather  than  play 
out-of-doors  with  other  boys.  His  mother  thought  that 
he  became  tired  much  more  easily  than  her  other  son.  Be- 
cause of  these  suggestive  symptoms  a  metabolism  test  was 
done  and  the  rate  was  found  to  be  — 29.  Exammation  was 
entirely  negative.  Response  to  thyroid  here  was  happy, 
his  pains  disappearing  in  three  or  four  days.  Here  the 
predominating  symptom  was  indefinite  pains  in  different 
parts  of  body. 

It  is  very  hkely  that,  in  spite  of  negative  physical  find- 
ings, this  case  had  been  one  of  mild  hypothyroidism  for 
a  number  of  years. 

Case  6. — This  little  girl,  aged  7  years,  had  suffered  with 
frequent  upper  respiratory  infections.  Tonsils  and  adenoids 
had  been  removed  at  the  age  of  five  years.  She  had  never 
been  robust,  and  had  been  a  poor  eater,  and  for  this  reason 
the  family  had  moved  to  the  country  two  years  ago.  There 
the  child  had  improved  considerably,  and  at  the  onset  of 
the  illness  that  apparently  lowered  the  function  of  her 
thyroid  she  was  in  splendid  condition.  In  Januan,-  of  this 
year   she    had   a    severe    upper-respiratory    infection    with 


November,  1036 


MILD   HYPOTHYROIDISM— Ashe 


otitis  media  and  cervical  lymphadenitis,  complicated  by 
pyuria.  She  had  considerable  fever  for  about  three  weeks. 
Convalescence  was  rather  slow,  and  when  she  was  able  to 
return  to  school  the  teacher  advised  the  mother  to  have 
her  looked  over  as  she  was  sluggish  and  could  not  keep  up 
with  her  studies,  cried  easily  from  the  slightest  cause  and 
was  apparently  very  unhappy.  Her  mother  observed  that 
she  tired  easily,  had  a  poor  appetite  and  showed  consider- 
able reluctance  in  staying  up  in  the  mornings.  Examina- 
tion was  entirely  negative.  She  was  5  inches  and  4  pounds 
over  the  e.xpected  height  and  weight  for  her  age.  Her 
basal  metabolic  rate  was  — 13.  She  was  put  on  '/^  grain 
of  thyroid  extract  once  a  day  and  in  two  days  all  of  her 
symptoms  had  disappeared.  She  now  looks  wonderfully 
well  and  is  happy  and  energetic.  She  has  been  on  thyroid 
for  one  month  and  repetition  of  the  metabolic  test  gave  a 
reading  of  — 19.  For  this  reason  dosage  has  been  increased 
to  one  grain  a  day. 

Simple  tonic  treatment  in  this  case  would  probably  have 
been  a  complete  failure.  There  was  never  any  indication 
of  hypothyroidism  in  this  child  until  after  her  illness  one 
month  before  the  condition  was  discovered. 

A  number  of  writers  on  adult  hypothyroidism  stress  the 
importance  of  infection  decreasing  the  function  of  the  thy- 
roid gland.  However,  infection  can  also  increase  its  output 
of  thyroxin.  I  have  recently  had  an  S-year-old  girl,  follow- 
ing a  severe  illness  with  pneumonia  and  empyema  lasting 
for  several  weeks,  to  develop  very  much  the  same  train 
of  symptoms — lack  of  energy,  fatigability,  poor  appetite, 
emotional  instability  and  indefinite  pains  in  legs.  Her 
metabolic  rate  was  -f  SO,  her  pulse  rate  was  increased  and 
she  developed  slight  enlargement  of  her  thyroid  gland.  On 
rest  and  iodine,  and  high-protein,  high-fat  and  low-carbo- 
hydrate diet,  she  became  normal  in  metabolic  rate  and 
clinical  symptoms  in  about  three  weeks. 

StrMMARY 

In  summarizing  the  symptoms  shown  by  the  six 
cases:  four  presented  definite  evidence  of  emotional 
instabiUty;  five  complained  of  vague  pains  in  va- 
rious parts  of  the  body;  and  five  suffered  from 
undue  fatigue. 

The  active  principle  of  the  thyroid  gland,  thy- 
roxin, through  its  catalytic  action  on  chemical 
changes  in  all  of  the  body  cells  normally  has  a 
tremendous  influence  on  all  the  body  functions. 
Variations  in  the  activity  of  this  gland  resulting  in 
either  increased  or  decreased  output  of  thyroxin 
produce  changes  in  function  in  every  tissue  of  the 
body.  The  symptoms  of  hypothyroidism  are  there- 
fore many  and  varied. 

The  diagnosis  of  mild  hypothyroidism  in  chil- 
dren is  made  from  the  clinical  history,  v^'hen  possi- 
ble confirmed  by  a  lowered  metabolic  reading. 
Physical  examination  adds  no  positive  evidence. 

The  most  important  symptoms  are  lack  of  en- 
ergy, shown  particularly  by  a  disinclination  for 
physical  activity  and  undue  fatigue,  moderate  men- 
tal sluggishness  and  emotional  instability,  accom- 
panied at  times  by  behavior  problems  or  mental 
changes,  particularly  on  the  depressive  side,  and 
various  indefinite  pains  in  different  parts  of  the 
body.  Other  less  common  symptoms  are  constipa- 
tion, diminished  tolerance  for  cold,  headaches  and 


irritability. 

With  the  aid  of  an  excellent  technician  we  have 
found  the  basal  metabolic  test  to  be  entirely  satis- 
factory in  children  as  young  as  six  years  of  age.  In 
taking  metabolism  tests  in  hypothyroid  children 
there  is  an  added  factor  in  safety  of  interpretation 
in  the  fact  that  any  error  through  leakage  or  lack 
of  cooperation  will  be  on  the  plus  side.  It  is  well, 
however,  to  remember  that  lowered  activity  of  the 
thyroid  gland  is  not  the  sole  cause  of  lowered 
metabolism.  Other  causes  are  inanition,  anemia, 
hypopituitarism,  ovarian  hypofunction,  Addison's 
disease  and  depressed  mental  states.  Many  inves- 
tigators believe  that  the  normal  range  of  the  metab- 
olic rate  is  wider  than  from  -j-lO  to  — 10,  and 
are  inclined  to  consider  lightly  readings  as  low  as 
— 20.  There  is  apparently  no  variation  in  rate 
due  to  differences  in  climate. 

Further  Aids  to  Diagnosis 

As  further  aids  in  diagnosis  and  control  of  treat- 
ment in  severer  types  of  hypothyroidism  in  chil- 
dren, the  blood  cholesterol  level,  the  extent  of 
renal  excretion  of  creatine,  and  roentgenological 
determination  of  bone  age  have  been  found  to  be 
very  useful. 

Epstein,  Lambe,  Lahey  and  others  have  shown 
that  there  is  an  inverse  relationship  in  the  blood 
cholesterol  to  the  metabolic  rate  and  the  degree  of 
activity  of  the  thyroid  gland.  Lahey,  Bronstein, 
Hess  and  others  have  found  the  level  of  the  blood 
cholesterol  more  useful  than  the  metabolic  rate  in 
determining  the  degree  of  thyroid  function  and  in 
regulating  replacement  therapy  in  severe  hypothy- 
roidism. Three  years  ago  I  reported  before  this 
society  the  remarkable  progress  of  a  cretin,  who,  too 
young  to  take  the  metabolism  test,  had  been  con- 
sidered to  be  doing  very  well  on  thyroid  dosage 
determined  entirely  by  clinical  appearance,  but  who 
improved  wonderfully  when  sufficient  thyroid  was 
given  to  bring  her  cholesterol  down  from  429  to 
135  mg.  per  100  c.c.  blood. 

Hinton  states  that  in  adults  with  mild  hypothy- 
roidism with  metabolism  readings  as  low  as  — 8 
to  — 10  the  cholesterol  will  be  at  the  upper  limit  of 
normal  or  just  above.  The  range  of  normal  values 
in  children  is  wide — from  129  to  217  mg.  The 
value  of  this  procedure  in  mild  degrees  of  hypo- 
thyroidism in  children  should  be  investigated. 

Rose  in  1911  discovered  that  creatine  was  nor- 
mally present  in  the  urine  of  children  up  to  puberty. 
Later  Beuner  and  Iseke  observed  that  hypothyroid- 
ism in  children  was  invariably  accompanied  by  a 
diminution,  and  sometimes  by  a  complete  suppres- 
sion, of  creatine  excretion,  and  that  in  these  chil- 
dren the  creatine  excretion  returns  to  normal  after 
administration  of  thyroid  extract.    Poncher  and  as- 


MILD  HYPOTHYROIDISM— Ashe 


November.  1936 


sociates.  and  Hess  believe  that  this  relatively  sim- 
ple laboratory  procedure  should  be  useful  in  the 
diagnosis  of  hypothyroidism  in  children,  particu- 
larly in  borderline  cases.  And  they  believe  that  it 
should  be  very  useful  in  controlling  the  treatment 
as  its  response  to  thyroid  extract  is  very  much 
quicker  than  the  changes  in  either  the  blood  choles- 
terol or  the  metabolic  rate. 

Dorff  and  others  have  shown  that  hypothyroid- 
ism of  sufficient  degree  developing  before  puberty 
produces  definite  delay  in  ossification,  shown  by 
late  appearance  or  poor  massing  of  the  ossification 
centers  and  epiphyseal  nuclei,  and  that  complete 
replacement  therapy  accelerates  the  development 
of  this  system  towards  normal.  With  the  collab- 
oration of  Dr.  C.  C.  Phillips,  roentgenologist,  we 
have  recently  investigated  this  possibility  in  two 
children  who,  in  the  beginning  had  similar  low 
metabolic  rates.  The  bone  age  of  one  was  normal 
but  the  other  showed  definite  retardation  of  one 
year  in  the  appearance  of  the  ossification  centers. 
Dosage  and  Administkatiox 

With  definite  symptoms  of  hypothyroidism  and 
a  lowered  metabolic  rate  the  margin  of  safety  in 
administering  thyroid  extract  is  large,  and  over- 
dosage with  the  appearance  of  toxic  symptoms  is 
unlikely.  Complete  replacement  therapy  in  chil- 
dren who  have  total  absence  of  thyroid  function 
requires  from  2  to  4  grains  of  thyroid  per  day. 
In  these  children  with  mild  hypothyroidism  the 
effective  dose  is  never  more  than  one-fourth  this 
amount.  I  have,  with  considerable  caution,  ad- 
ministered thyroid  extract  to  several  children  too 
young  to  have  metabolism  tests  and  to  one  child 
whose  symptoms  were  very  suggestive  but  whose 
rate  was  normal.  I  have  been  unable  to  find  any 
evidence  that  this  is  a  dangerous  procedure. 

Wieland  states  that  the  use  of  thyroid  extract 
is  not  dangerous  and  that  large  doses  produce  no 
disturbance  in  general  health  of  children.  Pro- 
longed use  of  large  doses  can  produce  headache, 
dizziness,  palpitation,  vomiting  and  other  gastro- 
intestinal disturbances  with  increase  in  pulse  and 
respiratory  rates.  These  symptoms,  however,  dis- 
appear as  soon  as  the  thyroid  administration  is 
discontinued. 

Krogh  and  others  point  out  that  by  administer- 
ing thyroid  in  sufficiently  large  doses  it  is  pxissible, 
in  both  man  and  animals,  to  produce  a  thyrotoxic 
condition,  but  that  the  condition  of  the  individual 
comes  back  to  normal  in  a  few  weeks  after  the  ad- 
ministration of  the  thyroid  substance  is  discon- 
tinued. In  feeding  thyroid  to  guinea  pigs  in  large 
amounts  for  one  week  there  was  considerable  in- 
crease in  metabolism  but  no  change  in  the  thyroid 
gland.     Feeding  large  doses  for  a  period  of  eight 


months  produced  very  slight  changes  in  the  gland. 
In  prescribing  thyroid  extract  it  is  important  to 
remember  that  the  preparation  as  put  out  by  dif- 
ferent manufacturers  varies  considerably  in  calori- 
genic  effect.  For  this  reason  any  one  particular 
product  should  be  specified  in  order  that  the  refills 
will  be  of  the  same  strength.  Original  sealed  pack- 
ages should  be  ordered  as  the  substance  deteriorates 
with  age  due  to  bacterial  decomposition.  Most 
authorities  agree  that  the  use  of  thyroid  extract  is 
preferable  to  thyroxin  in  children. 

The  therapeutic  objective  is  to  relieve  the  child 
from  all  symptoms  with  the  smallest  possible  daily 
dosage  of  the  dried  gland.  Therapeutic  response  is 
usually  very  prompt,  there  being  definite  improve- 
ment within  48  hours.  Failure  of  symptomatic  im- 
provement will  usually  mean  that  the  underlying 
cause  is  not  thyroid  deficiency. 

The  duration  of  the  treatment  necessary  varies 
considerably.  A  small  number  of  these  children 
after  treatment  for  one  to  three  months  seem  to  be 
in  perfect  health  and  apparently  no  longer  need 
thyroid  extract. 

Possible  explanation  of  these  apparent  recoveries 
after  definite  evidence  of  deficiency  is  the  iodine 
content  of  ths  thyroid  extract  and  the  resting  ef- 
fect that  an  additional  supply  of  thyroid  extract 
exerts  on  the  gland  itself. 

Conclusions 
This  series  of  children  with  definite  evidence  of 
mild  hypothyroidism   strongly   suggests    that    this 
condition  is  fairly  common  in  our  locality. 

Treatment  with  small  doses  of  thyroid  is  most 
effective  in  restoring  these  children  to  perfect 
health. 

X  large  percentage  of  these  children  reach  a  state 
of  recovery  making  further  administration  of  thy- 
roid unnecessary. 

A  determination  of  the  value  of  the  cholesterol 
level  in  the  blood,  the  degree  of  excretion  of  uri- 
nary creatine  and  bone-age  studies  in  the  mild  type 
of  hypothyroidism  in  children  should  be  interesting 
in  further  investigating  this  fascinating  subject. 

Supplementary  Notes 
C.4SE  1 — Metabolism  repeated  6  months  ago  was  -|-6.   This 

girl  is  now  symptom-free  and  doing  well  without 

thyroid  extract. 
Case  2 — Has  had  thyroid  irregularly  but  has  been  doing 

very   much   better  than   at   the  time  that   thyroid 

therapy   was   begun.     Metabolism   Oct.   30th,   was 

—16. 
Case  3 — Is  doing  well  on   ]/>   gr.  thyroid  gland  a  day — is 

symptom-free,  doing  excellent  work  in  school  and 

is  happy  and  full  of  energy. 
Case  4 — This  child  is  in  normal  health  but  is  on  thyroid 

regularly   because   of   delay   in   bone   development. 
C.\SE  5 — This    boy    was    on    thyroid    only    three    months. 

Metabolism   rate  on  Oct.   31st  was   -i-6.     He   has 


November,   1P36 


MILD   HYPOTHYROIDISM— Ashe 


S91 


apparently  had  a  complete  recover)-. 
Case  6 — This  child  is  doing  wonderfulh-   well  on   '4   grain 
thyroid  per  day.     She  is  in  better  general  health 
than  at  any  time  of  her  life. 


New  Concepts  in  the  Etiology  .\nd  Tre.atment  of 

Thyroid  Disease 
(J.   E.   Klein,  Chieaso,   in   Arch,  of   Pediatrics,  April) 

Calcium  affects  definitely  and  markedly  the  storage  of 
colloid  in  the  thyroid  gland.  Since  hyperthyroid  states  are 
accompanied  by  a  loss  of  colloid  from  the  gland,  with 
resulting  flooding  of  the  circulation  by  thyroglobulin  and 
increase  of  the  blood  iodine,  the  use  of  a  drug  which  re- 
verses this  toxic  flood  is  logical.  It  is  surprising  that  the 
calcium  supply  in  the  water  and  dietary  has  been  rather 
neglected  from  the  viewpoint  of  thyroid  disease.  The  geo- 
chemistry of  the  water  supply  in  endemic  zones,  partic- 
ularly the  calcium,  should  be  correlated  with  the  iodine 
determinations  in  these  regions.  Detailed  reports  on  any 
spring  or  river  are  available  in  these  studies  by  the  United 
States  Geological  Survey.  The  noteworthy  fact  is  that  in 
the  endemic  goiter  belt  there  is  an  excess  of  calcium  in 
the  water  supply,  a  fact  which  has  been  overlooked,  neg- 
lected or  minimized. 

The  dietary  calcium  intake  has  been  nefilected  as  a  fac- 
tor in  the  etiology  of  goiter.  Many  endemic  goiter  areas 
are  dairy  centers,  with  a  high  dietan.-  content  of  calcium 
due  to  liberal  consumption  of  milk  and  cheese.  In  regions 
near  the  coast  (Holland)  such  a  dietary,  rich  in  calcium, 
with  a  generous  iodine  supply  (sea  food)  affords  the  proper 
conditons  for  the  development  of  colloid  goiter.  Clinicians 
report  a  high  incidence  of  endemic  colloid  goiter  in  those 
regions  near  the  coast.  In  mountainous  regions  of  the 
endemic  zone,  dietar\-  and  water  supplies  rich  in  calcium 
act  in  the  presence  of  iodine  deficiency  to  form  hyperplastic 
goiter.  In  sporadic  cases  of  goiter  in  non-goitrous  regions 
look  into  the  dietary  habits  of  the  individual,  particularly 
as  to  calcium  and  iodine.  The  therapeutic  action  of  cal- 
cium in  hyperthyroidism  is  no  doubt  due  to  this  property 
of  increasing  colloid  storage  in  the  presence  of  an  excess 
of  thyroglobulin.  Similarly,  this  experiment  explains  the 
formation  of  colloid  goiter.  .\n  excess  of  calcium  in  the 
water  or  food,  combined  with  liberal  intake  of  iodine,  pro- 
duces an  exaggerated  storage  of  colloid  in  the  thyroid 
gland. 

The  thyroid  gland  may  be  stimulated  to  increased  activity 
by  any  bacterial  infection  occurring  in  the  body.  Thyro- 
globulin is  a  marked  stimulant  of  lymphocytic  activity. 
In  a  series  of  studies  on  chemotaxis  I  found  that  thyro- 
globulin injection  induced  a  leukocytosis  and  a  relative 
lymphocytosis  in  guinea  pigs. 

Experimental  studies  indicate  that  in  areas  with  a  rich 
calcium  supply  in  the  water  it  is  necessary  to  decalcify 
the  water  in  addition  to  the  usual  iodine  prophylaxis. 
Otherwise  the  tendency  to  colloid  goiter  is  encouraged. 
For  the  prevention  of  hyperplastic  and  exophthalmic  goiter 
it  is  necessary  to  have  a  normal  relation  of  calcium  and 
iodine  as  well  as  a  normally  functioning  sympathetic  nerv- 
»us  system. 

In  the  treatment  of  patients  with  thyroid  disease  we 
must  consider  that  we  are  dealing  with  a  metabolic  dis- 
order, which,  though  it  affects  the  entire  body,  is  mani- 
fested most  prominently  in  the  thyroid  gland. 

A  patient  with  a  colloid  goiter  should  be  given  a  diet 
free  from  calcium  and  iodine  This  would  tend  to  deplete 
the  follicles  of  stored  colloid  by  causing  a  body  hunger  for 
calcium  and  iodine.  In  mild  cases  of  this  type  dietary- 
management  might  be  sufficient  to  stay  the  process  and 
even    cause    a    cure.      Of    course,    extremely    large    colloid 


goiters  are  indications  for  surgery.  Simple  hyperplastic 
goiter  should  logically  be  treated  by  iodine  administration 
combined  with  calcium  therapy.  The  latter  would  tend 
to  encourage  deposition  of  colloid  in  the  depleted  follicles. 

Hyperthyroidism  (including  exophthalmic  goiter)  requires 
correction  of  the  vegetative  nervous  system  as  well  as  con- 
trol of  the  mineral  metabolism.  The  extreme  vascularity 
of  the  gland  in  hyperthyroid  states  should  be  treated  by 
cold  applications.  The  administration  of  calcium  intra- 
muscularly, and  intravenously  in  severe  cases,  may  be  a 
life-saving  measure.  Also  the  accumulating  colloid  distends 
the  follicles  and  constricts  the  intertoUicular  capillaries  thus 
preventing  rapid  absorption  of  the  intoxicating  secretions 
of  the  thyroid  gland. 

In  extreme  cases,  ergotamine  may  also  be  used  since  this 
inhibits  the  sympathetic,  lowers  basal  metabolism  and  en- 
courages colloid  storage.  However,  ergotamine  should  be 
used  cautiously  because  of  the  possibility  of  peripheral 
gangrene.  As  is  well  known,  Lugol's  solution  is  of  great 
value  in  the  preoperative  treatment  of  hyperthyroidism. 

It  is  becoming  more  and  more  apparent  that  thyroid 
disease  is  a  biochemical  disorder  in  which  calcium  and 
iodine  metabolism,  as  well  as  the  function  of  the  vegetative 
nervous  system,  are  the  chief  factors.  Thus  one  may  state 
that  normal  iodine  plus  normal  calcium  metabolism  plus 
a  normal  vegetative  nervous  system  equals  a  normal  thy- 
calcium  excess 

roid   gland.     The   formula =   hyperplasia 

iodine  deficiency 
calcium  excess 

of  the  thyroid;  =   colloid  goiter.     Iodine 

iodine  excess 
deficiency  alone  induces  atrophy  of  the  thyroid  gland  asso- 
ciated with  loss  of  colloid  and  reversion  to  a  fetal  resting 
state.  Overactivity  of  the  sympathetic  nervous  system,  in 
the  presence  of  iodine  deficiency,  causes  hyperplasia,  hy- 
peremia and  hyperthyroidism,  the  extreme  type  of  which  is 
represented  by  exophthalmic  goiter.  Calcium  administra- 
tion may  correct  this.  Likewise,  a  hyperactive  sympathetic 
system  in  the  presence  of  excessive  iodine  and  calcium  in- 
take spells  colloid  goiter. 


Sulphur,  a  Forgotten  Remedy 
(H.  Gates,  Bradenton.  in  Jl.  Fla.    IVIed.   Assn.,   Oct.) 

When  I  was  a  boy  old  people  who  suffered  from  back- 
aches and  sore  joints  took  sulphur  and  whiskey  or  sulphur 
and  cream  of  tartar. 

The  type  of  arthritis  and  neuritis  that  I  wish  to  stress 
in  the  use  of  sulphur  is  the  type  where  there  is  no  rise  of 
temperature  but  a  low-grade  poisoning  which  produces 
pain,  soreness  and  stiffness,  with  tenderness  on  pressure 
when  the  toxins  are  excessive.  There  is  a  muscular  soreness 
on  exertion  which  is  similar  to  that  of  a  man  who  has 
been  inactive  and  then  takes  a  good  deal  of  exercise. 

It  is  probable  that  the  forms  of  arthritis  from  which  I 
have  obtained  the  most  gratifying  results  with  sulphur 
were  those  in  which  the  intestinal  flora  were  modified  in 
the  growth  by  the  presence  of  sulphur. 

When  sulphur  is  lacking  in  the  system  the  hair  is  brittle 
and  has  a  tendency  to  split,  the  epidermis  generally  harsh 
and  dry.  In  these  conditions  I  give  sulphur  in  combination 
with  calcium  gluconate.  Lime  and  sulphur  are  natural 
elements  in  the  nails,  skin  and  hair. 

When  an  old  hen  that  has  arthritis  lays  an  egg,  the  yolk 
is  a  pale  yellow,  and  sometimes  almost  white.  These  eggs 
will  not  hatch.  A  piece  of  silver  dipped  into  the  yolk  will 
not  turn  as  dark  as  in  the  egg  with  a  bright  yolk. 

While  I  have  had  brilliant  results  in  some  cases,  others 
have  been  absolute  failures. 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


The  Injurious  Effect  of  Veronal  and  Related  Drugs  and  a 
Suggestion  for  Their  More  Restricted  Use* 

W.  C.  AsHwoRTH,  M.D.,  Greensboro,  North  Carolina 
Glenwood  Park  Sanitarium 


THE  stress  and  strain  experienced  by  the 
average  American  citizen  incident  to  solv- 
ing the  bread-and-butter  question,  tends 
to  exhaust  the  nervous  system,  and  the  natural 
result  is  in  the  direction  of  a  race  of  neurasthenics. 
The  individual  who  has  an  unstable  nervous  sys- 
tem, whether  acquired  or  inherited,  is  apt  to  be- 
come addicted  to  some  drug  which  will  obtund  his 
sensibilities  and  give  him  respite  from  the  exigen- 
cies of  life. 

The  habit-forming  drugs,  with  the  exception  of 
opiates,  can,  unfortunately,  be  obtained  promiscu- 
ously by  the  public,  and  the  deleterious  effects  are 
ofttimes  not  noticeable  until  addiction  is  fully 
established.  It  is  natural  for  most  of  us  to  en- 
deavor to  find  an  exit  of  escape  from  our  troubles. 
It  is  with  few  of  us  that  life  flows  on  like  a  song; 
not  many  tread  paths  strewn  with  roses.  For  most 
of  us  life  means  a  continual  struggle,  and  the  sur- 
vival of  the  strongest  is  the  rule.  Our  effort,  there- 
fore, to  escape  the  hard  things  of  life  is  a  form  of 
cowardice,  whether  such  escape  be  by  the  use  of 
alcohol  or  other  narcotic  drug,  by  simulation  of 
disease,  by  amnesia  or  otherwise. 

The  neurasthenic  especially  is  prone  to  be  on 
the  alert  for  some  drug  or  stimulant  which  will 
sedate  his  troubled  nervous  system  and  give  him 
oblivion  from  his  mental  and  physical  suffering. 
The  use  of  hypnotic  drugs  is,  therefore,  becoming 
more  common  and  the  results  more  appalling. 

We  must  reckon  with  the  craving  of  the  human 
soul  for  congenial  comradeship.  The  more  we  lack 
strength,  the  greater  our  fear  and  the  more  ready 
we  are  to  attempt,  by  any  means,  to  escape  our 
inefficiency.  The  fear  of  the  painful  and  the  dis- 
agreeable and  the  yearning  for  escape  or  ready  help 
when  unpleasant  things  make  up  most  of  life  cause 
us  to  search  more  diligently  for  nepenthe.  The 
habitues  differ  and  their  environments  differ;  and 
temperament  and  environment  determine  for  each 
individual  his  form  of  habituation.  One  without 
fortitude  to  suffer  pain  or  without  health  to  enjoy 
that  which  appeals  to  and  satisfies  the  strong  seeks 
his  solace  in  some  drug.  So,  the  soul  weary  of  the 
day's  toil,  the  depressed  in  spirit,  the  disappointed, 
seek  victory  or  solace  in  some  drug  which  will 
bring  oblivion.  The  will  of  the  average  psychas- 
thenic, with  all  his  conflicting  emotions,  ofttimes 


forbids  the  use  of  a  patent  nostrum,  narcotic  drug 
or  alcoholic  drink,  but  is  satisfied  with  some  simple 
religious  faith,  strong  ideal  or  sweet  soothing  in- 
fluence which  may  fill  the  measure  of  his  needs. 
The  love  of  woman  may  restrain  a  man  from  seda- 
tives and  hypnotic  drugs: 

"No,  Saki — take  the  wine  away ! 

I  have  no  need  of  it  today; 

So  drunk  am  I  with  adoration. 

No  longer  have  I  any  need 

Of  commonplace  intoxication ! 

How  should  a  man  whose  eyes  may  drink 

Her  beauty,  like  the  Northern  Star, 

In  a  delicious  meditation. 

Remain  contented  any  more 

With  common  wine  out  of  a  jar? 

No,  Saki — take  the  wine  away." 
But  the  underlying  factors  are  the  same  in  every 
case;  and  the  addiction,  whatever  the  form  of  it, 
began  in  response  to  a  sense  of  need.  The  addic- 
tion grows  with  repeated  effort  to  escape  the  dis- 
agreeable, to  find  a  ready  satisfying  of  your  hun- 
ger, your  feeling  of  inefficiency  and  your  fear.  The 
discontent  is  constantly  recurring  and  the  habitue 
is  bound  by  an  intolerable  craving.  The  desire  for 
solace  and  oblivion  is  imperious,  and  the  habit  has 
become  the  veritable  controlling  part  of  him. 

I  wish  especially  to  call  attention  to  the  pro- 
nounced mental  symptoms  following  in  the  wake  of 
the  continuous  use  of  veronal  and  the  derivatives 
of  barbituric  acid.  I  am  confident  that  members 
of  this  Society  who  have  observed  these  effects  will 
be  in  full  agreement  with  me,  that  the  continuous 
use  of  veronal  is  a  constant  menace  to  the  public. 
Every  practitioner  of  medicine  should  be  kept  fa- 
miliarized with  the  baneful  mental  effects  of  hyp>- 
notic  drugs.  It  is  certainly  unfortunate  that  vero- 
nal and  its  derivatives  can  be  purchased  indiscrim- 
inately in  many  States  of  this  country.  We  all  rec- 
ognize that  morphine  and  its  derivatives  are  habit- 
forming  and  that  the  effect  of  these  drugs  is  subtle 
and  insidious;  so  we  are  usually  on  the  alert  when 
prescribing  opiates,  especially  to  a  neuropathic 
person  or  one  suffering  from  some  chronic,  painful 
disease.  The  transition  from  the  use  of  opium 
derivatives  or  whiskey  to  hypnotic  drugs  is  very 
easy.  We  are  becoming  conversant  with  the  effects 
of  veronal  and  similar  hypnotics  following  the  dis- 
continuation of  morphine  and  alcohol.  The  mental 
inertia  plus  the  disturbance  of  muscular  coordina- 


*Presented  to  the  Guilford  County  Medical  Society,  meeting  at  Greensboro,  October  1st. 


November,  1936 


HYPNOTICS— Ash-ji<orth 


tion  stamps  the  veronal  user  as  a  person  suffering 
from  a  gravely  toxic  drug.  The  writer  has  many 
times  had  difficulty  in  differentiating  chronic  vero- 
nal poisoning  from  organic  diseases  of  the  nervous 
system.  The  symptoms  of  chronic  veronal  poison- 
ing are  often  so  protean  that  any  physician  not 
on  the  qui  vivc  may  be  seriously  misled.  The  dele- 
terious effects  of  the  continued  use  of  veronal, 
therefore,  are  so  obvious  as  to  convince  doctors 
and  druggists  who  have  an  opportunity  to  observe 
these  effects  that  the  drug  should  not  be  purchas- 
able by  any  one  not  under  the  immediate  observa- 
tion of  a  physician.  A  large  percentage  of  mental 
disorders  and  much  mental  deterioration  can  be 
traced  directly  to  the  drug.  The  semioblivion 
symptomatic  of  the  continuous  use  of  the  drug  is 
destructive  to  moral  and  physical  efficiency,  and 
obtunding  the  higher  sensibilities  makes  a  potential 
criminal. 

I  feel  that  we  can  obtain  the  cooperation  of  any 
druggist,  once  he  is  fully  informed  of  the  habit- 
forming  tendencies  of  veronal  and  similar  hypnot- 
ics. Druggists  are  in  accord  with  the  medical  pro- 
fession, that  legislative  restrictive  measures  should 
be  inaugurated  to  prevent  the  indiscriminate  sale 
of  harmful  drugs. 

As  to  the  therapeutic  effect  of  the  drug,  1  fre- 
quently notice  a  hang-over  from  a  10-gram  medi- 
cinal dose  of  veronal.  The  pronounced  toxic  effect 
should  constitute  a  danger  signal,  .^ny  drug  or 
drugs  with  a  predilection  for  the  higher  brain  cen- 
ters are  dangerous  and  should  be  given  with  every 
precaution,  since  the  baneful  effects  are  inescepa- 
ble,  and  result  in  the  mental  and  physical  undoing 
of  the  user.  I  have  observed  that  its  toxic  activity 
depends,  to  a  large  extent,  on  the  character  of  the 
drug  with  which  the  acid  combines.  It  seems  prob- 
able, however,  that  the  relative  toxicity  depends 
on  certain  physical  features  which  determine  the 
amount  absorbed  by  the  central  nervous  system. 
Toxic  action  appears  to  be  mainly  the  intensifica- 
tion of  the  depression  of  the  central  nervous  sys- 
tem, which,  in  therapeutic  doses,  produces  nearly 
normal  sleep.  The  toxicity  and  the  hypnotic  ac- 
tivity of  veronal  must  be  closely  parallel. 

Eddy,  of  Cornell,  gave  equal  fractions  of  fatal 
doses  of  veronal  to  cats,  and  compared  the  effects 
with  reference  to  posture,  sleep,  heart  and  respira- 
tion rate,  analgesia,  rectal  temperature,  conjunc- 
tival reflex,  knee  jerk,  and  other  particulars,  in 
which  he  recorded  more  than  11,000  observations. 
The  doses  administered  varied  from  20  to  60  per 
cent,  of  the  average  fatal  dose.  He  found  that 
none  of  the  compounds  was  much  more  actively 
hypnotic  in  proportion  to  toxicity  than  veronal. 
The  interference  with  metabolism  as  shown  by  the 
fall  in  temperature  is  accepted  as  an  index  of  the 


toxicity  of  sublethal  doses.  None  is  relatively  more 
toxic  than  veronal.  We  are  not,  therefore,  sur- 
prised at  the  appalling  death  rate  from  accidental 
overdoses  of  the  drug.  It  is  difficult  to  interpret 
accurately  the  lethal  effects  of  veronal  on  the  res- 
piratory organs.  Hypnotic  drugs  are  legion  and 
the  conscientious  physician  prescribes  them  with 
fear  and  trepidation.  An  article  in  the  British 
Medical  Journal  of  IVIay  22nd  tells  us  that  regula- 
tions covering  the  manufacture,  sale  and  profes- 
sional use  of  veronal  are  to  be  extended  and  made 
applicable  also  to  the  derivatives  of  barbituric 
acid.  ^lost  nations  of  the  world  require  a  pre- 
scription for  the  purchase  of  veronal.  Such  reg- 
ulations in  Great  Britain  resulted  largely  from  an 
inquiry  into  the  prevalence  of  addictions  by  a  de- 
partment committee,  and  a  general  agitation  against 
the  indiscriminate  sale  of  veronal  and  similar  drugs. 
It  is  interesting  to  note  the  restrictions: 

1.  To  a  duly  qualified  practitioner  only. 

2.  For  use  in  hospitals  and  other  similar  public 
institutions. 

3.  To  persons  authorized  by  the  Secretary  of 
State. 

4.  On  or  in  accordance  with  prescriptions  given 
by  a  duly  qualified  practitioner. 

The  prescription  for  veronal  and  its  derivatives 
must  be  dated  and  signed  by  the  physician,  and 
bear  his  address;  and  must  show  the  name  and  ad- 
dress of  the  patient  for  whom  the  drug  is  prescrib- 
ed. V^eronal  can  not  be  supplied  more  than  once 
on  the  same  prescription,  except  that  the  prescrib- 
ing physician  may,  on  one  prescription,  direct  that 
the  drug  be  supplied  not  more  than  three  times. 
Physicians  must  keep  a  record  of  all  they  dispense. 
For  the  promulgation  of  regulations  restricting 
such  sales  the  home  office  experts  show  copious 
evidence  of  deaths  caused  by  veronal,  sometimes 
suicidal,  but  perhaps  more  frequently  from  acci- 
dental overdoses  taken  for  sleeplessness. 

In  view  of  the  observation,  in  London,  of  the 
devastating  effects  of  these  hypnotic  drugs,  it  is 
to  be  hoped  that  we  will,  in  this  country,  enact 
similar  regulations,  and  such  measures  will  be  ta- 
ken to  obviate  the  danger  arising  to  the  public 
from  the  unrestricted  sale  of  veronal  and  allied 
drugs. 

The  following  cases  will  emphasize  the  deleteri- 
ous effects  of  veronal,  also  the  difficulty  of  differ- 
entiating between  veronal  poisoning  and  organic 
disease  of  the  nervous  system,  especially  locomotor 
ataxia. 

Case  1. — .An  unmarried  lady,  at;ed  2S,  with  no  history 
of  previous  diseases  except  those  incident  to  childhood,  en- 
tered our  institution  on  May  1st,  1027,  for  treatment  lor 
what  appeared  to  be  a  rather  obscure  and  comple.x  disease 
of  the  nervous  system.  In  obtaininc  a  history,  she  was 
questioned  very  closely,  especially  in  regard  to  the  use  of 


594 


MILD   HYPOTHYROIDISM— Ashe 


November.   lO.fb 


habit-forming  drugs,  but  she  emphatically  denied  any 
drug  addiction.  On  neurological  examination,  however,  she 
presented  all  the  classical  symptoms  of  locomotor  ataxia 
with  the  exception  possibly  of  the  Argyll  Robertson  pupil. 
She  had  no  knee-jerks,  her  body  swayed  in  various  direc- 
tions when  she  stood  erect  with  feet  close  together  and 
eyes  closed ;  and  she  was  unable  to  walk  along  the  floor 
on  a  straight  line.  It  was  especially  interesting  that  when 
a  spinal  puncture  was  advised  the  patient  became  highly 
emotional,  and  insisted  very  vigorously  that  she  did  not 
wish  it  done.  Then  the  patient  commenced  to  cry,  and 
confessed  that  she  had  been  taking  veronal  daily  for  the 
past  six  months,  and  an  occasional  dose  for  some  months 
prior  to  that  time. 

Case  2. — A  professional  man  of  40  years  came  to  us 
September  17th,  1028,  for  the  purpose  of  receiving  treat- 
ment for  veronal  poisoning.  For  the  past  four  years  he 
had  been  taking  from  four  to  six  5-grain  tablets  of  veronal 
daily  for  the  relief  of  nervousness  and  insomnia.  He  had 
lost  15  pounds  in  weight  in  the  last  six  months  and  his 
mentality  was  much  impaired.  He  realized,  however,  that 
his  business  was  in  a  deplorable  condition  and  that  this 
was  probably  due  to  addiction  to  veronal,  and  that  he  was 
incapable  of  doing  any  consecutive  thinking  or  construc- 
tive work  of  any  sort.  .\  few  years  before  this  man  had 
been  a  very  astute  and  prosperous  lawyer. 

The  two  cases  cited  are  striking  examples  of  the 
mental  deterioration  resulting  from  the  continuous 
use  of  veronal.  I  could  describe  cases  ad  libitum 
of  a  similar  nature,  but  the  results  of  veronal  in 
different  cases  are  so  palpably  alike  that  a  recitation 
of  other  cases  would  be  largely  repetition. 

There  is  not  time  sufficient  for  discussing  the 
effects  of  chloral  and  various  proprietary  prepara- 
tions containing  chloral,  as  revealed  in  the  cases 
of  sufferers  from  chronic  chloral  pwisoning  who  have 
come  under  my  care.  I  hope  that  at  some  future 
meeting  I  will  have  time  to  consider  chloral  and 
other  hypnotic  drugs,  the  sale  of  which  should  be 
regulated  and  controlled. 

We  all  recognize  that  hypnotic  drugs  are  neces- 
sary, that  insomnia  is  a  symptom  of  many  diseases 
which  it  is  difficult  to  combat,  and  that  a  hypnotic 
drug  is  often  a  solace  to  the  nervous  system.     We 
must  also  realize  the  danger   of  prescribing  hyp- 
notic drugs,  and  that  sleeplessness  may  generally  be 
overcome  in  some  other  and  better  way. 
A  wise  and  waggish  rhymester  has  written: 
"God  bless  the  man  who  first  invented  sleep! 
So  Sancho  Panza  said  and  so  say  I ; 
.\r\A  bless  him,  also,  that  he  didn't  keep 
His  great  discovery  to  himself,  nor  try 
To  make  it — as  the  lucky  fellow  might — 
A  close  monopoly  by  patent-right." 

StTMMARY 

1.  Veronal  is  a  habit-forming  drug  and  should 
be  sold  only  in  compliance  with  the  regulations  re- 
quired for  obtaining  narcotic  drugs. 

2.  The  continuous  taking  of  veronal  produces 
marked  deterioration  of  the  mentality. 

3.  Veronal  has  a  predilection  for  the  higher 
nerve  and  brain  centers. 


4.  Legislation  should  be  enacted  for  restricting 
and  controlling  the  sale  of  veronal,  and  most  of  the 
derivatives  of  barbituric  acid. 

If  I  have  succeeded  in  awakening  an  apprehen- 
sion of  the  danger  of  veronal,  especially  to  the  hy- 
persensitive and  neuropathic  patient,  I  shall  feel 
amply  repaid. 


The  Use  of  Hypnotics 
(G.  P.  Grabfield,  Boston,  in  Jl.  A.  M.  A.,  Oct.  24th) 
Paraldehyde  and  chloral  have  stood  the  test  of  time. 
The  disadvantage  of  paraldehyde  is  its  odor  on  the  breath 
the  following  day ;  this  is  often  more  than  compensated 
by  its  efficacy  and  practical  absence  of  toxicity.  It  must 
be  remembered,  however,  that  the  combined  use  of  mor- 
phine and  paraldehyde  is  highly  toxic.  Chloral  is  undoubt- 
edly the  most  useful  of  all  the  hypnotics  and  the  cheap- 
est. Given  well  diluted  in  water  it  produces  sleep  within 
an  hour,  and  in  proper  doses  (S  to  10  grains)  is  entirely 
harmless  even  in  heart  disease.  It  is  not  the  hypnotic  of 
choice  in  heart  disease,  though  it  may  be  used  if  the 
barbitals  and  paraldehyde  are  contraindicated.  For  quick 
action  of  short  duration  pentobarbital  1  to  2  grains  has 
proved  very  useful. 

Barbital  itself  is  still  probably  the  most  satisfactory  drug 
when  more  prolonged  and  less  prompt  action  is  desired. 
If  more  than  10  grains  of  barbital  is  found  necessary  to 
produce  the  effect  desired,  another  drug  should  be  used. 
Sulfonethylmethane  has  fallen  into  disuse  on  account  of 
the  long  period  before  it  acts  and  because  of  its  prolonged 
stay  in  the  body.  However,  these  very  qualities  can  be 
utilized  in  selected  cases.  It  is  usually  effective  from  5  to 
7  hours  after  administration ;  it  may  leave  a  certain  amount 
of  drowsiness  the  next  day.  Repetition  over  a  compara- 
tively short  period,  even  in  ordinary  doses,  is  said  to  lead 
to  liver  damage.  The  combination  of  barbital  with  sul- 
fonethylmethane given  an  hour  or  two  before  bedtime  may 
prove  more  satisfactory  than  double  the  dose  of  barbital 
for  producing  a  deep  sleep  throughout  the  night. 

The  physician  does  well  to  learn  thoroughly  all  the  pos- 
sibilities of  a  few  drugs  before  adding  to  his  armamenta- 
rium many  substances  hastily  introduced  and  inadequately 
tested. 


I 


The  Care  of  Hypodermic  Needles 


The  paraphernalia  necessary:  1)  Three  different  grades 
of  hones.  A. — One  carborundum  hone.  No.  124.  B. — One 
stone  hone.  C. — One  composition  compressed  hone.  2) 
One  tuberculin  syringe.  3)  One  can  3-in-l  oil.  4. — Two 
or  three  different  sizes  of  jeweler's  cutting  broaches,  ob- 
tained from  any  jeweler — the  5-sided  broach  for  opening 
up  occluded  needles,  filing  the  ragged  edges  of  the  bevel 
and  for  polishing  the  barrel  of  the  needle  on  the  inside, 
from  the  shoulder  to  the  point. 

A  smooth  and  sharp-cutting  needle  gives  but  little  pain 
when  used. 

The  psychologic  impression  made  upon  the  patient  by 
the  use  of  a  good,  sharp  needle  is  all  in  favor  of  the  phy- 
sician. 


In  a  patient  (pernicious  anemia)  seen  in  Montreal 
the  fatal  termination  occurred  within  ten  days  of  the  onset 
of  the  symptoms. — Osier, 


SvFFERERS  FROM  TRIGEMINAL  NEURALGIA  are  not  a  gabby 
lot.  They  will  stop  in  the  middle  of  a  word  when  a  pain 
comes  on. 


November,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


An  Analysis  or  Seventy  Cases  of  Acute  Intestinal  Obstruction 

Edgar  Angel,  i\I.D.,  and  Alexander  Kizinski,  M.D.,  Franklin,  North  Carolina 

Angel  Hospital 


IX  the  past  five  years  2600  abdominal  sections 
have  been  done  in  the  Angel  Hospital  and 
acute  intestinal  obstruction  has  been  encoun- 
tered 70  times,  a  proportion  of  one  to  40.  This 
study  will  deal  mostly  with  the  etiology  and  the 
management  at  the  time  of  operation. 

Etiology 
The  most  frequent  cause  of  intestinal  obstruc- 
tion is  that  produced  by  an  adhesion  or  peritoneal 
band  resulting  from  a  previous  peritonitis,  a  surgical 
operation  in  the  peritoneal  cavity,  or  an  abdom- 
inal injury.  Also,  bands  may  be  congenital  ano- 
malies. These  bands  may  angulate  or  twist  the 
intestine,  they  may  stretch  from  one  point  to  an- 
other, they  may  bind  coils  of  intestine  to  each 
other,  or  they  may  even  form  pockets  into  which 
the  intestine  is  carried  by  peristaltic  action.  The 
small  intestine  is  the  part  usually  affected:  the 
terminal  ileum  was  the  site  in  far  the  majority 
of  cases  in  this  series.  Obviously  this  is  because 
of  the  frequency  of  operation  around  the  ileocecal 
valve  and  because  of  the  nearness  of  the  fallopian 
tube.  Twenty-two  cases  were  due  to  adhesions, 
all  of  which  involved  the  terminal  ileum,  the  cecum 
or  the  ascending  colon.  In  any  patient  who  has 
colicky  pain  and  tenderness,  obstruction  should  be 
thought  of,  though  there  be  no  distention  or  change 
in  bowel  action. 

Volvulus  was  the  second  most  common  causative 
factor,  accounting  for  13  cases — eight  of  the  sig- 
moid colon;  one  each  of  the  transverse  colon,  the 
cecum  and  ileum  combined,  and  three  of  the  small 
intestine.  Two  of  the  sigmoid  variety  recurred 
three  times  each.  One  obstruction  was  due  to  a 
large  number  of  round-worms  in  the  terminal  ileum. 
X-ray  diagnosis  cannot  be  relied  upon  in  the  diag- 
nosis of  this  condition  as  is  shown  in  Fig.  1  where 
the  barium  passed  far  above  the  twisted  segment. 
At  operation  a  2  70  clockwise  twist  was  found  in 
the  sigmoid  colon. 

Strangulated  hernia  was  ne.xt  in  frequency  with 
15 — femoral,  inguinal,  ventral  and  incisional  all 
being  encountered.  The  small  intestine  was  strang- 
ulated in  all  e.xcept  two  cases  in  which  there  was 
a  sliding  hernia  of  the  colon:  one  of  these  was 
associated  with  a  ruptured  appendix  and  in  the 
other  the  colon  was  ruptured  by  forcible  taxis. 

-Meckel's  diverticulum  produced  obstruction  in 
three  cases.    In  one  it  was  adherent  to  the  abdom- 


inal wall  above  the  umbilicus  and  from  this  attach- 
ment a  fibrous  band  extended  down  to  be  attached 
to  the  mesentery  and  in  doing  so  constricted  a 
loop  of  ileum  ( Fig.  2 ) :  in  another  it  was  attached 
to  the  abdominal  wall  and  produced  a  kink  in  the 
intestine  (Fig.  3):  the  third  case  produced  obstruc- 
tion in  the  same  fashion  as  the  first  except  that  the 
apex  was  attached  to  the  omentum  (Fig.  3). 

Mesenteric  thrombosis,  considered  a  rare  and 
certainly  one  of  the  most  serious  of  all  abdominal 
disorders,  was  encountered  three  times.  The  ages 
of  the  patients  were  two  and  one-half,  36,  and  42 
years.  In  one  case  there  was  associated  car- 
diovascular disease:  another  occurred  secondary  to 
an  operation  for  retroperitoneal  cyst  and  was  diag- 
nosed at  autopsy,  and  the  third,  that  of  a  child 
aged  two-and-one-half  years,  was  without  apparent 
cause. 

Paralytic  ileus,  with  three  occurrenc€s  and  an 
equal  number  of  deaths,  was  the  next  in  frequency. 
All  followed  some  operative  procedure — cesarean 
section,  Porro  hysterectomy,  and  nephrostomy. 

-Although  patients  with  tumor  of  the  intestine 
are  rarely  admitted  to  the  hospital  until  chronic 
obstruction  develops,  (occasionally  an  acute  ob- 
struction first  calls  attention  to  the  existence  of 
the  tumor.  The  descending  and  the  ascending 
colon  were  both  found  to  be  the  site  of  acute  ob- 
struction— a  carcinoma  twice  in  each  location. 

One  intussusception  of  the  ileocecal  variety  was 
seen  in  a  child  six  years  old  whose  bowel  had  been 
completely  obstructed  for  two  days,  during  which 
time  he  had  received  many  purgatives.  Figure  4 
shows  the  ileum  invaginated  into  the  cecum  with 
the  ileum  greatly  distended,  and  under  great  ten- 
sion. It  also  demonstrates  the  ileum  constricted 
by  the  ileocecal  valve. 

Stenosis  of  the  small  intestine  probably  has  its 
origin  in  an  ulceration — stercoraceous,  syphilitic, 
tuberculous,  or  typhoid.  Two  cases  were  operated 
on  in  this  series  neither  of  which  could  be  definitely 
placed  in  either  of  these  classes.  One  patient  who 
used  alcohol  excessively  was  found  at  operation  to 
have  eight  inches  of  intestine  reduced  practically 
to  scar  tissue,  the  lumen  of  the  intestine  being  ob- 
literated. Resection  with  end-to-end  anastomosis 
was  carried  out  with  recovery. 

.Although  ascaris  infestation  is  widespread  in  the 
South,  intestinal  obstruction  by  this  typ>e  of  for- 
eign body  is  quite  rare.     However,  at  operation  in 


L\TESTIXAL   OBSTRUCTION— Angel  &  Kizinski 


Xovember,   1936 


FiG-    1 — Barium    enema   going   well   past   the   twist   in   a    volvulus  of  the  sigmoid  colon.     At  operation  270°  clockwise 
twist  found. 


a  boy  of  19  the  terminal  ileum  was  found  com- 
pletely blocked  by  a  large  mass  of  worms  (Fig.  2). 
This  mass  was  broken  up  and  the  worms  milked 
into  the  cecum.  General  peritonitis  was  present 
but  no  perforation  could  be  found.  Death  occurred 
19  days  following  operation  from  this  cause. 

Although  the  urachus  runs  between  the  trans- 
versalis  and  the  peritoneum  from  the  summit  of 
the  bladder  to  the  umbilicus,  in  one  case  it  was 
found  as  a  fibrous  band  running  between  these 
structures  and  over  it  was  looped  the  lower  ileum 
with  complete  obstruction.  The  patient,  a  boy  five 
years  old,  had  received  ref>eated  purgatives,  and 
death  followed  the  operation.  Enterostomy  was 
performed  two  days  before  death  without  benefit. 
Treatment 

.^siDE  from  the  efforts  at  combatting  dehydra- 
tion and  loss  of  chlorides  in  these  cases,  the  oper- 
ation  within   itself   offers   innumerable   difficulties. 


Whether  the  bowel  shall  be  simply  emptied  by  an 
enterostomy  or  cecostomy,  or  whether,  in  addition, 
relief  of  the  obstruction  and  restoration  of  the 
lumen  of  the  bowel  shall  be  carried  out,  depends 
on  the  condition  of  the  patient  and  the  difficulty 
which  will  accompany  these  procedures.  In  dealing 
with  peritoneal  bands  and  adhesions  there  is  no 
alternative:  they  must  be  divided.  However,  this 
can  be,  and  often  is,  advantageously  combined  with 
enterostomy  whether  this  be  in  the  jejunum  or  the 
ileum.  Enterostomy  was  done  five  times  in  22 
cases  with  adhesions  and  there  were  five  deaths  in 
the  entire  series. 

In  13  cases  of  volvulus  detortion  was  carried 
out  12  times,  three  were  fixed  to  the  abdominal 
wall  and  in  another  Mikulicz  resection  was  per- 
formed. Detortion  with  enterotomy  and  removal 
of  SO  round-worms  was  carried  out  with  recovery 
in  one  case.     There  were  two  deaths  in  the  series. 


November.   \0i6 


IXTESTINAL   OBSTRUCTION— Angd  &■  Kizinski 


S97 


Hound  Worms 


Mess  of  round  worms 
producln'  obstruction 


Diverticulum  iri  th  flbruus 
band  runnlna  Trom  attach- 
ment to  a&doininal  wall 
above  umbilicus  around 
diverticulum  to  mesentery 

Figure  2 


Fixation  is  impracticable,  especially  in  sigmoid 
magacolon  where  the  bowel  may  be  tremendously 
enlarged.  Fig.  5  shows  a  megacolon  with  a  diam- 
eter of  12  inches.  Sutures  in  such  an  intestinal 
wall  even  after  the  bowel  is  deflated  will  probably 
lie  pulled  out  when  the  bowel  again  becomes  in- 


omentorn 


cuel's  diverticulum 
;  -Juclni"  obstruction 
oy  fibrous  Band  extend 
ins  from  tl?  of  diver- 
ticulum to  nesentery 


Diverticulum  producing 
obstruction  by  kinking 
terminal   Ileum 


flated.  We  believe  the  ^Mikulicz  procedure  to  be 
far  the  most  expeditous  and  successful  in  this  con- 
dition, in  spite  of  the  fact  that  the  hospital  stay 
is  lengthened  considerably.     Two  of  the  cases  in 


which  the  bowel  was  fixed  to  the  abdominal  wall 
recurred  and  the  third  has  not  had  sufficient  time 
to  ascertain  whether  the  fixation  will  maintain  the 
bowel  in  a  satisfactory  position. 

In  cases  of  strangulated  hernia,  simple  release 
was  the  only  procedure  necessary  except  for  one 
case  in  which  colostomy  was  also  performed  be- 
cause a  sliding  hernia  of  the  colon  was  encountered 
which  was  adherent  in  the  sac  and  a  tube  was 
inserted  into  the  bowel  through  the  sac  without 
any  attempt  at  further  repair  of  the  hernia.  This 
case  was  further  complicated  by  ruptur^;  of  the 
appendix.  Repair  of  the  colostomy  opening  and 
the  hernia  were  carried  out  at  a  later  date. 

The  exteriorization  procedure  of  Mikulicz  was 
used  in  two  of  the  three  cases  of  mesenteric  throm- 
bosis— one  with  recovery.  In  the  oiher  death  oc- 
curred before  operation.  In  the  survivor  a  subse- 
quent side-to-side  anastomosis  and  closure  of  the 
ileostomy  was  performed  and  shortly  afterward  he 
swallowed  a  penny  which  has  since  remained  in  the 
region  of  the  original  operation,  evidently  in  one 
of  the  blind  ends  attached  to  the  abdominal  wall. 

Cecostomy  and  the  Mikulicz  technique  were 
used  in  the  four  cases  of  carcinoma  of  the  colon. 

The  ileocecal  intussusception  was  reduced  and 
the  ileum  sutured  to  the  head  r,i  the  cecum  (Fig. 
6). 

For  stenosis  of  the  small  intestine  a  longitudinal 
division  of  the  stenosis  with  a  transverse  closure 
was  used  in  one  case  and  a  resection  with  an  end- 
to-end  anastomosis  in  another. 

Enterostomy  in  one,  and  conservative  treatment 
— the  continuous  use  of  a  Rehfuss  tube  in  the 
duodenum  with  decompression — were  used  in  the 
three  cases  of  paralytic  ileus  but  death  followed  in 
all. 

Fifty  round-worms  were  removed  through  two 
incisions  in  the  ileum  and  with  immediate  closure 


'    T 


Figure  4 


INTESTINAL   OBSTRUCTION— Angd  &  Khinski 


November,   193b 


TABLE  ILLUSTRATING  FACTORS  INVOLVED  IN   70   CASES   OF   ACUTE   INTESTINAL    OBSTRUCTION. 


Hernia 


Meckel's  diverticulum 


Mesenteric  thrombosis 


Carcinoma 


Paralytic  ileus 


Intussusception 


Stenosis 


Foreign  bodies   (Ascarides), 


Urachus  (persistent) 


Total 


1  c  c  c  o  e 
o  _o  cs  o  m  o 

2  o  -'"  o  5  o 
■<  on  o  Q  3 


21 

3 

1 

3 

1 

1   8 

14 

1 

3 

2 

2 

3 

1 

2 

1 

1 

S 

5 

4 

4 

4 

^ 

3 

4 

2 

2 

6 

5 

4 

1 

1 

1           1 

3 

2 

1 

1 

3 

2   1 

1 

1   1 

1 

1 

22 

17 

S 

22 

13 

11 

2 

15 

15 

12 

3 

20 

2 

2 

3 

1 

2 

66 

3 

1 

2 

66 

4 

3 

1 

25 

3 

3 

100 

1 

1 

100 

2 

1 

1 

SO 

1       1   100 

1       1   100 

«« 

H 

a 

H 

^ 

U. 

Z 

e; 

22 

5 

11 

1 

3 

1 

3 

1 

1 

14       1    1 

2 

1 

2 

2          1 

3 

1 

1 

1 

1 

1          1 

1 

1 

1      14       5       4       4       4 


Intussusception  (lleo-ceool) 
before  reduction 


"K::^ 


Lissusceptlon  after 
reduction  and  fixation 
of  ileum  to  cecum 


in  the  case  of  volvulus  due  to  this  foreign   body 
with  recovery  (Fig.  7). 

A  fibrous  band  representing  a  persistent  urachus 
and  causing  obstruction  was  severed  but  death  fol- 
lowed eight  days  later  from  general  peritonitis. 


Routnd  Vicrr^i 


,'  Urinaru  b/aciJer 


Volvulus  of 
lleuiii,.prC'duced  by   round 
norms 


Obstruction  produced   by 
persistent  remnant  of 
urachus 


Figure  7 


Conclusions 

Seventy  cases  of  acute  intestinal  obstruction  en- 
countered in  2600  abdominal  sections  are  reported. 

The  mortality  for  the  series  was  31%. 

The  etiology  and  treatment  are  discussed. 

A  statistical  table  showing  the  various  factors 
involved  is  presented. 


F.-\R-.\DV.\NCED  Cervix  C.\ncer  .\t  21.    Body  Cancer  Likely 
TO  Complicate  Fibroids 
(M.    F.    Ridlon,   Bangor,   in    Maine    Med.    Jl.,   Oct.) 
I    have    under    treatment    an    unmarried    woman    oj    21 
years   with  a  far-advanced  cancer  of  the  cervix.     Cancer 
of  the  fundus  occurs  as  a  rule  definitely  past  the  meno- 
pause, and  one  of  the  pitfalls  of  diagnosis  is  the  associa- 
tion of  fibroids  with  the  disease. 


Influenza  and  the  Common  Cold 
(R.    L.  Cecil,  New  York  City,  in  Northwest   Med.,  Oct.) 

It  is  difficult  to  draw  a  sharp  line  between  the  common 
cold  and  so-called  grippe.  By  grippe,  however,  doctors 
and  laymen  both  think  of  a  cold  with  fever,  malaise  and 
headache.  Influenza  represents  the  third  degree  of  severity 
accompanied  by  chilly  sensations,  fever,  sometimes  quite 
high,  extreme  prostration   and  leukopenia. 

-Ml  evidence  points  to  the  fact  that  the  common  cold 
and  influenza  are  initiated  by  a  filterable  virus  but  that 
■mosi  of  the  toxemia,  discomfort  and  complications  are 
caused  by  the  invasion  of  secondary  pathogenic  bacteria 
f-uch  as  the  pneumococcus,  streptococcus,  staphylococcus 
and  influenza  bacillus.  Evidence  is  already  at  hand  that 
immunization  against  the  influenza  virus  is  feasible  and 
effective.  It  seems  quite  likely  that  within  the  next  few 
yLars  seme  sort  of  combination  vaccine,  containing  both 
virus  and  pathogenic  bacteria,  will  be  available  for  pro- 
phylactic purposes  and  that  by  the  use  of  such  a  vaccine 
an  active  immunity  against  upper  respiratory  infections 
will  be  achieved. 


I 


November,   10.^6 


SOUTHERN  MEDICINE  AND  SURGERY 


Case  Report 


A  Case  of  Idiopathic  Epilepsy  Treated  by  the 
Usual  Course  of  Antirabic  Vaccine 

Orpheus  E.  Wright,  M.D.,  Winston-Salem,  N.  C. 
Submitted  for  publication   October  13th.    1936. 

An  unmarried  man,  aged  35,  giving  history  of 
true  epileptic  attacks  since  puberty  at  age  13, 
seemed  when  first  seen  in  1928  to  be  in  a  constant 
daze — possibly  as  the  result  of  his  then  monthly 
seizures,  or  probably  as  the  result  of  the  cumula- 
tive effect  of  advertised  cures.  Living  directly 
across  the  street  from  my  office,  I  had  the  oppor- 
tunity of  observing  him  a  great  deal,  as  well  as  to 
minister  to  him  during  the  seizures. 

His  only  sister  had  two  attacks  of  petit  mat  at 
ages  13  and  14  years.  She  is  now  apparently  nor- 
mal at  age  25,  married  with  no  children.  The  one 
brother,  a  West  Point  graduate,  is  a  perfect  speci- 
men of  manhood  both  mentally  and  physically. 

The  mother  reports  the  patient's  birth  as  a  nor- 
mal delivery,  without  instruments.  She  states  that 
he  was  an  apparently  normal  child.  During  the 
World  War  he  was  in  the  Air  Service,  and  he  tells 
vividly  of  narrow  escapes  from  death  by  falling 
several  thousand  feet  from  a  plane,  all  which  tales 
have  to  be  discounted.  Following  discharge  from 
the  Army  in  1919,  he  was  treated  in  several  Gov- 
ernment hospitals  for  epilepsy  with  little  or  no 
benefit  and  was  finally  classed  a  75-per  cent,  per- 
manent disability  and  a  guardian  appointed. 

In  1932  the  attacks  had  increased  in  frequency 
to  one  in  every  week  or  ten  days.  In  several  of 
these  attacks  he  had  fallen  and  sustained  injuries, 
with  resulting  terrible  facial  disfigurement.  After 
one  particularly  severe  seizure  a  deaf  and  dumb 
condition  existed  for  ten  days,  which  proved  to  be 
functional  in  character.  I  persuaded  the  family 
at  that  time  to  allow  me  to  carry  him  to  New 
York  City  for  further  neurological  study.  There 
he  was  seen  by  Dr.  Foster  Kennedy,  whose  diag- 
nosis was  idiopathic  epilepsy,  and  he  advanced  the 
following  theory; 

During  birth  certain  brain  cells  are  injured  vo 
the  e.xtent  that  they,  so  to  speak,  lie  dormant,  but 
are  capable  of  being  so  stimulated  by  toxins  into 
sudden  activity  as  to  produce  seizures  at  intervals. 
That  is  to  say,  a  temporary  condition  of  constipa- 
tion which  would  merely  cause  a  headache  in  the 
normal  individual,  would  or  might  throw  this  indi- 
vidual into  a  grand  mal  fit.  He  concluded  that 
absolute  rest  for  these  abnormal  brain  cells  through 
prolonged  ether  anesthesia  at  three-month  intervals 
might  keep  off  the  attacks.  This  method  of  treat- 
ment was  followed  for  a  year.  No  attacks  occurred 
for    eight    months,    but    they    gradually    began    to 


recur;  accordingly  the  ether  treatment  was  discon- 
tinued, the  patient  went  back  to  his  patent  med- 
icines and  I  went  about  more  promising  work. 

One  day  in  April,  1935,  while  in  the  City  Lab- 
oratory, I  heard  a  man  who  had  brought  in  a  dog's 
head  for  examination  for  possible  hydrophobia  in- 
fection telling  the  technician  that  since  he  took  the 
hydrophobia  vaccine  five  years  ago,  he  had  not 
had  a  single  epileptic  attack.  He  related  that  he 
formerly  had  been  subject  to  typical  and  frequent 
seizures  of  the  most  severe  grand  mal  type,  on 
account  of  this  that  he  could  not  retain  a  steady 
job;  and  that,  five  years  ago,  he  had  been  exposed 
to  hydrophobia  and  had  been  given  the  standard 
treatment  of  vaccine,  since  which  time  he  has  had 
no  seizure. 

Realizing  that  the  anti-rabies  vaccine  is  made 
from  the  desiccated  spinal  cord  of  the  rabbit  and 
that  epilepsy  is  a  disease  of  the  central  nervous 
system,  I  wondered  if  probably  the  sequence  of 
events  in  this  case  might  be  cause  and  effect  rather 
than  happ>enings  connected  in  point  of  time  only. 
I  resolved,  therefore,  to  submit  the  case  to  the 
patient  whom  I  had  been  treating. 

He  was  willing  to  try  out  its  merits,  so  I  gave 
him  the  full  course  of  21  injections  just  under  the 
skin  of  the  lower  abdomen,  in  April  and  May  of 
1935.  Up  until  the  present  he  has  not  had  another 
seizure.  His  general  health  has  shown  marked 
improvement,  much  of  the  apathetic  disposition  and 
the  moron-like  conversation  has  disappeared.  He 
has  put  in  a  full  summer's  work  on  a  farm  and  is 
an  entirely  different  individual. 

Maybe  some  other  factors  have  accounted  for 
the  change;  apparent  cure  in  two  cases  is  insuffi- 
cient evidence  on  which  to  put  forward  a  claim 
that  a  cure  has  been  found  for  so  old  and  so  baf- 
fling a  disease. 

I  am  making  this  report  of  this  case  with  the 
hope  that  others  may  see  fit  to  use  it  in  an  effort 
to  find  out  if  it  is  consistently  of  value  in  the  treat- 
ment of  idiopathic  epilepsy. 


In  the  presence  of  a  positive  blood  culture  (J.  L. 
Maybaum,  in  //.  Mt.  Sinai  Hasp.),  especially  revealing  a 
hemolytic  streptococcus,  even  with  an  innocuous-looking 
ear  and  no  evidence  of  mastoid  involvement,  sepsis  of  otitic 
origin  must  be  given  first  consideration.  However,  before 
surgical  steps  are  taken,  all  other  foci  should  be  excluded 
as  the  primary  source  of  infection.  Highly  significant  is 
the  fact  that  in  recent  years  on  the  Otologic  Service  of 
the  Mount  Sinai  Hospital  positive  blood  cultures  before 
operation  were  obtained  in  almost  100%  of  our  cases. 


In  the  opinion  of  Palmer  and  Woodall  of  the  Dept.  of 
Medicine  of  the  Univ.  of  Chicago  (Jl.  A.  M.  A.,  Sept.  Sth) 
there  «  iiu  safe  method  for  the  udministration  oj  rinchu- 
phcn. 


SOtTTHERN  MEDICINE  AND  SURGERY 


November,  1936 


Surgical   Observations 

A  Column  Conducted  by 

The  Staff  of  the  Davis  Hospital 
Statesville,  N.  C. 


The  Investigation  of  Pain  Associated  With 
THE  Menstrual  Cycle 

The  fact  that  pain  just  before,  during  or  after 
the  menstrual  period  is  common  and  often  difficult 
to  relieve  makes  this  an  important  subject.  Some- 
times true  menstrual  pain  begins  early  and  persists 
for  some  time  after  the  period  is  over.  Aggravated 
cases  of  the  ovulation  pain  or  Mittelschmerz  may 
be  very  distressing,  although  the  menstrual  periods 
themselves  may  be  almost  painless. 

One  of  the  best  methods  in  investigating  dys- 
menorrhea is  to  see  the  patient  each  day  for  two 
or  three  days  after  the  period  and  question  her 
closely  as  to  the  exact  symptoms  each  day,  begin- 
ning with  the  first  premonitory  signs  of  the  begin- 
ning menstruation  and  ending  with  the  last  day  of 
the  period  or  the  last  day  of  the  symptoms.  Many 
patients  will,  for  from  one  to  four  days,  have  a 
definite  sensation  which  is  a  forerunner  of  the  pe- 
riod. This  may  range  all  the  way  from  slight  nerv- 
ousness or  depression  to  extreme  pain  and  some- 
times nausea  and  occasionally  vomiting.  The  exact 
relation  of  all  of  these  symptoms  from  the  very  be- 
ginning of  the  period  should  be  carefully  noted. 
Durin  gthe  menstrual  period  the  feelings  of  the 
patient  each  day  should  be  recorded.  Any  symp- 
toms after  the  cessation  of  the  menses  should  be 
recorded,  also  variations  in  the  onset  of  the  men- 
strual cycle  are  important  and  whether  the  inter- 
val is  21,  26,  28  or  30  days  and  whether  or  not  the 
onset  is  accurately  predictable.  .\ny  other  associ- 
ated signs  or  symptoms  should  be  carefully  record- 
ed and  studied  from  the  standpoint  of  possible  re- 
lation to  the  dysmenorrhea. 

Often  it  will  be  advisable  to  question  the  patient 
minutely  for  each  of  several  successive  months  and 
to  advise  patients  what  symptoms  to  note.  Obtain- 
ing an  accurate  history  is  sometimes  difficult,  but 
the  time  is  usually  well  spent. 

.After  a  careful  general  examination,  special  ex- 
amination of  the  blood  and  the  nervous  system 
should  be  given  considerable  attention.  The  pa- 
tient's background,  home  or  family  life,  occupation 
and  many  other  factors  exert  profound  influence 
and  these  factors  are  not  to  be  neglected.  Exam- 
ination of  the  pelvis  should  be  carefully  done  and 
particular  note  made  of  any  trouble  with  Bartho- 
lin's or  Skene's  glands.  The  cervix  should  be  ob- 
served under  a  good  light.  Smears  from  the  cervix 
and  vaginal  secretions  should  always  be  taken  and 


carefully  studied.  Position  of  the  uterus,  size. 
shape,  presence  or  absence  of  fibroid  tumors  should 
be  noted.  The  position  and  size  of  the  ovaries  and 
presence  or  absence  of  pelvic  adhesions  all  have  a 
bearing. 

The  rectum  should  be  examined  for  hemorrhoids, 
abscesses,  fissures,  fistulas,  cryptitis,  etc. 

In  young  girls  these  examinations  are  often  pos- 
sible only  after  the  patient  is  anesthetized.  All 
patients,  especially  sensitive  girls,  should  be  given 
the  utmost  consideration  in  conducting  an  examina- 
tion. Care  must  be  taken  not  to  cause  injury  or 
pain  or  mental  distress. 

.\  basal  metabolic  rate  determination  is  an  im- 
portant part  of  many  of  these  examinations,  as 
either  hypothyroidism  or  hyperthyroidism  may 
exert  a  profound  influence  upon  the  menstrual 
cycle. 

.Acute   Perforation  of  a  Pyloric   Ulcer  in   a 
Boy  14  Years  of  Age 

A  white  boy,  14,  admitted  to  the  hospital  at  2 
p.  m.  of  a  September  day,  suffering  with  acute  pain 
in  the  abdomen,  said  that  about  9:30  that  morning 
a  sudden  attack  of  pain  in  the  abdomen  "bent  me 
almost  double.  "  He  could  not  walk  upright.  The 
pain  began  in  the  region  of  the  epigastrium  and 
soon  spread  over  the  entire  abdomen,  esp>ecially  the 
lower  right. 

On  admission  the  abdomen  was  tender  and  some- 
what rigid  but  not  with  the  board-like  rigidity  of 
adults  with  a  perforation  of  a  viscus — especially 
perforation  from  a  pyloric  ulcer. 

The  physical  examination  disclosed  little  more. 
Urinalysis  was  negative:  white  blood  count  21,900 
— polys.  959^,  lymphs.  2%,  mononuclears  3% — 
temperature  98,  pulse  90,  blood  pressure  120/85. 
Weight  was  123  pounds,  height  5  feet  5  inches. 

A  diagnosis  of  probable  acute  apf)endicitis  with 
suppuration  was  made,  and  through  a  small  Mc- 
Burney  incision  the  appendix  was  removed.  The 
appendix  was  not  sufficiently  inflamed  to  account 
for  the  blood  picture  or  for  the  pain,  and  a  small 
flake  or  two  of  pus  was  noticed  in  this  region,  which 
evidently  did  not  come  from  the  appendix. 

A  diagnosis  of  probable  f>erforation  of  a  pyloric 
ulcer  was  made  and  the  McBurney  incision  closed 
immediately. 

The  original  spinal  anesthesia  was  sufficient  to 
permit  a  high  right-rectus  incision  without  any  pain 
whatever,  and  through  this  a  small  perforated  ulcer 
on  the  anterior  wall  of  the  pylorus  was  located, 
closed  with  chromic  catgut  on  atraumatic  needles 
brought  over  the  closure  and  held  with  catgut  su- 
tures to  further  strengthen.  Before  closing  this 
incision  a  suction  tube  was  passed  down  to  the 
pelvis  and  a  moderate  amount  of  fluid  removed. 


November,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Other  spaces  where  fluid  collects  were  carefully 
cleaned  by  suction  in  the  usual  way.  The  boy 
made  an  excellent  recovery  with  very  little  trouble 
after  the  operation. 

In  a  case  of  this  kind  the  blood  count  was  in 
keeping  with  the  perforation.  The  fact  that  his 
temperature  was  98  and  the  pulse  normal  also  was 
not  unusual.  A  certain  amount  of  shock  may  have 
accounted  for  the  low  temperature.  There  had 
been  no  very  marked  peritoneal  reaction,  as  very 
little  of  the  stomach  contents  had  escaped. 

Perforation  at  this  age  is  rare.  Recovery  after 
a  perforation  depends  upon  a  number  of  factors, 
one  of  the  chief  being  the  lapse  of  time  between  the 
perforation  and  the  operation.  The  greater  the 
delay  the  greater  the  mortality.  Roughly  speaking, 
we  may  say  that  the  mortality  increases  10*^;  for 
each  hour  after  perforation.  In  all  cases  of  per- 
forated ulcer,  immediate  operation  is  necessary.  In 
many  cases  of  appendicitis  where  the  findings  are 
not  compatible  with  the  blood  count  and  the  physi- 
cal examination,  the  abdomen  should  be  immedi- 
ately explored. 

As  a  resident  in  Philadelphia  I  saw  a  gangrenous 
appendix  removed  and  drainage  instituted  and  a 
day  or  so  later  the  patient  died  of  an  extensive  peri- 
tonitis. Post-mortem  examination  disclosed  a  per- 
forated gastric  ulcer.  He  had  a  perforation  in  ad- 
dition to  gangrene  of  the  appendix.  The  possibility 
of  both  conditions  being  present  at  the  same  time 
should  always  be  kept  in  mind. 

Tumors  of  the  Breast  in  Women  in  the  Late 
Child-bearing  Period 

A  review  of  a  large  number  of  tumors  of  the 
breast  in  women  between  the  ages  of  40  and  SO 
seen  during  the  past  year  revealed  the  fact  that 
many  of  these  patients  have  found  these  tumors 
months  before  a  doctor  was  consulted.  They  con- 
cealed the  fact  even  from  members  of  the  imme- 
diate family.  The  almost  universal  reply  to  the 
question  "Why  did  you  not  consult  a  doctor?"  was: 
"I  was  afraid  it  was  a  cancer."  Others  feared  it 
might  be  a  cancer  and  operation  might  be  necessary 
and  for  these  reasons  they  did  not  consult  a  doctor. 

The  public  mind  is  well  informed  about  the  dan- 
gers of  tumors  of  the  breast,  but  the  inclination  of 
many  people  to  conceal  these  things  and  to  refuse 
to  admit  to  themselves  a  fact  which  they  must 
realize  is  evident  is  responsible  for  many  of  the 
cases  of  carcinoma  of  the  breast,  which  are  seen 
by  doctors  long  after  a  malignant  process  is  under 
way  and  the  axillary  glands  involved. 

A  typical  case  is  that  of  a  woman  seen  this  morn- 
ing. .\  matron,  35,  states  that  since  the  birth  of  a 
child   two  years  ago  she  has   felt   a   tumor  in   the 


left  breast.  This  had  not  grown  any  and  she  had 
no  trouble.  Three  months  ago  she  began  to  have 
pain  in  this  region.  The  tumor  began  to  grow 
rather  rapidly  and  the  pain  increased. 

In  the  lower  anterior  part  of  the  breast  was  a 
nodular  growth  and  there  was  apparently  no  ax- 
illary involvement.  The  breast  itself  was  not  large 
and  it  was  amputated  without  any  difficulty.  The 
tumor  was  attached  to  the  skin,  the  growth  evi- 
dently malignant. 

Had  this  been  removed  when  it  was  first  noticed 
two  years  ago,  it  is  probable  that  there  would  have 
been  no  further  trouble.  As  it  is,  there  is  a  good 
chance  of  a  recurrence. 

The  treatment  of  carcinoma  of  the  breast,  after 
surgical  removal  of  the  whole  breast  and  all  the 
possible  tissue  that  may  be  involved  including  the 
axillary  glands,  is  deep  x-ray  therapy.  Possibly  a 
combination  of  radium  and  deep  x-ray  therapy  may 
be  best  in  some  cases,  but  our  experience  has  been 
that  deep  x-ray  therapy  has  been  most  satisfac- 
tory. 

Acute  Osteomyelitis  in  Children 

Acute  osteomyelitis  of  the  long  bones  in  chil- 
dren comes  on  suddenly,  works  rapidly  and  within 
a  short  while,  probably  within  72  hours,  the  maxi- 
mum amount  of  bone  involvement  takes  place.  If 
the  diagnosis  is  made  early  and  promptly  surgical 
treatment  instituted,  the  best  possible  results  are 
usually  obtained. 

In  the  diagnosis  the  history  should  be  carefully 
elicited,  but  without  delay.  In  most  cases  of  young 
children  there  is  a  history  of  some  slight  injury, 
but  any  child  who  runs  and  plays  can  remember 
some  little  bump  or  bruise  to  some  part  of  the 
body. 

Pain  is  often  intense  and  fever  and  leucocytosis 
develop.  Later  there  will  probably  be  a  little  swell- 
ing about  the  site  of  the  infection.  Most  important 
are  the  pain  and  leucocytosis. 

It  is  extremely  important  in  acute  osteomyelitis, 
to  open  into  the  area  of  infection  and  allow  the 
escape  of  purulent  material.  Pus  under  pressure  is 
extremely  destructive,  spreads  rapidly  and  if  not 
allowed  to  escape  will  cause  irreparable  damage. 
The  x-ray  appearance  of  long  bones  in  which  osteo- 
myelitis has  extended  from  one  end  to  the  other 
shows  just  what  can  occur  in  a  bone  within  a  very 
short  space  of  time,  and  this  destruction  is  seen 
too  often  at  operation  and  in  the  legs  of  cripples. 

If  an  acute  ostomyelitis  could  be  discovered  in 
time  and  the  bone  opened  right  over  the  area  in- 
volved, the  chances  are  there  would  be  very  little 
disturbance.  Many  patients,  however,  are  not  seen 
by  a  doctor  until  the  osteomyelitis  is  well  estab- 


SOXJTHERN  MEDICINE  AND  SURGERY 


November,   1936 


lished. 

X-ray  examination  often  shows  no  involvement. 
Sometimes  there  is  a  little  haziness  or  a  light  shad- 
ow in  the  involved  area,  but  this  is  usually  so  slight 
that  a  diagnosis  of  the  bone  involvement  is  not 
made  from  the  x-ray  examination. 

A  typical  case  is  that  of  a  somewhat  undernour- 
ished boy  of  14,  operated  upon  October  12th.  He 
said  that  three  days  before  he  had  had  a  pain 
above  his  left  knee  that  got  worse.  The  next  day 
there  was  some  swelling  of  the  knee.  He  attrib- 
uted this  trouble  to  an  injury  he  received  when 
playing. 

On  admission  he  had  some  swelling  of  the  left 
knee,  which  on  aspiration  yielded  sterile  fluid. 
White  blood  count  was  16,400 — polys.  85%;  t. 
102;  p.  100.  He  complained  of  severe  pain  around 
the  left  knee  joint — especially  just  above  and  to 
the  outer  side. 

An  incision  was  made  on  the  outer  side  of  the 
left  femur  near  the  lower  end  and  a  considerable 
amount  of  thick,  yellow  pus,  blood  stained  in 
places,  was  removed.  The  pus  had  collected  almost 
two-thirds  of  the  way  around  the  lower  end  of  the 
femur.  Then  holes  were  drilled  in  the  bone  and 
thick,  yellow  pus  escaped  from  the  medullary  cav- 
ity. Following  this  a  window  of  bone  was  removed 
to  permit  cleaning  out  of  the  lower  end  of  the 
femur  and  to  establish  free  drainage. 

In  this  case  the  salient  points  were  pain  in  the 
lower  end  of  the  left  femur,  t.  102,  p.  100,  w.  b.  c. 
16,400 — polynuclears  85% — and  a  slight  swelling 
around  the  knee. 

In  persons  of  any  age  osteomyelitis  is  always  a 
serious  condition.  In  cases  where  a  doctor  is  not 
called  in  until  after  a  day  or  so,  frequently  the 
infection  has  spread  from  one  end  of  the  bone  to 
the  other.  No  matter  what  treatment  is  given  there 
is  grave  danger  to  life  and  at  best  a  prolonged  sup- 
purative condition  which  is  distressing  in  every 
way.  In  children  it  may  mean  months  out  of  school 
and  in  adults  months  away  from  work. 


Seven  Cases  of  Obstructive  J-aundice  Asso- 
ciated With  Pancreatitis 

In  each  of  the  seven  cases  included  in  this  group 
the  pancreas  is  involved:  in  two  the  pancreatic 
enlargement  is  malignant  and  the  remaining  five 
are  associated  with  an  acute  or  subacute  pancreatitis 
with  a  moderate  enlargement  of  the  head  of  the 
organ. 

Each  of  these  cases  gave  a  history  of  digestive 
disturbance  over  a  period  of  two  months,  in  one 
case  ranging  from  several  months  to  two  years. 
Indigestion,  gas  formation,  sour  belches,  eructation 


of  food  and  occasional  vomiting  were  present  in 
all  the  cases.  Pain  was  a  constant  feature.  Th; 
pain  was  in  the  epigastrium  usually  and  sometimes 
in  the  right  upper  quadrant,  in  some  instances  radi- 
ated to  the  back  and  occasionally  to  the  right  shoul- 
der blade. 

In  all  cases  there  was  tenderness  in  the  epigas- 
trium and  the  right  upper  quadrant.  Jaundice  va- 
ried from  slight  to  very  marked  and  was  of  two- 
to  six-months  duration.  The  ages  of  the  patients 
ranged  from  56  to  77.  The  leucocyte  count  varied 
from  normal  to  18,000:  in  this  latter  case  the  in- 
flammation was  more  extensive  and  the  head  of 
the  pancreas  more  involved. 

In  one  case  giving  no  history  of  infection  with 
syphilis  or  of  taking  antisyphilitic  treatment  the 
Kahn  and  Wassermann  tests  were  both  4-plus.  It 
was  in  this  case  that  the  head  of  the  pancreas  was 
most  extensively  involved  and  the  general  symp- 
toms most  severe. 

Close  questioning  and  careful  analysis  of  each 
case  indicated  that  digestive  disturbance  had  ex- 
tended over  a  period  much  longer  than  that  given 
by  the  patient.  There  was  also  in  each  cas;  a  his- 
tory of  pain  in  the  abdomen — especially  the  epi- 
gastrium and  right  upper  abdomen — at  times,  com- 
ing on  to  some  extent  periodically  but  never  severe 
enough  to  cause  a  doctor  to  be  called  until  the  at- 
tack which  sent  the  patient  to  the  hospital. 

A  very  close  analysis  of  each  of  these  cases  indi- 
cates had  the  patient  been  carefully  examined  when 
the  first  symptoms  were  manifested,  prob- 
ably the  trouble  would  have  been  located  when  the 
involvement  of  the  pancreas  was  slight  and  the 
patient's  general  physical  condition  was  little  im- 
paired. 


Dr.  Z.  p.  Mitchell,  who  has  been  Heahh  Officer  for 
Vance  County  for  the  past  three  years,  has  tendered  his 
resignation  to  the  Board  of  Health,  effective  September 
30th.  or  sooner  if  he  can  be  released.  He  has  been  ap 
pointed  health  officer  in  charge  of  Swain  and  Graham 
Counties  in  western  North  Carolina,  near  the  Tennessee 
line.  It  is  expected  that  Dr.  A.  D.  Gregg,  now  Health 
Officer  in  Randolph  County,  wil  be  an  applicant  for  the 
Vance  County  post. 

s.  M.  &  s. 

Dr.  John  Hamtltoit  Scherer  announces  the  opening  of 
offices  and  laboratories  in  the  Memorial  Hospital,  Rich- 
mond, for  the  practice  of  Internal  Medicine  with  special 
reference  to  Hematologj'. 

s.  M.  &  s. 

Dr.  Porter  Paisley  Vinson  announces  the  opening  of 
offices  for  the  practice  of  Internal  Medicine,  Bronchoscopy, 
Esopliagoscopy  and  Gastrocopy,  Medical  .Arts  Building, 
Richmond,  Virginia. 


-s.  M.  &  s.- 


LoRD  MoYNiHAN,  one  of  the  greatest  of  British  surgeons, 
died  September  7th,  two  days  following  a  stroke  of  apo- 
plexy.   He  was  70  years  of  age. 


November,   1P36 


SOUTHERN  MEDICINE  AND  SURGERY 


603 


DEPARTMENTS 


HUMAN  BEHAVIOR 

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


On  Regression 

I  suppose  the  word  regression  means  literally  a 
retracing  of  one's  steps,  a  going  backward.  But 
in  mental  medicine,  at  least,  it  has  acquired  a 
somewhat  technical  meaning.  In  reference  to  be- 
haviour and  custom  the  use  of  the  word  implies 
the  return  to  a  former  method,  and  usually  to  a 
more  primitive  form  of  behaviour,  and  consequent- 
ly to  a  more  natural  type  of  conduct.  In  dreams, 
for  instance,  this  phenomenon  is  probably  not  in- 
frequently exhibited,  and  sometimes  the  dream- 
content  is  such  that  we  should  be  unwilling  either 
to  talk  about  it  or  to  publish  it. 

I  think  of  civilization  as  involving  walking  up- 
hill all  the  time.  The  attempt  to  be  continuously 
civilized  must  call  for  unceasing  effort,  and  if  the 
effort  fail  for  a  moment  there  is  the  danger  of 
lapsing  into  the  uncivilized  state — primitivism,  if 
not  barbarism.  This  notion  is  undoubtedly  at  va- 
riance with  the  popular  belief  that  it  is  natural 
for  mortals  easily  to  behave  in  civilized  fashion. 
^luch  of  our  behaviour  is  of  instinctive  origin, 
much  of  it  is  almost  wholly  reflex,  and  little  of 
it  is  rational  in  the  sense  of  being  formulated  and 
ordered  into  action  by  the  intellect. 

It  may  be  true  that  natural  behaviour  is  always 
devoid  of  any  ethical  quality.  I  think  of  instinc- 
tive urges  as  being  untinctured  by  ethical  coloring. 
We  try  to  project  either  right  or  wrong  into  acts 
that  have  already  been  performed. 

He  said  his  name  was  William,  and  although  I 
straightway  called  him  Uncle,  he  was  scarcely  fifty. 
I  am  certain  that  I  had  never  seen  a  more  benign- 
looking  nor  a  more  inoffensive-looking  Negro. 
When  my  medical  colleague  asked  why  he  was  in 
jail  William  said  that  he  had  killed  his  wife — shot 
her  to  death  with  a  pistol.  And  when  we  asked 
why  he  had  killed  her  he  promptly  replied  that  he 
had  no  idea  why  he  killed  her.  ^^'ithin  little  more 
than  ten  years  she  had  given  birth  to  ten  children. 
She  and  he  had  worked  hard  and  they  had  saved 
and  prospered.  Her  character  was  said  to  be  good, 
and  his  physician  told  us  that  no  man  in  the  county 
had  a  better  character  than  the  Negro. 

His  wife  had  gone  on  a  visit  to  her  people,  as 
she  was  occasionally  accustomed  to  do.  Within  a 
day  or  so  he  came  to  see  her,  and  as  he  entered  the 
room  where  she  was  talking  to  her  mother,  he  drew 
a  revolver  and  shot  her  dead. 


He  did  express  the  opinion  that  another  Negro 
had  visited  his  home  when  he  was  not  there,  and 
he  had  asked  his  wife  if  she  had  been  carrying  on 
with  him.  But  there  was  no  proof  that  his  notion 
was  valid.  His  own  children  by  his  first  wife 
thought  their  step-mother  was  a  good  woman  and 
they  believed  she  was  loyal  to  their  father. 

For  a  year  or  two  before  the  tragedy  her  hus- 
band had  been  projecting  into  some  of  her  conduct 
a  meaning  that  no  one  else  could  see  in  it.  He 
had  become  suspicious  of  her,  and  such  an  attitude 
easily  transforms  by  misinterpretation  good  con- 
duct into  bad  behaviour.  William  was  not  suffi- 
ciently intelligent  to  enable  him  to  analyze  care- 
fully his  wife's  behaviour  and  his  own  unhappy 
suspicions.  When  he  saw  her  in  her  mother's  home 
he  probably  felt  certain  that  she  had  been  unfaith- 
ful to  him.  Within  a  few  seconds  he  might  have 
lost  all  those  restraining  qualities  that  civilization 
had  been  building  up  in  him  for  a  few  hundred 
years,  and  reverted  to  savagery  and  natural  animal 
behaviour.  But  William  is  not  sufficiently  familiar 
with  words  to  enable  him  to  set  forth  in  polysylla- 
bic verbalizations  in  involved  sentences  an  elaborate 
explanation  and  justification  of  his  fatal  assault. 
He  could  not  rationalize.  He  said  in  the  fewest 
possible  words:  I  don't  know  why  I  done  it.  And 
perhaps  no  one  else  knows. 

Fortunately  the  tendency  to  retrogression  in  most 
of  us  does  not  take  the  direction  that  it  took  in 
William.  But  all  of  us  experience  difficulty,  prob- 
ably several  times  each  day,  in  keeping  from  step- 
ping backward  to  a  more  primitive  method  of  be- 
haviour. Were  our  brakes  not  kept  in  good  order 
we  should  all  probably  behave  in  such  fashion  as 
to  cause  us  to  be  brought  into  jail.  Civilized  be- 
haviour is  affected,  unnatural,  difficult  behaviour, 
and  all  of  us  ultimately  tire  of  being  unnatural. 
For  that  reason,  perhaps,  some  of  us  leave  home 
(jccasionally  for  a  vacation,  where  we  may  do  more 
nearly  as  we  please;  others  of  us  sometimes  relieve 
the  tension  by  getting  drunk  on  alcohol  or  some 
other  drug;  some  of  us  become  engaged  in  brawls; 
some  participate  in  political  ballyhooing  hurrah- 
ing, and  release  much  energy.  And  many  individ- 
uals become  either  neurotic  or  psychotic — always 
an  exhibition  of  personal  failure.  All  of  us,  of 
course,  or  at  least  most  of  us,  go  sometimes  to 
church;  we  read  good  literature;  we  engage  in 
uplifting  activities  and  we  subject  ourselves  to 
beneficent  influences  in  order  to  enable  us  to  keep 
from  going  back  in  conduct  to  that  of  our  primi- 
tive ancestors.  When  mankind  in  the  mass  tires 
in  the  effort  to  remain  civilized  warfare  occurs. 
But  in  order  that  the  national  conscience  may  con- 
tinue to   think   comfortably  of  itself  some  highly 


SOUTHERN  MEDICINE  AND  SURGERY 


November,   1936 


ethical  reason  is  always  assigned  for  the  mass- 
murder.  Most  of  us  experience  little  difficulty  in 
thinking  approvingly  of  our  own  behaviour.  But 
trying  to  be  civilized  is  ui>hill  business,  literally 
and  figuratively.  Natural  conduct  is  the  easy  sort, 
but  it  leads  to  lawlessness.  Is  the  natural  indi- 
vidual sane  or  insane? 


UROLOGY 

For  this  issue,  N.  Oliver  Benson,  M.D.,  Lumberton,  N.  C. 


The  Treatment  of  Acute  Gonorrheal  Trigon- 
iTis  With  Neoarsphenamine 

Trigonitis  has  long  been  one  of  the  most  dis- 
tressing complications  of  gonorrhea  and  I  am  de- 
lighted to  bring  forward  to  the  medical  profession 
a  system  of  treatment  which  in  my  hands  has  prov- 
en to  be  almost  specific. 

Prior  to  the  use  of  neoarsphenamine  I  had  used 
many  kinds  of  treatment,  all  of  which  required  the 
patient  to  be  confined  to  bed  for  a  period  of  ten 
days  or  longer.  During  almost  the  entire  confine- 
ment the  patient  was  usually  very  uncomfortable 
even  with  the  help  of  opiates.  Almost  all  of  these 
patients  earned  their  living  by  manual  labor,  and 
could  not  well  afford  to  lose  many  days  from  work, 
so  my  desire  was  to  find  some  form  of  treatment 
that  would  permit  them  to  be  ambulatory. 

If  I  were  to  determine  the  definite  location  and 
character  of  lesion  that  caused  such  distressing 
symptoms,  it  was  necessary  to  make  cystoscopic 
examinations  even  in  the  presence  of  acute  gonor- 
rheal infection.  I  used  both  the  posterior  Brown- 
Buerger  cystoscope  and  the  Young  endoscope,  and 
the  consistent  findings  were:  A  marked  congestion 
of  the  mucosa  covering  the  trigone  and  adjacent 
part  of  the  vesical  orifice  giving  the  appearance  of 
raw  beef.  If  any  of  this  congested  area  was  touched 
with  an  instrument  it  would  bleed  profusely.  Except 
for  that  covering  the  trigone  the  bladder  mucosa 
was  apparently  uninvolved.  The  posterior  urethra 
and  upper  portion  of  the  vesical  orifice  were  mod- 
erately, or  only  slightly,  congested.  There  was 
little  or  no  edema  of  the  mucosa  even  where  the 
congestion  was  most  severe.  The  bladder  capacity 
was  from  five  to  20  c.c,  and  if  distention  above 
this  capacity  was  attempted  there  would  occur  a 
violent  contraction  of  the  bladder  musculature  forc- 
ing the  fluid  in  the  bladder  out  around  the  cysto- 
scope. The  rectal  examination  in  these  cases  re- 
vealed no  associated  pathology,  unless  a  compli- 
cating vesiculitis,  or  prostatitis,  had  already  taken 
place. 

Since  the  trigone  was  consistently  more  involved 
than  any  other  structure  in  this  condition,  I  felt 


that  the  term,  .Acute  Trigonitis,  would  be  apt. 

After  locating  the  lesion  I  attempted  to  apply 
treatment  directly  to  it,  but  in  no  case  was  any 
benefit  derived,  and  in  the  majority  of  the  cases 
the  condition  was  aggravated.  Next  I  tried  the 
intravenous  route,  giving  10  c.c.  of  a  10-per  cent, 
solution  of  sodium  iodide.  This  did  not  help  the 
acute  trigonitis,  but  it  did  definitely  relieve  the 
symptoms  of  acute  epididymitis,  in  the  cases  where 
this  structure  had  become  involved.  Calcium  dias- 
poral  (120  mg.  Ca.  in  10  c.c.)  seemed  to  help  those 
with  seminal  vesiculitis,  but  did  not  relieve  the 
trigonal  symptoms.  Last  I  tried  neoarsphenamine, 
and  the  results  obtained  were  truly  gratifying. 

The  following  results  are  based  on  the  findings 
in  30  cases  of  acute  gonorrheal  trigonitis  treated 
with  neoarsphenamine. 

Sixteen  of  these  cases  gave  a  history  of  a  pre- 
vious gonorrheal  infection;  of  these,  12  had  symp- 
toms of  a  posterior  urethritis,  and  of  the  twelve, 
10  had  a  terminal  hematuria.  The  infection  oc- 
curred on  an  average  of  8.6  years  prior  to  the 
present  illness,  but  most  of  the  patients  were  free  of 
symptoms  for  several  years  before  the  present  ill- 
ness. 

A  comparison  of  the  cases  in  which  there  was 
previous  gonorrheal  infection  and  those  with  no 
such  history  revealed  the  fact  that  a  previous  in- 
fection has  no  effect  on  the  course  of  the  present 
illness.  Symptoms  of  the  present  illness  in  both 
the  previously  infected  cases  and  those  infected 
for  the  first  time  existed  from  six  months  to  two 
days.  In  those  cases  with  symptoms  for  over  two 
weeks,  general  symptoms  were  not  continuous  nor 
severe,  nor  did  hematuria  occur  until  a  few  days 
before  coming  to  my  office.  I  also  noted  that  the 
patient  whose  symptoms  had  existed  only  a  few 
days  before  the  hematuria  started  had  more  severe 
symptoms  than  if  the  condition  had  existed  for 
some  weeks  or  months  before  the  hematuria  start- 
ed. 

The  patient  would  become  infected  with  gonor- 
rhea, and  because  of  shame  or  lack  of  funds  would 
not  go  to  a  doctor,  but  would  confide  in  some 
druggist  or  friend.  One  of  these  parties  would 
assure  him  that  he  could  "knock  it  up"  in  a  few 
days  by  using  his  sure  cure.  This  sure  cure,  in 
some  cases,  was  an  injection  of  a  very  slightly 
diluted  solution  of  turpentine,  lysol,  or  even  fish 
brine;  however,  some  of  the  more  accepted  urethral 
injections  are  usually  prescribed  by  the  druggists. 
Further  investigation  revealed  that  the  causative 
factor  was  not  the  injection  used,  but  how  it  was 
injected.  All  of  the  patients  used  a  syringe  of  a 
one-quarter-ounce  capacity,  or  larger  (usually  one 
of  the  plunger  tyjie),  and  those  using  the  smaller 
size  syringes   would  usually  inject   from  four  to 


November,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


1 2  syringefuls  into  the  urethra,  hence  to  the  bladder 
before  allowing  any  of  the  solution  to  return.  The 
consistent  finding,  therefore,  was  that  the  patient 
injected  the  solution,  whatever  it  might  be,  back 
into  the  posterior  urethra  and  bladder,  the  injec- 
titon  being  made  during  the  first  stage  of  the 
urethritis  or  while  a  definite  urethral  discharge  was 
still  present. 

Within  24  to  36  hours  following  the  posterior 
injection  the  patient  would  begin  having  frequent 
urination  which  was  soon  followed  by  urgency, 
strangury,  dysuria  and  lasting  hematuria.  The 
patient  comes  to  you  voiding  every  five  to  25 
minutes,  having  little  control  over  his  urine  when 
the  desire  to  void  arises.  As  the  bladder  empties 
marked  strangury  and  pain  occur,  accompanied 
by  the  passing  of  a  small  amount  of  usually  bright 
red  blood. 

These  are  the  symptoms  found  in  the  average 
case  of  acute  trigonitis;  however,  some  of  the 
symptoms  may  become  extremely  severe.  One  of 
my  patients  had  what  might  be  termed  a  contin- 
uous frequency.  He  could  obtain  partial  relief  by 
sitting  on  the  edge  of  a  chair  over  a  pan,  and 
continuously  strain  a  few  drops  of  urine  and  blood 
from  his  bladder;  he  did  this  for  16  hours.  In 
another  case  the  pain  at  the  end  of  voiding  was  so 
severe  that  the  patient  fainted  in  my  office. 

In  connection  with  the  preventative  treatment 
allow  me  to  bring  out  a  few  points  concerning 
syringes  for  urethral  injections,  especially  if  the 
patient  is  to  give  himself  the  injection.  The  plun- 
ger type  of  syringe  is  dangerous  in  that  one  cannot 
control  the  amount  of  fluid  injected,  for  if  the 
plunger  tends  to  stick  and  an  added  amount  of 
pressure  is  brought  to  bear  the  entire  contents  of 
the  syringe  is  forcibly  injected  into  the  urethra, 
and  perhaps  the  bladder.  An  opague  syringe,  as 
e.xample,  the  hard-rubber  type,  is  prohibitive  be- 
cause it  is  impossible  to  know  just  how  much  of 
the  injection  fluid  you  have  in  the  syringe,  hence, 
another  chance  for  a  posterior  injection.  The  Ya- 
ounce  asepto  bulb  syringe  is  the  one  of  preference, 
for  here  the  patient  can  see  how  much  fluid  he  has 
in  the  syringe,  how  fast  he  injects  the  fluid,  and 
can  easily  control  the  speed  of  injection.  Some 
might  disagree  with  the  capacity  of  the  syringe, 
but  on  tests  I  find  that  one  dram  will  satisfactorily 
fill  any  male  anterior  urethra.  Even  with  this  small 
syringe,  I  always  caution  a  patient  that,  when  he 
feels  the  injection  solution  reach  the  penoscrotal 
junction,  not  to  inject  any  more,  for  this  amount 
will  reach  the  external  sphincter,  which  is  the  dead 
line. 

The  treatment  I  use  is:  first,  stop  urethral  injec- 
tions, then  apply  some  form  of  an  adhesive  support 


to  the  scrotum  for  the  purpose  of  preventing  epi- 
didymitis, if  possible.  By  mouth  give  fluids  freely, 
bland  diet,  a  urinary  sedative  and  antiseptic.  The 
intravenous  treatment  consists  of  giving  .6  gram 
of  neoarsphenamine,  using  the  usual  precautions. 
In  three  cases  only  was  it  necessary  to  repeat  the 
dose  to  control  the  original  symptoms,  and  here 
no  untoward  results  were  observed  when  the  doses 
were  only  three  days  apart.  To  determine  if  the 
supplementary  treatment  was  of  any  definite  value 
I  gave  the  neoarsphenamine  alone,  and  the  results 
were  just  as  favorable. 

The  results  of  the  treatment  are  manifest  usually 
within  24  hours,  the  patient  noticing  a  decrease  in 
all  his  symptoms,  especially  the  strangury,  the 
dysuria  and  to  some  degree  the  hematuria,  the 
of  frequency  being  the  last  symptom  to  subside. 
.\11  of  these  cases  were  normal  as  to  trigonal  symp- 
toms within  an  average  of  43^  days.  There  were  a 
few  cases  in  which  the  symptoms  returned  after 
abating  for  some  days,  and  here  the  response  to 
the  treatment  was  the  same  after  each  dose,  that 
is,  subsidence  of  all  symptoms  in  four  to  five  days. 

I  have  had  only  one  case  where  the  symptoms 
were  completely  relieved  for  a  period  of  over  two 
months,  and  the  patient  again  injected  his  medicine 
into  the  bladder,  causing  a  trigonitis  for  the  second 
time.  The  response  to  the  neoarsphenamine  was 
again  satisfactory. 

Four  of  my  cases  were  complicated  by  involve- 
ment of  the  epididymis  on  one  side,  by  a  prostatic 
abscess.  In  these  cases  symptoms  of  the  trigonitis 
subsided,  but  more  slowly  than  in  the  uncompli- 
cated cases,  subsidence  requiring  from  seven  to 
nine  days.  After  such  results  in  acute  trigonitis,  I 
attempted  to  help  other  acute  gonorrheal  infection 
and  nonsp>ecific  infections  in  the  genitourinary  tract 
— as  acute  epididymitis,  vesiculitis  and  prostatitis — ■ 
with  neoarsphenamine,  but  in  such  conditions  no 
help  whatsoever  was  derived  from  the  injections. 

Although  the  neoarsphenamine  relieves  the 
trigonal  symptoms  it  has,  as  far  as  I  can  determine, 
no  effect  on  the  disease  itself,  for  the  gonorrhea 
continues  the  same  course  as  in  a  case  without  the 
trigonitis. 

Conclusions 

1.  That  the  principal  lesion  in  cases  of  pos- 
terior gonorrheal  urethritis  accompanied  by  hema- 
turia is  located  on  the  trigone. 

2.  That  topical  applications  to  the  affected  area 
did  more  harm  than  good. 

3.  That  the  cause  of  acute  trigonitis  is  the  in- 
jection of  solution  into  the  posterior  urethra  and 
bladder  during  the  acute  stage  of  an  anterior  gon- 
orrheal urethritis. 

4.  That  we  should  use  a  small  glass-barrel  rub- 


SOUTHERN  MEDICINE  AND   SURGERY 


November,  1936 


ber-bulb  syringe  for  urethral  injections. 

5.  That  neoarsphenamine  has  proven  absolutely 
satisfactory  in  the  treatment  of  cases  of  acute  trig- 
onitis. 

6.  That  neoarsphenamine  does  not  have  any 
effect  on  the  course  of  the  gonorrhea  as  to  curing 
the  disease. 


HOSPITALS 

R.  B,  Davis,  M.D.,  M.S.,  F..\.C.S.,  Editor,  Greensboro^.  C. 


Let's  Call  a  Spade  a  Spade 

Hospital  trustees  and  staff  physicians  alike 
are  prone  at  times  to  evade  the  question,  to  beat 
the  devil  around  the  bush.  In  the  final  analysis  it 
never  pays,  e.xcept  perhaps  in  politics,  to  sit  strad- 
dle the  fence. 

The  hospital  owes  the  staff  physician  something 
and  the  staff  physician  owes  the  hospital  some- 
thing. However,  neither  of  these  debts  is  as  im- 
portant as  the  obligation  to  the  patient.  A  well- 
organized  and  well-operated  hospital  will  have  little 
trouble  in  paying  its  obligations  to  patient  and 
doctor  if  the  trustees  will  call  a  spade  a  spade. 

It  is  the  duty  and  responsibility  of  the  trustees 
to  appoint  well  trained,  ethical  and  morally 
straight  doctors  as  staff  members.  It  is  further 
their  duty  to  formulate  and  set  up  rules  and  reg- 
ulations for  the  staff  in  keeping  with  those  of  a 
hospital  approved  by  the  .\merican  College  of  Sur- 
geons. 

After  these  rules  and  regulations  have  been 
formulated  and  approved  by  the  staff  they  should 
become  law,  and  every  member  of  the  staff  should 
be  held  strictly  to  their  observance.  If  the  rules 
are  not  right  and  fair  the  staff  has  an  opportunity 
to  discuss  them  and  request  the  trustees  to  make 
changes  so  that  a  hardship  will  not  be  worked  on 
anyone:  but  the  welfare  of  the  patient  should  be 
kept  uppermost  in  the  minds  of  all  parties  con- 
cerned. 

The  author  has  very  little  patience  with  the 
physician  who  tries  to  hide  behind  the  reputation 
of  the  hospital,  and  attempts  to  render  such  treat- 
ments as  he  is  not  qualified  to  render.  The  results 
of  his  work  tend  to  tear  down  the  reputation  of 
the  hospital:  he  probably  has  very  little  reputation 
to  tear  down. 

It  should  be  made  very  plain  by  the  hospital 
administrators  that  doctors  are  expected  to  conform 
to  the  rules  as  set  forth  for  their  conduct,  and  if 
they  persist  in  failing  so  to  do  new  staff  members 
should  be  appointed  to  take  their  places.  Words 
should  not  be  minced  by  anyone  but  the  plain  facts 
definitely  and  concretely  pointed  out. 


A  doctor  who  fails  to  write  his  histories  and 
physical  e.xaminations,  keep  progress  notes  on  his 
patients,  write  his  orders  rather  than  give  them 
verbally  to  some  nurse  on  the  hall  is  an  unprofit- 
able staff  member,  and  no  hospital  should  tolerate 
these  gross  violations  of  good  hospital  rules.  A 
purge  of  the  hospital  staff  once  in  a  while  would 
be  a  wholesome  procedure  and  would  make  for 
much  better  cooperation. 

The  staff  physician  has  a  right  to  expect  and 
demand  courtesy,  consideration  and  obedience  to 
his  orders  from  all  of  the  hospital  employees,  from 
the  administrator  to  the  orderlies.  Nothing  less 
than  this  should  be  tolerated  by  the  physician. 
Loyalty  and  support  should  be  given  him  in  his 
effort  to  maintain  his  department  in  an  up-to-date 
and  scientific  manner.  Unless  the  hospital  has 
confidence  in  his  judgment  and  ability  it  has  no 
right  to  keep  him  on  the  staff,  and  if  it  does  have 
such  confidence  it  should  let  it  be  known  to  all  of 
the  patients  in  his  department. 

If  the  staff  doctor  does  not  receive  support  and 
cooperation  he  should  not  mince  words  in  telling 
the  hospital  and  trustees  wherein  they  are  not  giv- 
ing him  a  square  deal. 

The  title  of  this  paper  practically  answers  the 
question  as  to  the  cause  of  a  great  deal  of  mis- 
understanding, inefficiency  and  lack  of  cooperation 
which  in  the  end  destroys  the  reputation  of  both 
the  doctor  and  the  hospital.  Let's  call  a  spade  a 
spade. 


PEDIATRICS 

G.  W.  KUTSCHJ^K,  M.D.,  F  A  A.P..  Editor,  .Asheville,  N.  C. 


Pick-ups 

Urotropin  is  bactericidal  in  an  acid  medium 
only.  For  years  acid  sodium  phosphate  has  been 
used  to  acidify  the  urine.  Now  we  read  that  acid 
sodium  phosphate  is  of  little  value  as  an  acidifier; 
in  fact  it  may  actually  alkalinize  the  urine.  .\11 
of  which  may  ex-plain  certain  difficulties  encoun- 
tered in  the  treatment  of  pyelitis  by  the  use  of  these 
drugs. 

AcRODYNiA  or  pink  disease  may  be  the  result  of 
exposure  to  the  sunshine  of  exceptionally  sun-sen- 
sitive children.  The  heat  of  the  sunshine  is  prob- 
ably the  allergen,  but  it  is  well  known  that  photo- 
phobia is  a  prominent  symptom  of  the  disease. 

Additional  reports  of  accidents  following  the 
use  of  B.  C.  G.  vaccine  against  tuberculosis  in  in- 
fancy continue  to  appear  in  the  literature.  A  re- 
cent report  is  contained  in  an  editorial  in  the  June 
2nd  issue  of  the  British  Medical  Journal.  In  this 
instance,  tuberculous  meningitis  developed  and  an- 
other life  was  sacrificed. 


November,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


607 


The  use  of  iron  in  the  treatment  of  anemia  re- 
quires an  understanding  of  the  metal  for  best  re- 
sults. Liver  extract  plays  the  important  role  in 
pernicious  anemia  and  sprue,  but  iron  is  the  im- 
portant agent  in  hypochromic,  nicrocytic — in  other 
words,  old-fashioned  secondary — anemia.  Liver 
therapy  given  intramuscularly  is  to  be  preferred, 
but  iron  salts  by  routes  other  than  the  digestive 
tube  have  little  or  no  value.  They  should  be  given 
by  mouth  exclusively. 

Iron  is  given  in  massive  doses  because  it  is  poor- 
ly assimilated.  When  the  optimum  dose  has  been 
reached,  to  increase  the  dose  is  wasteful.  Iron 
salts  are  best  given  in  the  presence  of  a  high  gastric 
acidity.  .\ny  acid  given  with  the  iron  is  beneficial, 
which  explains  the  reason  for  following  iron  medi- 
cation with  dilute  lemon  juice.  Gastric  acidity  is 
high  just  before  meal  time,  which  is  a  favorable 
time  to  administer  the  drug.  Most  of  the  favorite 
salts  of  iron  hold  the  iron  in  an  unavailable  form 
until  acted  upon  by  the  gastric  acids.  Reduced 
iron  must  be  acted  upon  by  the  stomach  acids  to 
produce  ferrous  chloride.  The  ferrous  salts  are  the 
most  readily  assimilated.  Ferrous  sulphate  is  read- 
ily absorbed  and  the  dosage  is  consequently  low  in 
comparison  with  the  other  iron  salts.  The  iron  in 
food  is  not  readily  available.  A  dose  of  two-and-a- 
half  to  seven  grains  of  ferrous  chloride  appears  to 
equal  six  to  10  grains  of  ferrous  sulphate,  30  to  SO 
grains  of  reduced  iron,  or  60  to  90  grains  of  iron 
and  ammonium  citrate  and  about  the  same  amount 
of  Blaud's  pills. 

The  important  thing  in  treating  any  anemia  re- 
quiring iron  is  to  give  plenty  of  it.  There  is  little 
danger  of  overdosage  by  mouth. 

Iron  does  most  good  when  hemoglobin  loss  is  in 
excess  of  the  loss  of  red  blood  cells.  This  is  the 
type  of  anemia  frequently  seen  in  children. 

.■\ppENDiciTis  IN  CHILDHOOD  (according  to  Bas- 
tianelli):  "When  physicians  are  discussing  wheth- 
er the  case  is  appendicitis  or  not,  it  is  When  they 
are  inclined  to  admit  the  possibility  of  appendicitis 
without  being  perfectly  sure  of  it,  it  not  only  is, 
but  is  about  to  perforate.  When  the  diagnosis  is 
sure,  there  is  already  perforation  with  more  or  less 
circumscribed  peritonitis." 

Routinely  look  for  pyelitis  in  every  little 
girl  convalescing  from  summer  diarrhea  just  as  you 
do  in  the  Spring  following  upper  respiratory  infec- 
tions. 

S.   M.    &   B. 

Some  Evidences  or  Woma.n's  Emaxltpatio.v 
(G.   Theohold,  in  Jour,  of  State  Med.,  June) 
She  copies  the  cooHe  woman  of  the  Chinese  bazaar  in 
plucking  her  eyebrows,  the  Siamese  peasant  in  bobbing  her 
hair,  the  Arab  in  letting  her  nails  grow  like  claws  and  paint- 
ing them  a  hideous  red,  the  courtesan  in  paintine  all  visible 


parts  of  her  anatomy,  and  in  painting  and  powdering  her- 
self in  public  betrays  incredible  vulgarity.  She  is  so  restless 
that  she  cannot  sit  peacefully  at  home;  she  cannot  eat  her 
meals  without  smoking,  and  is  unhappy  unless  she  is  at 
the  dance  or  cinema. 


SURGERY 

Gio.  H.  BuKCH,  M.D.,  Editor,  Columbi*,  S.  C. 


The  F.^llopian  Tube  as  a  Portal  of  Entrance 
FOR  THE  Causative  Agent  of  Chemical  Peri- 
tonitis— Turpentine  Peritonitis. 
Although  the  lumen  of  the  fallopian  tube  is 
small  its  patency  is  essential  to  reproduction,  for 
in  it  the  sperm  cell  from  without  and  the  ovum 
from  within  the  abdomen  meet  for  fertilization  of 
the  ovum  on  its  way  from  the  ovary  through  the 
tube  to  the  uterus.  Gynecologists  have  been  great- 
ly concerned  about  bacterial  infection  in  the  tube 
and  of  the  peritoneum  through  the  tube.  Gonor- 
rhea, because  of  its  prevalence  and  because  of  its 
predilection  for  the  tubal  mucosa,  is  the  most  fre- 
quent cause  of  tubal  suppuration,  of  pelvic  peri- 
tonitis and  of  sterility  in  women. 

That  the  tube,  when  patent,  may  be  a  passage- 
way for  irritating  or  poisoning  drugs  into  the  abdo- 
men is  not  appreciated,  that  chemical  peritonitis 
from  this  source  has  not  been  more  frequently  rec- 
ognized and  reported  is  surprising.  There  is  noth- 
ing found  on  the  subject  in  the  literature  conveni- 
ently available,  although  the  condition  should  not 
be  rare,  for  there  is  ample  evidence  that  by  pres- 
sure or  by  gravity  fluid  can  be  made  to  pass  from 
the  uterus  through  the  tube  into  the  peritoneal  cav- 
ity. 

At  laparotomy,  the  writer  has  been  small  spurts 
of  bloody  fluid,  obviously  of  uterine  origin,  dis- 
charged from  the  fimbriated  end  of  the  tube.  Samp- 
son, in  his  original  descriptions  of  endometriosis, 
attributed  the  transplants  of  aberrant  endometrium 
on  the  surface  of  the  pelvic  viscera  to  transtubal 
passage  of  menstrual  blood,  with  small  bits  of  en- 
dometrium, into  the  peritoneal  cavity.  He  thought 
that  such  regurgitation  of  menstrual  fluid  through 
the  tubes  might  more  readily  occur  in  women  with 
retroversion  or  fibroid  uterus  because  of  mechani- 
cal interference  with  adequate  dependant  drainage 
through  the  cervix.  Rubin,  in  the  study  of  steril- 
ity by  transuteral  insufflation  of  opaque  media, 
readily  demonstrates  the  passage  of  the  fluid 
through  the  tube. 

Case  Report 
.\  white  matron,  27,  of  medium  size,  was  admitted  into 
the  South  Carolina  Baptist  Hospital  May  3rd,  1934,  with 
t.  102,  r.  28,  p.  140,  urine  normal,  her  leucocytes  18,400 — 
with  87%  polys. — the  hemoglobin  86%.  Her  abdomen 
was  acutely  distended  and  tympanitic  with  the  generalized 


608 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


tenderness  of  diffuse  peritonitis.  On  bimanual  pelvic  ex- 
amination there  was  tenderness  without  palpable  masses. 
She  gave  the  history  of  having  several  small  children  and 
of  having  missed  two  menstrual  periods,  and  she  had  leu- 
corrhea.  She  was  taken  acutely  ill  at  night  7  days  before 
admission  with  violent  pain  beginning  about  the  umbilicus 
and  becoming  generaUzed  over  the  abdomen.  There  was 
nausea  but  no  vomiting.  There  has  never  been  increased 
frequency  or  burning  at  urination.  This  was  the  first 
attack.  Since  onset  her  condition  had  become  progres- 
sively worse. 

Exploratory  laparotomy  was  done  on  the  day  of  admis- 
sion for  diffuse  peritonitis  of  unknown  cause  and  plastic 
lymph  was  everywhere  found  in  patches  over  the  distended 
gut.  In  the  pelvis  there  was  almost  a  pint  of  sanguinous 
exudate  with  the  strong,  unmistakably  characteristic  odor 
of  spirits  of  turpentine.  The  tubes  were  greatly  congested 
but  apparently  contained  no  pus.  The  uterus  was  not 
pregnant.  The  fluid  was  sponged  away  and  the  pelvis 
drained.  Convalescence  was  uneventful  although  there  was 
some  fever  until  shortly  before  dismissal  on  the  21st  day. 
Stained  smears  of  the  peritoneal  fluid  showed  numerous 
red  and  white  blood  cells  with  no  organisms.  Some  of 
the  fluid  kept  in  a  corked  bottle  retained  the  odor  of  tur- 
pentine for  several  weeks. 

When  confronted  with  the  operative  findings  the  patient 
at  first  said  she  had  rubbed  spirits  of  turpentine  on  her 
abdomen  to  cause  abortion.  She  later  admitted  placing 
cotton  saturated  with  turpentine  about  the  cervix  before 
going  to  bed.  She  denied  forcing  the  turpentine  into  the 
cervix  with  a  syringe  although  the  findings  strongly  suggest 
that  this  was  done. 

This  case  proves  that  chemical  peritonitis  may 
be  caused  by  douches  or  other  intrauterine  medi- 
cation. When  these  are  used  the  patient's  body 
should  be  elevated  and  the  back-flow  through  the 
cervix  should  be  free  and  unobstructed.  The  con- 
dition is  not  recognized  because  it  is  not  suspected. 
The  diagnosis  in  this  case  was  made  only  by  the 
odor  of  turpentine.  Without  this  the  inflammation 
would  doubtless  have  been  considered  a  manifes- 
tation of  infection.  The  lesson  to  us  is  that  all 
cases  of  acute  salpingitis  with  jjeritonitis  are  not 
of  bacterial,  gonorrhoea),  origin. 


RADIOLOGY 

Wright  Clarkson,  M.D.,  and  Allex  Barker,  M.D., 
Editors,  Petersburg,  Va. 


PiTRESsiN  IN  Cholecystography  and  Urography 
During  the  past  few  months  several  authors, 
among  them  Collins  and  Root,'  have  reported  grat- 
ifying results  from  the  use  of  pitressin  to  eliminate 
gas  shadows  during  cholecystography  and  urogra- 
phy. The  drug  consists  of  the  pressor  principle 
of  posterior  pituitary  extract. 

Since  July,  1936,  we  have  administered  pitressin 
to  approximately  25  patients  on  whom  cholecysto- 
graphic  or  urographic  examinations  were  being 
made.  In  all  of  these  cases,  with  the  exception  of 
one,  the  confusing  gas  shadows  were  almost  entirely 
eliminated. 


As  the  drug  has  not  yet  been  widely  used,  the 
possibility  that  it  might  have  some  influence  in 
emptying  the  gallbladder  has  been  taken  into  con- 
sideration, and  preliminary  films  have  been  made 
on  all  our  patients  to  determine  the  size  and  den- 
sity of  the  gallbladder  before  the  administration 
of  the  drug.  Patients  presenting  confusing  shad- 
ows were  then  given  one  ampoule  ( 10  pressor  units) 
of  the  drug  injected  into  the  deltoid.  Within  10 
to  20  minutes  mild  intestinal  activity  occurred, 
evidenced  by  mild  cramp-like  abdominal  pains  and 
a  desire  to  defecate.  The  majority  of  patients  had 
one  or  more  stools  within  30  minutes  after  the  drug 
was  given.  Films  made  after  defecation  showed 
an  almost  entire  absence  of  gas.  Even  in  those 
patients  who  did  not  have  stools  the  results  were 
gratifying,  though  not  so  good  as  in  those  who  had 
evacuations.  One  patient  had  opaque  material 
scattered  throughout  the  colon,  and  a  film  after 
pitressin  showed  all  of  this  in  the  sigmoid  and 
rectum,  even  though  she  did  not  have  a  stool  and 
the  gallbladder  examination  was  completed  satisfac- 
torily. 

In  this  relatively  small  group  of  patients,  it  has 
not  been  necessary  to  wait  longer  than  45  minutes 
after  injection  before  proceeding  with  the  roentgen 
study.  In  none  of  this  group  has  there  been  any 
evidence  that  gallbladder  function  was  in  any  way 
influenced  by  pitressin.  However,  it  seems  wise 
that  for  some  time  yet  the  use  of  the  drug  in 
cholecystography  should  be  preceded  by  prelimi- 
nary cholecystograms,  in  order  to  be  certain  that 
failure  to  visualize  a  gallbladder  is  the  result  of 
disease  rather  than  of  premature  emptying  caused 
by  pitressin. 

If  reasonable  care  be  exercised  in  the  selection 
of  patients  reactions  are  insignificant.  In  two  of 
our  cases,  vomiting  occurred  within  10  minutes 
after  injection,  but  these  patients  were  already  ac- 
tively nauseated  and  had  been  vomiting.  The  only 
severe  reaction  occurred  in  a  weak,  emaciated  wo- 
man 60  years  of  age,  who  had  not  been  able  to 
retain  food  for  seven  days.  She  became  intensely 
nauseated,  with  skin  pale,  clammy  and  covered  with 
a  profuse  cold  perspiration.  Her  pulse  was  quite 
feeble,  but  regular.  The  reaction  lasted  only  a  few 
minutes  and  there  were  no  bad  after  effects. 

We  believe  that  it  is  best  not  to  administer  the 
drug  to  weak,  emaciated,  aged  individuals,  or  to 
those  with  cardiovascular  disease,  particularly  if  a 
coronary  lesion  is  susp)ected,  or  if  much  hypoten- 
sion or  hypertension  is  present. 

In  a  group  of  73  patients,  Collins  and  Root 
noted  blood-pressure  changes  in  91  per  cent.  In 
approximately  50  per  cent,  a  drop  in  blood  pressure 
occurred — systolic,  diastolic,  or  both.  The  systolic 
drop  averaged   15   mm.  of  mercury,  the  diastolic 


November,  193« 


SOUTHERN  MEDICINE  AND  SiniGERY 


14.  In  .56  per  cent,  of  cases  there  was  an  increase 
in  systolic,  or  diastolic  blood-pressure,  the  average 
rise  in  both  being  10  mm.  mercury.  However,  the 
terminal  reading  in  all  their  cases  was  below  that 
recorded  before  the  administration  of  pitressin. 

.As  a  further  aid,  in  those  patients  without  con- 
traindications, and  in  whom  the  first  injection  fails 
to  give  the  desired  results,  a  second  dose  of  10 
pressor  units  may  be  given  one  to  two  hours  later. 
Certain  authors  have  found  that  the  second  ad- 
ministration is  effective  when  the  first  fails.  In 
our  cases  the  second  injection  has  not  been  neces- 
sary. 

The  elimination  of  confusing  gas  shadows  is  one 
of  the  most  perple.xing  technical  problems  met  with 
in  roentgenologic  investigations  of  the  gallbladder 
and  the  urinary  tract.  Roentgenograms  made  at 
different  angles  will  sometimes  solve  the  problem 
in  cholecystography  by  changing  the  gas  shadows' 
relation  to  the  gallbladder.  Often  this  method 
fails,  however,  and  the  use  of  additional  films  adds 
greatly  to  the  expense  of  the  examination.  The 
use  of  cleansing  enemas  to  be  rid  of  the  gas  is 
common  practice,  but  this  procedure  is  time-con- 
suming and  frequently  unsuccessful.  It  is  common 
experience  to  find  more  intestinal  gas  after  the  use 
of  enemas  than  before.  In  our  experience  pitressin 
has  proven  highly  efficient  in  removing  this  gas 
from  the  intestinal  tract  and  we  heartily  recom- 
mend its  use  for  this  purpose. 

References 
1.     Collins,   E.   N.,   and   Root,  J.   C:      Elimination   of 
Confusing    Gas    Shadows    During    Cholecystography. 
/.  A.  M.  A.,  July  4th,  1936. 


PHARMACY 

W.   L.  Moose,  Ph.G.,  Editor,  .^sheville,  N.   C. 


Some  Changes  in  U.  S.  P.  and  N.  F. 

The  N.  F.  VI  has  a  real  improvement  among  the 
vehicles  in  Iso-Alcoholic  Elixir.  This  elixir  has  the 
same  flavor  as  Aromatic  Elixir.  There  are  two 
parts  to  the  Elixir,  one  High-Alcoholic  and  one 
Low- Alcoholic.  These  are  mixed  in  varying  pro- 
portions to  produce  the  desired  alcoholic  concentra- 
tion. 

To  illustrate  how  the  Iso-Alcoholic  Elixir  is  used 
the  following  prescription  will  serve — 
Rx     Tr.  Nux  Vomica  3vi. 

Iso-Alcoholic  Eli.-?ir  q.s.  ad.  oz.  iv. 

M.  Sig.    A  teaspoonful  in  water  3  times  a  day  before 

meals. 

Since  Tr.  Nux  Vomica  contains  70%  alcohol  the 

table  given  in  the  N.  F.  VI  shows  that  1  volume  of 

low-alcoholic  (6'/.  drams)  and  3  volumes  of  High- 


-Alcoholic  q.s.  (3  oz.  and  3V2  drams)  should  be  add- 
ed. This  will  give  a  clear  solution  instead  of  a 
turbid  mixture  in  which  each  teaspoonful  (5  c.c.) 
will  contain  15  minims  of  Tr.  Nux  Vomica. 

Elixir  of  Lactated  Pepsin  is  given  as  the  synonym 
of  Compound  Elixir  of  Pepsin.  It  may  make  for 
some  uniformity  in  this  preparation  of  many  for- 
mulas. 

.•\  deodorant  solution  has  been  added  in  Solu- 
tion of  .-Xluminum  Chloride  (Liq.  Aluminum  Chlor.) 

Syrup  of  .Acacia  has  been  improved  by  adding  a 
flavor — vanilla — and  a  little  sodium  benzoate  to 
prevent  fermentation. 

Syrup  of  Cherry  is  an  addition  and  a  fine-flavor- 
ed vehicle. 

The  formulae  for  preparing  diluted  acids  have 
been  changed  from  a  system  of  weight-in-weight 
to  volume-in-volume.  The  important  part  to  the 
physician  is  the  fact  that  the  strengths  of  several 
of  the  concentrated  acids  have  also  been  changed. 
Hydrochloric  .Acid  has  been  increased  from  32% 
to  36'/( .  Many  stores  have  been  making  this  by  a 
volume-to-volume  solution  for  a  long  time  accord- 
ing to  a  formula  in  Remington's  Practice  oj  Phar- 
macy. 

If  the  new-strength  acid  is  used  just  a  little  less 
than  }i  of  an  ounce  too  much  of  the  strong  acid 
will  be  used  giving  a  diluted  acid  above  the  desired 
10%,  nearly  2%  too  much. 

The  strength  of  Sulfuric  .Acid  has  been  increased 
about  2%. 

Solution  of  Potassium  .Arsenate  has  had  its  color 
and  odor  removed  by  dropping  the  Co.  Tr.  Lav- 
ender from  the  formula.  This  is  probably  an  un- 
wise move.  It  was  improved,  however,  when  the 
amount  of  potassium  bicarbonate  used  was  cut  to 
about  1/3.  A  more  suitable  formula  would  be  to 
use  the  new  amount  of  Potassium  Bicarbonate  and 
retain  the  Compound  Tincture  of  Lavender. 

Mild  Tincture  of  Iodine  is  added  which  is  a  real 
improvement.  It  has  2%  of  iodine  in  a  diluted 
alcohol  with  sodium  iodide.  It  is  not  so  likely  to 
blister  and  sodium  iodide  is  not  as  irritating  as  po- 
tassium iodide.  As  it  is  in  diluted  alcohol  it  tends 
to  penetrate  better. 

Benzoinated  Lard  is  not  used  as  the  vehicle  in 
any  U.  S.  P.  XI  ointments.  It  is  used  in  several 
of  the  N.  F.  VI.  Apparently  it  is  on  the  way  out. 
Well  it  may  be  as  it  is  nearly  always  rancid  and 
granular. 

Sulfur  Ointment  U.  S.  P.  XI  is  now  made  with 
precipitated  sulfur  instead  of  sublimed  sulfur 
which,  in  addition  to  the  change  of  vehicle,  gives  a 
very  much  improved  ointment. 

Compound  Elixir  of  Chloral  and  Potassium  Bro- 
mide X.  F.  VI,  which  is  the  new  name  for  Com- 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


pound  Mixture  of  Chloral  and  Potassium  Bromide, 
is  25'7f  stronger.  Each  teaspoonful  (5  c.c.)  con- 
tains about  20  grains  each  of  chloral  hydrate  and 
potassium  bromide  and  1/6  grain  each  of  extracts 
of  cannabis  and  hyoscyamur-. 

Syrup  of  Cinnamon  is  improved  by  being  made 
from  the  oil  and  adding  Compound  Tincture  of 
Cudbear  to  give  a  fine  color. 

The  flatness  of  Syrup  of  Licorice  is  removed  by 
the  flavoring  added. 

Whitfield's  Ointment  is  now  official  under  the 
title  of  Compound  Ointment  of  Benzoic  Acid. 

The  Epitome  of  the  U.  S.  P.  and  X.  F.  represents 
60c  well  invested. 


GENERAL  PRACTICE 

Wi.vG.ATE  M.  Johnson.  M.D.,  Editor,  Winston-Salem,  N.  C. 


I'.\RTNERS  IN  Public  Health 

At  the  A.  M.  A.  meeting  in  Kansas  City,  it  was 
my  lot  to  serve  on  the  Committee  on  the  Executive 
Session  of  the  House  of  Delegates.  One  of  the 
members  was  Dr.  Floyd  Winslow,  President  of  the 
New  York  State  Medical  Society.  His  splendid 
physique  first  attracted  me:  then  his  sound  judg- 
ment, good  common  sense,  and  ready  humor.  I 
was  not  surprised,  therefore,  to  find  in  a  reprint 
of  the  following  article  from  his  pen,  published  in 
The  Survey  for  September,  1936,  the  sanest  dis- 
cussion of  the  relation  between  the  private  practi- 
tioner and  the  public  health  officer  that  I  have  yet 
seen.  It  is  so  good  that  I  am  reproducing  it  in 
full. 

"Partners  in  Public  Health" 

"By  FLOYD  S.  WINSLOW,  M.D." 

"President,  Medical  Society  of  the  State  of  New   York." 

"Anybody  can  tell  us  what  a  public  health  per- 
son should  know,  if  somebody  will  first  tell  us  what 
that  person  is  to  do. 

"Public  health  workers  and  private  practitioners 
alike  engage  in  an  occupation  whose  purpose  is  the 
improvement  of  people's  health.  The  health  offi- 
cer's work  is  extensive,  that  of  the  doctor  is  inten- 
sive, that  of  the  public  health  nurse  may  be  either 
or  both.  The  health  officer  thinks  in  terms  of 
cases  of  pneumonia,  the  doctor  thinks  in  terms  of 
persons  with  pneumonia.  The  health  officer  is 
more  or  less  abstract  and  communal  in  his  attitude, 
the  doctor  is  essentially  concrete  and  individual, 
the  nurse  often  serves  as  a  link  between  the  two 
and  an  interpreter  of  their  aims  to  actual  or  poten- 
tial patients. 

"None  can  get  along  without  the  others.  We 
should  be  more  than  just  acquaintances;  we  should 
be  friends.    We  should  understand  each  other  more 


fully  than  we  do  and  we  should  cooperate  to  better 
purpose  than  we  have  sometimes  done.  It  is  easy 
to  be  critical.  I  admit  at  the  start  that  the  average 
doctor  might  very  well  know  more  about  commu- 
nity' health  problems,  the  value  of  vital  statistics, 
the  importance  of  certain  sanitary  procedures.  On 
the  other  hand,  the  health  officer  might  well  under- 
stand more  about  conditions  as  the  doctors  encoun- 
ters them  in  the  sick  room,  the  personality  prob- 
lems involved  in  almost  every  one  of  his  relation- 
ships, the  difficulties  which  stand  in  the  way  of 
his  obtaining  the  cooperation  of  the  patient  in 
some  particulars  without  seriously  disturbing  the 
whole  confidential  relationship.  To  a  health  offi- 
cer, statistics  on  a  chart  may  be  too  easily  inter- 
preted as  failures  of  private  physicians  to  achieve 
ends  which  bulk  black  on  the  roll  of  the  com- 
munity's total;  but  to  the  individual  doctors,  these 
imperfect  results  may  mean,  in  each  case,  the  best 
that  could  be  accomplished  under  the  given  condi- 
tions. Angels  perhaps  could  have  done  no  more — 
health  officers,  even  if  endowed  with  plenary  pow- 
ers of  compulsion,  might  have  done  much  less. 

"I  believe  I  could  write  on  the  imperfections  of 
the  medical  profession  until  the  celebrated  Sara- 
toga Springs  ran  dry.  The  trouble  with  us  is  that 
we  are  so  busy  with  our  individual  cases  of  people 
who  are  sick  that  we  have  no  time  left  to  devote 
to  aggregates  of  sick  people,  and  we  fail  to  sympa- 
thize as  fully  and  instinctively  with  communal 
purposes  as  no  doubt  we  should.  Some  have  been 
kind  enough  to  point  this  out  to  us  on  a  number 
of  occasions;  it  must  be  admitted  that  we  are  im- 
proving. On  the  other  hand,  there  are  those  of 
us  who  think  that  some  public  health  efforts  are 
operating  to  increase  the  number  of  instances  in 
which  persons  who  should  go  to  a  private  practi- 
tioner are  allowed  to  feel  secure  in  the  advice  of 
persons  of  inadequate  ability  and  experience. 

'That  popular  health  instruction  in  the  mass 
and  individually  is  a  part  of  the  function  of  health 
departments,  as  well  as  the  obligation  of  voluntary 
health  agencies,  is  clear  from  the  examination  of 
their  activities.  The  school  nurse  and  the  school 
physician,  for  example,  are  strategically  placed  to 
protect  the  school  body  in  many  particulars  which 
would  never  pass  under  the  observation  of  the 
family  doctor.  They  can  do  things  which  he  can- 
not do  in  this  respect;  therefore  they  should  do 
them.  But  are  they  ready  to  assume  the  respon- 
sibility for  diagnosis  or  treatment,  and  do  they 
realize  fully  enough  that  they  may  be  innocently 
diagnosing  or  treating  when  they  think  they  are 
doing  educational  work? 

"What  matters  is  not  the  purpose  but  the  effect 
of  that  which  is  done.  The  difficulty  of  the  public 
health   worker's  position,   particularly   that   of   thj 


November,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


nurse,  is  apparent.  She,  like  the  doctor,  must  ob- 
tain and  retain  the  confidence  of  the  people  she 
serves.  It  is  difficult  to  say,  "You  should  see  your 
doctor,"  when  an  apparently  trivial  question  is 
asked.  It  is  easy  to  respond  to  a  request  to  be 
more  specific.  The  extent  to  which  the  nurse  may 
be  substituted  for  the  doctor,  quite  unintentionally 
on  her  part,  is  not  to  be  overlooked  as  one  of  the 
problems  inherent  in  the  e.xtension  of  her  activities. 
Should  she  express  opinions  on  conditions  of  indi- 
N'idual  persons  even  when  coupled  with  a  warning 
to  "see  your  doctor?"  The  temptation  to  do  so 
is  great,  and  the  more  confidence  in  herself  which 
she  establishes,  the  more  frequent  and  insistent  will 
be  the  temptation.  Yet  she  will  be  the  first  to 
admit  that  she  is  not  ready  to  accept  the  full  re- 
sponsibilities of  such  a  relationship. 

"If  we  agree  that  vital  statistics  can  only  tell  us 
where  to  apply  therapeutics  and  not  how;  that  the 
healing  process  cannot  be  performed  by  means  of 
surveys:  that  a  person  with  public  health  training 
is  not  equipped  to  diagnose  or  prescribe,  then  we 
should  agree  that  in  the  last  analysis,  the  health  of 
the  community  will  depend  to  a  great  extent  on 
what  goes  on  in  the  doctor's  office  and  in  the  sick 
room.  No  other  situation  in  the  picture  can  be 
more  important.  Yet  no  other  situation  in  the 
picture  receives  less  popular  emphasis  outside  the 
strictly  medical  forum  of  the  medical  school,  the 
clinic  and  the  technical  journal. 

"I  do  not  decry  health  instruction.  It  is  of  value 
especially  when  it  results  in  action  on  the  part  of 
those  to  whom  it  is  directed,  which  is  not  always 
the  case.  Often,  I  fear,  it  either  unduly  frightens 
or  unduly  allays  disquietude.  Prevention  is  im- 
portant, but  the  most  effectual  prevention  is  not  a 
story  in  a  newspaper,  but  the  story  which  the  doc- 
tor tells  the  patient  after  he  has  examined  him. 
The  official  and  voluntary  agencies  do  well  to  create 
a  demand  for  preventive  medicine.  It  is  then  un- 
doubtedly the  province  of  the  doctor  to  administer 
these  measures. 

"The  delineation  of  functions  in  a  composite 
administrative  picture  is  never  an  easy  one — since 
human  beings  are  not  absolutes — which  may  be 
blue-printed  with  certainty.  The  head  of  a  great 
establishment  employing  thousands  of  persons  once 
e-xamined  a  chart  of  his  organization  on  which  he 
and  his  e.xecutives  had  labored  long,  and  said  with 
a  smile,  'This  all  looks  very  fine,  but  how  long  will 
we  be  able  to  keep  these  people  inside  their  little 
rectangles?'  He  might  also  have  asked,  'How  long 
would  I  wish  to  do  so,  if  my  organization  is  to 
continue  growing?' 

"Every  group  possesses  something  like  a  biologi- 
cal will  to  live,  and  tends  to  increase  its  powers,  as 
we  know  is  true  of  all  individual  life  on  this  planet. 


Every  group  has  the  virtue  and  the  vice,  the  insight 
and  the  blindness,  of  its  peculiar  species.  Death- 
rates  among  large  groups  are  meaningless  to  the 
physician  who  wakes  up  in  the  middle  of  the  night, 
asking  himself  if  there  could  be  anything  addi- 
tional that  he  might  have  done  for  the  cases  which 
are  most  upon  his  mind.  These  sick  people  are  his 
responsibility.  His  days  and  nights  are  occupied 
with  the  seriousness  of  this  responsibility.  When 
he  has  a  moment  to  spare  he  wishes  to  study,  to 
keep  up  with  the  march  of  medicine.  He  has  no 
time  to  devote  to  statistics  of  thousands  of  persons 
unless  he  is  specially  interested  for  some  reason 
other  than  clinical. 

"Persons  in  the  mass  are  not  his  responsibility. 
They  are  the  responsibility  of  public  health  au- 
thorities to  the  extent,  and  in  the  degree,  that  it  is 
possible  to  do  something  for  thousands  of  persons 
en  masse.  But  you  cannot  diagnose  thousands  of 
persons  as  thousands,  but  only  as  the  sum  of  indi- 
vidual diagnoses:  you  cannot  treat  the  diseases  of 
thousands  of  persons  except  as  the  sum  of  indi- 
vidual treatments:  therefore  the  public  health  func- 
tion ceases  where  diagnosis  and  treatment  begin.  I 
would  go  a  little  farther  and  say  it  ceases  when 
education  or  instruction  is  in  fact  construed  by  the 
recipient  as  diagnosis  or  treatment. 

"The  public  health  groups  and  voluntary  health 
organizations  have  done  an  excellent  job  of  teach- 
ing the  people  certain  scientific  facts  which  have 
not  only  sent  them  to  the  private  practitioner  for 
help  when  they  needed  it,  but  have  sent  them  better 
prepared  to  be  good  patients.  Taboos  are  being 
removed  which  kept  people  from  seeking  medical 
care,  especially  in  tuberculosis  and  syphilis.  In 
many  other  ways  the  medical  profession  should  be 
thankful  for  the  work  of  these  groups  which  are 
able  to  tell  the  public  things  which  the  doctor  can- 
not tell  them  without  loss  in  public  esteem,  and 
therefore  in  healing  ability.  However,  it  is  possible 
for  one  to  learn  and  teach  the  value  of  an  X-ray 
in  suspected  tuberculosis  without  really  knowing 
anything  about  X-rays.  The  word  'shadows"  may 
be  used  by  a  person  who  does  not  know  whether 
shadows  show  black  or  white  on  a  negative.  This 
is  merely  to  say  that  it  is  not  necessary  for  the 
salesman  of  preventive  medicine  to  know  how  to 
conduct  a  physical  examination,  just  as  a  man  can 
sell  automobiles  who  could  not  make  one.  By  the 
same  token,  care  should  be  exercised  that  these  of- 
ficial and  voluntary  groups  in  easy  access  to  the 
public  mind  do  not  become  substituted,  through 
identification  with  the  subject,  for  the  services 
which  only  a  trained  and  experienced  physician  is 
able  to  provide.  Wise  is  the  man,  be  he  the  doctor 
or  one  of  his  co-workers,  who,  with  Plato,  can  say, 
'What  I  do  not  know,  1  do  not  think  I  know.'  " 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


"We   Do  Not  Want   Security" 

It  seems  as  though  I  am  using  Ur.  Winslow's 
opinions  rather  freely  this  month;  but  the  follow- 
ing few  sentences  from  an  address  of  his  delivered 
for  the  Public  Relations  Bureau  of  the  New  York 
State  Medical  Society,  express  so  aptly  the  attitude 
of  the  independent  private  practitioner  that  I  want 
to  pass  it  on.  "The  advocates  of  socialized  med- 
icine lure  the  profession  with  the  siren  song  of 
bureaucratic  jobs,  assured  income — security — false 
security.  We  do  not  want  to  be  secure.  We  want 
to  remain  insecure.  We  want  to  continue  to  be 
required  to  give  our  very  best  to  every  patient,  or 
lose  out  in  the  gentlemanly  competition  which 
e.xists  within  our  ranks.  This  is  an  incentive  that 
operates  to  our  insecurity,  but  to  the  security  of 
the  patient.  We  prefer  the  discipline  of  private 
practice  which  keeps  us  on  our  toes,  to  an  assured 
income  under  bureaucratic  control  where  our  high- 
est ambition  is  more  likely  to  be  to  keep  ourselves 
solid  with  the  politicians  who  have  taken  over  the 
job  of  running  our  profession. 

"I  repeat,  security  for  the  doctor  means  insecur- 
ity for  the  patient.'' 

Duke's  Post  Graduate  Course 

Last  year  the  Duke  Medical  School  set  a  high 
standard  in  its  post  graduate  course  on  the  diges- 
tive system.  This  year  it  came  up  to  this  standard 
in  its  symposium  on  the  heart,  circulation  and  kid- 
ney. The  list  of  distinguished  speakers  included 
Doctors  Stewart  Roberts,  William  Porter,  F.  N. 
Wilson,  H.  L.  Blumgart,  C.  C.  Wolferth,  Claude 
Beck,  J.  C.  White,  M.  R.  Reid,  C.  J.  Wiggers,  J. 
E.  Wood,  W.  T.  Longcope,  W.  F.  Braasch,  Louis 
Hamman,  Hugh  Young,  and — last  but  by  no  means 
least — our  own  Bill  MacNider. 

It  would  be  too  great  a  task  to  undertake  to 
abstract  all  these  addresses,  and  unfair  to  select  a 
few  from  a  list  of  such  excellent  ones;  but  at  least, 
as  one  humble  guest,  I  wish  to  thank  our  gracious 
host,  and,  remembering  my  early  training,  say  that 
I  certainly  had  a  good  time.  The  large  attendance 
was  ample  evidence  that  the  invitations  were  ap- 
preciated. Let  us  hope  for  another  such  treat  next 
fall. 


-S.   M.    Si   6.- 


The  Diagnosis  of  Gout  and  Gouty  -Arthritis 


In  100  cases  of  gout  that  I  have  observed  an  average 
of  15  years  had  elapsed  from  the  first  attack  of  gouty 
arthritis  to  the  first  diagnosis  of  gout. 

The  first  attack  usually  appears  after  the  age  of  40  years. 
Its  onset  is  sudden.  It  generally  lasts  only  3  to  7  days 
and  then  disappears  completely.  A  large  toe,  or  with 
almost    equal    frequency,    another    joint,    may    have    been 


affected;  an  instep,  heel,  ankle,  or  knee.  After  a  year  or 
two  another  attack  appears,  often  more  severe  and  of 
perhaps  7  to  14  days'  duration.  Sooner  or  later  the  dis- 
ease increases  in  tempo  and  severity,  attacks  coming  every 
few  months.  At  first  attacks  have  little  tendency  to  invade 
another  region ;  later  attacks  may  be  frankly  polyarticular, 
another  region  being  affected  as  one  recovers.  Of  greatest 
diagnostic  import  (aside  from  the  discovery  of  tophi)  is 
that  after  a  variable  number  of  days  or  weeks  the  acute 
arthritis  disappears  with  no  symptomatic  residue. 

Five  to  40  years  (average  12  years)  after  the  first  attack 
joints  no  longer  recover  completely.  In  this  stage  the 
joints  at  first  are  subject  to  acute  exacerbations  with  in- 
complete remissions.  Finally,  exacerbations  cease  and  the 
patient  presents  misshapen  extremities  with  multiple  tophi, 
yet  the  joints  are  relatively  painless. 


CLINICAL  PSYCHIATRY 

Clavde  A.  BoSEMAN,  M.D..  Editor.  Pinebluff,  X.  C. 


Therapy  in  Modern  Psychiatry 

We,  as  physicians  of  whatever  special  branch  of 
medicine,  have  dedicated  ourselves  to  the  high  art 
of  treating  sick  people,  and  whatever  our  special 
interest  in  signs,  symptoms,  underlying  pathology 
or  prognosis,  we  do  hold  constantly  focused  in  our 
attention  this  dedication  to  the  healing  art.  And 
well  you  may  ask  of  psychiatry,  just  what  do  you 
have  to  offer  in  the  treatment  of  the  mentally  sick. 
I  have  been  asked  this  question  repeatedly  by  both 
patients  and  their  relatives,  and  ofttimes  have  been 
accused  of  doing  nothing  towards  treating  the  pa- 
tient. 

In  times  past  it  was  thought  that  all  that  could 
b^  done  was  to  lock  patients  up  in  asylums,  prevent 
their  injuring  themselves  or  others  and  look  after 
their  physical  well-being.  Gradually  this  attitude 
has  changed  until  today  a  carefully  planned  course 
of  psychiatric  therapy  is  considered  as  essential  as 
any  other  form  of  therapy.  It  is  my  purpose  to 
outline  briefly  this  system  of  therapy. 

It  has  long  been  known  that  drugs  are  of  little 
value  in  the  treatment  of  mental  illness.  The 
psychiatrist  does  feel  it  incumbent  upon  himself, 
however,  to  promote  the  physical  well-being  of  his 
patient.  Careful  physical  examinations  are  a  part 
of  all  psychiatric  examinations  and  physical  mal- 
adjustments are  corrected  as  far  as  possible.  The 
patient  must  oftentimes  be  built  up  and  tonics 
and  special  diets  are  useful.  Daily  free  bowel 
movements  are  promoted.  Chronic  constipation 
nearly  always  afflicts  the  neurotic  patient  and  in 
nearly  every  case  mineral  oil  over  a  long  period 
overcomes  this.  Insomnia  is  an  almost  constan' 
feature,  sometimes  so  extreme  that  for  weeks  th? 
patient  has  only  a  very  little,  disturbed  sleep.  Of 
all  drugs  barbital  is  probably  the  least  harmful 
over  a  long  period  and  generally  as  efficacious  as 


November,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


any.  Morphine  should  by  all  means  be  avoided 
in  the  neurotic  patient  because  he  is  entirely  too 
susceptible  to  the  drug  habit.  These  measures, 
along  with  others,  are  intended  to  build  up  the 
patient  physically  so  that  he  is  better  able  to  cope 
with  his  nervous  or  mental  disorder. 

Of  psychiatric  therapy  two  elements  of  great 
importance  are  time  and  the  removal  of  the  patient 
from  the  family.  Psychiatric  therapy  is  essentially 
"Of  Time  and  the  River."  The  human  personality 
has  flowed  on  endlessly  and  relentlessly  to  a  catas- 
trophe in  a  nervous  illness.  No  one  event  can  be 
ascribed  as  the  cause;  it  is  the  culmination  of  one's 
life  experiences.  Hence  it  is  impossible  to  correct 
in  a  few  weeks  or  often  a  few  months  a  personality 
or  an  attitude  or  a  reaction  to  reality  that  has 
taken  a  lifetime  to  build  up.  The  time  element  is 
just  as  important  in  psychiatric  therapy  as  it  is 
in  the  treatment  of  tuberculosis.  We  are  not 
amazed  that  a  tuberculous  patient  must  spend  a 
year  in  a  sanatorium  bed,  but  many  often  expect  a 
nervous  disorder  to  be  corrected  in  a  few  weeks. 
If  anything,  psychiatric  therapy  is  more  time-con- 
suming than  tuberculosis  therapy.  Too  often  rela- 
tives become  impatient  and,  since  the  patient  has 
not  recovered  in  a  few  weeks,  decide  they  should 
try  another  hospital,  or  give  the  patient  up  as 
hopeless  of  cure. 

The  mental  sickness  has  arisen  in  the  family  sit- 
uation and  it  is  essential  that  the  patient  be  re- 
moved from  this  situation  if  he  is  to  readjust,  to 
acquire  a  proper  perspective,  to  realign  his  emo- 
tional balance,  and  to  view  things  as  they  are,  life 
as  it  is.  The  schizophrenic  boy  with  the  over- 
fond,  over-attentive  mother  must  be  removed  from 
this  misguided  devotion:  the  depressed  husband 
must  be  removed  from  the  aggressive  wife;  the 
obsessional  wife  must  be  removed  from  the  husband 
whom  she  unconsciously  sexually  fears;  the  over- 
sensitive, unattractive  girl  must  be  removed  from 
the  attractive,  superior  sister  and  so  on.  Trips 
to  Florida  or  Bermuda  or  to  Europe  accomplish 
nothing  when  the  disturbing  member  of  the  family 
is  the  companion.  Often  the  family  physician  is 
perplexed  by  this  because  he  feels  that  the  family 
situation  is  aggravating  the  illness,  and  the  patient 
for  financial  or  other  reasons  is  unable  to  go  away 
to  a  hospital.  In  such  cases  probably  removal  to 
the  home  of  another  member  of  the  family  offers 
the  patient  his  best  chance  of  recovery. 

In  hospitals  for  nervous  and  mental  diseases, 
hydrotherapy  and  occupational  therapy  have  long 
been  widely  and  successfully  used.  Cold  wet,  sed- 
ative packs  and  continuous  baths  are  useful  for 
their  sedative,  relaxing  effect,  on  disturbed,  highly 
excited  patients,  and   in  the  treatment   of  depres- 


sions and  withdrawn  schizophrenics  as  well.  In 
these  latter  the  tension  is  inward  and  hydrotherapy 
affords  relaxation.  Continuous  baths  are  given  for 
a  few  hours  or  for  days  when  the  patient  is  highly 
excited.  Cold  packs  are  just  as  beneficial,  require 
no  exfjensive  apparatus  and  can  be  given  at  home. 
They  are  usually  arranged  by  wringing  out  a  sheet 
in  tap  water,  wrapping  it  around  the  patient  from 
his  neck  to  his  feet,  then  rolling  a  blanket  around 
the  patient  over  this.  During  the  treatment  even 
the  most  excited  patients  generally  relax  and  often 
go  to  sleep.  The  patient  can  be  taught  to  give 
himself  packs  at  home  and  many  continue  this 
after  having  seen  the  benefit  from  it  in  a  hospital. 

Occupational  therapy  is  any  activity  that  the 
patient  can  be  persuaded  to  engage  in.  All  mental 
patients  are  so  engrossed  with  the  activities  of 
their  own  minds,  or  their  emotions,  that  they  are 
unable  to  direct  their  attention  and  interest  out- 
ward. The  manic  type  of  manic-depressive  psycho- 
sis is  an  exception  to  this.  His  activities  must  be 
curbed.  Various  forms  of  occupational  therapy  are 
useful.  Arts  and  crafts  of  various  sorts,  manual 
work,  basketry,  weaving,  carpentry,  etc.,  are  use- 
ful. In  general  outdoor  work  is  most  beneficial, 
athletics  of  all  sorts,  gardening,  construction  of 
athletic  courts  or  walks  are  apparently  of  most 
benefit  and  especially  where  contact  with  the  soil 
is  involved. 

I  come  now  to  what  I  believe  is  the  most  im- 
portant psychiatric  therapeutic  measure,  namely: 
psychotherapy,  and  this  is  the  contribution  of  mod- 
ern psychiatry  to  therapy.  Several  generations  ago 
when  it  was  decided  that  the  insane  were  really 
sick  people  and  not  criminals,  our  insane  asylums 
became  mental  hospitals,  but  they  became  hospitals 
in  the  sense  that  they  concerned  themselves  with 
the  physical  well-being  of  the  patient  and  little 
with  the  mental.  Nurses  were  put  in  charge  who 
were  graduate  nurses  from  general  hospitals,  psych- 
iatric training  being  considered  non-essential.  The 
physicians  devoted  themselves  to  the  physically 
sick,  because  with  the  vast  number  committed  to 
their  care  they  had  little  time  for  the  mental  side 
of  the  illness.  However,  during  the  last  few  years 
there  has  been  a  great  impetus  given  the  study  of 
the  psychic  illness  of  the  patient.  An  enormous 
amount  of  literature  has  been  produced  dealing 
with  mental  mechanisms  and  human  behavior,  and 
this  psychotherapy  is  what  distinguishes  the  old 
from  the  new  psychiatry. 

Psychotherapy  consists  of  talking  with  the  pa- 
tient about  his  mental,  emotional  and  behaviour 
difficulties  and  by  frank  discussions  endeavoring 
to  arrive  at  an  understanding  of  the  process  in- 
volved in  the  illness  and  to  achieve  some  solution, 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


The  patient  is  asked  to  talk  frankly  and  freely 
of  the  things  that  are  on  his  mind,  to  hold  back 
nothing,  and  to  feel  that  the  physician  is  not  sit- 
ting in  judgment  but  is  sympathetically  attempt- 
ing to  treat  a  sick  person.  The  cooperation  of 
the  patient  is  essential.  Often  patients  will  come 
and  talk  for  days  without  really  disclosing  the 
topic  that  they  feel  is  the  real  cause  of  the  diffi- 
culty. Finally  the  anxiety  is  sufficiently  decreased 
and  the  sense  of  guilt  lessened  to  the  extent  that 
they  at  last  bring  themselves  to  talk  about  the  real 
worry.  The  process  requires  time,  but  the  results 
are  encouraging. 

Psychoanalysis,  about  which  all  of  you  have 
probably  heard  much,  is  a  form  of  psychotherapy. 
Probably  no  subject  related  to  medicine  has  been 
so  widely  discussed,  both  pro  and  con,  as  the  sub- 
ject of  psychoanalysis.  It  has  been  misrepresented, 
misunderstood  and  exploited  by  the  ignorant.  It 
has  been  presented  to  the  public  at  times  by  pan- 
derers  of  pornography,  the  subject  of  articles  in 
cheap  sex  magazines,  and  misunderstood  at  times 
by  members  of  the  medical  profession.  In  general 
psychoanalysis  is  considered  today  by  most  psych- 
iatrists as  a  useful  form  of  therapy  in  certain 
mental  disorders.  It  offers  the  most  complete  and 
thorough  exploration  of  the  psychic  life  and  the 
greatest  hope  of  permanent  cure.  The  treatment 
requires  generally  a  year's  time  at  least,  one  hour 
a  day  and  five  days  a  week.  Due  to  the  time  in- 
volved the  cost  is  necessarily  great;  but  to  those 
who  want  to  leave  no  stone  unturned  to  effect  a 
permanent  cure,  psychoanalysis  offers  the  greatest 
hop>e. 

To  family  physicians  or  specialists  in  other 
branches,  the  time  comes  often  when  treatment  of 
a  psychiatric  patient  becomes  a  matter  not  of 
choice  but  of  necessity.  Many  patients  cannot 
afford  to  go  to  a  psychiatric  hospital  and  the 
psychiatrist  is  often  remote.  Such  patients  must 
receive  help  from  the  family  physician. 

Most  of  the  theraf)eutic  measures  mentioned 
briefly  above,  with  the  exception  of  psychoanalysis, 
are  such  that  they  can  be  used  by  the  family  phy- 
sician at  home.  Psychoanalysis  is  a  measure  that 
should  be  used  only  by  one  trained  in  the  psycho- 
analytic technique.  These  therapeutic  measures 
pertain  mainly  to  the  psychoneuroses  and  functional 
psychoses.  Of  special  techniques  such  as  malarial 
or  heat  therapy  in  general  paresis  and  others  I 
have  made  no  note  here,  nor  have  I  included  any 
discussion  of  the  organic  psychoses.  When  brain 
cells  are  destroyed,  or  arteries  calcified,  no  therapy 
of  any  sort  is  likely  to  modify  the  condition  mate- 
rially. 

Psychotherapy  affords  the  greatest  hope  in  nerv- 


ous and  mental  conditions  modifiable  by  therapy. 
It  is  a  measure  that  can  be  used  at  home  or  in  the 
office  as  well  as  in  the  hospital.  To  one  willing  to 
e.xpend  both  time  and  patience  it  offers  not  only 
help  to  the  patient,  but  interesting  rewards  to  the 
physician.  The  patient  is  enabled  to  understand 
something  of  his  own  mental  mechanisms,  and  to 
acquire  a  tolerance  for  himself  that  makes  life 
more  endurable.  To  the  physician  comes  not  only 
the  reward  of  the  knowledge  of  a  patient  benefited 
by  his  effort,  but  interesting  sidelights  on  normal 
human  personality  in  general  that  may  well  make 
the  expenditure  of  time  and  patience  worth  while. 


INTERNAL  MEDICINE 

Paul  H.   Ringer,  A.B.,  M  D.,  F.A.C.P., 
Asheville,  N.  C. 


Steeptothrix  and  ;\Ionilia  Infections  as 
Clinical  Entities 

Under  the  above  caption  the  late  Dr.  Reuben 
Hayes  Irish,  of  Troy,  New  York,  presents  an  in- 
teresting paper  in  the  New  York  State  Journal  of 
Medicine  for  October  15th.  Dr.  Irish  states  as  his 
reason  for  bringing  the  matter  before  the  medical 
public  that  streptothrix  and  monilia  infections  are 
as  yet  all  too  insufficiently  recognized  as  being  defi- 
nite clinical  entities.  This  statement  the  editor 
would  heartily  endorse,  having  seen  many  cases 
erroneously  diagnosed  as  pulmonary  tuberculosis 
and  referred  for  treatment.  In  view  of  the  fact 
that  the  treatment  for  streptothrix  and  monilia  is 
diametrically  opposed  to  that  for  tuberculosis,  the 
making  of  the  faulty  diagnosis  leads  to  erroneous 
treatment.  Of  course,  the  primary  cause  for  failure 
to  make  the  proper  diagnosis  is  failure  to  bear  the 
conditions  in  mind.  When  tubercle  bacilli  are  not 
found  in  the  sputum  other  causes  of  infection  must 
be  sought,  and  these  organisms  can  be  identified  by 
proper  cultural  methods.     Dr.  Irish  says: 

"The  organisms  in  question  are  thread-like,  budding  or 
branching.  They  grow  slowly  in  culture  media,  yet  more 
readily  than  tubercle  bacilli,  take  carbol-fuchsin  stain  read- 
ily, and  usuallj"  resist  decolorization  by  weak  acids  and 
alcohol.  Care  must  be  taken  not  to  mistake  them  for 
branching  tubercle  bacilli  from  which  they  may  be  distin- 
guished by  their  longer  thread-like  form,  tendency  to  ap- 
pear in  loose  clusters  of  numerous  interlacing  filaments,  less 
resistance  to  acids,  greater  readiness  with  which  they  may 
be  cultivated,  and  results  of  animal  experimentation  in 
special  cases.  For  it  must  always  be  borne  in  mind  that 
they  are  frequently  contaminating  organisms  in  other  in- 
fections, apparent!}'  without  special  pathological  signifi- 
cance." 

Dr.  Irish  then  gives  nine  case  histories  in  consid- 
erable detail.  In  these  case  histories  are  included 
two  very  acute  cases  and  one  chronic  case  of  strep- 


November,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


tothrix  infection,  the  rest  being  monilia  infections. 
His  conclusions  are  interesting  and  practical: 

"Streptothrix  and  monilia  infections  are  frequently  defi- 
nite clinical  and  pathological  entities. 

Cultures  of  these  organisms  grow  slowly,  and  it  takes 
time  for  animal  e.xperimentation,  therefore  in  acute  pul- 
monary infections  our  chief  reliance  in  diagnosis  must  be 
upon  finding  these  organisms  predominating  in  the  smears 
from  the  sputum. 

In  subacute  or  chronic  infections,  diagnosis  should  be 
based  upon  cultural  findings  and  animal  experimentation. 

In  this  connection  the  experiments  of  Bast,  Hazard  and 
Foley,  of  Boston,  published  with  histories  of  three  cases 
and  an  extensive  bibliography,  are  worthy  of  note.  They 
prepared  an  antigen  for  intradermal  test  in  diagnosis,  and 
prepared  and  used  a  vaccine  in  the  treatment  of  pulmonary 
moniliasis.  This  is  a  very  interesting  experiment  and  may 
be  of  definite  service  in  both  diagnosis  and  treatment. 

These  infections  may  involve  not  only  bronchi,  lungs 
and  pleura,  but  also  joints,  the  gastrointestinal  tract,  men- 
inges of  the  spinal  canal,  or  the  general  blood  stream.  They 
show  a  marked  preference  for  the  respiratory  tract,  every 
case  which  I  have  reported  showing  some  involvement 
there.  There  is  also  a  marked  tendency  to  general  septic 
or  blood  stream  infection,  over  forty  per  cent,  of  the  cases 
reported  above  giving  a  positive  blood  culture.  These 
cases  have  convinced  us  that  the  primary  infection  in  the 
large  majority  of  cases  takes  place  through  the  respiratory 
tract  and  is  acquired  by  inhalation,  although  primary  in- 
fection may  take  place  in  operative  or  other  wounds,  or 
through  the  gastrointestinal  tract. 

Streptothrix  infections  seem  to  show  a  greater  tendency 
to  pus  and  abscess  formation  than  the  MoniUa  infection. 

I  think  there  is  no  doubt  that  iodide  in  some  form  is 
almost,  if  not  quite,  a  specific  drug  in  the  treatment  of 
these  infections.  Sodium  iodide,  by  preference,  should  be 
given  intravenously  in  the  ver\-  acute  cases,  or  where  there 
is  general  septic  infection,  and  sodium  or  potassium  iodide 
or  syrup  of  hydroiodic  acid  by  mouth  in  subacute  or 
chronic  infections.  Whenever  possible  the  patient  should 
first  be  tested  for  susceptibility  to  the  iodide  treatment. 

In  general,  I  believe  that  the  procedure  in  treatment  of 
these  cases  is  to  make  a  probable  diagnosis,  based  upon 
the  predominating  organisms  in  the  smears,  and  to  start 
treatment,  if  necessary,  before  the  diagnosis  is  confirmed 
by  cultures  and  animal  experimentation.  There  is  certainly 
nothing  to  be  lost  and  much  to  be  gained  by  this  method. 

In  conclusion,  I  believe  that  where  these  organisms  are 
definitely  found  as  the  predominating  organisms  in  smears 
and  cultures,  they  should  be  given  the  same  consideration 
as  one  would  give  the  streptococcus,  pneumococcus  or 
'Vincent's'  organisms  under  like  conditions." 

In  large  medical  centers  failure  to  recognize  these 
cases  is  not  frequent,  but  the  run-of-mine  practi- 
tioner is  apt  to  overlook  the  possibility  of  their 
existence  and  turn  at  once  to  the  far  more  common 
condition  of  tuberculosis.  It  is  appropriate  here  to 
refer  to  one  of  the  axioms  of  diseases  of  the  res- 
piratory system:  namely,  that  in  a  patient  who  has 
a  fair  or  a  large  amount  of  sputum,  which  on  re- 
peated examinations  is  continually  free  from  the 
presence  of  tubercle  bacilli,  in  all  probability  tuber- 
culosis does  not  exist. 


CHUCKLES 

Easily   Settled 
First  Imbiber — ^I  hound  (hie)  a  half  dollar. 
Second  Itifbriate — 's  mine,  's  got  my  name  on  it. 
"Wats  your  name?" 
"E.  Pluribus  Unum." 
"Yeah,  'sh  ours." 


.\  Southern  judge  was  perplexed  over  the  conflicting 
claims  of  two  Negro  women  each  of  whom  asserted  that 
a  certain  little  black  baby  belonged  to  her.  Finally  the 
judge  thought  of  Solomon  and  told  the  two  women  that 
he  would  divide  the  baby  in  two  and  give  each  of  them 
half.  They  were  so  shocked  that  they  both  screamed: 
"Don't  do  dat.  Judge.     You  kin  keep  him  yourself." 


"Did  the  defendant  use  improper  language  while  he  was 
beating  his  horses?"  asked  counsel. 

"Well,  he  talked  mighty  loud,  sah." 

"Did  he  indulge  in  profanity?  Did  he  use  words  that 
would  be  proper  for  a  minister  to  use  in  a  sermon?" 

"Oh,  yes,  sah,"  the  old  man  replied  with  a  grin,  "but 
dey'd  have  to  be  'ranged  in  different  order." — Postage  & 
the  Mailbag. 


"This  stuff  you  sold  me  might  be  all  right  for  some 
things,"  said  the  baldheaded  man,  "but  it  hasn't  brung  back 
my  hair.    Look  at  them  bumps  on  my  head." 

The  druggist  looked  at  the  label  on  the  bottle. 

"Great  Scott,"  he  gasped.  "I've  made  a  terrible  mistake. 
This  is  bust  developer." — Od  Quarterly. 


The  guards  set  about  their  task  of  affixing  the  electrodes 
to  the  body  of  the  doomed  man  in  the  chair.  The  kindly 
chaplain  bent  over  him. 

"Any  request,  my  poor  mortal?"  he  asked. 

"Yes,  parson,"  the  victim  replied.  "It'll  comfort  me  a 
lot  if  you'll  just  hold  my  hands." 


First  Westerner — Yes,  stranger,  I  lost  my  wife  in  a  card 
game. 

Second — What!  You  mean  you  put  her  up  as  a  stake? 

First — No.  She  trumped  my  ace  and  there  was  nothing 
to  do  but  shoot  her." 


Private    Detective — I    trailed    your    husband    into    three 
night  clubs  and  two  bachelor  apartments. 

Suspicious  Lady — Good  grief.     What  was  he  doing? 
Private  Detective — He  was  trailing  you. 


"Papa,  how  can  you  tell  when  men  are  drunk?" 
"Well,  my  son,  do  you  see  those  two  men  over  there — 
well,  if  you  were  drunk  they  would  look  like  four!" 
"But,  papa,  there  is  only  one." 


The  cat  drowsed  on  the  hearth  rug;  the  knitting  needles 
were  in  their  place  by  the  old  rocking  chair;  the  great 
grandfather  clock  struck  eight. 

Grandma — Now,  where's  that  gigolo? 


Kind  Old  Lady — Yes,  my  good  man,  I,  too,  have  had 
my   trials. 

Hank  (Hungry  but  Sympathetic) — Indeed,  ma'am.  And 
what  did  they  pinch  you  for? 


No  GOOD  comes  of  promising  the  impossible. 


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

"No."' 

"But  he  looks  different,  somehow." 

"He's  a  new  husband." 


SOUTHERN  MEDIQNE  AND  SURGERY 


November.   193.b 


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..  Editc 


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 
Eye,  Ear  and  Throat  Hospital  Group        Charlotte,  X.  C. 
Orthopedic   Surgery 

0.  L.  Miller,  M.D.  

John  Stuart  Gattl,  M.D. 


Charlotte,  N.  C. 


uroioa; 
HcKav,  M.D  I 
•Cay,  M.D.        I 


Charlotte,  N.C. 


Hamilton  W.  McKay, 
Robert  W.  McKay 

Internal    Medicine 
P.  H.  Ringer,  M.D.    Asheville,  N.  C. 


Geo    H.   Bunch,  M  D 

Obstetrics 
Henry  J    Langston,  M.D. 

Gynecology 
Chas.  R.  Robins,  M.D 

Pediatrics 
G.  W.  Kutscher,  jr.,  M.D. 

General   Practice 
Wingate  M.  Johnson,  M.D. 

Clinical  Chemistry  and   Microscopy 
C.  C.  Carpenter,  M.D. 


Hospitals 
Pharmacy 


R.  B.  Davis,  M.D. 

W.  Lee  Moose,  Ph.G.  

Cardiology 
Clyde  M.  Gilmore,  A.B.,  M.D. 

Public  Health 
N.  Thos.  Ennett,  M.D. 

Radiology 
Allen  Barker,  M.D.        I 
Wright  Clarkson,  M.D.  ( 

Therapeutics 
J.  F.  Nash,  M.D.  . 

Clinical    Psychiatry 
C.  A.  BOSEM.VV,  M.D.  .  Pinebluff,  N.  C. 


Columbia.  S.  C. 

Danville.  Va. 

Richmond.  Va. 

Asheville,  N.  C. 

Winston-Salem,  N.  C. 
:roscopy 
Wake  Forest,  .\.  C. 

Greensboro,  N.  C. 

Asheville,  N.  C. 

Greensboro,  N.  C. 

Greenville,  N.  C. 

Petersburg,  Va. 
Saint  Pauls,  N.  C. 


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  Depaitment  of  Engraving  all 
costs  of  cuts.  etc..  for  illustrating  an  article  must  be 
borne   by   the   author. 


Dr.  p.  T.  Beem.an:   He  Fed  Fever 

Several  years  ago  somebody  told  me  that  a  doc- 
tor -who  had  spient  his  years  of  practice  in  western 
Anson  County  had  fed  his  typhoid  fever  patients, 
and  that  the  words  "I  fed  fever"  were  cut  on  his 
gravestone.  Right  recently  this  information  was 
recalled  and  I  wrote  Dr.  J.  M.  Boyce  of  Polkton 
who  gave  ready  confirmation  and  offered  his  ser- 
vices in  getting  more  information:  so.  a  bright 
Sunday  in  the  early  fall  was  chosen  for  going  to 
Anson  and  looking  further  into  the  matter. 

As  we  drove  out  to  the  old  Beeman  homestead 
over  the  almost-abandoned  road  that  was  one  of 
the  main  highways  of  the  State  in  the  Old  Doctor's 
time.  Dr.  Boyce  told  me  what  little  he  had  been 
able  to  gather,  and  commented  on  the  independ- 
ence of  mind  and  moral  courage  the  Doctor  must 
have  had  to  have  enabled  him  to  go  counter  to 
the  fixed  ideas  of  all  those  who  made  up  his  pro- 
fessional world. 

We  talked  with  two  sons  of  Dr.  Beeman.  one 
of  whom  lives  alone  at  the  old  place,  and  they  said 
their  father  fed  his  fever  patients  a  full  diet.  We 
looked  into  the  office  built  out  in  the  corner  of 
the  yard  close  by  the  road,  and  saw  the  old  desk 
and  cot.  and  glass-stoppered  bottles  of  squills  and 
cream  of  tartar  and  Dover's  powder  just,  so  it 
seemed,  as  the  Doctor  had  left  them  a  third  of  a 
century  ago.  We  wondered  how  many  had  writhed 
in  pain  on  the  little  porch  while  awaiting  the  Doc- 
tor's return,  and  of  how  much  more  of  agony  had 
been  suffered  there  as  husband  or  father  cast  anx- 
ious eyes  up  and  down  the  road  by  which  must 
come  the  one  so  sorely  needed  by  wife  in  child-bed 
ccrvulsicns  or  child  v.ith  suffocative  croup. 


November,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


We  walked  across  the  road  to  the  family  grave- 
yard, where,  not  a  hundred  yards  from  his  work- 
shop, the  Doctor  takes  his  last  sleep.  The  older 
son  told  us  his  father  had  fed  his  fever  patients 
on  solid  food  and  that  he  had  seriously  charged 
him  that  he  wanted  only  the  three  words  "I  fed 
fever"  put  over  him;  and  his  wishes  were  carried 
out.  The  irregularities  seen  on  the  picture  of  the 
gravestone  below  the  inscription  with  some  appear- 
ance of  lettering  are  naught  but  mosses  and  shad- 
ows. 

\'olunies  have  been  written  on  feeding  in  fevers, 
to  feed  or  not  to  feed:  but  most  of  the  apparent 
divergences  of  opinion  were  distinctions  rather  than 
differences.  Generally,  those  who  championed 
feeding  gave  little  more  food  than  those  who  de- 
cried feeding,  as  is  revealed  by  detailed  examina- 
tion of  the  different  diets  prescribed. 

The  earliest  English  explorers — and  perhaps  the 
still  earlier  Spanish — to  come  into  intimate  con- 
tact with  the  American  Indians  recorded  that  these 
people  bathed  fever  patients  with  cold  water,  and 
at  least  one  chronicler  marveled  that  they  got  well. 

Twenty-five  years  ago  Dr.  Rufus  Cole  made  a 
careful  study  of  this  subject  and  he  tells  us  that 
the  discussion  began  before  Hippocrates  and  is 
not  yet  ended.  He  cites  Galen  as  having  said  that 
in  his  time  (about  200  A.  D.)  some  starved  their 
patients,  whereas  "Petronus  allowed  his  patients 
flesh  and  wine." 

Long  before  any  attention  was  paid  to  ulcerating 
Peyer's  patches,  the  orthodox  "antiphlogistic 
method'  required  depletion  by  bleeding,  purging, 
vomiting,  and  starving.  Especially  were  animal 
foods,  including  milk,  excluded  as  "heating." 

These  ideas  prevailed  with  little  material  change 
until  less  than  a  century  ago,  when,  under  the  in- 
fluence of  Graves  (1797-1853)  of  Dublin,  and 
prominent  members  of  the  English  school,  a  some- 
what more  liberal  diet  became  che  rule.  However, 
although  Stokes  (1804-1878)  has  left  a  record  that 
his  friend  Graves  once  said  to  him,  "Will  you, 
when  my  time  comes,  write  my  epitaph?  and  let 
it  be:  'He  fed  fevers,'  "  it  would  appear  that  he 
fed  them  very  abstemiously  and  wholly  on  liquids 
and  a  few  farinaceous  foods. 

Nathan  Smith,  of  Yale  (1762-1829),  regarded 
in  his  time  as  a  great  authority  on  tj^Dhoid  fever, 
gave  no  more  liberal  a  diet,  although  he  advocated 
cold  water  baths  and  cold  water  ad  libitum  by 
mouth:  while  the  reactionary  Chomel,  of  Paris, 
(1788-1858),  called  the  god-father  of  typhoid,  de- 
nied his  patients  liquids  even — a  practice  which 
extended  its  baleful  influence  even  to  our  own 
times. 

The  second  edition  (1831)  of  the  popular  Prac- 


tice of  Medicine  by  Dr.  John  Eberle  of  the  Ohio 
Medical  College,  advises  sponging  with  cool  water 
and  cool  acidulated  drink  in  quantity,  but  that  on 
no  account  shall  any  article  of  food  be  allowed 
other  than  barley  water,  thin  oatmeal  gruel  or  gum 
arable  dissolved  in  water! 

The  Theory  and  Practice  oj  Physic  (1848)  of 
Bell  and  Stokes  counsels  the  free  use  of  acidulated 
drinks  and  cold  baths;  but  the  feeding  with  "oyster 
liquor,  chicken  water  "  and  the  like  is  next  to  noth- 
ing. 

That  ambitious  German  work,  von  Ziemssen's 
Cyclopedia  oj  the  Practice  oj  Medicine  of  1874, 
while  recommending  cold  water  abundantly,  inter- 
nally and  externally,  would  have  the  diet  limited 
to  such  thin  and  non-nutritious  stuff  as  barley  wa- 
ter and  oatmeal  gruel. 

Austin  Flint's  Practice  (1884)  advises  all  the 
nutritious  food  that  can  be  assimilated,  but  says 
the  diet  should  consist  of  liquid  articles. 

Pepper's  System  oj  Medicine  (1885)  says  all 
solid  food  should  be  excluded  from  the  diet  so  long 
as  the  fever  lasts,  or  longer,  and  cites  disastrous 
results  from  a  too-early  return  to  solids. 

Hare's  Practice  (1905)  puts  its  trust  in  milk  and 
well-boiled  and  strained  rice,  cornstarch  and  barley 
gruel. 

.As  late  as  1907,  Thomas  McCrae  said  (Osier's 
Modern  Medicine)  that  a  great  many  more  typhoid 
patients  are  overfed  than  are  underfed,  and  that 
the  diet  should  be  liquid. 

Warren  Coleman,  of  New  York,  began  the  use 
of  high-calory  diets  in  1907  and,  ten  years  later, 
reported  shortening  of  the  convalescence  and  re- 
duction of  mortality  by  more  than  half  in  a  series 
of  222  cases. 

The  great  French  clinician,  Dieulafoy,  wrote  in 
1912  that  there  is  no  food  so  good  as  milk  in  this 
condition  and  advised  three  pints  daily. 

Osier's  Practice,  of  1912,  advises  a  liberal  diet 
including  bread  and  butter  and  mashed  potatoes, 
but  does  not  mention  meat. 

In  the  1925  edition  of  his  textbook,  Savill,  of 
London,  praises  milk  and  says  "no  solids.'' 

Cecil's  edition  of  1928  says  the  greatest  advance 
has  been  the  adoption  of  a  high-calory  diet  and 
that  milk  curds  may  cause  trauma  to  the  intestinal 
tract,  but  the  most  nearly  solid  food  he  prescribes 
is  mashed  potato. 

Beckman's  Treatment  (1930)  boldly  declares 
that  the  full  diet  is  the  greatest  contribution  of  all 
time  to  the  control  of  the  malady. 

A  contributor  to  The  London  Lancet's  issue  for 
January,  1930,  says  nothing  for  solids;  neither  does 
an  article  in  the  Kentucky  Medical  Journal  for 
November,  1933. 


SOUTHERN  MEDICINE  AND  SURGERY 


November,   1936 


This  sketch  affords  one  more  illustration  of  the 
well-established  but  much-disregarded  fact  that  the 
march  of  knowledge  has  not  been  a  steady  upward 
progress;  but  rather  a  series  of  alternating  progres- 
sions and  regressions,  with  a  little  tendency  up- 
ward. 

It  also  illustrates  the  tenacity  with  which  man- 
kind holds  on  to  erroneous  concepts  and  its  facility 
in  bringing  forward  new  arguments  to  support  such 
concepts  as  the  old  ones  fall  before  increasing 
knowledge. 

The  idea  that  the  fire  of  fever  had  best  be  not 
fed  with  fuel  and  that  animal  food  is  heating  can 
be  comprehended;  but  this  does  not  explain  the 
reluctance  to  give  cool  water  to  drink  and  to  allow 
cool  baths. 

The  only  theory  which  readily  explains  the  whole 
story  is  that  our  forefathers  in  the  profession  were 
dominated,  consciously  or  subconsciously,  by  the 
original-sin  idea  that  all  of  man's  natural  inclina- 
tions are  evil,  that  his  craving  for  water  and  food 
constituted  positive  proof  that  these  were  the  very 
worst  thinks  for  him.  What  idea  other  than  this 
could  have  been  so  compelling  as  to  have  caused 
otherwise  rational  men  to  ignore  the  patent  fact 
that  fever  meant  increased  combustion  and  that 
withholding  food  caused  the  body  to  consume  it- 
self?; and  that  withholding  water  caused  accumula- 
tion in  the  system  of  the  products  of  combustion? 
And  why  is  it  that,  although  the  injurious  consump- 
tion is  mostly  of  nitrogen  and  physiologists  have 
told  us  for  ever  so  long  that  meat  is  the  most  con- 
centrated and  most  easily  assimilable  of  nitrogenous 
foods,  and  that  at  the  time  of  passing  Peyer's 
patches  the  residue  of  ingested  meat  is  so  soft  as  to 
be  entirely  incapable  of  inflicting  trauma,  even  now 
doctors  fear  to  give  their  fever  patients  meat? 

It  seems  that  in  all  the  long  weary  stretch  of 
years  from  Rome's  Petronus,  of  the  Second  Century, 
to  North  Carolina's  Beeman,  of  the  Nineteenth, 
not  a  doctor  is  to  be  found  who  thoroughly  believed 
in  feeding  meat  to  his  fever  patients. 

The  fashionable  consultant.  Graves,  claimed  to 
have  fed  fevers,  but  the  feeding  was  with  mighty 
thin  stuff,  little  different  from  that  given  by  every- 
body else  of  his  time.  The  country  doctor,  Beeman, 
fed  his  patients  on  meat  and  other  solids  and  almost 
certainly  brought  down  on  his  head  the  wrath  of 
all  the  doctors  round  about. 

A  search  of  the  Transactions  of  the  Medical  So- 
ciety of  the  State  of  North  Carolina  discovers  no 
mention  of  Dr.  Beeman.  Most  likely  this  is  ex- 
plained by  his  retiring  within  himself  as  a  protec- 
tion against  the  attacks  of  the  ultra-orthodox,  who 
can  be  counted  on  to  denounce  and  persecute  all 
those  who  earnestly  seek  more  light. 


I  wish  I  knew  more  about  this  country  doctor, 
who  is  here  commemorated  that  he  not  be  allowed 
to  sink  into  oblivion.  Such  qualities  as  his  should 
not  be  forgotten,  but  remembered  and  emulated. 


.A  Promising  Treatment  for  Epilepsy 

The  oldest  medical  writings  contain  accounts  of 
epilepsy.  The  ancients  called  it  variously  the  sac- 
red disease,  the  disease  of  assemblies,  the  disease 
of  the  dining-table,  the  disease  of  the  star-struck 
and  the  dangerous  disease.  Every  doctor  of  ex- 
perience can  understand  the  implications  carried 
by  each  name.  Old  sturdy,  sensible  Hippocrates 
had  no  hesitancy  in  saying  there  was  nothing  sacred 
about  it.  Julius  Caesar's  "falling  sickness"  has 
been  attributed  to  epilepsy;  but  that  a  victim  of 
epilepsy  could  so  long  retain  such  physical  and 
mental  stamina  is  highly  improbable:  indeed,  it  is 
questionable  whether  the  mighty  Julius  had  any 
disease  whatsoever. 

It  has  been  and  remains  a  terrible  affliction  of 
all  times  and  all  races.  Today  there  is  hardly  a 
civilized  State  that  does  not  maintain  a  large  in- 
stitution for  their  care,  and  the  total  number  of 
those  so  diseased,  and  the  unsatisfactory  results  of 
the  present  methods  of  treatment  make  us  welcome 
any  suggestion  holding  out  promise  of  betterment. 

A  few  weeks  ago  there  came  from  a  former 
comrade-in-arms,  since  turned  physician.  Dr.  Or- 
pheus Wright  of  Winston-Salem,  a  report  of  his 
management  of  a  case  of  epilepsy  of  the  grand  ma! 
type  by  a  method  new  to  us  and  with  results  to 
date  of  the  greatest  encouragement.  This  report 
is  carried  on  page  599  of  this  issue.  It  will  bs 
noted  that  Dr.  Wright  makes  no  extravagant 
claims:  he  writes  down  the  facts  and  passes  them 
on  for  possible  help  to  other  doctors  and  their  pa- 
tients. 

Reading  his  report  one  must  be  impressed  by 
that  alertness  to  learn  how  to  better  care  for  his 
patients,  which  is  the  distinguishing  characteristic 
of  the  real  doctor. 

\\'hether  or  not  these  patients  will  remain  cured 
no  one  knows;  but  if  their  convulsions  were  to 
return  tomorrow  in  full  force,  the  good  derived  so 
far  abundantly  justifies  the  trial.  .Any  epileptics 
coming  under  our  care  will  get  this  mode  of  treat- 
ment until  and  unless  some  contraindication  ap- 
pears which  is  not  now  discernible  on  the  horizon. 

Perusal  of  the  Cumulative  Medical  Index  since 
1916  (combined  with  Index  Medicus  since  1927) 
revealed  only  one  article  on  the  subject,  this  in  the 
Proceedings  oj  the  American  Association  on  Mental 
Deficiency  for  the  year  1934.  We  wrote  the  secre- 
tary and  he  informed  us: 


I 


November,   1P36 


SOUTHERN  MEDICINE  AND  SURGERY 


"My  Dear  Dr.  Northington: 

I  am  sending  a  copy  of  this  card  directly  to  Dr. 
E.  A.  Whitney  at  Elwyn,  Pennsylvania,  under 
whom  Drs.  Shick  and  Huniker  work,  asking  that 
he  send  a  copy  to  you  of  their  reprint."  But  noth- 
ing has  come  from  Dr.  Whitney. 

There  is  not  a  hint  on  the  subject  in  Osier's  sys- 
tem. Modern  Medicine  (1910),  or  Osier's  own 
Practice  oj  Medicine  (1912),  or  Musser  and  Kel- 
ley's  Treatment  (1913),  and  the  Superintendent  of 
the  Virginia  Colony  for  Epileptics  says  he  has  never 
heard  of  the  method.  No  reply  has  come  from 
South  Carolina  or  North  Carolina  authorities.  As- 
tonishingly, Dr.  Frederick  P.  Henry's  revision 
(1894)  of  Flint's  Practice  carries  this  pertinent  in- 
formation: 

"Remarkable  statements  have  been  recently  made  con- 
cerning the  curative  effect  upon  epilepsy  of  Pasteur's  anti- 
rabic  inoculations.  Two  children  who  had  been  bitten  by 
rabid  dogs  were  treated  at  the  Pasteur  Institute  in  Paris, 
with  the  result  of  curing  them  of  epilepsy.  Charcot,  hear- 
ing of  this  accidental  discovery,  sent  to  the  Pasteur  Insti- 
tute an  inveterate  epileptic  aged  12.  .\fter  6  days'  inocula- 
tion treatment  the  attacks  ceased  entirely,  and  had  not 
returned  2  weeks  later,  at  the  time  the  case  was  reported. 
The  beneficial  effect  is  probably  due  to  the  ner\'e-matter 
contained  in  the  inoculation  fluid,  for  Babes  of  Bucharest 
has  treated  6  cases  of  epilepsy  with  subcutaneous  injections 
of  aseptic  nerve-matter  from  the  brain  of  the  rabbit  and 
sheep,  and  with  benefit  in  every  case.  This  novel  addition 
to  the  therapeutics  of  epilepsy  demands  the  fullest  investi- 
gation." 

This  reference  to  the  use  of  this  treatment  in 
Paris  caused  us  to  look  hopefully  to  see  what  might 
be  found  in  the  Text-book  of  Medicine  (1912)  of 
G.  Dieulafoy,  Professor  of  Clinical  Medicine  at  the 
Faculte  de  medicine  de  Paris:  but  not  a  word  I 

It  would  seem  impossible  that  such  a  trial  at  the 
Pasteur  Institute  would  not  be  followed  up,  and 
impossible  that,  whatever  the  results  in  further 
cases,  they  would  fail  to  be  reported  in  any  of  the 
records  searched.  If  further  use  of  the  method 
proved  beneficial,  certainly,  the  expectation  would 
be  that  it  would  be  proclaimed  round  the  world: 
if  ineffectual  or  harmful,  one  would  expect  to  see 
mention  made  of  its  trial  as  a  historical  event. 

Whatever  be  the  answer.  Dr.  Wright  has  done  a 
highly  creditable  piece  of  scientific  work:  he  has 
done  his  patient  inestimable  good:  and  we  are 
proud  of  him  for  North  Carolina  Medicine. 

And  when  we  or  our  patients  develop  epileptic 
fits,  rabies  vaccination  is  going  to  get  a  hopeful 
trial. 


WnE.N  the  arteries  to  the  foot  are  diseased  little  or  no 
increase  of  flow  may  be  brought  about,  but  the  warming 
uill  increase  the  metabolism  and  thus  increase  the  blood- 
flow   requirement. — Sir   Thomas  Lewis. 

s.  M.  &  s. 

Carbon  tetrachloride  will  loosen  adhesive  plaster  from 
the  skin  and  make  its  removal  painless. 


On  Choosing  Medicine* 

Gentlemen: — I  use  the  term  advisedly,  and,  it 
might  be  said,  against  advice,  in  preference  to 
fellows,  boys,  comrades,  or  any  of  the  other  pop- 
ular luncheon-club  terms  which  are  alleged  by 
the  go-getters  to  break  down  defenses,  and,  in  their 
vernacular,  "sell  myself"  to  you — I  have  been  ask- 
ed to  talk  to  those  of  you  students  who  are  inter- 
ested in  the  Practice  of  Medicine  as  a  means  of 
livelihood. 

I  am  not  come  to  offer  advice.  My  honored 
father,  in  whose  wisdom  I  have  more  and  more  of 
confidence  as  the  years  go  by,  has  often  told  me 
to  be  chary  of  giving  advice;  for,  he  says:  "If 
one  follows  advice  and  it  turns  out  well,  he  attrib- 
utes the  result  to  his  own  good  judgment;  if  it 
turns  out  badly,  he  blames  you  for  leading  him 
into  the  wrong  course." 

It  is  a  privilege  to  commune  with  the  students 
of  Davidson,  an  institution  founded  and  supported 
by  the  voluntary  contributions  of  earnest  men,  who 
realized  that  the  broadening  of  the  understanding 
is  among  the  highest  of  human  endeavors,  and 
which,  throughout  its  life,  has  carried  out  the  pur- 
pose of  its  founders. 

Lack  of  familiarity  with  the  particular  circum- 
stances of  its  foundation  and  early  history  makes 
it  impossible  that  I  quote  from  the  expressions  of 
these  great  men  dead  and  gone,  but  one  need  not 
draw  unduly  on  his  imagination  to  realize  that  this 
institution  was  founded  that  there  might  be  light, 
that  life  should  be  more  abundant. 

Our  present  great  Chief  Justice  of  the  Supreme 
Court  of  the  United  States  has  advised  the  bright 
men  who  contemplated  going  into  professions  to 
choose  The  Law.  At  the  time  Mr.  Taft's  advice 
appeared  in  the  papers  my  mind  registered  the 
opinion  that  he  was  not  as  wise  as  I  had  thought 
him.  It  is  true  that  the  issues  in  a  case  in  court 
are  probably  more  influenced  by  the  relative  men- 
tal abilities  of  the  opposing  counsel,  than  are  they 
in  a  case  of  illness  by  the  learning  of  the  doctor 
in  charge;  for  Death  cannot  be  stayed  by  argu- 
ment, or  clever  playing  on  human  passions,  and 
in  our  trials  juries  cannot  be  packed.  In  our  work 
there  are  many  imponderables.  A  great  nation 
went  to  its  destruction  because  heed  was  not  paid 
to  its  most  subtle  statesman  when  he  advised  the 
sovereign:     "Sire,  beware  the  imponderables.'' 

Most  of  those  of  you  who  have  it  in  mind  to 
become  doctors  of  medicine  most  likely  are  includ- 
ed in  two  classes:  on  the  one  hand,  those  who  note 
the  prominence,  honors  and  wealth  attained  by 
specialists  in  medicine;  on  the  other,  a  few  so  rarely 

•A  talli  to  the  Class  of  11127  iit  Davidson  College,  now 
published  for  the  first  time  at  request. 


SOUTHERN  MEDICINE  AND  SURGERY 


November,   1936 


constituted  as  to  crave  the  greatest  opportunity 
life  offers  to  go  about  continually  doing  good. 
And  this  is  a  providential  arrangement  in  accord- 
ance with  the  great  idea  of  both  extremes  being 
accepted  and  the  mean  rejected  which  pervades  so 
much  of  life;  "So  then  because  ye  are  lukewarm 
and  neither  cold  nor  hot,  I  will  spue  thee  out  of 
my  mouth." 

The  man  of  exceptional  ability  who  will  apply 
himself  assiduously  has  nothing  to  fear  in  any  line. 
The  commonly  heard  statement  that  a  certain  per- 
son is  a  born  doctor,  if  it  be  taken  to  mean  that  to 
this  end  was  be  born,  is  obviously  absurd.  An 
unfeigned  sympathy  for  suffering  and  an  unselfish 
willingness  to  relieve  it  does  constitute  a  predilec- 
tion to  medicine  as  a  vocation  and  give  the  pos- 
sessor of  these  qualities  a  great  advantage — an  ad- 
vantage which  is  realizable  to  his  prospective  pa- 
tients far  more  than  to  himself,  except  he  be  one 
of  those  serene  souls,  living  on  the  heights,  to 
whom  the  gods  have  given  it  to  know  the  truth  of 
Cato's  observation: 

"  'Tis  not  in  mortals  to  command  success; 
But  we'll  do  more  Sempronius, — 
We'll  deserve  it." 
There  is  ample  room  in  Medicine  for  the  play 
of  the  intellect  of  even  a  Lord  Bacon.     Some  of 
you  may  be  deterred  by  the  thought  that  little  re- 
mains to  be  discovered.     There  is  a  well  authenti- 
cated story  that,  within  the  first  50  years  of  the 
foundation  of  our  national   government,  an  over- 
cautious employe  of  the  patent  office  resigned  his 
position    because    he    thought   everything    possible 
had  been  patented,  and  he  wanted  to  get  into  some 
employment  with  a  future.    Consider  the  important 
bearing  on  your  daily  life  of  things  which  have 
been  invented  since  that  timel 

In  the  advances  in  ^Medicine  you  will  be  pecul- 
iarly interested.  In  the  view  of  the  knowledge 
we  have  today,  George  Washington's  premature 
death  was  unnecessary:  Stonewall  Jackson  died  at 
Chancellorsville  because  surgery  had  not  learned 
the  management  of  an  infected  wound:  and,  even 
as  late  as  the  shooting  of  McKinley  at  Buffalo, 
there  is  every  reason  to  believe  that  had  a  good 
surgeon  of  today  been  there,  he  had  not  died. 

How  much  greater  the  triumphs  of  medicine,  as 
distinguished  from  surgery!  It  should  be  said  here 
that  nine  out  of  every  ten  of  the  advances  of  sur- 
gery were  made  possible  by  the  laborious  researches 
of  men  in  medicine  or  the  medical  specialties.  It 
astonishes  most  hearers  to  learn  that,  prior  to  the 
40's  of  the  last  century  there  was  no  such  thing 
known  as  a  general  anesthetic.  Amputations  made 
up  a  great  part  of  the  surgery  of  that  time;  when 
it  became   necessary   to   perform  one   the  patient 


was  given  a  dose  of  laudanum  and  whiskey,  strap- 
ped to  a  table — and  the  horror  proceeded.  Kindly 
Nature  frequently  arranged  that  fainting  would 
supervene.  There  was  no  surgery  of  the  abdomen 
until  about  1870,  when  the  investigations  of  the 
Chemist,  Pasteur,  on  the  nature  of  fermentation 
and  putrefaction,  made  it  possible. 

Following  the  lead  of  Pasteur,  who  had  dealt  a 
killing  blow  to  the  teaching  that  even  the  simplest 
life  could  originate  de  novo,  Medicine  has  made 
advances  in  such  and  importance  as  to  be 
scarcely  comprehended.  Diphtheria  had  carried  off 
an  average  of  one  child  in  every  household;  infants 
born  of  mothers  with  gonorrhea  never  saw  the 
light  of  day;  typhoid  was  a  regular  summer  visitant 
and  its  great  toll  of  life  was  accepted  as  natural 
(if  not  indeed  ordained  of  God);  there  was  no 
preventive  of  lockjaw;  those  bitten  by  rabid  dogs 
died  horrible  deaths;  syphilis  filled  our  institutions 
for  those  with  mental  disease  and  the  diagnosis 
was  general  paralysis  of  the  insane;  scarlet  fever 
killed,  deafened  or  invalidized  unhindered. 

Contemplating  these  things  you  must  realize  that 
much  has  been  accomplished,  but  look  at  the  other 
side  of  the  picture.  Allowing  for  the  opinions  of 
those  who  hold  that  conditions  of  wearing-out 
should  not  be  called  diseases  at  all,  that  they  are 
essentially  beneficent  in  that  they  remove  those  no 
longer  useful  and  that  little  can  be  done  to  stay 
their  hand,  so  much,  obviously,  remains  to  be  done 
as  to  make  it  plain  that  the  harvest  is  plenteous. 
The  great  problems  of  tuberculosis,  cancer,  deaths 
in  childbed,  influenza,  pneumonia  and  all  the 
psychoses  (to  mention  but  a  few)  await  solution. 

The  expense  of  an  education  in  medicine  today 
is  truly  terrific,  even  though  endowments  and  ap- 
propriations discharge  the  major  portion.  How- 
ever, an  earnest  and  ambitious  student  should  not 
allow  this  consideration  to  discourage  him.  In 
practically  every  medical  school  of  high  order,  op- 
portunities are  open  for  qualified  men  who  are 
willing  to  work  to  make  their  own  way.  Many  do 
this  by  teaching  in  physics,  chemistry,  botany,  an- 
atomy or  other  elementary  branches;  some  by  con- 
ducting private  classes;  some  by  obtaining  schol- 
arships; and  some  by  waiting  on  table.  One  of 
the  most  prominent  ear  and  throat  specialists  in 
New  York  today  worked  at  night  in  a  telephone 
exchange  to  make  his  way  through  medical  school. 

So  it  rather  comes  to  the  point  of  whether  or 
not  you  wish  to  follow  the  practice  of  medicine  as 
a  means  of  showing  your  reason  for  being.  Before 
deciding  this  question,  each  for  himself,  weighty 
matters  should  be  considered. 

The  practice  of  medicine  is  a  far  more  private 
thing  than  is  the  practice  of  any  other  profession. 


N'ovember,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


The  work  of  the  engineer,  the  architect,  the  lawyer 
or  the  clergyman  is  much  more  under  the  eye  of 
the  public.  Consultations,  referring  for  special  ex- 
aminations, and  hospital  records  do  much  toward 
letting  in  the  light  which  is  welcomed  by  the  com- 
petent. 

In  former  times  it  was  entirely  possible  for  a 
doctor  to  see  a  patient  at  his  home  in  a  chill,  make 
a  diagnosis  of  malaria  and,  when  the  fever  con- 
tinued, add  the  diagnosis  of  typhoid:  then,  if  the 
patient  recovered,  all  was  well,  for  it  was  assumed 
that  the  doctor  must  have  treated  him  for  the 
right  disease  or  he  would  have  died;  if  the  patient 
died  he  was  buried,  and  no  one  ever  knew  for 
certain  whether  or  not  he  had  either  of  the  diseases 
diagnosed.  This  is  not  said  in  disparagement  of 
the  doctor.  It  is  calling  attention  to  indisputable 
facts.  Necessarily  when  this  was  continued  over 
many  years  the  doctor  grew  to  look  upon  himself 
as  infallible,  just  as  the  Kaiser  regarded  himself  as 
the  peer  of  Alexander,  Caesar  and  Napoleon,  and 
as  ''Admiral  of  the  Atlantic"  because  no  one  dared 
tell  him  the  contrary.  The  means  of  publicity 
mentioned  have  done  much  to  correct  this  dogma- 
tism. With  their  increase,  and  particularly  with 
the  increase  in  post-mortem  examinations,  will  come 
more  correction  of  this  error.  There  is  nothing  so 
chastening  to  the  cock-sure  doctor  as  the  revela- 
tions of  the  dead  house.  We  of  the  South  are  but 
shortening  our  own  days  when  we  allow  any  con- 
sideration to  cause  us  to  oppose  investigation  of 
the  dead  body  for  explanation  of  the  cause  of 
death. 

It  is  a  standard,  and  very  poor,  joke  that  doc- 
tors frequently  disagree.  Let  us  see  how  it  is  with 
other  so-called  learned  men.  The  Supreme  Court 
of  the  United  States  is  supposedly  picked  from  the 
most  learned  members  of  the  bar  in  all  this  wide 
land.  In  a  recent  decision  of  great  importance  to 
dfKtors  and  their  patients  (which  is  only  another 
way  of  saying  to  all  us  hundred  million  Americans) 
five  were  on  one  side  and  four  on  the  other.  Did 
anyone  ever  hear  of  such  a  division  among  cross- 
roads doctors?  And  this  is  far  from  being  a  unique 
case.  Off-hand  I  cannot  recall  an  instance  in  which 
there  has  been  rendered  a  unanimous  opinion  by 
the  Supreme  Court  of  the  United  States  or  of  the 
State.  I  will  only  mention  the  disagreements  of 
theologians,  that  it  may  not  be  thought  that  they 
have  been  overlooked. 

That  doctors  err  often  is  but  another  way  of 
saying  that  their  judgments  are  fallible  and  their 
problems  complex.  We  have  our  charlatans,  our 
wind-bags  and  our  knaves;  what  profession  has 
not?  Like  sunburn,  baldness,  insurance  agents  and 
boosters — these  are  things  to  be  endured,  not  es- 


caped. 

My  earliest  conception  of  a  doctor's  life  was 
gained  from  seeing  a  great-uncle  going  about  on 
his  calls,  on  fox  hunts,  on  barbecues  and  fishing 
trips.  It  looked  like  a  very  pleasant  way  of  spend- 
ing life,  and  doubtless  was.  I  rode  in  a  fox  hunt 
with  my  doctor  kinsman  and  his  brother,  my 
grandfather,  when  they  were  both  past  seventy. 

In  his  delightful  account  of  his  experiences  as  a 
surgeon  for  the  Confederacy,  my  dear  old  friend 
Dr.  William  H.  Taylor  succinctly  describes  the 
medical  practice  of  the  time.  He  says  a  ball  of 
blue  mass  was  carried  in  one  breeches  pocket  and 
a  ball  of  gum  opium  in  the  other;  that  diagnosis 
was  made  by  the  single  question,  "How  are  your 
bowels?",  and  blue  mass  or  opium  was  given  ap- 
propriately. This  simplicity  has  given  place  to  a 
complexity  bewildering  to  contemplate.  Happily 
there  are  signs  of  partial  relief;  but  we  cannot 
hope  for  a  return  of  the  good  old  days. 

In  the  last  hundred  years  more  was  learned  about 
the  nature  and  cure  of  disease  and  the  relief  of 
suffering,  than  in  all  the  centuries  before.  To  pros- 
pective students  it  may  be  well  to  tell  you  that  it 
is  not  necessary  to  carry  in  your  mind  many  of 
the  facts  of  medicine:  you  must  only  know  where 
to  look  them  up. 

Those  who  adopt  Medicine  as  a  vocation  thereby 
declare  themselves  champions  of  science,  and 
should  be  prepared  to  defend  it  against  the  assaults 
of  the  uninstructed  and  the  misled.  Unless  he  is 
willing  to  do  this  no  one  can  be  happy  in  medicine. 
There  is  no  antagonism  between  science  and  re- 
ligion, and  the  best  friends  of  both  must  deeply 
deplore  attempts  to  array  them  in  opposition  to 
each  other.  It  is  difficult  to  understand  how  one 
can  regard  the  individual  creation  of  man  as  a 
nobler  concept,  than  that  he  is  the  culmination  of  a 
long,  orderly  and  stately  series  of  developments. 
Whether  or  not  the  latter  belief  is  literally  true  is 
a  matter  of  no  real  concern.  The  theory  explains 
so  much  that  is  necessary  for  the  daily  work  of 
doctors  that  we  shall  hold  to  it,  and  use  the 
knowledged  gained  thereby  in  the  curing  of  Greek 
and  barbarian,  without  discrimination. 

The  concern  of  doctors  with  man's  kinship  to 
other  animals  is  a  vital  one.  Until  this  kinship 
was  recognized  little  interest  was  taken  in  animal 
experimentation,  for  results  in  other  animals  were 
not  regarded  as  translatable  to  man.  In  the  little 
more  than  a  century  just  past  such  advances  have 
been  made  as  to  astound  every  student  who  looks 
into  the  matter.  Some  time  ago  I  came  across  a 
letter  written  by  a  citizen  of  Charlotte  in  1850 
giving  some  account  of  a  smallpox  epidemic  then 
prevailing.     In  this  letter  it  was  stated,  "All  pur- 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


suits  of  the  town  are  completely  paralyzed;  the 
spirits  of  our  people  are  demoralized,  our  town  in 
the  course  of  another  week  will  be  entirely  dispop- 
ulated."  Our  protection  against  a  return  of  such 
a  condition  lies  in  the  recognition  on  the  part  of  a 
doctor  that  cowpox  could  readily  infect  man  and 
its  relationship  to  smallpox  is  close  enough  that 
those  who  have  had  cowpox  are  no  longer  suscep- 
tible to  smallpox.  That  is  a  long  story  worthy  of 
your  study  as  citizens  and  leaders  of  thought.  The 
general  opinion  is  that  the  danger  from  the  small- 
pox of  today  is  negligible.  Our  United  States  has 
the  largest  incidence  of  smallpox  of  any  country 
called  civilized,  and  last  year  there  was  an  epidemic 
in  this  country  in  which  more  than  30  per  cent,  of 
those  having  the  disease  died. 

For  the  attainment  of  the  knowledge  which  en- 
ables us  to  prevent  and  cure  diphtheria,  scarlet 
fever,  typhoid,  erysipelas  and  diabetes  mellitus; 
and  to  ward  off  the  horrors  of  lockjaw  and  rabies, 
it  was  requisite  that  the  research  worker  realize 
the  close  kinship  between  Homo  sapiens  and  some 
of  his  humble  friends,  and  that  his  labors  not  be 
brought  to  naught  by  the  mistaken  zeal  of  those 
who  did  not  understand. 

You  who  are  to,  be  doctors  will  have  a  special 
responsibility  to  the  sick,  and  will  place  yourselves 
under  obligation  to  champion  their  causes,  however 
unpopular  it  may  be  and  from  whatever  direction 
attacks  on  their  interests  may  come. 

Many  will  tell  you  that,  unless  you  are  eager  to 
serve  the  best  earthly  interests  of  mankind  without 
thought  of  gain,  you  are  not  worthy  to  tread  in 
the  footsteps  of  the  Fathers  of  Medicine.  What 
such  a  frame  of  mind  really  qualifies  one  for  is 
treatment  at  the  hands  of  one  who  understands 
vagaries  of  the  mind.  Certainly  a  doctor  should 
be  compassionate,  and  responsive  to  all  legitimate 
appeals  to  sympathy;  but  this  does  not  at  all  mean 
that  he  should  allow  public  opinion,  or  any  other 
influence,  to  make  him  assume  the  burden  of  all 
those  who  choose  to  call  him  and  cannot  or  will 
not  pay,  any  more  than  should  the  grocer  respond 
in  like  manner  with  food,  the  clothier  with  vest- 
ments, the  coal  dealer  with  fuel,  or  the  banker 
with  money.  All  these  make  contributions  to  the 
support  of  charities  through  gifts  of  money  and 
through  taxation,  and  so  does  the  doctor:  when  it 
becomes  necessary  that  a  charity  organization  sup- 
ply a  needy  family  with  food,  fuel  or  clothing,  it 
is  paid  for  at  the  market  price;  but  I  never  knew 
of  a  doctor  receiving  anything  from  such  a  source. 
This  is  manifestly  unjust;  and  there  is  good  reason 
to  regard  Justice  as  a  much  nobler  quality  than 
the  sloppy  sentimentality  which  often  passes  under 
the  name  of  either  Mercv  or  Charity. 


Every  man  who  intends  to  go  into  Medicine 
should  have  a  training  in  business  methods.  A 
summer  in  a  bank,  a  department  store,  or  a  col- 
lecting agency  will  prove  immensely  profitable. 
Much  time  may  be  well  spent  with  a  seasoned 
general  practitioner  whose  experiences  have  brought 
understanding  of  the  meaning  of:  "What  is  man, 
that  thou  art  mindful  of  him?"  Such  a  doctor 
knows  men's  hearts  as  they  are,  "deceitful  above 
all  things  and  desperately  wicked";  but,  in  his 
lovable  easy-going  way,  he  ministers  to  all  those 
calling  him  as  though  he  regarded  the  worst  of 
them  as  but  a  little  lower  than  the  angels.  With 
great  advantage  may  his  virtues  be  emulated  and 
his  mistakes  avoided. 

The  practice  of  medicine  brings  many  rewards 
aside  from  those  which  can  be  deposited  at  the 
bank  and  drawn  on  for  food,  shelter  and  transpor- 
tation. Humankind  is  impulsively  kindly.  It  is 
not  reasonable.  The  most  treasured  member  of  the 
family  may  die  under  your  care;  and  if  it  so  be 
that  you  have  shown  interest  and  concern,  you  be 
gainer  in  the  affection  and  confidence  of  the  re- 
maining members. 

I  have  been  impressed  by  finding  innate  dignity, 
courtesy  and  sympathy  where  I  had  least  suspect- 
ed their  presence.  The  toughest,  most  blasphe- 
mous man  in  the  community,  when  his  child  died 
under  my  care,  replied  to  my  expression  of  sympa- 
thy: "I'm  sorry,  too,  doctor,  that  you  lost  the 
case."  Only  once  have  I  seen  a  woman  who  rep- 
resented to  me  Cornelia,  the  mother  of  the  Grac- 
chi. It  might  appear  incongruous  to  thus  associate 
a  Roman  patrician  with  a  humble  widow  in  the 
backwoods  of  North  Carolina.  This  woman's  hus- 
band died  leaving  her  with  three  small  children 
and  200  or  so  acres  of  land,  all  but  20  or  30  of 
which  required  clearing  and  draining.  Largely  with 
her  own  hands  she  cleared,  ditched,  broke  and  tend- 
ed this  land.  Of  the  three  children,  one  was  less 
than  half-witted  and  the  other  boy  was  afflicted 
with  tuberculosis  of  the  hip  at  about  15.  This 
marvelous  woman  gave  her  children  every  advan- 
tage of  the  schools  available  in  her  neighborhood, 
and,  indeed  made  of  one  of  them  the  intellectual 
leader  of  the  township.  I  came  to  know  her  only 
after  she  was  65  or  so,  when  I  was  called  to  see 
the  simple  son  in  an  attack  of  appendicitis.  The 
calm  dignity  with  which  she  accepted  advice  that 
cost  her  the  income  from  a  year  of  labor,  and  the 
hearty  hand-clasp  she  gave  me  at  parting,  along 
with  the  words,  "I  wish  you  well,  sir,"  were  deeply 
impressive.  To  Mrs.  Brown  no  opportunity  came 
for  presenting  her  sons  as  jewels;  her  jewels  were 
her  heart,  her  brain,  her  indomitable  will! 

For  only  one  job  have  I  ever  craved  the  ability 


November,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


to  paint  a  portrait.  She  had  been  married  more 
than  SO  years  to  a  strapping  "biped  without  feath- 
ers"— as  Plato  designated  man — whose  sole  contri- 
bution to  industry  had  been  making  shoes  for  the 
Confederate  army  in  order  to  get  out  of  carrying  a 
musket.  She  had  borne  a  dozen  children,  eight  of 
whom  were  living  and  prosperous;  and  there  was 
a  horde  of  strong  young  grandsons  grown  to  man- 
hood. 

She  came  into  my  office  to  ask  me  if  I  knew 
where  she  could  "buy  an  ox  or  a  little  mule,"  ex- 
plaining that  her  mule  had  died  and  she  had  to 
have  some  cheap  animal  to  draw  the  plough.  There 
she  sat — a  frail  little  gray  woman,  70  years  old, 
who  wouldn't  have  weighed  90  pounds — accepting 
the  call  of  seed  time  and  harvest  as  calmly  and 
confidently  as  one  who  had  just  come  to  robust 
manhood's  estate.  It  was  the  sweetest  face  on 
which  my  eyes  had  ever  looked;  on  its  wrinkled, 
baked-apple  surface  was  written  the  record  of  a 
life  of  uncomplaining  (indeed  unrealized)  and  un- 
appreciated sacrifice,  and  of  unquestioning  faith 
that  this  world  was  good  to  her  and  the  next  would 
be  even  better!  1  would  not  exchange  that  ex- 
perience for  much  gold;  and  such  experiences  come 
to  doctors  far  more  than  to  those  in  other  callings. 

I  have  attempted  to  give  you  some  idea  of  what 
a  doctor's  life  is,  hoping  to  convey  some  informa- 
tion of  his  experiences,  his  problems  and  his  re- 
wards that  might  serve  to  help  some  of  you  to 
decide  wisely  to  choose  Medicine  as  a  vocation; 
and  with  the  equal  hope  of  helping  others  to  decide 
wisely  to  stay  out  of  Medicine.  The  greatest  doc- 
tor of  our  time,  William  Osier,  has  defined  success 
as  "Getting  what  you  want  and  enjoying  it."  It 
could  be  simplified  into:  Success  is  happiness. 
One  of  the  greatest  of  the  French  philosophers  com- 
mented sadly  on  a  dear  friend;  "He  is  doomed 
to  failure  for  he  assumes  that  men  are  governed 
by  reason.' 

If  you  are  wise  enough  to  realize  the  hypocrisy, 
dishonesty  and  stupidity  which  must  have  been 
the  qualities  to  cause  The  Almighty  to  repent  him 
that  he  had  made  man — an  dare  not  wise  enough 
to  overlook  these  unlovely  characteristics;  then  dis- 
miss the  idea  of  studying  medicine,  for  to  the  eye 
of  the  clear-seeing  doctor  all  is  revealed.  If  you 
are  wise  to  the  point  of  disregarding  the  knowledge 
of  man's  unworthiness;  of  having  in  this  regard 
that  faith  which  is  an  ability  to  believe  what  one 
knows  is  not  true.  Medicine's  shrine  is  that  at 
which  you  should  pay  your  worship;  She  will  re- 
ward you  with  satisfactions  to  be  had  in  no  other 
pursuit;  She  will  give  you  what  you  want,  oppor- 
unities  in  abundance  to  soften  and  smooth  the 
harshnesses  of  life,  and  you  will  enjoy  it.  Yours 
will  be  success. 


Why  We  Fail 

In  the  preface  to  Bastedo's  Materia  Medica  I 
find  the  following:  "The  physician  deals  with 
human  beings  at  all  stages  from  birth  to  death; 
animals  of  highly  developed  nature  frequently 
harassed  by  the  trials  and  difficulties  of  human 
existence,  living  in  all  sorts  of  conditions  and  cli- 
mates, improperly  fed,  undernourished  or  overnour- 
ished;  victims  of  bad  habits,  inherited  weaknesses, 
dangerous  exposures,  chronically  diseased  organs, 
injuries,  or  acute  illnesses.'' 

Into  our  hands  as  physicians  is  committed  the 
care,  physical  and  mental,  of  these,  the  most  highly 
developed  of  all  God's  creatures,  and  on  us  depend 
their  life  and  death,  their  sanity  or  insanity.  Daily, 
hourly,  we  battle  with  disease  and  death — often 
successfully,  but  quite  often  we  fail.  I  mention 
here  a  few  causes  why  we  fail. 

Success  is  the  attainment  of  a  goal — the  achiev- 
ing of  that  for  which  we  strive.  Success  in  the 
highest  sense  is  not  to  know,  though  that  is  a  high 
ambition;  it  is  not  to  have,  to  possess;  it  is  not 
simply  to  do,  which  is  a  still  higher  goal,  but  to  be. 
He  that  lives  in  the  hearts  and  lives  of  the  people 
for  whom  he  labors,  with  the  love  of  God  and  of 
man  in  his  heart,  is  a  successful  man  though  he  die 
poor,  and  the  measure  of  his  success  may  be  greatly 
increased  by  his  own  efforts. 

As  the  first  reason  why  we  as  physicians  fail  I 
mention  lack  of  knowledge.  A  few  years  ago  I 
heard  one  of  the  prominent  doctors  in  the  state 
say  that  the  young  men  just  starting  out  in  practice 
did  not  know  any  materia  medica  or  therapeutics. 
He  said  that  they,  after  making  a  diagnosis,  were 
unable  to  utilize  the  curative  agents  needed,  be- 
cause of  ignorance  of  their  action.  To  be  deserving 
of  the  confidence  of  our  patients  we  must  know 
not  only  disease,  but  remedies  and  all  their  effects. 

The  second  reason  I  give  is  lack  of  sympathy 
with  the  patient  and  his  family.  We  are  so  used 
to  being  dictator  that  it  is  sometimes  hard  to  be 
patient  and  sympathetic  with  an  irritable,  exacting 
patient,  whom  we  know  to  be  in  no  danger  what- 
ever, or  to  be  gentle  with  a  mother  who  frantically 
demands  instant  relief  for  her  child.  In  cases  of 
this  kind  we  need  to  remember,  "He  that  ruleth 
his  spirit  is  better  than  he  that  taketh  a  city,"  and 
that  self-control  sometimes  will  serve  you  better 
than  much  medical  knowledge. 

.\  third  reason  I  give  is  lack  of  adaptability.  To 
be  able  to  go  to  the  homes  of  the  rich  and  great, 
the  highly  educated  and  cultured,  and  from  there 
to  the  homes  of  poverty  and  ignorance,  and  be  wel- 
comed by  all  as  a  real  friend,  one  who  is  interested 
in  the  patient  and  sympathetic  with  his  interests, 
is  a  high  goal;  and  because  we  do  not  reach  it  we 
find  that  our  former  patients  are  no  longer  ours. 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


A  fourth  reason  I  suggest  is  that  we  are  so  self- 
centered,  so  sure  of  our  own  ability,  or  possibly  so 
afraid  of  losing  the  patronage  of  the  patient  that 
we  do  not  ask  help  from  a  brother  practitioner  as 
soon  as  we  should.  No  one  is  infallible  and  an- 
other man  may  discover  something  that  has  escaped 
our  notice.  Sometimes  the  surest  way  to  hold  a 
patient  is  to  send  him  for  examination  to  another 
man. 

Jealousy  of  another  doctor  is  a  trait  that  gets  us 
nowhere,  and  instead  of  holding  our  patronage  we 
will  find  it  inevitably  drives  it  away.  Motor  travel 
has  made  it  so  easy  to  see  a  distant  doctor  that 
people  do  not,  as  they  did  50  years  ago,  continue 
to  consult  one  for  years  if  they  do  not  get  better, 
and  this  condition  makes  it  imperative  that  we  put 
all  jealousy  aside  and  stand  together. 

The  encroachment  of  State  medicine  on  private 
practice  and  the  almost  universal  desire  for  free 
treatment  has  already  taken  much  of  our  practice. 

Possibly  half  of  my  present  practice  is  for  peo- 
ple who  might  be  considered  to  belong  to  some 
other  doctor,  and  I  am  exceedingly  careful  to  say 
nothing  to  the  detriment  of  any  other  man  whom 
they  have  consulted,  realizing  that  if  they  do  not 
get  better  at  once,  I,  too,  will  be  among  the  has 
beens. 

If  we,  then,  are  properly  equipped  with  knowl- 
edge of  diseases  and  can  make  reasonably  accurate 
diagnoses,  and  understand  remedies  so  as  to  suc- 
cessfully treat  those  diseases;  if  we  are  sympathetic 
and  patient  with  unattractive  and  unmanageable  as 
well  as  the  attractive  and  grateful  patients;  if  we 
can  be  equally  at  home  in  mansion  or  hovel,  with 
the  learned  or  the  ignorant;  and  if  we  can  sink  self 
in  our  desire  for  our  patients'  welfare,  we  will  leave 
the  world  a  little  better  than  we  found  it,  and  will 
be  in  the  highest  sense  successful. 

— C.  C.  HUBBARD,  M.D.,  Farmer,  N.  C. 


Obituary 


A  Post  Graduate  Course  in  Pulmonary  Diseases  was 
given  for  Negroes  at  Lincoln  Hospital,  Durham,  October 
ISth  and  16th,  through  the  co-operation  of  the  North 
Carolina  Department  of  Education,  Duke  University,  Wake 
Forest  College  and  University  of  North  Carolina. 

Speakers  were  Drs.  O.  C.  P.  Hansen  Pruss,  David  T. 
Smith,  C.  E.  Gardner,  F.  M.  Hanes,  Wm.  Allan,  Wm.  deB. 
MacNider,  Milton  J.  Rosenau,  C.  S.  Mangum,  C.  C. 
Carpenter,  Macdonald  Dick,  W.  R.  Berryhill,  W.  C. 
Davison,  Deryl  Hart,  P.  P.  McCain  and  Julian  Moore. 


Dr.  Walter  Feeman,  Professor  of  Neuropathology  in  the 
U.  S.  Naval  Medical  School,  delivered  the  third  in  the 
series  of  University  extension  lectures  for  physician  given 
at  Goldsboro  in  October. 


To   STOP   THE   MENSES,   apply   as   large   cupping   instru- 
ments as  possible  to  the  hTsasti.— Hippocrates. 


Dr.  Thomas  Craig  Redfern 

Another  proof  of  the  old  adage,  "Death  loves  a 
shining  mark,"  is  found  in  the  passing  of  Dr. 
Thomas  Craig  Redfern  at  his  home  on  October 
16th.  On  August  ISth,  one  day  less  than  nine 
weeks  previously,  he  had  suffered  a  severe  coronary 
thrombosis.  Three  and  a  half  weeks  later  a  cere- 
bral embolus  gave  him  a  transient  paralysis  of  the 
left  arm  and  leg.  Still  later  another  embolus 
brought  about  a  gradual  blocking  of  the  circulation 
in  the  left  leg,  and  the  foot  became  gangrenous 
several  days  before  the  end.  Death  finally  resulted 
from  gradual  failure  of  the  myocardium. 

Tom  Redfern  was  a  comparatively  young  man — 
just  passed  his  forty-fourth  birthday — but  he  had 
come  to  fill  a  place  in  our  profession  and  in  the 
community  that  will  be  hard  to  fill.  He  came  to 
Winston-Salem  in  1920,  fresh  from  a  residency  at 
Barnes  Hospital,  and  was  first  resident  physician, 
then  superintendent,  of  the  City  Memorial  Hos- 
pital. In  1924  he  entered  the  field  of  internal 
medicine,  and  was  recognized  from  the  beginning 
as  a  leader.  He  achieved  the  solid  reputation  and 
success  that  comes  to  the  man  who  loves  his  pro- 
fession, who  continues  all  his  life  as  a  student,  and 
who  has  a  big  brain  and  a  big  heart.  He  was  an 
original  thinker,  a  keen  diagnostician,  and  such  an 
adept  at  transfusions,  spinal  punctures,  and  other 
technical  procedures  that  it  was  a  pleasure  to  see 
him  at  work. 

Honors  came  to  him  easily.  He  was  at  various 
times  president  of  the  Forsyth  County  Medical  So- 
ciety, president  of  the  Eighth  District  Medical  So- 
ciety, councilor  of  the  State  Medical  Society  from 
the  Eighth  District,  and  a  member  of  the  Board 
of  Governors  of  the  Forsyth  County  Tuberculosis 
Hospital.  Since  1931  he  has  been  a  Fellow  of  the 
American  College  of  Physicians. 

His  lovable  personality,  ready  humor,  sincerity, 
loyalty  to  his  friends,  high  professional  ideals,  to- 
gether with  his  great  ability,  will  make  him  missed 
for  years  to  come  by  all  who  knew  him,  and  espe- 
cially by  those  privileged  to  call  him  friend. 

It  is  rather  singular  that  he  and  Gene  Gray 
should  have  gone  Home  almost  together.  They 
shared  offices  in  the  same  suite,  were  inseparable 
friends,  and  were  stricken  in  a  similar  manner.  I 
am  glad  I  have  enough  of  my  Mother's  faith  to 
picture  them  in  imagination  as  happily  reunited  on 
the  other  side. 

—WING ATE  JOHNSON. 


November,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


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SOUTHERN  MEDICINE  AND  SURGERY 


November,  1Q36 


BOOK  REVIEWS 


A  PRACTICAL  MEDICAL  DICTIONARY  of  words 
used  in  Medicine  with  their  Derivation  and  Pronunciation; 
Anatomical  Tables  of  the  Titles  in  General  Use;  Pharma- 
ceutical Preparations  Official  in  the  U.  S.  and  British 
Pharmacopoeias  or  Contained  in  the  National  Formulary, 
and  Comprehensive  Lists  of  Synonyms,  by  Thomas  Lath- 
KOP  Stedmax,  A.M.,  M.D.,  lith  Revised  Edition,  Hlus- 
trated.     Wm.  Wuod  &  Co.,  Baltimore,   1936,  S7.S0. 

To  those  new  to  medicine,  only,  is  it  necessary 
that  a  word  be  said  about  Stedman's  Medical  Dic- 
tionary. It  is  accurate:  it  is  authoritative;  it  is 
scholarly;  it  is  complete. 


UROLOGICAL  ROENTGENOLOGY,  A  Manual  for 
Students  and  Practitioners,  by  Milev  B.  Wesson.  M.D.. 
E.x-President  American  Urological  Association,  and  How- 
ard E.  RuGGLES,  M.D.,  Roentgenologist  to  Universitv  of 
California  Hospital  and  Clinical  Professor  of  Roentgen- 
ology, University  of  California  Medical  School,  with  227 
Engravings.     Lea  &  Febiger,  Philadelphia,  1036,  .S5.00. 

Members  of  the  American  Urological  Association 
have,  over  a  period  of  years,  sent  their  unusual 
films  of  diagnostic  value  to  the  authors,  and,  along 
with  the  films,  the  case  histories.  The  authors  say 
that  thus  was  the  book  made  possible.  Certainly 
this  afforded  an  opportunity  to  make  a  book  of 
unusual  value,  and  the  authors  have  improved  the 
opportunity. 

The  book  does  not  assume  that  the  reader  knows; 
it  assumes  that  he  does  not  know,  and  then  teaches 
him.  The  text  is  plain,  concise,  adequate.  The 
illustrations  are  well  chosen,  well  made  and  well  re- 
produced. 


BRIGHT'S  DISEASE  AND  ARTERI.\L  HYPERTEN- 
SION, by  WILL..WD  J.  Stone,  B.Sc,  M.D.,  F.A.C.P.,  Clin- 
ical Professor  of  Medicine,  School  of  Medicine,  University 
of  Southern  California,  Los  Angeles;  Attending  Physician 
to  the  Pasadena  Hospital,  Pasadena,  Calif.  352  pages  with 
31  illustrations.  Philadelphia  and  London.  W .  B.  Saun- 
ders Company.  1936.     Cloth,  .SS.OO  net. 

The  basis  of  the  book  is  notes  kept  over  twenty 
years  on  patients  with  Bright's  disease.  The  evi- 
dence afforded  by  these  notes  has  been  correlated 
with  reports  of  others  in  this  wide  field.  Chapter  1 
is  made  up  of  brief  sketches  of  fifteen  investiga- 
tions from  de  Saliceto  to  Cushny.  Not  too  much 
space  is  given  to  classification.  The  physiology 
of  kidney  function,  water  balance,  edema,  tests 
of  function,  acidosis  and  alkalosis,  and  uremia  are 
discussed  in  this  order.  Treatment  for  uremia  is 
outlined  with  unusual  definiteness  and  vigor.  The 
author  says  the  most  distinguishing  feature  of 
Bright's  disease  is  inability  of  the  kidneys  to  con- 
centrate urine.  A  chapter  is  devoted  to  renal  in- 
sufficiency in  conditions  other  than  Bright's  dis- 
ease. Hemorrhagic  Bright's  disease  is  discussed 
under   first,   second  and   third   stage.      Restriction 


of  protein  in  the  diet  is  not  favored.  Measures 
are  recommended  for  relief  of  the  severe  headaches. 

Degenerative  Bright's  disease  is  the  term  used 
to  cover  what  has  been  called  parenchymatous 
nephritis,  lipoid  nephrosis,  amyloid  nephrosis,  and 
so  on. 

In  one  chapter  are  well  grouped  arterial  hyper- 
tension, arteriosclerosis  and  arteriosclerotic  Bright's 
disease,  and  the  relationship  these  conditions  bear 
to  one  another  are  traced. 

Helpful  autopsy  abstracts  conclude  a  volume 
which  will  help  toward  the  clarification  of  this  still 
murky  subject. 


VASCULAR  DISORDERS  OF  THE  LIMBS  DESCRIB- 
ED FOR  PRACTITIONERS  .\ND  STUDENTS,  by  Sir 
Thomas  LEW^s,  C.B.E.,  F.R.S.,  M.D.,  D.Sc,  LL.D., 
F.R.C.P.,  Physician  in  Charge  of  Department  of  Clinical 
Research,  LTniversity  College  Hospital,  London.  The  Mc- 
Millan Company,  N.  Y.  ,,'?2.00. 

First  are  described  the  circulation  in  the  limb 
and  the  methods  of  testing  it,  then  the  effects  of 
circulatory  arrest,  embolism  and  thrombosis.  The 
important  subject  post-ischemic  contractures  is 
called  to  attention.  Arterial  disease  of  the  elderly 
and  diabetic  and  thromboangiitis  obliterans  are 
dealt  with  in  practical  fashion.  'Valuable  informa- 
tion is  given  on  vasoconstriction  and  spasmodic 
arterial  obstruction,  vasodilatation  and  vascular 
disorders  in  diseases  of  the  nervous  system. 


Anal-  Sed 

.■\nalgesic.    Sedative    and    Antipyretic 

.Affords  relief  in  migraine,  headache,  sciatica  and 
neuralgia.  Rheumatic  symptoms  are  frcqucntl\  re 
lieved  by  a  few  doses. 

Descriplion 
Contains   i^i    grains   of    Amidopyrine,    1,6    grain    of 
Caffeine  Hydrobromide  and   15  grains  of  Potassium 
Bromide  to  the  teaspoonful. 

Dosage 
The  usual  dose  ranges  from  one  to  two  teaspoonfuls 
in  a  little  water. 

Ho'cv  Supplied 
In  pints  and  gallons  to  physicians  and  druggists. 


Burwell  &  Dunn  Company 


Manufacturing    <^=^^ 
Established 


Pharmacists 
in    1SS7 


CHARLOTTE,  N.  C. 


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


November.  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


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. 


^5(ssCs^^ 


M    E    L    L    I    E 

2112        LOCUST 


R       DRUG 

STREET,        ST. 


COMPANY 

LOUIS,       MISSOURI 


Sir  Thomas  Lewis,  the  world's  greatest  authority 
on  vascular  disorders,  here  gives  us  another  text- 
book of  great  everyday  usefulness. 


NEWS  ITEMS 


MEDICAL  CLINICS  OF  NORTH  .'\MERICA.  Issued 
serially,  one  number  every  other  month.  Volume  20,  Num- 
ber 2.  St.  Louis  Number — September,  1936.  Octavo  of 
350  pages  with  24  illustrations.  Per  Clinic  year  July,  1936, 
to  May,  1937.  Paper,  $12.00;  Cloth,  $16.00  net.  Phila- 
delphia and  London.     W.  B.  Saunders  Company,  1936. 

Clinics  here  reported  cover  subjects  of  such  im- 
portance as:  Borderline  Endocrine  Disturbances, 
Endocrine  Infantilism,  Endocrine  Obesity,  Pituitary 
Hypo-  and  Hyperfunction  and  Hyperinsulinism. 
Encephalitis  is  brought  again  to  our  attention,  and 
our  old  enemies  emphysema  and  constipation.  Pep- 
tic ulcer,  stoneless  gallbladder,  pulmonary  bleeding 
and  silicosis  are  all  subjects  on  which  we  should 
know  more:  and  this  is  true  of  the  next  two — infan- 
tile colic  and  uremia.  An  unusually  practical  heart 
clinic  is  given,  followed  by  one  equally  as  good  on 
neuroses  and  psychoses  as  the  general  practitioner 
sees  them.  The  whole  number  is  one  of  unusual 
quality. 

S.    M.   &  6.— 

Eunuchs  bo  not  take  the  t;ouT  nor  become  bald. — 
Hippocrates. 


Doctor  Horslev   Honored 
(Richmond    Times-Dispatch,    Oct.    7th) 

Two  hundred  doctors  yesterday  met  in  the  auditorium  of 
the  Richmond  Academy  of  Medicine  for  the  presentation 
of  a  portrait  of  Dr.  J.  Shelton  Horslev,  nationally  noted 
Richmond  surgeon,  to  St.  Elizabeth's  Hospital,  of  which 
Dr.  Horsley  is  head. 

The  portrait,  a  life-size  oil  painting  by  Mordi  Gassner, 
was  presented  by  the  Ex -Internes  Association  of  St.  Eliz- 
abeth's in  appreciation  of  Dr.  Horsley  as  an  outstanding 
figure  in  .American  surgen,-  and  as  the  man  under  whom 
the   internes  worked  at   the   hospital. 

Dr.  Roy  W.  Upchurch  of  Danville,  president  of  the  asso- 
ciation, made  the  presentation  of  the  portrait,  which  was 
unveiled  by  J.  Shelton  Horsley  3d,  grandson  of  the  sur- 
geon. It  was  accepted  for  the  hospital  by  Dr.  W.  W. 
Higgins,  who  spoke  in  praise  of  Dr.  Horsley  as  a  stimu- 
lating influence  on  hundreds  of  young  men  who  served  jn- 
terneships  under  him. 

-Dr.  Stuart  McGuire,  whose  talk  was  of  personal  reminis- 
cences of  Dr.  Horsley  as  a  friend.  Dr.  J.  M.  T.  Finney, 
Professor  of  Surgery  at  Johns  Hopkins  University  in  Bal- 
timore, also  spoke  in  appreciation  of  the  Richmond  surgeon. 

The  portrait,  which  shows  Dr.  Horsley  seated  in  a  chair 
at  his  home  on  Westmoreland  Place  with  a  manuscript  in 
his  hand,  will  be  hune  in  the  hall  at  St.  Elizabeth's  Hos- 
pital. 

Dr.  Horsley  has  been  head  of  St.  Elizabeth's  Hospital 
since  he  opened  the  in-liiutiun  in   1912.     Many  of  the  doc- 


628 


SOUTHERN  MEDICINE  AND  SURGERY 


November,   1936 


tors  and  surgeons  who  were  internes  there  returned  for 
yesterday's  exercises,  including  some  from  North  and 
South  Carolina. 


The  American  Clinical  and  CLrMAXoLOGiCAL  Associa- 
tion held  its  53rd  annual  meeting  at  the  Jefferson  Hotel, 
Richmond,  October  26th  to  28th.  Among  features  of  spe- 
cial interest  was  a  presentation  on  Sprue,  by  Dr.  F.  M. 
Hanes  of  Duke  University;  on  Antipneumococcus  Serum, 
by  Dr.  Russell  Cecil  of  New  York;  on  Gonococcus  Men- 
ingitis, by  Dr.  Walter  Steiner  of  Hartford;  on  Arthritis 
of  Bacillan.-  Dysentery,  by  Dr.  B.  M.  Baker,  jr.,  of  Balti- 
more; on  Rheumatic  Heart  Disease,  by  Dr.  T.  Duckett 
Jones  of  Boston  and  on  Speed  Healing  of  Myocardial  In- 
farcts, by  Dr.  Paul  White  of  Boston. 


Seventh  District  Medical  Society  meeting,  Gastonia, 
October  2Qth.  Program:  The  Poisonous  Spiders,  Dr.  W. 
C.  Bostic,  jr..  Forest  City;  Eye,  Ear,  Nose  and  Throat— 
Some  Incidents  of  Interest  to  the  General  Practitioner,  Dr. 
J.  Sidney  Hood,  Gastonia;  Irradiation  Therapy  in  E.xces- 
sive  Uterine  Bleeding  from  Causes  Other  than  Cancer — 
Report  on  327  Cases,  Drs.  Lafferty  and  Phillips,  Charlotte; 
Lowering  the  Mortality  in  Intestinal  Obstruction,  Dr.  T.  C. 
Bost,  Charlotte;  Diagnosis  and  Treatment  of  Vincent's  In- 
fection (Oral  Fusospirochetosis),  S.  E.  Moser,  D.D.S.,  Gas- 
tonia, and  Medical  Clinic,  Dr.  Louis  Hamman,  Associate 
Professor  of  Clinical  Medicine  of  Johns  Hopkins  Univer- 
sity Medical  School. 

At  the  banquet  held  at  the  Gaston  Country  Club  Ad- 
dress of  Welcome,  Dr.  W.  M.  Roberts,  president  Gaston 
County  Medical  Society ;  Response,  Dr.  Addison  G.  Bre- 
nizer,  Charlotte. 

Officers  elected:  president.  Dr.  McG.  Anders,  Gastonia; 
vice  president,  Dr.  Ben  Gold,  Shelby;  secretary  (re-elected). 
Dr.  C.  H.  Pugh,  Gastonia. 


Meeting  of  the  Southeastern  Branch  of  the  American 
Urologic.al  Association  is  to  be  held  in  Charlotte  Decem- 
ber 4th  and  Sth.  Dr.  Hamilton  W.  McKay  of  Charlotte  is 
president-elect  and  will  succeed  to  the  office  of  president 
at  this  meeting.  Dr.  Wm.  M.  Coppridge  of  Durham  is  a 
member  of  the  executive  committee. 


From  Dr.  .\.  E.  Baker.  Charleston 

Dr.  Alsey  R.  Fuller  of  Mountvillc,  the  dean  of  Laurens 
County  doctors,  died  at  his  home  Oct.  9th.  He  was  82 
years  of  age;  and  he  had  practiced  medicine  and  surgery 
there  for  the  last  55  years. 

On  October  9th,  word  of  the  allotment  by  PWA  of 
$120,000  to  Dorchester  County  for  a  county  hospital  was 
received  from  Senator  Byrnes  in  a  telegram  to  Legare 
Walker,  jr.,  president  of  the  Summerville  Infirmary,  Inc. 
Of  this  amount,  $54,000  is  a  direct  grant  and  $66,000  is 
a  loan  which  the  county  will  bond  itself  to  repay.  The 
site  for  the  new  hospital  will  be  Summerville,  but  the 
exact  location  has  not  been  decided  upon.  It  will  have  a 
separate  wing  for  Negro  patients.  The  hospital  will  be 
administered  by  the  officers  and  directors  of  the  Summer- 
ville Infirmary.  It  will  be  a  modern  50-bed  hospital,  32 
of  the  beds  to  be  for  white  patients  and  IS  for  colored. 
The  present  infirman,-  with  live  bedrooms,  operating  room, 
nursery  and  x-ray  room  is  the  only  white  hospital  in 
Dorchester  County.  Formerly  a  residence,  it  was  made 
into  a  hospital  in  1916.  The  building  has  had  several  addi- 
tions since.  For  maintenance,  the  infirmary  receives  $250 
a  month  from  the  county  and  $300  a  year  from  the  town 
of  Summerville.     The  Duke  Foundation  contributes  to  it? 


Surgeons,  who  has  charge  of  the  standardization  move- 
ment. Since  the  inauguration  of  the  standardization  plan, 
support  to  the  number  of  charity  patients  cared  for  each 
year.  Last  year,  the  endowment  payment  amounted  to 
$21,061.  The  Summerville  Infirmary,  Inc.,  and  its  auxiliary 
have  been  instrumental  in  obtaining  funds  through  mem- 
bership fees  and  various  projects  for  raising  funds.  Sub- 
stantial donations  have  been  made  by  individuals  and 
business  concerns.  Local  physicians  give  their  services, 
serving  by  turns  for  a  month  at  a  time.  The  A.  B.  Lee 
(Negro)  Hospital  there  was  built  in  1922.  It  has  four 
bedrooms,  operating  room  and  two  nurses'  rooms.  It  is 
supported  by  the  county,  the  Duke  Endowment  and  funds 
raised  by  its  board.  The  assets  of  both  the  Summerville 
Infirmary  and  the  A.  B.  Lee  Hospital  will  be  turned  over 
to  the  new  hospital. 

The  wedding  of  Miss  Caroline  Anderson,  daughter  of 
Mr.  and  Mrs.  John  Julius  Anderson,  and  Dr.  John  Mokma 
van  de  Erve,  both  of  Charleston,  took  place  at  6  o'clock 
on  Oct.  24th  in  the  French  Protestant  (Huguenot)  Church, 
with  the  Rev.  Dr.  John  van  de  Erve,  pastor  of  the  church, 
and  father  of  the  bridegroom,  officiating. 

Four  Charleston  hospitals — Baker  Memorial  Sanatorium, 
Roper  Hospital,  St.  Francis  Xavier  Infirmary  and  the 
United  States  Naval  Hospital — together  with  the  United 
States  Hospital  at  Paris  Island,  on  Oct.  19th,  were  put  on 
the  approved  list  of  the  American  College  of  Surgeons, 
according  to  an  announcement  of  the  college  board  at' 
the  26th  annual  clinical  congress  in  Philadelphia.  The 
local  hospitals  are  among  19  in  South  Carolina  approved 
by  the  organization.  The  approved  list  was  made  up  at 
the    opening   of    the   congress   by    Dr.   Malcolm   T.    Mac- 


ARTHRITIS 

Prompt  and 
Sustained 


Relief 


SUlPHOGEn 


i 


THERAPEUTIC  ACTION 

Pain    checked,    reduction     in     swelling    hastened. 
joint  mobility  definitely  increased. 
Therapeutic  doses  produce  no  toxic  symptoms. 
Non-irritating,    painless   and   no   "protein   shock." 

FORMULA: 

.\  5%  solution  of  Dipeptyl-Amino  Thiol.  Con- 
tains the  special  determinants  obtained  from  the 
protein  molecule  complex  and  organic  sulphur 
molecularly  combined  in  the  form  of  disu'phide — 
S:S — and  sulphydryl — S  H — groups,  so  that  each 
2  c.c.  will  contain  the  equivalent  of  10  mgms.  of 
available  sulphur. 

.WAILABLE:   2  c.c.  ampuls,  boxes  of  12.  25,  100. 

'Write  for  complete  literature. 


HYPO-MEDICAL 

CORPORATION 

4X0  BROADWAY  .  NEW  YORK.N.  Y. 


November,  1P36 


SOUTHERN  MEDICINE  AND  SURGERY 


The   Tulane   University  of  Louisiana 
GRADUATE  SCHOOL  of  MEDICINE 

Postgraduate  instruction  offered  in  all  branches  of  medicine. 

Special  Courses: 

Surgery,  Gynecology  and  Obstetrics — May  10  to  June  5,  1937. 
Tropical  Medicine  and  Parasitology — June  14  to  July  24,  1937. 

Courses  leading  to  a  higher  degree  are  also  given. 

A  bulletin  furnishing  detailed  information  may  be  obtained  upon  application  to 

THE  DEAN.  GRADUATE  SCHOOL  OF  MEDICINE 


1430  Tulane  Avenue, 


New  Orleans,  La. 


Eachern,  associate  director  of  the  .American  College  of 
the  death  rate  in  approved  hospitals  has  been  cut  in  half. 
Risk  in  major  surgical  operations  has  been  reduced  to  a 
minimum,  the  report  says,  methods  of  administering  anes- 
thetics have  greatly  improved  and  treatment  of  serious 
conditions  is  vastly  more  effective. 

Other  approved  hospitals  in  South  Carolina  are  as  fol- 
lows: .Anderson  County  Hospital,  Anderson;  Columbia 
Hospital  of  Richland  County  (provisionally  approved) ; 
South  Carolina  Baptist  Hospital  and  Veterans'  Adminis- 
tration Hospital,  Columbia;  Conway  Hospital,  Conway; 
McLeod  Infirmary,  Florence;  Greenville  General  Hospital, 
Hospital  for  Crippled  Children,  Greenville;  Berkley  County 
Hospital,  Moncks  Corner;  Tri-County  Hospital,  Orange- 
burg;  Mary  Black  Memorial  Hospital,  and  Spartanburg 
General  Hospital.  Spartanburg;  Tuomey  Hospital,  Sumter. 


From  Dr.  L.  B.  McBrayer,  Southern  Pines 

The  North  Carolina  Eye,  Ear,  Nose  and  Throat  Society 
held  a  meeting  at  Durham  on  October  Sth  at  which  the 
following  officers  were  elected:  president,  J.  M.  Lilly, 
M.D.,  Fayetteville ;  vice  president,  Casper  W.  Jennings, 
M.D.,  Greensboro;  secretary,  Frank  Smith,  M.D.,  Char- 
lotte. 

Dr.  and  Mrs.  Richard  B.  Dunn  have  moved  to  Greens- 
boro from  Baltimore,  where  Dr.  Dunn  has  been  on  the 
Johns  Hopkins  obstetrical  staff.  Mrs.  Dunn  graduated 
from  McGill,  receiving  a  B.Sc.  degree.  Dr.  Dunn  received 
a  B.S.  degree  from  St.  Lawrence  University  and  M.D. 
degree  from  McGill.  Dr.  Dunn  will  practice  obstetrics  and 
gynecology  in  Greensboro. 

Dr.  Harry  L.  Brockmann,  High  Point,  was  elected  chief- 
of-staff  of  the  Burrus  Memorial  Hospital,  October  4th,  to 
succeed  Dr.  Jno.  T.  Burrus,  head  of  the  hospital  up  to 
the  lime  of  his  death  this  summer.  Dr.  Emmett  A.  Sum- 
ner has  been  made  associate  chief-of-staff.  Dr.  Brockmann 
has  been  surgeon  on  the  staff  of  the  Burrus  Hospital  ior 
a  number  of  years,  formerly  practiced  in  Greensboro  and 
was  surgeon  in  the  U.  S.  Navy  during  the  World  War. 
Mrs.  Jno.  T.  Burrus  has  been  appointed  a  member  of  the 
Board  of  Trustees  to  fill  the  vacancy  caused  by  the  death 
of  her  husband. 

.August  24th  Buncombe  County  Medical  Society,  Ashe- 
ville,  had  as  guests  Dr.  Richardson  of  Johns  Hopkins  Uni- 
versity, Dr.  Jeckel.  of  Washington  University,  St.  Louis 
Dr.  Hardin,  of  Banner  Elk,  Dr.  Folsom,  of  Swannanoa, 
Dr.  Sullivan  of  Asheville,  with  several  other  physicians 
from  Oteen  and  nearby  towns.  The  president  requested 
Dr.  C.  H.  Cocke  to  introduce  the  guest  speaker  of  the 
evening.  Ur,  John  H.  Musser.  Professor  of  Medicine,  Tulane 


University.  Dr.  Musser  spoke  interestingly  on  Some  Ob- 
servations on  Coronarv'  Occlusion  and  illustrated  his  talk 
with  several  slides. 

Dr.  Horace  G.  Strickland,  after  serving  a  year's  interne- 
ship  in  Baltimore  at  Mercy  Hospital  and  another  year  at 
the  same  institution  as  resident  in  nose  and  throat  diseases, 
has  been  in  Chicago  for  two  years  assistant  to  Dr.  W.  F. 
Zinn.  A  native  of  North  Carolina  and  graduate  of  the 
University  of  North  Carolina,  he  returns  home  to  associate 
himself  with  Dr.  Shahane  R.  Taylor  in  the  practice  of  eye, 
ear,  nose  and  throat  diseases  at  Greensboro. 


Dr.  Howard  Patterson,  of  New  York,  lately  visited  his 
former  home  at  Chapel  Hill. 


Dr.  Asher  L.  Baker,  of  the  medical  staff  of  Craig 
House,  Beacon,  New  York,  has  lately  been  visiting  his  old 
home  at  Newport  News,  and  friends  in  Richmond. 


Dr.  George  Bachman,  Director  of  the  School  of  Practi- 
cal Medicine  of  San  Juan,  Porto  Rico,  has  lately  visited 
in   Richmond. 


Dr.  Yates  S.  Pauiier,  Valdese,  has  returned  from  New 
York  where  for  three  months  he  has  made  a  special  study 
of  children's  diseases.  While  there  he  served  as  assistant 
house  physician  at  the  Seaside  Hospital,  operated  by  St. 
John's  Guild  which  was  established  in  1866  as  a  benevolent 
foundation. 


Dr.  J.  H.  Meacows,  Fairmont,  is  a  new  member  of  the 
Robeson  Countv  Medical  Societv. 


Dr.  W.  .'\mbr(i.se  McGee  announces  the  removal  of  his 
office  to  1601  Monument  .Avenue,  Richmond,  Virginia. 


Dr.  Wu.i.iam  W.  Rixey,  Richmond,  announces  the  open- 
ing of  his  new  offices,  207  Professional  Building,  practice 
limited  to  Proctology. 


Baker  Sa.vatorium,  of  Lumberton,  is  doubling  the  ca- 
pacity of  its  nurses'  home,  purchasing  new  x-ray  equip- 
ment and  making  other  extensive  improvements. 


Dr.  Berry  Hayden  Smith,  54,  a  native  of  Rutherford 
County,  N.  C,  for  a  number  of  years  in  practice  at  BIythc, 
(Ja.,  was  injured  in  a  car  wreck  September  28th  and  died 
within  24  hours. 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


MARRIED 


Deaths 


Miss  Margaret  Hess  Hay,  of  Hemphill,  W.  Va.,  and 
Dr.  Rowland  Edwards,  of  Palls,  King  William  County,  at 
Trinity  Chapel  in  Buck  Run,  Pa.,  on  October  15th.  The 
groom  was  attended  by  his  cousin,  Dr.  Joseph  Alexander 
Robinson,  of  Bluefield,  W.  Va.,  and  Fontainbleau,  King 
William  County,  Va.  Dr.  and  Mrs.  Edwards  will  make 
their  home  in  Welch,  W.  Va.,  where  he  is  chief  surgeon  of 
Stevens  Clinic  Hospital. 


Dr.  William  Alexander  Green  and  Miss  Kayte  Wine- 
sette,  of  Whiteville,  North  Carolina,  were  married  on  Octo- 
ber 17th. 


Dr.  Ralph  Gibson  Fleming  and  Miss  Sue  Fleming  Thomp- 
son, of  Creedmoor,  North  Carolina,  were  married  on  Oc- 
tober 15th.  Dr.  Fleming  is  a  graduate  of  the  School  of 
Medicine  of  the  University  of  Pennsylvania,  and  is  serving 
an  intemeship  at  the  Geisinger  Memorial  Hospital,  Dan- 
ville, Pennsylvania. 


Dr.  Charles  Eugene  Cheek  and  Mrs.  Eli2abeth  Hancock 
Ragsdale  were  married  at  Fuquay  Springs,  North  Caro- 
lina, on  October  17th. 

Dr.  Wiliam  Dewey  Hall,  of  Raleigh,  and  Miss  Sue  Ruth 
Hutto,  Gaston,  South  Carolina,  were  married  in  Raleigh 
on  October  17th.  Dr.  Hall  is  a  member  of  the  medical 
staff  of  the  State  Hospital  at  Raleigh. 


Dr.   Cecil  Porter  Hurt   of   Lynchburg  and  Miss  Nancy 
Elizabeth  Johnson  of  Richmond,  October  10th. 


Miss  Doris  Darling  of  Endicott,  New  York,  and  Dr. 
Thomas  Jefferson  Tyler  of  Scotland  Neck,  N.  C,  October 
3rd. 


INHALANT 

No.  77 


An  Ephedrine  Compound  used  as  an  inhalant 
and  spray,  in  infections,  congested  and  irritated 
conditions  of  the  nose  and  throat.  Relieves 
pain  and  congestion,  preventing  infection,  and 
promotes  sinus  ventilation  and  drainage  with- 
out irritation. 

Description 
Inhalant  No.  77  contains  Ephedrine,   Menthol, 
and  essentials  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 
Established 


CHARLOTTE,  N.  C. 

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


Mrs.  Carrie  Dail  Laughinghouse,  widow  of  Dr.  Charles 
O'Hagan  Laughinghouse,  died  at  the  home  of  her  daughter, 
Mrs.  R.  C.  Stokes,  jr.,  Greenville,  N.  C,  October  19th, 
following  an  illness  of  several  months. 


Dr.  James  Clifford  Perry,  72,  of  San  Francisco,  retired 
physician  in  the  United  States  Public  Health  Service,  who 
recently  presented  a  Chinese  porcelain  collection  to  the 
Norfolk  Museum  of  Arts  and  Sciences,  died  about  11:30 
o'clock  p.  m.,  Oct.  19th,  on  the  Washington  steamer 
"District  of  Columbia."  Dr.  Perry  was  bom  in  Pasquotank 
County,  N.  C.  He  was  a  student  at  the  University  of 
North  Carolina  from  1881  to  1883,  and  received  his  medi- 
cal degree  from  the  University  of  Maryland  in  1885. 


Dr.  John  R.  Blair,  S3,  for  nearly  thirty  years  a  promi- 
nent Richmond  physician,  died  at  his  home,  October  31st. 
About  three  years  ago  Dr.  Blair  was  struck  by  a  street  car 
and  since  the  accident  had  retired  from  the  active  practice 
of  his  profession.  In  1919  Dr.  Blair  decided  to  devote  him- 
self to  surgery  and  a  year  later  opened  the  Hygeia  Hospital 
which  he  conducted  for  many  years.  After  closing  the 
Hygeia  Dr.  Blair  operated  the  Northside  Hospital. 


Our  Medical  Schools 


Untversity  of  Virgiota 

Dr.  Alfred  Chanutin,  Professor  of  Biocbembtry,  was 
awarded  the  Phipps  and  Bird  Prize  of  $100.00  for  his  pa- 
per on  "The  effect  of  whole  dried  meat  diets  on  renal  in- 
sufficiency produced  by  partial  nephrectomy"  submitted 
in  competition  with  papers  selected  by  the  State  Academies 
of  Science  of  North  Carolina  and  South  Carolina.  The 
three  competing  papers  for  this  prize  were  those  selected 
by  the  three  State  Academies  for  the  award  of  the  Phipps 
and  Bird  Gold  Medal  Prize. 

Dr.  J.  Edwin  Wood,  in  a  symposium  on  Diseases  of  the 
Heart  and  Kidney  held  at  Duke  University  October  ISth- 
17th,  spoke  on  Recent  Advances  in  the  Study  of  Rheumatic 
Fever  and  The  Use  of  Diuretics  in  Edema. 

Dr.  C  C.  Speidel  presented  a  paper  on  The  Experimen- 
tal Induction  of  Structural  Changes  in  Nerve  Fibers  in 
Tadpoles  in  the  symposium  on  Excitation  Phenomena  held 
last  .August  at  the  Biological  Laboratory  at  Cold  Spring 
Harbor,  New  York. 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  October  5th,  Dr.  W.  W.  Waddell  read  a  paper 
on  Premature  Infants  and  Dr.  J.  E.  Kindred  spoke  on 
Quantitative  Studies  in  Lymphoid  Tissues. 

Dr.  D.  C.  Wilson  spoke  on  Maladjustment  as  a  Cause 
of  Mental  Disease  before  the  Wake  County  (N.  C.)  Med- 
ical Society  on  August  13th. 

Duke 

On  .\ugust  20th,  Dr.  William  A.  Perlzweig  spoke  at  the 
School  of  Bacteriology,  Workers'  University  of  Mexico, 
on  Recent  .Advances  in  Clinical  Chemistry  in  the  United 
States. 

On  September  2ath,  the  North  Carolina  Neuropsychiatric 
Association  held  a  meeting  at  Duke  Hospital  with  Dr.  R. 
S.  Crispell.  Means  of  promoting  mental  hygiene  work  in 
the  State  were  discussed. 

On  October  5th,  the  autumn  quarter  of  the  School  of 
JVIfdicine  commenced,  with  an  enrollment  of  242  students, 


November,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


631 


JOIN  NOW 


,l,.'^.l,.l..l..l,.t,.i,.i,.i..r..^,-^.l.^,.l^,l.^.,^^,^.ij^,^^,^,.^ 


and  the  autumn  quarter  of  the  School  of  Nursing  with  an 
enrollment  of  80,  three  of  whom  are  postgraduate  students. 
On  October  15th,  16th  and  17th,  Duke  University  School 
of  Medicine  held  its  third  annual  symposium;  this  year  on 
diseases  of  the  heart,  circulation  and  kidney.  Si.xteen  phy- 
sicians and  surgeons  participated  in  the  program,  represent- 
ing the  medical  schools  of  Harvard,  Virginia,  Johns  Hop- 
kins, Western  Reserve,  University  of  North  Carolina,  Em- 
ory, Pennsylvania,  Cincinnati,  University  of  Minnesota  and 
Mavo  Clinic. 


The  Bogey  of  Abnormality 
(H.    H.   Hart,  New  York,   in   Med.    Rec,   Oct.    7th) 

It  is  a  vague  concept  this  abnormality.  We  can  see  the 
wide  variation  from  the  normal — yet  the  normal  we  do 
not  know,  except  as  the  usual.  The  behavior  of  a  Hotten- 
tot at  a  dinner  party  of  English  clergymen  would  be  dis- 
tinguished as  abnormal.  Conversely,  the  behavior  of  the 
English  clergyman  at  a  dinner  of  Hottentots  would  also 
seem  abnormal  to  the  Hottentots. 

Any  one  who  has  travelled  widely  comes  to  recognize 
the  provincial  quality  of  "normality." 

When  we  try  to  discover  what   norm,   or  standard,   by 


which  we  can  judge  the  normality  of  others,  we  can  think 
of  4  groups:  1)  The  personal  norm.  2)  The  perfect  norm. 
3)  The  individual  average  norm.  4)  The  group  average 
norm. 

By  the  personal  norm,  I  mean  that  comforting  tendency 
which  we  all  have  of  assuming  ourselves  as  the  nonn  by 
which  to  measure  other  people. 

The  perfect  norm  is  the  normality  of  perfect  function, 
perfect  health.  This  is  an  ideal  rather  than  an  actual 
state. 

If  we  know  that  the  average  height  for  man  is  5  feet 
7  inches  then  a  man  6  feet  tall  is  abnormal  in  the  matter 
of  height.  If  the  rating  by  Binet-Simon  tests  indicates 
that  the  average  citizen  has  an  intelligence  of  a  12-year-old 
child,  then  any  one  with  an  intelligence  over  or  under  this 
childish  level  must  be  abnormal.  If  the  average  American 
has  dental  caries,  then  a  person  with  no  teeth  or  very 
good  teeth  is  abnormal. 

We  have  no  exact  information  to  determine  what  the 
average  norms  of  behavior  are. 

Group  averages  must  be  ascertained  before  norms  can 
have  much  practical  value. 

We  shall  be  well  advised  to  drop  the  terms  normal  and 


SOUTHERN  MEDICINE  AND  SURGERY 


November,  1936 


F'OR 


PAIN 


The  majority  of  the  phy- 
sicians in  the  Carolinas 
are  prescribing  our  new 


tablets 


AND 


751 


A"-'-"  »'"'  S-a«'v«     L"p?;i^  PheSattin   <!a?Al*n 


(Te  will  mail  professional  samples  Tegiilarly 
with  our  compliments  if  you  desire  them. 
Carolina   Pharmaceutical    Co.,    Clinton,   S.    C. 


abnormal  until  we  have  something  more  than  impression- 
ism to  stand  upon,  and  in  the  meantime  devote  some  study- 
to  the  accumulation  of  well  established  normals  of  be- 
havior which  have  some  vaUdity. 

S.   M.   &   B. 

In  The  Raleigh  News  &  Observer,  October  11th,  Dr. 
HtJBERT  A.  RoYSTER  revicws  From  a  Surgeon's  Journal,  by 
Dr.  Harvey  Gushing.  Dr.  Royster  sets  forth  in  splendid 
fashion  not  only  a  review  of  the  book,  but  an  excellent 
portrayal  and  appraisement  of  its  distinguished  author. 

s.  M.  &  B. 

OPEN  THE  WINDOWS 
They  blindfolded  old  Nero, 
King  Tut  and  Richelieu; 
Then  each  one  puffed  a  cigaret, 
The  way  all  heroes  do. 

"I  know  this  brand,"  said  Nero; 

"There's  brains  inside  my  dome. 
It  smells  the  way  the  camels  did 
When  I  burned  'em  in  old  Rome." 

— Springfield   Union. 

s.  M.  &  s. 

And  the  Baby   Can't   Even   Read  It 

(New  Hope  item,  Forest  City  Courier) 

Mrs.  Eva  Cudd  and  baby  are  both  sick  at  this  writing. 


Dl U  RBITAL 


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Write  for  literature  and  samples 


GRANT  CHEMICAL  COMPANY 

315  EAST  77th  STREET        •        •        NEW  YORK.  N.  Y. 


RsYTaMic  Movements  Within   Red  Blood   Corpuscles 
Previously  Unobserved 

(C.  E.  Forkner,  L.  S.  Zia  and  Chia-Tung  Teng,  in  Chinese 
Med.  Jl.,  Sept.) 
Two  years  ago  while  studying  a  fresh  specimen  of  hu- 
man blood  by  means  of  the  supravital  technique  it  was 
found  that  practically  all  red  blood  corpuscles  exhibited 
peculiar  movements  within,  or  on  the  surface  of  the  cells. 
One  of  us  has  been  studying  fresh  blood  films  for  15  years 
in  thousands  of  specimens,  but  these  movements  had  not 
been  recognized  before,  although  it  now  appears  certain 
that  they  always  have  been  present.  The  phenomenon  has 
been  demonstrated  repeatedly  to  members  of  our  own  staff 
and  to  visiting  professors  of  histology  and  physiology.  It 
has  not  been  possible  to  find  any  record  of  previous  obser- 
vations of  this  phenomenon. 

The  phenomenon  may  be  seen  easily  in  fresh  blood  films 
made  by  allowing  a  coverslip,  on  the  surface  of  which  is 
a  fresh  drop  of  blood,  to  fall  on  a  glass  slide,  the  coversUp 
then  being  rimmed  with  vaseline,  best  seen  with  an  oil- 
immersion  lens  and  with  10  X  eyepieces  in  an  area  where 
the  cells  are  not  too  much  compressed.  They  appear  more 
clearly  with  binocular  vision,  but  are  also  seen  with  an 
ordinary  monocular  microscope.  Rather  intense  illumina- 
tion is  necessary. 

Three  types  of  movements  of  or  within  the  cells  may  be 
observed:  a)  a  coarse  jiggling  of  the  corpuscles  suggesting 
Brownian  movement,  a  phenomenon  observed  by  other 
workers,  b)  an  irregular  but  more  or  less  constant  rate  of 
pulsation  of  the  borders  of  the  corpuscles,  and  c)  an  in- 
tense, exceedingly  rapid  and  apparently  rhythmic  activity 
within  the  cells  themselves.  These  latter  types  of  move- 
ment have  not  been  described  heretofore. 

As  yet  there  is  no  clear  indication  of  the  physical  or 
physiologic  nature  of  the  process. 


Vice  President  Garner's  visitor  introduced  himself  as  the 
head  clown  of  Hagenbeck's  circus,  the  genial  "Cactus 
Jack"  replied:  "And  I  am  Vice  President  of  the  United 
States.  Stick  around  a  while.  You  might  pick  up  some 
new  ideas." 


A  thief  made  away  with  a  400-pound  church  bell.  Police 
are  advised  to  keep  an  eye  on  bulky  strangers  who  jingle. — 
Detroit  News. 


Hall  Boy:     "De  man  in  room  seben  done  hung  hisself!" 
Hotel  Clerk:     "Hung  himself?     Did  you  cut  him  down?" 
Hall  Boy:     "  No,  sah !     He  want  quite  dead!" — Stanley 
News-Herald. 


Dizzy    17-year-old    blond    shows    restlessness    as    reading 
passes  third  minute. 

Grand  Dame  in  next  Seal:     "Shh  !   That's  Browning." 
D.  B  :     "Mv  Gawd!     No  wonder  Peaches  left  him." 


.\  human  being  has  thirty-two  permanent  teeth,  unless 
he  or  she  decides  to  cure  the  neuritis  on  expert  medical 
advice. — Ohio  State  Journal. 


"Where  is  that  ham  you  said  you  would  bring  me?" 
"Well,  doctor,  I  intended,  just  like  I  told  you,  but  that 
hog  up  and  got  well." 


.\   bewildered   man   entered   a   ladies'   specialty  shop, 
want  a  corset  for  my  wife,"  he  said. 
"What  bust?"  asked  the  clerk. 
"Nothin'.    It  just  wore  out." 


Journal 

of 

SOUTHERN  MEDICINE   ^   SURGERY 


Vol.  XCVIII  Charlotte,  N.  C,  December,  1936 


No.   12 


Fetal   Birth   Injuries  and   the   Care  of   Premature   Infants* 

Hubert  A    Royster,  jr.,  A.B.,  M.D.,  Bryn  :\Iavvr,  Pennsylvania 


I  am  to  speak  to  you   this   morning  upon   two 
topics  intimately  connected  with  the  manage- 
ment of  the  parturient  woman,  both  concernsd 
with  the  product  of  conception;  namely,  fetal  birth 
injuries  and  the  care  of  premature  infants.    These 
two  problems  of  childbirth  are,  in  many  localities 
and  institutions,  never  the  worry  of  the  obstetri- 
cian, but  that  of  the  pediatrician.    When,  however, 
the  duties  of  the  two  are  combined   it   behooves 
the  physician  to  know  what  is  generally  thought 
to  be  the  best  possible  care  for  the  child  as  well 
as  the  mother.     I   greatly   fear  that  my  remarks 
will  be  a  repetition  in  your  own  minds  of  what 
you  know  and  have    known    for    some    time.     If 
I  can  add  to  your  knowledge,  I  will  be  fortunate; 
if  I  can  put  in  order  any  small  existing  chaos  of 
ideas,  I  will  indeed  be  satisfied.     The  importance 
of  these  topics  to  the  physician   may  readily  be 
seen  in  glancing  at  the  fetal  mortality  figures  from 
the   Philadelphia   Lying-in    Hospital    for   the   past 
si.x  years.     Out  of  12,000  births  there  have  been 
some   800   fetal  deaths,  with  a   general   mortality 
of  6.8  per  cent.     Out  of  the  800  deaths,  prema- 
turity is  the  cause  of  death  in  290,  or  36  per  cent., 
by  far  the  greatest  percentage  in  the  list  of  causes. 
Third  in  the  list  of  causes  is  intracranial  hemor- 
rhage due  to   birth   trauma,  with   65   cases,  or   8 
per  cent.     These  figures  are  in  line  with  other  re- 
ports and  make  us  doubly  zealous  in  our  efforts 
to   combat    the    high    mortality    average    of    birth 
trauma  and  premature  birth. 
I 
The  first  grouping    under    consideration,    fetal 
birth  injuries,  is  rather  well  classified  in  anatomi- 
cal systems.    Starting  with  the  most  obvious  struc- 
ture, the  skin,  I  need   hardly   mention   the  abra- 
sions,   contusions,    and    hematomata    which    are 
singly  or  collectively  the  almost   invariable   com- 
panions of  forceps  delivery.     Usually  we  are  satis- 
fied with  a  hands-off  policy,  but  we  must  bear  in 
mind    the    susceptibility    of    the    infant's    skin    to 

•Read  before  the  Harrisburg  Academy  of  Medicine,  Harr 


infection,  and  its  proximity  to  contaminating  or- 
ganisms such  as  the  streptococcus  erysipelatis  in 
the  child's  passage  over  the  perineal  roof  of  the 
rectum.  Subcutaneous  hematomata  are  best  left 
untampered  with.  The  withdrawal  of  the  blood  will 
result  in  its  quick  reformation,  while  if  left  in  situ 
absorption  will  slowly  but  surely  be  effected. 

Muscle  injuries  are  extremely  common,  partic- 
ularly in  forceps  delivery  and  breech  extraction. 
In  the  former  the  commonest  site  is  probably  in 
the  sternomastoid  muscle,  giving  rise  to  a  hard 
and  probably  painful  hematoma,  and  often  to 
temporary  wryneck.  In  breech  extraction  the 
child's  feet  are  frequently  bruised  from  manual 
traction,  and  may  show  livid  edema  for  several 
days,  its  only  harmful  effect  being  to  frighten  the 
mother. 

As  we  proceed  to  more  serious  injuries  those  of 
the  skeletal  system  seem  next  in  order,  the  two 
categories  being  fracture  and  dislocation.  Disloca- 
tion is  rare,  the  order  of  frequency  being:  lower 
epiphysis  of  the  humerus,  upper  epiphysis  of  the 
humerus,  lower  epiphysis  of  the  femur,  and  the 
jaw.  That  of  the  lower  humeral  epiphysis  is  the  only 
one  deserving  of  mention.  It  is  caused  by  forcible 
traction  on  the  arm  during  breech  delivery,  and 
its  presence  may  be  suspected  by  limitation  of 
motion  and  crepitation  when  the  arm .  is  flexed. 
X-ray  findings  will  be  negative  until  about  the 
twelfth  day,  when  a  new  centre  of  ossification  be- 
gins. The  treatment  consists  in  doing  nothing,  as 
the  injury  will  tend  to  right  itself. 

Fractures  are  commonest  in  these  sites:  clavicle, 
humerus,  femur  and  skull.  There  is  probably  not 
one  of  you  who  has  not  heard  the  crack  of  a 
clavicular  fracture  during  a  difficulty  delivery  of 
the  shoulders.  It  is  an  extremely  common  frac- 
ture in  the  new-born,  and  is  often  done  on  pur- 
pose to  facilitate  delivery.  Usually  sufficient  treat- 
Pi.,nf  r-:-5->t=,  in  oivl-.r-tiror  pn^  extf^'-nnlly  rotat'n-^ 
the  affected  arm  while  allowing  nature  to  heal  the 

■isburs.  Pa.,  Oct.  23rd,  1936. 


FETAL   BIRTH   INJURIES— PREMATURE   INFANTS— Rovster 


December,  1936 


fracture.  A  fracture  of  the  humerus  is  not  infre- 
quently caused  during  delivery  of  the  arms.  It  is 
usually  accompanied  by  wrist-drop  due  to  injury 
of  the  radial  nerve,  but  both  the  fracture  and  the 
nerve  lesion  will  heal  in  a  few  days  or  weeks  on 
the  application  of  a  simple  splint.  In  a  fracture 
of  the  femur  the  only  precaution,  an  important  one, 
is  to  prevent  antero-posterior  bowing  by  the  ap- 
plication of  proper  splints.  Fractures  of  the  skull 
are  rare  and  of  the  fissured  type;  but,  if  a  cranial 
hematoma  is  irregular,  and  of  a  rather  soft  and 
mushy  consistency,  we  may  suspect  a  depressed 
fracture  of  the  vault,  and  this  extremely  rare  con- 
dition requires  surgical  elevation  of  the  depressed 
fragments. 

More  important  still  to  the  child's  outlook  are 
injuries  to  nervous  structures.  Under  this  heading 
are  the  two  common  peripheral  nerve  injuries — 
Erb's  and  Bell's  palsies.  Erb's  palsy  is  caused 
by  stretching,  rupture,  or  hematoma  of  parts  of 
the  brachial  plexus  when  too  forcible  traction  is 
exerted  on  the  arm.  It  may  show  itself  in  tem- 
porary weakness  or  permanent  flaccid  paralysis  of 
the  affected  arm.  In  the  management  of  this  af- 
fliction the  arm  is  placed  out  at  right  angles  to 
the  body  with  the  forearm  held  vertically.  This 
lessens  any  tension  which  might  be  put  upon  the 
nerve  plexus,  and  should  be  continued  for  several 
weeks.  The  speed  and  completeness  of  recovery 
depend  upon  the  nature  of  the  lesion.  If  there  is 
mild  stretching  and  hematoma  formation,  with  the 
nerve  sheath  comparatively  intact,  the  prognosis 
is  good;  if  there  is  complete  rupture,  a  favorable 
outcome  is  not  to  be  expected.  Further  manage- 
ment will  consist  in  observing  the  improvement 
during  the  first  year  of  life.  If  there  is  no  marked 
return  of  function  many  surgeons  think  there  is 
justification  for  an  ex-ploratory  operation  in  the 
hope  of  finding  adhesions  about  the  brachial  plexus 
which  may  be  excised,  perhaps  with  recovery  from 
the  paralysis.  The  prognosis  may  be  encouraging  if 
faradic  stimulation  gives  a  response,  but  in  cases 
giving  the  reaction  of  degeneration  the  outlook  is 
bad.  Bell's  palsy  is  usually  caused  by  forceps 
pressure  over  the  facial  nerve  as  it  makes  its  exit 
from  the  stylomastoid  foramen.  It  is  practically 
always  unilateral,  since  it  is  rare  to  have  both 
forceps  blades  on  S3'mmetrical  spots.  This  palsy 
will  practically  always  disappear  spontaneously  in 
one  or  more  weeks.  It  does  not  interfere  with 
nursing  since  practically  all  sucking  efforts  are 
made  with  the  infant's  tongue. 

In  the  ventral  nervous  system  cerebral  hemor- 
rhage is,  of  course,  the  commonest  and  most  feared 
of  birth  traumata.  Its  causes  are  more  or  less 
mechanical    in   nature;    a   narrow   pelvis   or   tight 


perineum  with  hard  uterine  contractions  can  hardly 
be  expected  not  to  give  the  fetal  head  a  severe 
drubbing.  A  very  long  labor  with  or  without 
marked  disproportion  may  often  compress  the 
brain  enough  to  rupture  its  delicate  structures. 
Forceps  applied  incorrectly  and  used  with  incau- 
tious traction  have  been  serious  offenders  and 
should  serve  to  deter  those  who  have  not  had 
sufficient  training  and  experience  in  their  use.  The 
delivery  of  the  after-coming  head  has  always  been 
a  bugaboo  in  dealing  with  the  prevention  of  cere- 
bral hemorrhage  in  the  new-born.  Its  background 
is  obvious;  the  fetal  head  usually  has  not  been 
moulded  enough  to  permit  its  passage  through  the 
birth  canal  without  sudden  damaging  pressure. 
This  increases  the  high  percentage  of  breech  and 
version  fetal  deaths.  Occasionally  we  find  a  nor- 
mal woman  giving  birth  to  a  child  of  normal  size 
by  a  short  labor,  and  yet  the  child  is  a  victim  of 
cerebral  hemorrhage.  When  it  occurs  the  hem- 
orrhage is  most  commonly  due  to  a  tear  of  the 
tentorium,  and  consequently  is  likely  to  be  around 
the  base  of  the  brain  near  vital  centres.  Elsewhere 
the  immediate  danger  to  life  is  not  so  great,  and 
surgical  removal  of  the  clots  may  be  done  at  a 
later  date.  Recognition  of  cerebral  hemorrhage  is 
not  difficult  as  a  rule.  The  signs  are  ushered  in 
with  primary  difficulty  in  resuscitation.  A  few 
hours  later  the  child  may  show  intermittent  cyan- 
osis, not  associated  necessarily  with  nursing  or 
crying,  poor  sucking  actions,  and  an  almost  con- 
stant state  of  irritability.  When  the  bassinet  is 
jarred  the  child  immediately  jerks  its  legs  and  arms 
and  will  cry,  providing  the  hemorrhage  has  not 
rendered  it  comatose.  Fresh  blood  in  the  spinal 
fluid  is  pathognomonic  in  the  presence  of  the  other 
signs,  but  may  be  present  in  normal  babies. 

In  the  treatment  of  cerebral  hemorrhage  of  the 
new-born  we  first  examine  the  situation  from  the 
standpoint  of  potential  hemorrhage,  taking  into 
consideration  the  length  of  labor  and  the  mode  and 
difficulty  of  delivery.  If  there  is  any  suspicion 
that  there  might  have  been  possible  cerebral  dam- 
age, we  give  an  intramuscular  injection  of  mother's 
blood  before  the  baby  leaves  the  delivery  room, 
mainly  in  the  hope  and  on  the  assumption  that 
the  coagulating  power  of  the  baby's  blood  will  be 
enhanced.  The  point  is  a  difficult  one  to  prove. 
Following  this  the  infant  is  kept  as  quiet  as  possi- 
ble with  gentle  handling.  Inhalations  of  oxygen 
may  tide  over  the  cyanotic  attacks.  When  the 
attacks  grow  frequent  and  the  child  appears  in- 
creasingly irritable,  even  to  convulsions,  we  advise 
drainage  of  the  cerebrospinal  fluid,  preferably  from 
the  cisterna  magna.  Since  there  is  always  edema 
of  the  brain,  at  least  locally,  in  cerebral  hemor- 


December,   1036 


FETAL   BIRTH   INJURIES— PREMATURE   INFANTS— Roysler 


rhage,  we  might  consider  the  intravenous  injection 
of  a  hypertonic  sucrose  solution  in  an  attempt  to 
withdraw  fluid  into  the  blood  stream.  Sucrose  is 
superior  to  glucose  because  of  its  higher  osmotic 
power  and  from  the  fact  that  it  is  not  oxidized  in 
the  blood  stream,  but  excreted  as  such,  thus  length- 
ening its  effect. 

With  all  our  therapeutic  armamentarium  the 
mortality  is  still  far  too  high  and  we  must  plead 
for  prevention.  By  careful  judgment  in  the  use 
of  instruments,  by  adequate  prenatal  predictions 
as  to  vaginal  delivery,  by  patience  and  puttering 
until  sufficient  moulding  has  been  effected,  and  a 
holy  respect  for  the  infant's  tender  tissues,  let  us 
hope  to  strike  a  blow  at  one  arrogant  adversary  of 
child  welfare. 

II 

Next  I  will  take  up  briefly  the  subject  of  the 
prematurely  born  infant,  a  subject  highly  import- 
ant in  view  of  the  fact  that  prematurity  is  by  far 
the  commonest  cause  of  fetal  mortality.  The  sit- 
uation is  made  very  difficult  when  we  know  that 
in  40  per  cent,  of  premature  births  the  cause  of 
early  labor  is  unknown,  thus  giving  us  a  check- 
mate in  that  large  percentage  of  cases  where  the 
mother  and  baby  are  normal  to  our  examination 
and  preventive  measures  are  of  no  avail.  Perhaps 
in  the  next  few  years  the  fast-growing  endocrine 
therapeutic  agents  will  furnish  the  answer. 

A  premature  child,  according  to  the  recent  report 
of  the  American  Public  Health  Association,  is  one 
having  a  birth  weight  of  SJ^  lbs.  or  less,  a  crown: 
heel  length  of  18  inches  or  less,  and  a  gestation 
period  of  37  weeks  or  less.  Birth  weight  is  the 
most  important,  and  Bonar  thinks  the  other  two 
criteria  should  be  disregarded.  Certainly  birth 
weight  and  the  signs  of  prematurity,  such  as  in- 
frequent feeble  movements,  soft  delicate  skin  cov- 
ered with  lanugo,  a  low  feeble  cry,  and  markedly 
irregular  respirations,  should  lead  one  to  consider 
special  handling  of  the  infant. 

The  60  per  cent,  of  premature  births  which  are 
from  known  causes  may  be  due  to:  1.  Mechanical 
means,  such  as  a  fall,  fibroid  tumors  of  the  uterus, 
iir  multiple  gestation.  2.  Toxemias,  as  seen  in 
eclampsia,  in  which  the  premature  birth  may  be 
therapeutic.  3.  Syphilis.  4.  Acute  infections,  such 
as  influenza  and  pneumonia.  5.  Metabolic  diseases, 
as  diabetes.  ^Mechanical  causes  are  usually  insur- 
mountable, and  care  must  consist  for  the  most 
part  in  attention  to  the  baby  after  delivery.  Toxe- 
mias can  be  controlled  to  a  great  extent  by  assid- 
uous prenatal  care,  though  the  fulminating  cases 
can  strike  with  terrifying  speed,  leaving  us  help- 
less. Syphilis  is  mainly  dependent  on  adequat-j 
and  early  treatment,  while  infections  raise  the  mor- 


tality according  to  their  severity,  showing  us  the 
need  for  sheltering  the  expectant  mother.  The 
diabetic  premature  birth  is  always  attended  by 
danger  from  hyperinsulinism  in  the  child,  partic- 
ularly with  an  untreated  mother.  It  has  been  defi- 
nitely shown  that  increase  in  insulin  output  and 
pancreatic  islet  hypertrophy  have  occurred  in  chil- 
dren born  of  such  a  mother. 

Knowledge  of  the  care  of  premature  babies  has 
been  widely  disseminated  following  the  herculean 
efforts  of  Madame  Dionne  and  Dr.  Dafoe.  They 
have  shown  us  the  three  cardinal  points:  mainten- 
ance of  body  temperature,  adequate  nourishment, 
and  prevention  of  infection.  The  whole  picture  of  a 
premature  child  is  that  of  an  organism  with  little 
vitality,  and  we  must  protect  what  little  it  has. 
Body  temperature  is  the  first  regard  after  birth 
since  nourishment  and  isolation  may  wait  a  few 
hours.  The  infant's  thermal  regulation  is  embry- 
onal and  it  will  take  on  the  temperature  of  its  en- 
vironment. Temperatures  have  been  known  to 
vary  13°  F.  This  labile  characteristic  is  seen  to 
best  advantage  when  a  child  born  prematurely  in 
the  home  is  brought  to  the  hospital.  The  act  of 
travel,  even  though  a  few  blocks,  may  reduce  body 
temperature  to  as  low  as  92°  or  less.  And  so  we 
try  to  maintain  an  atmospheric  temperature  of 
from  98  to  100°  as  constantly  as  possible.  An 
added  wrinkle  recently  introduced  consists  of  an 
apparatus  to  control  room  humidity  at  50. 

Isolation  is  imperative.  A  premature  baby's 
power  of  resistance  to  disease  is  notoriously  low, 
so  that  all  nurses  and  doctors  in  contact  with  the 
baby  must  be  free  from  infective  processes  and 
all  apparatus  used  must  be  sterile.  Each  premature 
baby  should  have  a  room  or  cubicle  to  Itself.  Once 
normal  vitality  is  established  the  precautions  can 
be  less  stringent 

In  feeding,  what  Oliver  Wendell  Holmes  said 
about  breast  milk  for  babies  in  general  applies  to 
premature  babies  in  particular:  "A  pair  of  sub- 
stantial mammary  glands  has  the  advantage  over 
the  two  hemispheres  of  the  most  learned  profes- 
sor's brains  in  the  art  of  compounding  a  nutritious 
fluid  for  infants."  Breast  milk  is  without  question 
the  food  of  choice.  When  this  is  not  available  the 
dry  preparation,  Similac,  has  been  found  by  us  to 
be  most  satisfactory.  The  feedings  should  be  small 
r,nd  frequent  depending  on  the  size  of  the  child. 
They  range  from  half  a  drachm  every  hour  to  an 
ounce  every  two  hours.  It  is  well  to  give  a  few 
drops  of  whiskey  with  each  feeding  for  the  first  48 
hours  to  act  as  a  stimulant  and  digestive.  The 
baby  must  be  fed  with  the  least  effort  on  his  part. 
There  are  many  choices  among  gavage,  dropper, 
Brek  feeder,  etc,     I  recently  saw  a  baby  weighing 


FETAL   BIRTH  INJURIES— PREMATURE   INFANTS— Royster 


December,  1936 


3J^  lbs.  who  was  put  to  breast  every  three  hours 
and  on  the  second  day  became  so  exhausted  that 
it  regurgitated  a  quantity  of  milk  which  found  its 
way  into  the  lungs  causing  a  disastrous  pneumonia. 
The  child's  energy  and  normal  reflexes  must  be 
matured  gradually  until  the  dangers  of  weakness 
and  exhaustion  are  passed. 

Among  additional  precautions  which  are  helpful 
I  would  like  to  mention  the  administration  of  car- 
bon dioxide  and  oxygen  by  inhalation  to  enable 
the  child  to  expand  the  commonly  occurring  patches 
of  atelectatic  lung.  This  is  best  done  every  few 
hours  for  at  least  the  first  day.  Aeration  of  the 
room  is  not  necessary  because  of  the  very  tiny 
respiratory  exchange.  After  one  week  we  usually 
add  to  the  child's  diet  complements  of  viosterol, 
orange  juice  and  some  iron  preparation,  knowing 
the  premature  baby's  susceptibility  to  rickets, 
scurvy  and  secondary  anemia.  The  prognosis  is 
usually  good  if  born  of  a  healthy  mother,  if  the 
initial  weight  is  not  too  low,  and  if  there  is  ade- 
quate temperature  control. 


Making  Ether  .-Xn  Ideai  Anesthetic 

(V/.    N.    Kemp.    Vancouver,    in    Canadian    Med.    Assn.    Jl., 

AprU) 

Valuable  as  other  anesthetics  undoubtedly  are  in  expert 
hands,  their  range  of  sati5factor\'  surgical  application  is 
definitely  more  limited  than  is  that  of  ether. 

The  patient  demands  safety  during  the  entire  anesthesia 
and  comfort  in  the  induction  and  recovery  stages;  the 
surgeon  demands  muscular  relaxation  (in  laparotomies) 
and  safety;  the  anesthetist  prefers  an  anesthetic  that  is 
simple  and  flexible  in  its  administration,  is  of  low  cost, 
and  is  easily  transported.  It  is  my  opinion  that  ether  most 
nearly  measures  up  to  these  desiderata.  Discomfort  in 
the  induction  stage  can  be  readily  eliminated  by  the  judi- 
cious use  of  avertin  or  the  barbiturates,  while  post-opera- 
tive nausea  and  vomiting  can  also  be  eliminated  by  ultra- 
conservative  pre-operative  care. 

The  unpleasant  psychic  reactions  that  often  occur  in 
unpremedicated  patients  awaiting  operation  should  be  ob- 
viated by  rendering  the  patient  stuporose  or  even  uncon- 
scious with  avertin,  one  of  the  barbiturates,  or  morphine 
and  scopolamine,  or  at  least  a  combination  of  several  pre- 
medicants.  At  least  l/6th  of  a  grain  of  morphine  and 
l/150th  grain  of  atropine  should  be  given  at  least  30  min- 
utes before  the  induction  of  anesthesia,  for  the  purpose  of 
controlling  the  secretion  of  mucus  and  saliva.  In  lightly 
premedicated  patients  ethyl  chloride  makes  a  very  satisfac- 
tory inducing  agent  preliminar>-  to  a  drop  ether  induction. 

When  second-stage  anesthesia  is  reached  a  change  is 
made  to  vaporized  ether,  using  oxygen  as  the  vehicle  to 
earn,-  the  ether  vapour  to  the  patient  by  way  of  the  face 
mask  or  the  endophar\-ngeal  or  endotracheal  catheter,  ac- 
cording to  the  dictates  of  the  operation.  The  plane  of  the 
anesthesia  should  be  kept  adjusted  to  the  varying  require- 
ments of  the  surgeon.  The  maintenance  of  a  free  airway 
and  adequate  oxygen  supply  is  essential  to  a  well  con- 
ducted anesthesia.  We  have  found  the  routine  suction 
removal  of  endotracheal  mucus  at  the  close  of  the  opera- 
tion is  of  value  in  decreasing  post-operative  nausea  and 
vomiting.  Subcutaneous  or  intravenous  normal  saline  solu- 
tion is  a  sine  qua  non  of  any   major  surgical  procedure. 


There  will  still  be  sufficient  nausea  and  vomiting  to  pre- 
vent our  anesthetic  being  considered  ideal.  I  believe  that 
this  can  be  eliminated  in  toto  (or  nearly  so)  by  pre-oper- 
ative care. 

In  a  series  of  20  patients  the  daily  pre-operative  admin- 
istration of  10  minims  of  Lugol's  solution  for  5  days  defi- 
nitely reduced  post-operative  nausea  and  vomiting.  Simi- 
larly, in  a  smaller  series  of  cases  in  the  same  service  that 
the  pre-operative  administration  of  desiccated  suprarenal 
cortex  (.Armour)  in  a  dose  of  6  grains,  3  times  daily,  for 
5  days  beofre  operation,  almost  entirely  eMminated  post- 
operative vomiting  in  patients  narcotized  with  ether  for 
major  surgery. 

For  one  week  prior  to  operation  the  patient  should  be 
on  a  meat-free,  high  carbohydrate  diet,  abundant  in  vita- 
mins and  calcium,  supplemented  with  1.5  ounces  of  lactose 
daily.  For  S  days  prior  to  operation  he  should  take  10 
minims  of  Lugol's  solution  daily.  For  3  days  prior  to 
operation  he  should  be  in  the  hospital,  getting  into  physical 
and  environmental  equilibrium. 

The  fact  that  the  majority  of  patients  survive  our  pres- 
ent customary  lack  of  preparation  is  no  argument  for  its 
continuance.  Undoubtedly  the  next  great  advance  in  sur- 
ger\-  w-ill  be  in  the  field  of  pre-operative  care.  When  this 
ensues  and  when  anesthetists  are  trained  to  administer 
ether  according  to  the  technique  outlined  above,  or  in 
even  better  fashion,  then  we  will  have  made  ether  an  ideal 
general  anesthetic. 


X-R.4Y  Therapy  in  Infections 
(D.  A.  Rhinehart,  Little  Rock,  in  Jl.  Ark.  Med.  Soc,  Dec.) 

Furuncles  and  boils  in  any  region  usually  respond 
promptly  to  a  single  short  x-ray  treatment.  The  swelling 
decreases,  with  or  without  an  initial  increase  in  severity, 
the  pain  ceases,  the  induration  softens,  and  the  infection  is 
absorbed  or  promptly  suppurates  and  can  be  drained,  heal- 
ing taking  place  by  granulation  in  the  usual  manner.  Be- 
cause of  the  severe  pain  from  lack  of  room  in  which  to 
swell,  more  furuncles  in  the  external  auditory  canal  have 
been  treated  than  elsewhere.  Furuncles  and  boils  about 
the  nose,  lips,  and  face  are  next  in  frequency.  The  danger 
of  spreading  such  infections  to  the  cavernous  sinus  espe- 
cially prohibits  the  usual  manipulative  therapy. 

Unless  the  patient  be  a  diabetic,  in  which  the  results 
often  are  not  satisfactory,  the  x-ray  treatment  of  a  car- 
buncle in  any  locality  usually  gives  a  spectacular  result. 

Kelly  of  Omaha  has  collected  a  series  of  cases  of  gas 
gangrene  treated  with  x-rays  with  a  mortality  of   10%. 

Manges  suggests  that  roentgenologists,  particularly  those 
connected  with  large  hospitals,  be  permitted  to  treat  every 
patient  who  has  an  active  infection. 


Roentgen  Therapy  of  Cellulitis 


Roentgen  therapy  is  the  rational  treatment  of  infections 
involving  the  soft  tissues  of  the  mouth,  face  and  neck. 
F.  M.  Hodges,  of  Richmond,  has  found  it  efficacious  in 
furuncles,  carbuncles,  metastatic  parotitis,  en."5ipelas,  and 
cellulitis  of  the  mouth,  face  and  neck. 

Surgery  is  unnecessarily  or  contraindicated  in  most  such 
infections. 

Rresults  are  rapid  and  with  few  exceptions  excellent. 
Treatment  is  painless  and  when  properly  supervised  does  no 
harm  and  leaves  no  scars.  With  rare  exceptions  no  subse- 
quent dressings  or  treatments  are  necessary. 

The  earlier  in  the  course  of  the  infection  the  roentgen 
therapy  can  be  started  the  better  the  results. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


637 


Gout:  The  Modern  Disease* 

Abraham  Cohen,  M.D.,  Philadelphia 


IX  the  eighteenth  and  nineteenth  centuries 
much  was  written  about  this  disease  as  afflict- 
ing the  rich,  pleasure-loving  people  of  Eng- 
land, France  and  Germany.  Very  little  material 
has  appeared  in  the  last  quarter  century  because 
it  was  thought  that  there  was  nothing  new  and 
that  it  was  gradually  passing  from  our  midst.  The 
recent,  more  careful,  studies  of  joint  disease  sug- 
gest that  gout  is  just  as  prevalent  as  it  was  a  cen- 
tury ago.  It  is  now  believed  that  it  goes  unrec- 
ognized in  about  90  per  cent,  of  cases.  Two  new 
conceptions  have  become  crystallized:  (1)  that 
gout  is  not  limited  to  the  great  toe;  (2)  that  the 
disease  is  common  to  all  classes  of  society — the 
rich  as  well  as  the  poor,  and  even  the  destitute. 
Gudzent  and  Holzmann^  reported  76  cases  of  true 
gout  in  32,089  autopsies,  while  McCrae-  quotes 
Futcher  as  having  discovered  59  cases  in  18,000 
autopsies.  Schnitker  and  Richter''  report  55  cases 
in  the  23-year  period  from  1913  to  1935  at  Peter 
Bent  Brigham  Hospital,  Boston.  In  a  previous 
article,^  I  reported  47  cases  diagnosed  at  the  Phil- 
adelphia General  Hospital  in  the  25-year  period 
from  1906  to  1929,  and  30  cases  from  1929  to 
1935.  The  number  of  admissions  in  the  former 
period  reached  approximately  414,296,  while  in  the 
latter  period  it  was  146,992.  This  discrepancy 
points  to  one  of  two  conclusions — either  that  gout 
is  more  prevalent  today  than  it  was  25  years  ago, 
or  that  it  has  been  misdiagnosed.  We  believe  that 
new  criteria  for  diagnosis  are  necessary  if  we  are 
to  recognize  gout  in  its  atypical  forms.  It  is  the 
purpose  of  this  paper  to  point  out  criteria  which 
may  aid  in  the  diagnosis  of  a  disease  which  is 
vastly  more  prevalent  than  one  is  led  to  believe. 
Etiology 
Gout  occurs  at  any  age.  It  is  most  common  in 
the  third  decade  of  life  and  in  the  sthenic  indi- 
vidual. It  is  less  common  in  females  than  in  males, 
the  proportion  being  about  1:10.  Heredity  has 
been  claimed  as  an  etiological  factor,  but  in  our 
series  of  cases  this  is  almost  negligible.  .According 
to  Garrod'  about  50  per  cent,  of  his  patients  gave 
a  positive  family  history,  while  Brame  and  Gar- 
dinac  found  it  positive  in  90  to  100  per  cent,  of 
cases. 

Apparently  little  is  known  about  the  nutritional 
factor.  From  my  own  experience,  it  would  seem 
that  the  ravenous  appetite  which  occurs  prior  to 
an  attack  of  gout  is  not  the  cause,  but  rather  the 


•From  the  Arthritis  Clinics  of  the  Philadelphia  Ueneral 
lent  of  Philadelphia. 


result,  and  is  merely  a  symptom  much  as  in  dia- 
betes mellitus.  It  is  commonly  observed  that  prior 
to  an  attack  of  acute  gout  the  patient  consumes 
large  quantities  of  purins  and  ofttimes  alcoholic 
beverages.  As  a  result,  this  lowly  disease  has  been 
designated  the  disease  of  high  livers.  Hench  and 
Barnall"  found  that  a  sudden  feast  on  purins  is  a 
factor  which  might  precipitate  an  attack.  In  the 
days  of  Garrod^  it  was  perhaps  only  the  rich  who 
could  afford  such  a  diet. 

Infection,  trauma,"  and  seasonal  changes  are  pre- 
disposing factors  in  this  series  of  cases. 
Pathology 

This  condition  begins  with  an  increase  of  fiuid 
within  the  joint  and  a  deposition  of  sodium  biurate 
crystals  within  the  fluid.  Soon  the  crystals  begin 
to  adhere  to  and  erode  the  cartilage,  replacing  the 
destroyed  portion.  As  the  disease  progresses,  the 
capsule  and  periarticular  tissues  become  involved; 
while  in  the  later  stages  the  sodium  biurate  finds 
its  way  into  the  ends  of  the  bone  and  even  into 
the  marrow,  completely  replacing  all  structures.  It 
is  at  this  period  that  evidence  of  gout  is  recogniz- 
able by  x-ray  examination. 

Similar  changes  may  occur  in  other  structures 
of  the  body,  particularly  in  the  helices  of  the  ears, 
subcutaneous  tissues,  bursae,  muscle  and  cartilage. 
These  concretions  are  known  as  tophi. 

The  most  important  visceral  changes  occur  in 
the  renal  system.  Tophi  sometimes  are  found  in 
the  form  of  ureteral,  vesical  or  renal  calculi.  The 
kidney  appears  in  the  later  stages  as  the  character- 
istic small  white  kidney  of  arteriosclerosis  produc- 
ing the  typical  clinical  picture  of  this  disease. 
Sclerosis  of  the  blood-vessels  with  associated  myo- 
carditis is  found  to  be  more  advanced  than  the 
age  of  the  individual  would  lead  one  to  suspect. 

Uric  acid  is  the  product  of  cleavages  of  nucleo- 
proteins  which  contain  phosphorus,  and  a  combina- 
tion of  protein  with  nucleic  acid.  The  chief  sources 
of  nucleic  acid  are  the  thymus,  the  pancreas,  and 
yeast.  JNIendel  and  Lyman  as  quoted  by  Macleod* 
have  found  that  about  50  per  cent,  of  the  exo- 
genous purins  are  excreted  in  the  urine  in  the  form 
of  uric  acid  and  the  intake  and  output  of  purins 
are  about  proportionate.  This  would  indicate  that 
individuals  with  a  predisposition  to  gout  should 
ingest  purin-rich  foods  sparingly.  This  has  been 
; '.iljstantiated  by  the  work  of  Folin."  The  normal 
uric  acid  as  estimated  by  the  method  of  Folin  is, 

and  Jefferson  Hospitals  and  the  Police  and  Fire  Depart- 


GOVT— Cohen 


December,  1936 


according  to  our  observations  at  the  Philadelphia 
General  Hospital,  2  to  4.5  mgms.  per   100  c.c.  of 
blood.    In  the  female  this  is  somewhat  less. 
Clinical  Manifestations  of  Acute  Gout 

Prior  to  the  acute  attack  of  gout  the  patient  for 
a  few  weeks  feels  out  of  sorts;  he  is  irritable  and 
difficult  to  get  along  with.  His  appetite  is  partic- 
ularly good  and  toward  the  onset  of  the  attack  it 
becomes  almost  ravenous.  Large  quantities  of  tea, 
coffee  or  beer  are  consumed  and  there  is  an  in- 
satiable desire  for  meats.  Soon  the  patient  begins 
to  complain  of  numbness  in  the  muscles  and  a 
sensation  of  heat  in  the  joints. 

The  acute  attack  comes  on  in  the  night  as  a 
rule.  It  is  usually  polyarticular,  but  may  be  mon- 
articular. There  is  sudden  severe  pain  in  the 
joints  which  often  causes  the  patient  to  cry  out. 
The  weight  of  the  bedclothes  is  unendurable;  there 
may  be  chills,  the  temperature  rises,  the  pulse  be- 
comes rapid.  The  joints  now  become  red  and 
swollen  and  the  patient  begins  to  perspire  profusely. 
The  subjective  symptoms  are  those  of  acute  infec- 
tion. 

The  next  day  the  patient  appears  apprehensive 
and  gives  the  impression  of  great  suffering.  His 
appetite  is  now  very  poor.  The  periarticular  tissues 
become  swollen  and  tender,  blood  count  shows  a 
moderate  leucocytosis,  urine  is  concentrated  and 
scanty,  blood  uric  acid  is  usually  increased  but 
may  be  normal.  In  some  cases  the  condition  re- 
mains confined  to  one  or  two  joints,  while  in  others 
it  is  migratory,  but  not  evanescent.  X-ray  e.xam- 
ination  at  this  time  is  negative  except  perhaps  for 
the  periarticular  swelling,  unless  the  joint  involved 
is  one  which  has  suffered  many  attacks  and  tophi 
are  present. 

As  regards  the  blood  uric  acid,  there  are  three 
types: 

1.  Those  in  whom  the  blood  uric  acid  is  ele- 
vated prior  to  and  during  the  acute  attack, 
following  which  there  is  a  return  to  normal. 

2.  Those  in  whom  there  is  an  elevation  of  blood 
uric  acid  at  all  times,  but  during  an  attack 
it  is  more  elevated. 

3.  Those  in  whom  there  is  never  an  elevation 
of  blood  uric  acid. 

The  attack  may  last  a  week  or  two  in  the  sthenic 
individual;  in  the  asthenic  it  sometimes  goes  on  for 
months.  One  morning  the  patient  awakes  to  find 
his  pain  completely  disappeared,  and  except  for 
weakness,  the  result  of  febrile  reaction,  he  feels 
none  the  worse  for  wear.  He  may  suffer  but  one 
attack  a  year  or  he  may  suffer  many.  I  have  seen 
patients  who  have  had  as  many  as  six  or  eight 
attacks  yearly  for  many  years. 

The  degree  of  deformity  depends  as  a  rule  upon 


the  number  of  attacks:  however,  it  may  take  but 
a  few  before  signs  of  chronic  tophaceous  gout  be- 
come manifest.  Tophi  may  appear  in  the  helices 
of  the  ears,  in  the  cartilages  of  the  eyelids  and  the 
nose,  and  in  the  joints.  They  may  also  appear  in 
the  subcutaneous  tissues  or  in  the  muscles,  where 
they  sometimes  assume  comparatively  large  pro- 
portions. They  may  be  the  size  of  a  baseball,  hard 
and  irregular  in  outline  and  feel  very  close  to  the 
skin,  or  deeper  and  apparently  within  the  muscles. 
These  painless  formations  contain  the  characteris- 
tic crystals  of  sodium  biurate  and  cholesterin. 

The  joints  between  attacks  are  free  from  pain 
and  usually  present  normal  range  of  motion.  After 
uric  acid  has  penetrated  the  cartilage  and  bone, 
x-ray  films  show  a  characteristic  punched-out  ap- 
pearance in  the  ends  of  the  bones.  The  kidney 
may  show  necrotic  areas  in  the  medulla  and  cap- 
sule, but  this  is  very  rare.  As  has  been  mentioned, 
stones  giving  symptoms  typical  of  ureteral  and 
kidney  calculi  are  not  uncommon.  Renal  sclerosis 
with  resultant  shrunken  kidney  is  a  late  result. 
Schnitker  and  Richter^  report  31  per  cent,  with 
definite  nephritis  in  their  group  of  cases. 

Arteriosclerosis  occurs  in  a  large  percentage  of 
cases,  and  hyf>ertension  is  very  common.  The  path- 
ology of  these  vascular  changes  is  not  unlike  that 
in  non-gouty  patients.  Digestive  disturbances  are 
manifested  by  the  increased  appetite  and  some- 
times violent  attacks  of  gastroenteritis  occur,  with 
diarrhea,  pain  in  the  abdomen  and  jaundice.  The 
liver  is  often  palpable  and  tender  during  an  attack, 
but  the  cardiac  insufficiency  is  not  great  enough  to 
account  for  the  liver  changes. 

The  accompanying  table,  a  summary  of  25  cases 
of  proved  gout  in  the  Police  and  Fire  Department 
of  Philadelphia,  will  serve  to  show  that  this  disease 
attacks  the  man  of  moderate  means,  though  per- 
haps not  of  entirely  moderate  habits. 

.All  these  patients  are  under  control  so  that  there 
are  only  three  who  have  had  recurrences.  Two 
admitted  indiscretions  in  diet  while  one  had  an 
attack  following  the  removal  of  a  gangrenous  ap- 
pendix. 

Age  at  Onset 
10-20  21-30  31-40  41-50  51-60  Over  60 

No  cases  3  10  6  5  1 

Duration  of  Disease   in    Years 

Less  than  1  1-5  5-10  10-15  15-20  20-30 

10  cases  5  2  3  3  2 

Family  History 

Positive     0  cases 

Negative    25 

Attacks  Precipitated  hy 

Appendicitis    _    1  case 

Cold    -  1 

Trauma    1 

La  Grippe  -— — —  2 


December,  1936 


GOUT—Cohen 


639 


Length  of  Attacks 

Two  days  to  ten  weeks. 

Vric  Acid  in  Blood 

Normal — 3-4.5  mgms.  Elevated — Above  4.5  xugms. 

1  case  24  cases 

Mgms.  per  100  c.c. 

Average   high   6.2 

Average  low 3.9 

Highest  observed 12.0 

Lowest  observed   3.0 

Joints  Involved 
Confined  to  great  toe     Joints  other  than  great  toe 


Great  toe 
7  cases 


Polyarticular 

14 

Length  of  Time   Treated 

Three  years  or  over 1  case 

Two-three  years  7 

One-two  years  8 

Three  months  to  one  year 9 


ILLUSTRATIVE   CASE  REPORTS 

Case  I.  An  Italian  laborer  of  65,  complaining  of  swell- 
ing and  severe  pain  in  left  hand;  when  the  swelling  leaves 
his  left  hand,  his  right  foot  swells.  Family  and  past  his- 
tory- are  negative  except  for  tendency  to  frequent  colds. 

Hand  has  been  swollen  for  about  three  weeks.  Swelling 
in  foot  started  at  the  same  time.  The  same  condition  was 
present  three  months  ago.  It  goes  from  hand  to  foot,  is 
worse  in  the  evening,  keeps  him  awake  at  night.  Has  to 
keep  arm  in  sling.  The  hand  and  foot  do  not  pain  simul- 
taneously, but  alternately  for  periods  of  a  few  days. 

Ears  show  no  signs.  Patient  is  nearsighted,  wears  bi- 
focals. Edentia  is  compensated.  He  has  a  chronic  cough, 
productive  (purulent),  no  night  sweats,  no  hemoptysis,  no 
dyspnea  apparent.  Cardiovascular  examination  is  negative. 
.Appetite  poor  only  since  pain.  Bowel  movements  regular. 
Nocturia  3-4  times,  frequency  during  day,  difficulty  on 
urination,  slight  burning,  mucopurulent  urethral  discharge. 

Physical  examination  was  negative  except  for  imbedded 
tonsils,  enlarged  left  ventricle  wdth  a  soft  systolic  murmur 


Age 


Family 
History 


Etiology 
Onset 


Site  of 
Onset 


Joints 
Severity 


Appearance 
of  Patient 

Blood 

Prodromal 
Symptoms 


Exacerbations 


Social 
Status 


ATROPHIC  ARTHRITIS 


May  begin  at  any  age. 


Male  or  female — somewhat  more 
common  in  females.  (.About  65% 
f.,  35%  m.) 

Hereditary  factor  disputed,  but 
positive  family  history  not  un- 
common. 

Probably  a  streptococcus. 

May  be  sudden  or  gradual. 
Usually  begins  as  a  chronic  dis- 
ease.    Night  and  day  alike. 

May  begin  in  any  joint,  but 
usually  begins  in  the  knees  and 
middle  joint  of  fingers. 

Usually  polyarticular. 

Pain  and  stiffness  severe. 


Periods  of  remissions,  but  until 
patient  is  well,  pain  and  stiffness 
almost  always  present. 

Becomes  debilitated,  and  loses 
weight  rapidly. 

Anemia  usually  present. 

Progressive  weakness  and  stiffness 
in  the  joints. 


May  follow  acute  infections. 


.Attacks  all  classes,  rich  and  poor 
aUke. 

May   or  may   not   be  symmetri- 
cal. 


HYPERTROPHIC 
ARTHRITIS 


Usually  begins  after  40. 


Most    common    in    females — rare 
in  males.     (99%  f.) 


No  basis  for  positive  family  his- 
tory. 


Always     gradual,     never     acute. 
Night  and  day  alike. 


Distal  joints  of  fingers  and  knees, 
rarely  other  joints. 


Pain    mild    or    absent.      Stiffness 
marked. 


No  periods  of  remission.    Disease 
is  progressive. 


Usually  obese. 


No  anemia  present. 
None. 


None  as  a  rule. 


Attacks  all  classes,  rich  and  poor 
alike. 


May  begin  at  any  age,  but  most 
commonly    between    20    and    40. 


Most  common  in  males,  but  does 
occur  in  females. 


Family    history    usually    positive. 


Metabolic. 

Usually  acute,  but  may  begin  as 
a  chronic  disease.  Usually  comes 
on  at  night. 

Begins  in  great  toe  in  about  30% 
of  cases,  but  may  begin  in  any 
joint  or  joints. 

Usually  polyarticular. 

Pain  excruciating  when  acute. 
Not  marked  when  chronic. 

Periods  of  remission  during  which 
patient  is  pain-free.  Attacks  last 
from  few  days  to  three  months. 

Usually  well  built.  May  or  may 
not  be  obese. 

No  anemia  present. 

Excessive  appetite,  or  indigestion 
with  burning  sensations  in  the 
joints  and  muscles. 

May  follow  acute  infections  or 
indiscretions  in  diet. 

Attacks  all  classes,  rich  and  poor 

alike. 

Usually  asymmetrical. 


640 


GOVT— Cohen 


December,  1936 


at  mitral  area,  enlarged  liver  (three  fingers  below  costal 
margin),  and  wrist  joints  were  both  swollen,  left  more 
painful,  red  and  tender.  Swelling  involves  three  fingers, 
toward  dorsal  surface  of  the  hand.  No  marked  loss  of 
mobility. 

Wassermann  blood  examination  was  reported  negative. 

The  diagnosis  made  at  this  time  was  gonorrheal  arthritis. 

X-ray  report  October  24th:  There  are  very  slight  osteo- 
arthritic  changes  of  the  bones  of  the  left  wrist,  even  less 
than  one  would  expect  for  a  patient  of  this  age.  There 
is  no  evidence  of  bone  destruction.  The  joint  spaces  are 
somewhat  narrowed  and  there  is  general  demineralization 
of  all  the  bones  of  the  hand  and  lower  third  of  the  radius 
and  ulna. 

Arthritis   Clinic    {report   and  progress} 

The  condition  began  about  two  years  ago  with  pain 
in  the  right  great  toe.  Was  incapacitated  for  three  months 
at  that  time.  Was  perfectly  well  for  one  year  when  he 
noticed  that  he  had  swelling  of  the  hands.  Soon  the  swell- 
ing subsided  and  he  began  to  have  pain  in  the  hands.  This 
persisted  for  three  months,  until  he  came  to  this  clinic. 
Has  never  worked  in  lead.  Family  history  negative.  Has 
had  only  two  attacks. 

Nov.  19th:  This  condition  althougn  not  clinically  so 
from  the  history  resembles  podagra.  In  spite  of  a  normal 
blood  uric  acid  of  3.4  mgms.,  I  feel  that  the  patient  should 
be  treated  for  gout. 

Ri.    Purin-free  diet. 

Colchicine  gr.  1/120,  t.  i.  d.,  p.  c. 

Nov.  26th:  Feeling  very  much  better.  Began  to  im- 
prove as  soon  as  he  took  the  colchicine. 

To  continue  as  above. 

Dec.  3rd:  Patient  is  much  improved.  The  diagnosis 
here  is  that  of  gout,  unquestionably.  Although  the  blood 
uric  acid  is  normal,  he  has  responded  to  treatment. 

To  continue  diet,  to  discontinue  medicine  for  one  week. 

Dec.  17th;  Began  to  have  pain  in  joints  when  he 
stopped  taking  the  medicine. 

To  return  to  colchicine  gr.  1/120,  t.  i.  d.,  p.  c. 

Dec.  24th:     Feeling  much  better. 

To  return  in  one  month. 

Jan.  21st,  1936:     Shortness  of  breath  for  past  4-5  weeks. 

Jan.  28th:     Feeling  better,  warned  about  climbing  stain. 

Rx.     Tine.  Digitalis — m.  x,  t.  i.  d.,  p.  c. 

Colchiciae  gr.  1/120,  t.  i.  d.,  p.  c,  every  other  week. 
Purin-low  diet. 

Feb.  25th:  Foot  bothered  him  last  week,  but  it  is  better 
now. 

Renew  digitalis  and  colchicine. 

Mar.  3d:     Feels  better. 

Continue. 

Mar.  10th:     Condition  very  good. 

Purin-low  diet  and  colchicine  one  week  out  of  four. 

To  return  in  one  month. 

To  date  this  patient  is  free  from  discomfort.  This 
case  represents  an  error  in  diagnosis  which  is  easily 
understood.  One  can  readily  see  that  in  the  pres- 
ence of  a  urethral  discharge,  an  acute  arthritis  might 
easily  be  mistaken  for  the  gonorrheal  type.  How- 
ever, one  must  also  remember  that  infection  might 
easily  be  the  precipitating  factor  in  a  known  gouty 
individual. 

Case  H.  A  Jewish  housewife  of  57,  was  seen  July 
25th,  1932,  complaining  of  pain  in  the  hands,  shoulders 
and  feet  for  over  two  years. 

This  condition  came  on  gradually,  beginning  in  the  fingers 
and  continued  for  one  year.    There  has  never  been  an  acute 


attack.  For  the  past  year,  pain  has  been  felt  in  the  shoul- 
ders and  the  feet.  She  is  affected  by  the  changes  in  the 
weather.  The  pain  is  accompanied  by  swelling  and  slight 
redness  with  clammy  overlying  skin  on  the  fingers  and 
the  feet.  There  is  no  symmetn,'.  Pain  is  more  severe  at 
night.  Patient  is  a  moderate  eater,  not  particularly  partial 
to  meats  and  partakes  of  no  alcoholic  beverages. 

Blood  uric  acid  reports  as  follows: 

Jan.  2nd,  '34 — 0.85  mg.  per  100  c.c. 

Jan.  11th— 1.45. 

Mch.  26th,  '35—3.04. 

X-ray  report,  Feb.  13th,  '35:  There  are  arthritic  changes 
involving  some  of  the  terminal  joints  of  the  fingers  of  the 
right  hand.  The  changes  are  most  pronounced  in  the  Sth 
finger  where  there  is  absorption  of  the  cartilage  as  well 
as  bony  changes.  There  are  early  arthritic  changes  involv- 
ing the  left  acromioclavicular  joint. 

Her  weight  was  140  pounds,  height  5  feet  S'/i  inches, 
with  no  tendency  toward  obesity,  no  tophi  in  the  cartilages 
of  the  ears  or  of  the  nose;  head  and  neck,  heart  and  lungs 
negative.  There  was  tenderness  and  limitation  of  motion 
over  both  acromioclavicular  joints,  particularly  the  left. 
There  was  swelling  and  deformity  of  the  distal  joints  of 
the  fingers  and  toes,  little  or  no  atrophy  of  muscle. 

This  patient  had  been  treated  for  three  years  for 
atrophic  arthritis  without  any  benefit.  Since  she 
was  put  on  the  treatment  for  gout,  as  outlined  in 
case  1,  she  has  been  pain-free.  The  inflammatory 
processes  have  ceased  and  for  the  first  time  in  a 
few  years,  the  patient  has  been  free  from  discom- 
fort.   This  has  persisted. 

Case  HI.  A  Protestant  salesman  of  45,  height  5  feet  8 
inches,  weight  170  pounds,  was  admitted  to  the  Arthritis 
Clinic,  Philadelphia  General  Hospital,  March  20th,  1929, 
with  the  complaint  of  pain  in  most  of  his  joints.  His  past 
history  was  irrelevant.  There  was  no  family  history  of 
gout,  rheumatism,  diabetes  or  obesity. 

The  first  attack  of  pain  in  his  knee  joints,  in  1905  at 
the  age  of  21,  lasted  one  week.  There  was  a  slight  swelling 
of  the  joints  w'ithout  redness.  The  symptoms  completely 
disappeared.  His  next  attack  was  in  1913  when  he  had 
pain  in  the  toes  of  the  left  foot  except  for  the  great  toe. 
These  were  swollen  and  red  for  a  few  months,  but  the 
patient  was  not  confined  to  bed.  These  symptoms  dis- 
appeared leaving  no  signs.  He  would  have  similar  difficulty 
each  spring  and  sometimes  in  the  fall.  At  times  it  would 
be  manifested  in  the  left  foot,  the  hands,  knees  or  elbows, 
but  each  time  there  were  no  residual  symptoms.  The 
diagnosis  of  gout  was  made  in  this  clinic  in  1929.  The 
only  positive  physical  signs  were  the  presence  of  tophi  in 
the  cartilages  of  the  ears. 

Treatment  consisted  of  a  purin-free  diet,  and  neocincho- 
phen,  5  grains  ever>-  4  hours.  He  is  now  on  a  purin-low 
diet  and  takes  colchicine,  1/120  grain  t.  i.  d.,  one  week  out 
of  four. 

This  patient  now  feels  fine  and  has  had  practically  no 
pain  since  he  has  been  treated  at  this  clinic.  There  have 
been  no  recurrences.  His  blood  chemistr>-  findings  are  as 
follows: 

Mgms.  per  100  c.c. 

Mch.    20,    1929— Uric  acid  7.3 

Urea  nitrogen  16 

June    5th  — Uric  acid  7.6 

Urea  nitrogen  23 

12th  Uric  acid  6.6 

May  25th,  1932 — Uric  acid  6.7 

Jan.   2nd,   1934— Uric  acid  6.7 


December,  1936 


GOUT— Cohen 


641 


This  case  is  illustrative  of  the  type  of  gout  in  which 
the  onset  was  not  in  the  great  toe.  Even  though  this  pa- 
tient has  been  freed  of  his  symptoms  his  blood  uric  acid 
has  never  returned  to  normal.  Present  condition  is  as 
above  except  that  he  has  been  free  from  discomfort  for 
eight  years. 

The  most  common  source  of  error  in  diagnosis 
is  incomplete  information  in  the  case  history.  The 
patient  frequently  volunteers  the  information  that 
he  has  been  cured  of  attacks  of  arthritis.  This 
point  should  not  be  ignored;  if  investigated,  one 
soon  may  learn  that  the  patient  was  not  suffering 
from  arthritis  but  from  gout. 

The  important  facts  to  be  remembered  in  the 
diagnosis  of  gout  are  the  following: 

1.  It  occurs  at  any  age,  but  mostly  in  the  third 
decade. 

2.  It  is  usually  polyarticular. 

3.  It  may  begin  as  an  acute  or  a  chronic  dis- 
ease. 

4.  There  are  attacks  and  remissions,  the  patient 
being  pain-free  during  the  remission,  even 
in  the  face  of  deformity. 

5.  There  may  be  but  one  attack  yearly  or  there 
may  be  many. 

6.  The  uric  acid  concentration  in  the  blood  may 
or  may  not  be  increased.  When  not  in- 
creased the  diagnosis  must  be  made  on  the 
history  of  repeated  attacks  with  remissions. 

Treatment 

The  treatment  of  gout  is  relatively  easy.  It  is 
the  purpose  of  this  article  to  emphasize  that  not 
only  are  there  pertinent  facts  that  tend  to  make 
the  diagnosis  less  difficult,  and  that  the  disease  is 
more  prevalent  than  one  is  led  to  believe,  but  also 
that  a  definite  routine  of  treatment  exists  which 
should  keep  the  patients  free  from  symptoms,  per- 
l-.aps  throughout  their  lives. 

We  have  seen  individuals  who  have  been  subject- 
ed to  periodic  attacks  of  gout  for  years,  and  we 
can  now  safely  state  that  although  the  blood  uric 
acid  level  has  still  remained  elevated,  the  patient 
has  been  free  from  seizures  for  one  to  five  years. 

During  an  acute  attack  of  gout,  rest  in  bed,  hot 
applications  of  saturated  magnesium  sulphate  solu- 
tion to  the  affected  part,  colchicine  and  a  liquid 
purin-free  diet  are  the  chief  agents  to  use,  aside 
from  supportive  symptomatic  treatment. 

The  purin-low  diet  is  used  when  the  patient  gets 
colchicine  every  fourth  week.  During  the  acute 
attack  colchicine,  grain  1/60,  is  administered  three 
times  daily  by  mouth.  As  the  attack  subsides,  it 
is  given  for  one  week  with  a  rest  period  of  three 
weeks,  the  patient  adhering  strictly  to  his  diet  as 
prescribed. 

Cinchophen  or  its  derivatives  should  not  be  used 
in  the  treatment  except  when  there  is  ar.  idiosyn- 


crasy to  colchicine.  jNIuch  has  been  written,  re- 
cently, on  the  subject  of  cinchophen  poisoning  and, 
since  colchicine  is  of  equal  efficacy  and  less  toxic, 
its  use  is  to  be  recommended  in  preference  to  the 
cinchophens. 

PuRiN-Low  Diet 

Foods  permitted:  A'lilk,  cream,  butter,  cheese, 
eggs,  white  bread,  rice,  macaroni,  sago,  tapioca, 
cabbage,  cauliflower,  lettuce,  watercress,  fruit,  su- 
gar, honey,  jam,  jelly,  marmalade,  potatoes. 

Foods  jorbiddcn:  Tea,  coffee,  coca-cola,  fish, 
fowl,  and  meat,  glandular  organs,  brown  bread, 
peas,  beans,  ale,  beer,  and  other  alcoholic  bever- 
ages. 

Purin-Free  Diet 

Foods  to  be  taken:  Cereals,  potatoes,  rice, 
green  vegetables  and  salads;  fresh  and  stewed 
fruits;  ham,  bacon  or  beef  once  a  week,  chicken, 
lamb  or  mutton  once  or  twice  a  week;  simple  des- 
serts such  as  junket,  prune  or  fig  whip,  orange, 
lemon,  grape,  pineapple  or  apricot  gelatin;  bread, 
rice  or  tapioca  pudding,  and  plain  vanilla  ice 
cream. 

Foods  to  be  omitted:  Meat  broths  and  extracts; 
strong  tea  or  coffee;  alcoholic  beverages;  liver,  kid- 
ney, sweetbreads,  rich  sauces  and  gravies;  condi- 
ments and  spices;  pastries  and  fried  foods;  strong 
flavored  foods  such  as  onions,  and  rhubarb. 

In  conclusion,  gout  is  more  prevalent  than  one 
is  ordinarily  led  to  believe.  Increase  in  the  uric 
acid  of  the  blood  is  not  necessary  to  make  a  diagno- 
sis. It  is  a  disease  occurring  in  the  poor  as  well 
as  in  individuals  of  better  economic  circumstances. 
Finally,  it  can  be  controlled  by  proper  treatment. 

StTMMARY 

1.  Attention  is  called  to  the  prevalence  of  gout 
in  the  Philadelphia  Police  and  Fire  Depart- 
ment. 

2.  A  description  of  the  disease  is  given  as  we 
see  it  today  to  emphasize  the  diagnosis. 

3.  The  differential  diagnosis  between  arthritis 
and  gout  is  presented. 

4.  A  summary  of  25  cases  treated  over  periods 
ranging  from  a  few  months  to  a  few  years  is 
given. 

5.  A  method  for  the  control  of  gout  is  sug- 
gested. 

— 210G  Spruce  Street 

References 

1.  Gudzent,  F.,  and  Holzman,  E.:     Ztschr.  Klin.  Med., 
1927,  106,  107. 

2.  McCrae,  T.:     Principles  of  Medicine— Textbook. 

3.  SciiNiTKER,  M.  A.,  and  Richter,  A.  B.:     Nephritis  in 
Gout.    Am.  Jl.  of  the  Med.  Sc,  Aug.,  1936. 

4.  Cohen,   .■\.:      Gout.     Am.  Jl.   of  the   Med.   Sc,  Oct., 
1936. 

5.  Gakrod,  .\.  B.:     The  Nature  and  Treatment  of  Gout 
and  Rheumatic  Gout,  London,  1859. 


642 


GOUT— Cohen 


December,  1936 


6.  Hench  and  Darnall:     Medical  Clinics  of  N.  A.,  May, 
1933. 

7.  Hench:      Proceedings    of    the    Staff    Meetings    of    the 
Mayo  Clinic,  Nov.  29th,  1933. 

S.     Macleod;      Physiology    and    Biochemistry    in   Modern 

Medicine — Textbook. 
9.     FoLiN,  O.:     Standardized  Methods  for  Determination  of 

Uric  Acid   in   Unslal^ed   Blood   and   in   Urine.     //.   of 

Biol.  Chem.,  June,  1933. 


Medicai,  Ethics — President's  Address  to  the  Malaya 
Branch  British  Med.  Assx. 
(C.  C.  B.  Gilmore,  in  Malayan  Med.  Jl..  June) 
Few  I  think  choose  a  medical  career  from  a  fully  form- 
ulated wish  to  do  good,  though  they  may  find  inspiration, 
and  perhaps  consolation,  in  that  view  of  it  later.  Of  late 
years  more  and  more  look  on  a  medical  qualification  as 
entithng  them  to  safe  official  employment.  Some  few 
study  medicine  with  a  view  to  a  career  of  scientific  re- 
search and  possible  fame,  but  such  are  scarcely  medical 
practitioners.  In  the  East  there  is  another  incentive. 
Medicine  can  open  a  door  to  a  political  career  and  obtain 
for  a  clever  man  a  position  in  the  political  circles  of  his 
town  or  country  almost  equal  to  that  which  the  study 
and  practice  of  law  can  in  Europe.  Most  men  enter 
medicine  to  make  a  living. 

In  the  relations  of  a  doctor  to  his  colleagues  and  to  the 
public  perhaps  advertising  is  the  most  frequent  form  of 
unethical  conduct.  The  great  medium  of  advertising  just 
now  is  the  press  and  the  relations  of  the  press  and  the 
profession  to  each  other  seem  to  me  to  bristle  with  ethical 
problems.  In  using  it  there  is  no  need  for  the  mentioning 
of  individuals,  or  for  anything  which  may  be  construed 
as  advertisement.  Care  should  be  taken  that  what  is  com- 
municated is  not  edited  or  sub-edited,  but  that  any  correc- 
tions, cuttings,  or  amplication  will  be  made  by  the  medical 
man  who  wrote  it,  and  who  will  be  able  to  judge  what 
the  effect  of  these  modifications  will  be  on  the  message  he 
intended  to  give.  The  press  lives  by  sensation  and  medical 
news  is  capable  of  being  presented  in  a  very  sensational 
manner.  The  publication  of  important  discoveries  in  med- 
icine, or  theories,  may  be  premature,  raise  false  hopes  in 
the  breasts  of  sufferers,  and  in  the  end  lower  the  reputation 
of  the  profession.  The  proper  channels  for  communicating 
all  discoveries,  theories,  and  policies  of  importance  in  the 
world  of  medicine  are  medical  and  scientific  journals  and 
societies.  What  is  published  there  is  open,  and  may  be 
legitimate  subject  for  public  comment  and  criticism.  My 
personal  opinion  is  that  the  public  has  no  inherent  right 
to  be  instructed  or  informed  of  the  tendencies  of  medical 
and  scientific  research  and  thought.  Unfortunately  research 
and  treatment  cannot  be  carried  out  nowadays  without  the 
expenditure  of  large  sums  of  money,  and  those  wso  pay 
the  piper  must  be  persuaded  that  a  tune  is  being,  or  can 
be,  played. 

I  have  grave  doubts  when  I  read  the  tender  solicitude  of 
insurance  companies  for  the  health  of  the  public.  It  may 
be  a  very  subtle  advertisement  of  our  profession,  but  I 
doubt  if  we  are  intended  to  be  the  beneficiaries.  Our  pro- 
fession is  always  open  to  e.xploitation,  and  there  are  many 
who  are  ready  to  do  so,  but  it  is  not  unethical  to  be  un- 
willing to  be  exploited. 


ticing  medicine. 

For  many  years  prior  to  1932  at  ever\'  New  York  State 
Medical  Society  Convention  many  delegates  from  various 
groups  tried  to  get  action  to  have  the  institute  restrained. 
They  were  usually  met  with  the  statement  that  the  Insti- 
tute was  too  powerful  and  well  entrenched  and  that  it 
would  cost  in  the  neighborhood  of  $50,000  to  get  any  ac- 
tion. 

It  is  interesting  to  note  that  I  submitted  a  bill  to  the 
Medical  .Alliance  for  ,'?12  in  full  payment  for  all  my  ser- 
vices, which  were  the  basis  of  the  Attorney  General's  ac- 
tion; and  which  amount  represented  the  charge  for  photo- 
stats of  certain  documents  in  the  County  Clerk's  office. 

During  1931,  I  was  requested  by  the  Medical  .Alliance, 
Inc..  to  look  into  and  make  a  study  of  the  Institute,  its 
organization  and  methods.  I  found  that  this  Corporation 
originally  was  capitalized  at  S4,000,  and  that  by  1925  its 
capital  stock  had  increased  to  $1,500,000.  I  also  studied 
the  methods,  and  procedure  of  the  Institute,  including  a 
number  of  their  Reports  of  patients  they  had  examined. 

My  report  was  made  to  the  membership  of  the  Medical 
AlUance  on  the  evening  of  January  7,  1932.  Thereafter,  I 
prepared  a  Brief  wherein  I  set  forth  the  facts  and  the  law 
as  I  had  found  them.  This  work  consumed  a  great  deal 
of  time  and  study.  I  did  not  mind  it,  because  I  was  in- 
terested in  the  aims  of  the  Medical  Profession,  and  fur- 
ther, because  I  felt  that  the  Institute  was  doing  grave  in- 
justice to  the  Medical  Practitioner. 

My  Brief  was  enthusiastically  received  by  the  member- 
ship of  the  Medical  .Alliance.  A  meeting  was  arranged  at 
its  Clubhouse  in  1932,  which  was  attended,  amongst  others, 
by  officials  of  the  New  York  County  and  State  Medical 
Societies. 

A  copy  of  my  Brief  was  requested  by  the  State  Medical 
Society  and  in  due  course  found  its  way  into  the  .Attorney 
General's  office.  Subsequently  the  .Attorney  General  insti- 
tuted the  proceeding  to  annul  the  Charter  of  the  Life  Ex- 
tension Institute  which  resulted  in  the  Decree  of  Injunc- 
tion. 

This  victory  for  organized  medicine  is  monumental  and 
should  do  much  to  establish  the  physician  as  the  only 
person  qualified  to  practice  medicine. 


.Athletic    Heart — Modern    Conceptions    and    a    Recent 

Investigation 

(J.   W.    Wilce,  Columbus,   in   Jl.-Lan.,   Xov.) 

Inadequate  recognition  is  given  potential  heart  disease 
in  some  allowing  participation  in  athletics.  The  question 
of  what  constitutes  a  degree  which  is  a  danger  in  future 
athletic  participation  is  not  settled. 

The  tremendous  variation  in  so-called  normal  hearts 
should  be  subject  of  continuous  study  in  various  age 
groups. 

Because  of  the  willingness  to  say,  "There  is  nothing  in 
this  athletic  heart  business,  your  heart's  all  right,"  other 
conditions  which  are  criteria  of  the  degree  of  activity 
individuals  should  indulge  in  are  many  times  overlooked 
in  sports  examinations — silent  pericarditis,  or  silent  endo- 
carditis, varying  degrees  of  mediastinal  distortion,  small 
degrees  of  pleuro-pericarditis,  tuberculosis  and  others. 


Lite  Extension  Institute  Halted 

(M.    D.   Reiss,  Attorney  at  Law,  in   The   N.  Y.    Physician, 

Nov.) 

Organized  medicine  celebrated  a  signal  victory  when  the 
New  York  State  Attorney  General  issued  a  Decree  of  In- 
junction restraining  the  Life  Extension  Institute  from  prac- 


There  are  comeort-words  (W.  B.  Cannon),  expressions 
which,  coming  from  a  trusted  physician,  banish  fear.  By 
use  oj  these  symbols  the  nervous  system  can  be  played 
upon  as  though  on  an  instrument.  The  charlatan  employs 
them  to  establish  conditions  which  he  can  capitalize  for  his 
own  profit.  The  wise  doctor  knows  how  to  use  them  as  a 
part  of  his  therapy. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


643 


A  Preliminary  Report  of  a  New  Method  of  Blood 
Transfusion* 

J.  Elliott,  Salisbury,  North  Carolina 

Laboratorv-  of  Pathology-,  Rowan  Memorial  Hospital 


THh,  indications  for  blood  transfusion  are 
many.  That  shock  and  hemorrhage  may 
be  indications  is  familiar  to  all.  Its  im- 
portance as  a  means  of  maintaining  the  serum  pro- 
teins at  safe  level  in  patients  who  have  been  oper- 
ated upon  and  who  are  unable  to  take  food  by 
mouth  is  being  recognized  more  and  more. 

Blood  transfusions,  as  ordinarily  done,  are  pro- 
cedures requiring  a  competent  operator,  and  time  for 
typing  and  cross  agglutinating  the  blood  of  donors 
and  recipients  and  for  preparing  the  necessary 
equipment.  Using  some  methods,  two  operators,  sev- 
eral nurses  and  a  hospital  are  necessary  for  a  suc- 
cessful transfusion.  Often  only  one  or  two  doctors 
in  a  community  or  hospital  do  transfusions.  This  is 
usually  due  to  the  lack  of  familiarity  of  the  others 
with  the  method  in  use  in  the  community  or  hos- 
pital. 

Occasionally  obstetrical  patients  being  delivered 
in  the  home  or  hospital  become  profoundly  shocked, 
with  or  without  profuse  hemorrhage.  Surgical 
shock  is  seen  on  the  operating  table,  and  delayed 
shock  coming  on  hours  after  operation  or  injury 
is  familiar  to  all  who  practice  medicine.  Often  an 
emergency  transfusion  is  indicated  but  unavailable 
because  of  inability  to  find  a  suitable  donor  or  be- 
cause of  lack  of  time  or  facilities  for  typing  and 
cross  agglutinating  and  preparing  the  necessary  ap- 
paratus. 

Wassermann-negative  blood,  properly  typed  and 
stored  in  a  container  ready  for  immediate  use 
would  obviate  many  of  these  difficulties.  Professor 
Sergius  Judin,  Chief  Surgeon  of  Sklifasovaki  Emer- 
gency Hospital  in  Moscow,  has  made  more  than 
300  transfusions  using  stored  blood.  Judin  has 
kept  this  blood  as  long  as  a  month  and  used  it 
without  reaction.  Sodium  citrate  has  been  used 
to  defibrinate  the  blood.  The  blood  has  been  ob- 
tained from  individuals  dying  from  causes  other 
than  disease. 

According  to  an  account  of  Judin's  work,  in  a 
recent  publication  entitled.  La  Transjiision  du  Sang 
de  Cadavre  a  I'Homnie,  the  blood  of  many  cadavers 
has  been  tested  and  found  sterile.  Of  course,  the 
subjects  used  are  persons  who  have  died  suddenly, 
from  an  accident,  a  heart  attack  or  some  such 
cause.    GradwohF  raises  the  question  as  to  whether 


or  not  this  is  true.  In  1904,  he  reported  an  ac- 
count of  a  research  upon  this  question.  This  was 
in  reply  to  Simmonds'-  statement  that,  in  a  bac- 
teriological examination  of  the  cardiac  blood  ob- 
tained at  autopsy  from  12  to  36  hours  after  death 
of  1,200  subjects,  he  found  a  streptococcus  in  95 
per  cent,  of  the  cases.  Gradwohl  states  that  Ca- 
non* later  claimed  that  Simmonds'  work  was  in 
error  in  that  cardiac  blood  alone  was  examined,  it 
would  have  been  found  that  venous  blood  was  ster- 
ile, even  with  streptococci  in  the  heart  blood.  His 
own  work  was  undertaken  in  an  attempt  to  settle 
this  point.  Fifty  cases  were  selected  from  his  ser- 
vice at  the  coroner's  office,  in  the  main  gunshot 
wounds  of  the  chest,  fractures  of  the  skull,  ten 
cases  of  valvular  leak,  three  cases  of  rupture  of 
aortic  aneurysm,  six  cases  of  nephritis,  a  few  cases 
of  purulent  peritonitis  from  abortions,  etc.  The 
time  elapsing  from  death  to  autopsy  performance 
varied  from  two  to  10  hours.  In  78  per  cent,  of 
these  cases,  bacteria  of  various  kinds  were  found 
in  the  cardiac  blood,  in  only  three  cases  were  bac- 
teria found  in  the  blood  from  the  median  basilic 
vein.  His  conclusions  were  that  there  is  a  rapid 
invasion  of  the  cardiac  blood  soon  after  death  from 
neighboring  organs.  This  being  true  it  should  not 
be  safe  to  use  the  blood  of  cadavers. 

However,  there  should  be  no  objections  to  the 
use  of  stored  blood  from  healthy,  living  donors. 
Others  have  confirmed  Judin's  work,  that  blood 
stored  for  a  period  of  as  long  as  30  days  can  be 
used  without  reaction.  It  has  been  used  in  this 
country  and  abroad  sufficiently  to  prove  its  safety. 

Whole  blood  is  necessary  in  the  treatment  of 
some  anemias  where  the  importance  of  the  trans- 
fusion lies  in  increasing  the  number  of  red  cells. 
However,  in  surgical,  obstetrical  or  traumatic  shock, 
where  transfusion  is  indicated,  the  importance  of 
the  red  cells  in  the  transfused  blood  is  nil  or  neg- 
ligible. The  important  factor  is  the  serum  or 
plasma  which  builds  up  the  colloid  pressure  thus 
improving  the  peripheral  circulation.  McKenzie' 
has  pointed  out  the  importance  of  maintaining  the 
serum  proteins  in  patients  who,  following  abdom- 
inal operations,  are  unable  to  take  food  by  mout!i 
and  are  constantly  losing  proteins  through  kidneys 
and   drainage    from   operative   wounds.      In    thes3 


•Pre.sented   to   the  Ninth   District   Medical   Association   meeting  in  Salisbury.  N,  C,  September  24th,  I'JSii 


NEW  METHOD  OF  BLOOD  TRANSFUSION— Elliott 


December,  1936 


cases  blood  transfusion  are  the  only  source  of  the 
proteins,  so  necessary  for  the  building  up  of  tissues 
and  the  maintenance  of  the  normal  serum  proteins. 
Here,  also,  the  red  cells  play  an  insignificant  role, 
the  serum  or  plasma  being  the  element  of  import- 
ance. 

Red  cells  being  of  little  or  no  importance  in  the 
treatment  of  these  conditions,  there  is  no  advan- 
tage in  transfusing  them  if  serum  or  plasma  is 
available.  There  is  a  question  as  to  whether  or 
not  whole  blood  can  be  stored  and  used  with  safety 
over  a  period  of  longer  than  30  days.  However, 
there  is  no  question  as  to  the  safety  of  using  serum 
or  plasma  stored  for  an  indefinite  period. 

The  danger  in  transfusing  lies  in  agglutination 
of  the  cells  of  the  donor  by  the  serum  of  the  re- 
cipient, not  in  agglutination  of  the  cells  of  the 
recipient  by  the  serum  of  the  donor.  Individuals 
belonging  to  group-four  (Moss),  whose  cells  are 
not  agglutinated  by  the  serum  of  any  group,  serv3 
as  universal  donors  in  spite  of  the  fact  that  the 
cells  of  the  recipient  are  agglutinated  by  the  serum 
of  the  donor.  In  my  experience  anaphylaxis  has 
never  occurred,  nor  have  I  ever  heard  of  it  occur- 
ring, when  others  have  used  group-four  (;\Ioss) 
donors. 

The  danger  of  transfusing  incompatible  blood  is 
due  to  the  fact  that  cells  of  the  donor  will  be  de- 
stroyed by  the  serum  of  the  recipient.  The  ag- 
glutinants  present  in  the  serum  of  the  donor  of 
incompatible  blood  should  not  cause  anaphylaxsis 


termine  the  litre  of  agglutinants  present  in  serums 
of  types  one,  two  and  three,  so  that  the  litres  may 
be  compared  with  the  litre  of  agglutinants  in  type- 
four  serum.  If  the  agglutinants  present  in  all  four 
types  of  serum  are  approximateh'  the  same,  an 
attempt  will  be  made  to  prove  that  any  type  of 
serum  or  plasma  may  be  given  to  any  type  recipient 
with  safety. 

There  are  two  major  difficulties  in  preserving 
serum  or  plasma  so  that  it  is  available  for  imme- 
diate use.  The  first  is  in  obtaining  the  blood  and 
the  second  the  separation  of  the  cells  from  the 
plasma.  The  problem  of  obtaining  the  blood  can 
be  solved  in  any  one  of  a  number  of  ways.  Blood 
may  be  obtained  from  professional  donors,  from 
volunteers,  from  patients  bled  to  reduce  blood  pres- 
sure and  from  other  sources. 

The  separation  of  the  cells  from  the  plasma  pre- 
sents a  more  difficult  problem  for  the  isolated  phy- 
sician and  the  small  hospital.  With  this  in  mind 
we  have  devised  a  vacuum  tube  which  makes  the 
separation  of  the  cells  from  plasma  possible  in  the 
small  hospital  or  the  doctor's  office.  Incidentally 
it  also  makes  the  storage  of  whole  blood  an  easy 
and  safe  procedure  and  a  transfusion  of  blood 
almost  as  simple  as  the  administration  of  glucose 
intravenously.  Neither  nurse,  assistant  nor  hos- 
pital is  necessary.  It  is  not  necessary  to  scrub  up 
and  put  on  a  gown  and  gloves.  The  blood  never 
touches  the  air  and  being  received  in  a  sterile  con- 
tainer should  remain  sterile  over  an  indefinite  pe- 
riod. 


any  more  than  the  agglutinants  present   in   type-  The  tube  illustrated  in  the  figure  is  a  vacuum 

four  serum.    If  this  be  true,  it  should  be  possible  bulb-tube,  sealed  at  both  ends  with  rubber  which 

to  use  the  serum  of  anyone,  if  the  cells  are  entirely  may  be  perforated  with  a  needle.     The  vacuum  is 

removed.    Experiments  are  being  conducted  to  de-  sufficient  to  draw  from  a  vein  620  c.c.  of  blood. 


December,  1936 


NEW  METHOD  OF  BLOOD  TRANSFVSION—Ettiott 


The  tube  contains  SO  c.c.  of  solution  containing 
22.5  grains  of  sodium  citrate — sufficient  to  prevent 
the  coagulation  of  from  450  to  550  c.c.  of  blood. 
The  concentration  of  the  citrate  when  450  c.c.  of 
blood  is  added  to  the  solution  in  the  tube  is  0.3 
p)er  cent.  The  citrate  is  in  solution  in  0.9  per  cent, 
salt  solution. 

The  long  end  of  the  tube  has  two  rubber  stop- 
pers J  2  inch  apart.  Perforating  the  first  rubber 
stopper  is  a  mechanism  consisting  of  two  needles 
connected  by  a  rubber  tube  and  two  glass  cannu- 
las; one  needle  is  for  insertion  into  the  vain  and 
the  other  into  the  vacuum  tube  through  the  two 
rubber  stoppers. 

The  median  basilic  vein  of  the  donor  is  prepared 
in  the  usual  manner.  The  sterilized  package,  con- 
taining the  vacuum  tube  with  the  connecting  mech- 
anism in  place,  is  opened,  the  protecting  tube  re- 
moved and  the  needle  put  into  the  vein.  When 
the  needle  enters  the  vein,  blood  will  flow  into  the 
glass  cannula  indicating  that  the  vein  has  been 
entered.  The  needle  is  then  tap)ed  to  the  arm  and 
the  second  needle  pushed  through  the  second  rub- 
ber stopper  into  the  vacuum.  The  vacuum  pulls 
the  blood  from  the  vein  into  the  tube,  the  rate  of 
flow  being  controlled  by  the  clamp  midway  between 
the  two  needles.  The  flask  is  rotated  so  that  the 
blood  will  mix  with  the  citrate,  defibrinating  it  so 
that  it  will  not  clot.  Immediately  that  500  c.c. 
of  blood  is  drawn  into  the  vacuum  tube  the  needles 
are  withdrawn  from  the  tube  and  vein  simultane- 
ously leaving  the  defrinated  blood  in  a  sterile  seal- 
ed container.  It  is  then  ready  for  storage  or  imme- 
diate transfusion. 

After  the  period  of  safety  of  storing  whole  blood 
has  elapsed,  with  the  aid  of  a  simple  water  suction- 
pump  and  a  sterile  connection  to  a  sterile  needle, 
perforation  of  a  rubber  stopper  at  the  bottom  of 
the  tube  where  the  red  cells  have  collected  permits 
their  withdrawal  without  contaminating  the  residual 
plasma.  The  plasma  can  then  be  preserved  for  an 
indefinite  period. 

The  blood  or  plasma  is  given  by  gravity  after 
sterile  needles  connected  by  rubber  tubing  are 
placed  in  the  tube  through  the  rubber  stopper  and 
in  the  vein.  Another  needle  is  passed  through  the 
rubber  stopper  at  the  top  of  the  tube  into  the  tube 
to  create  positive  pressure  so  that  the  blood  will 
flow  readily  by  gravity. 

Should  it  be  proven  that  serum  or  plasma  of 
any  type  may  be  transfused  with  safety  and  that 
scrum  or  plasma  is  equally  as  effective  as  whole 
blood,  as  suggested  earlier  in  this  paper,  the  ne- 
cessity of  typing  donors  and  recipients  will  be 
removed.  Then,  with  the  aid  of  the  vacuum  tube 
described   and   illustrated,   the  safe  storage  of  a 


transfusable  medium,  as  satisfactory  as  any  now 
available,  will  be  possible  and  practicable;  the  ne- 
cessity of  typing,  of  preparing  more  or  less  elabor- 
ate equipment  and  of  having  hospital  facilities  will 
be  removed;  the  cost  of  transfusion  will  be  mate- 
rially reduced;  the  difficulties  attending  a  present- 
day  transfusion  will  be  removed  and  a  safe  and 
satisfactory  transfusable  medium  will  be  readily 
available  at  all  times. 

References 

1.  Gradwohl:     Clinical  Laboratory  Methods  and  Diagno- 
sis, 282. 

2.  SnrMONDS:     Virchow  Arch.,  17S:  No.  3,  1904. 

3.  Casnon:     Centralf  F  Allg.  W.  Path.  Anat.,  15:  No.  4, 
1904. 

4.  McKenzie  &  Elliott:     Blood  Serum  Proteins  in  Pyo- 
genic Infections.    So.  Med.  &  Surg.,  Jan.,  193S,  7-10. 


The  Delicate  Child  and  Tubercltlosis 
(Edi.  Jl.-Lan.,  Nov.) 

The  observations  of  Ward  (Brit.  Jl.  of  Tub..  29:  128, 
1935)  made  over  a  period  of  21  years:  we  were  emphasiz- 
ing the  delicate  child  as  the  future  consumptive.  We 
strongly  recommended  summer  camps,  special  schools  and 
preventoria,  in  the  hope  that  we  could  prevent  these  chil- 
dren whom  we  believed  to  have  low  resistance,  because 
they  appeared  delicate,  from  becoming  tuberculous.  We 
placed  great  stress  upon  the  child  whose  weight  was  10% 
or  more  below  the  theoretical  normal.  The  years  have 
shown,  however,  that  these  children  are  no  more  likely  to 
develop  tuberculosis  than  apparently  normal  healthy  chil- 
dren and,  therefore,  our  program  of  coddling  them  from 
the  standpoint  of  preventing  tuberculosis  has  collapsed. 

Observations  in  Lancashire  showed  that  "the  frail  chil- 
dren grow  into  frail  but  non-tuberculous  adults,  whereas 
the  young-adult  and  adult  cases  of  florid  or  more  chronic 
tuberculous  disease  come,  alas !  from  among  the  apparently 
healthy  children."  The  aim  of  the  observations  in  Scot- 
land, published  by  McKinley  and  Watt  (Lancet,  .^ug.  11th, 
1934),  was  to  determine  whether  by  routine  clinical  ex- 
amination it  was  possible  to  predict  the  type  of  child 
likely  to  become  tuberculous  later.  Height  and  weight 
gave  no  clue  as  to  those  who  would  later  become  con- 
sumptive. They  found  that  those  children  who  had  had 
the  various  communicable  diseases  of  childhood  were  no 
more  likely  to  develop  tuberculosis  later  than  those  who 
had  not,  with  a  possible  exception  of  scarlet  fever. 

Ward  cites  a  case  of  a  boy  of  10  years  who  had  always 
been  delicate  but  clinical  and  x-ray  examinations  were 
negative.  In  1928,  he  was  exposed  to  a  brother  who  died 
of  tuberculosis  and  was  immediately  .sent  to  a  children's 
sanatorium  because  of  the  exposure.  He  remained  there  2 
years  and  3  months.  In  1935  he  had  bilateral  upper-lobe 
tuberculosis.  On  the  basis  of  the  evidence  available.  Ward 
says  that  "sooner  or  later  we  shall  be  driven  to  conclude 
that  the  debilitated  child  is  just  .-is  likely,  no  more  and  no 
less,  to  develop  young  adult  or  adult  phthisis  as  the  robust 
or  normal  schoolboy." 

With  such  fads  established,  we  should  immediately  dis- 
continue some  of  the  tuberculosis  work  of  today,  and  re- 
establish it  on  the  fundamental  principles  that  we  have 
used  in  other  communicable  diseases. 

S.   M.    Sc  B. 

Bei-ore  MAKiXd  UP  YOUR  MLVD  as  to  thc  cause  of  your 
patient's  bellyache,  think  about  urinary  stones  and  acute 
conditions  above  the  diaphragm. 


646 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


Essential  Enuresis 


Frederick  R.  Taylor,  M.D.,  F.A.C.P.,  High  Point,  North  Carolina 


Definition 

BY  essential  enuresis  is  meant  a  chronic  state 
characterized  by  a  lack  of  control  of  blad- 
der function  by  day  after  the  age  of  two 
years  or  by  night  after  the  age  of  three  years  in 
persons  of  normal  mentality  without  detectable 
causative  organic  lesion,  resulting  in  incontinence 
of  urine.  In  many  cases  the  incontinence  is  lim- 
ited to  the  hours  of  sleep,  but  in  many  others  it  is 
present  during  waking  hours,  and  in  a  few  cases  it 
is  combined  with  fecal  incontinence.  Acute  transi- 
tory incontinence  due  to  marked  emotional  disturb- 
ances such  as  severe  fright  and  chronic  incontinence 
due  to  abnormally  irritating  urine  are  excluded  as 
well  as  cases  due  to  organic  disease. 
History 

Enuresis  has  probably  existed  as  long  as  the 
human  race.  To  write  its  history  would  be  a  fas- 
cinating task,  but  would  require  almost  a  life-time 
of  research.  Doubtless  the  bizarre  theories  of  eti- 
ology and  the  equally  bizarre  methods  of  treatment 
in  days  gone  by  could  almost  fill  a  volume.  Earl 
writes  of  the  Anglo-Saxon  remedy  of  "drinking  the 
ashes  of  a  pig's  pizzle  dissolved  in  sweet  wine.'' 
He  notes  pithily  that  the  drugs  that  have  been 
recommended  range  alphabetically  from  acetates  to 
valerian  (zinc  must  have  been  overlooked!)  In 
the  17th  and  18th  centuries  amulets  and  other 
devices  were  worn  about  the  neck,  the  bed  was 
faced  in  some  special  direction,  the  child  was  placed 
for  a  long  time  daily  in  baths  containing  various 
decoctions,  aromatic  herbs,  etc.  Severe  punish- 
ments had  their  vogue  in  the  Victorian  era.  Red- 
dening the  buttocks  with  blows  was  supposed  to 
have  a  beneficial  counterirritative  effect!  All  man- 
ner of  surgical  and  mechanical  procedures  have 
been  employed,  and  even  faradization  of  the  neck 
of  the  bladder. 

Etiology 

Many  causes  have  been  alleged  only  to  be  dis- 
proved. Among  these  are  intestinal  parasites,  phi- 
mosis, diseased  tonsils  and  adenoids,  etc. 

At  times  excessive  acidity  or  alkalinity  of  the 
urine  may  be  a  factor  in  incontinence  of  urine,  but 
if  it  is  the  sole  factor,  the  condition  is  not  of  the 
truly  "essential"  type.  At  times  there  is  a  reversal 
of  the  usual  ratio  between  the  specific  gravities  of 
the  day  and  night  urines,  the  night  urine  having  a 
lower  gravity  than  the  day.  At  times  diuresis  due 
to  excessive  water  intake  or  to  diuretics  such  as 
cocoa,  chocolate,  tea,  coffee,  etc.,  play  a  part.  How- 
ever, none  of  these  factors  are  fully  adequate  to 


account  for  enuresis.  Grover  has  probably  given 
the  most  satisfactory  discussion  of  the  etiology  of 
this  condition.  He  points  out  that  it  is  due  to  a 
general  neuromuscular  fatigue  dependent  upon 
mental  strain,  insufficient  sleep,  emotional  excite- 
ment, excessive  muscular  exertion,  and  often  a  poor 
diet.  Excessive  fatigue  causes  such  deep  sleep  that 
the  child  cannot  wake  himself,  and  if  taken  up 
without  being  awakened  he  may  fail  to  void  only 
to  do  so  unconsciously  a  few  minutes  after  being 
put  back  to  bed.  When  incontinence  of  feces  is 
associated  with  enuresis  it  has  the  same  etiology. 

Most  cases  of  enuresis  simply  persist  from  in- 
fancy. Normally,  bed-wetting  should  cease  by  the 
time  a  child  is  three  years  old,  and  clothes-wetting 
about  a  year  earlier.  Some  cases,  however,  that 
have  been  "dry"  from  about  the  age  of  three  or 
even  earlier,  develop  enuresis  later,  following  some 
acute  disease  such  as  scarlet  fever  or  some  emo- 
tional shock  such  as  severe  fright.  Jealousy  over 
a  new  baby  seems  to  be  a  factor  in  a  few  cases. 
In  addition  to  the  above-mentioned  causes,  another 
important  factor  may  be  present,  especially  in  cases 
showing  diurnal  incontinence,  and  that  is,  an  ab- 
normally small  bladder,  one  that  fails  to  dilate  nor- 
mally.   The  sexes  are  affected  about  equally. 

No  structural  pathology  is  demonstrable  other 
than  the  abnormally  small  bladder  in  certain  cases 
just  described. 

The  symptomatology  is  obvious.  Horton  classi- 
fies cases  as  follows:  Day  only,  5%.  Night  only, 
30%.  Day  and  night,  55%.  With  incontinence  of 
feces,  10%.  No  classification  by  ages  is  given  in 
connection  with  these  figures,  but  it  is  safe  to  say 
that  among  older  children  nocturnal  enuresis  alone 
is  more  frequent  than  nocturnal  and  diurnal  com- 
bined. 

Diagnosis 

Our  first  concern  is  the  exclusion  of  organic 
causes  of  incontinence  such  as  mental  deficiency, 
organic  nervous  diseases  affecting  sphincter  control 
(including  that  easily  overlooked  darling  of  the 
roentgenologists,  spina  bifida  occulta),  diabetes  in- 
sipidus or  mellitus,  exstrophy  of  the  bladder,  vesi- 
covaginal fistula,  infections  of  the  urinary  tract, 
urinary  calculi,  etc.  Gross  changes  in  the  reaction 
of  the  urine  should  also  be  excluded.  They  may 
be  present,  of  course,  as  complications  of  essential 
enuresis,  and  after  they  have  been  corrected  the 
enuresis  may  still  persist. 

Treatment 

Obviously,  if  any  of  the  above  organic  or  chem- 


December,  1936 


ESSEA  TIA  L  EN  URESIS— Ta  vior 


ical  causes  of  incontinence  are  found  they  should 
receive  appropriate  treatment.  The  treatment  of 
the  true  essential  cases  has  in  the  past  been  a  re- 
proach to  the  medical  profession.  Almost  every 
drug  has  been  tried  and  found  wanting.  Atropine 
and  belladonna  have  probably  had  the  longest 
vogue,  but  usually  fail.  Ephedrin  and  pseudo- 
ephedrin  are  perhaps  the  latest  drugs  to  be  ad- 
vocated, ephedrin  being  preferred  and  given  in 
doses  oi  yi  to  y2  grain  at  bedtime.  Malavozos 
claims  good  results  from  follutein,  an  anterior 
pituitary-like  substance  in  the  urine.  Others  have 
reported  about  as  good  results  with  hypodermics 
of  sterile  water,  one  series  of  cases  having  shown 
87%  cured  by  this  method  according  to  reports. 
The  present  writer  believes,  however,  that  such 
methods  while  apparently  successful  in  the  hands 
of  a  few  are  of  questionable  value  as  a  general 
routine.  He  also  considers  various  surgical,  me- 
chanical, and  electrical  procedures  as  likely  to  b; 
worse  than  useless,  and  does  not  employ  them. 
Drugs  such  as  those  suggested  may  perhaps  be 
tried  justifiably  when  cooperation  of  the  parents 
cannot  be  secured  in  the  treatment  about  to  h: 
described,  but  when  it  can,  the  neuromuscular  train- 
ing, diet,  and  hygiene  recommended  by  Grover  is 
based  on  so  firm  a  foundation  of  rational  theory 
and  has  given  such  excellent  results  in  practice, 
that  it  is  by  all  odds  the  therapy  of  choice. 

In  this  treatment,  drugs  have  no  place.  A  good 
nourishing  balanced  diet  is  indicated,  but  specially 
diuretic  or  irritant  foods  such  as  cocoa,  chocolate, 
sweets,  coffee,  tea,  highly  seasoned  or  spiced  foods, 
such  as  pickles  or  smoked  fish,  gas-producing  foods 
such  as  baked  beans,  peanuts,  etc.,  should  be  for- 
bidden. After  4:00  p.  m.  as  little  liquid  as  possi- 
ble is  to  be  given.  Not  over  a  half  a  glass  of 
liquid  is  to  be  given  with  the  evening  meal.  Still 
more  difficult,  but  of  great  importance,  is  that  the 
child  must  be  kept  quiet  after  4  p.  m.  He  must 
sit  down  and  play  quietly,  or  if  an  older  child, 
read,  but  avoid  exciting  literature.  All  his  running 
about  and  hard  exercise  must  be  over  for  the  day 
by  4  p.  m.  He  should  urinate  at  7  p.  m.,  just  be- 
fore going  to  bed.  He  should  be  taken  up  at 
exactly  10  p.  m.  and  6  a.  m.  When  taken  up,  he 
should  be  awakened  and  encouraged  to  go  to  the 
toilet  under  his  own  power,  rather  than  be  carried 
there.  He  should  not  be  slapped  or  shaken  very 
severely  to  awaken  him — if  it  is  difficult  to  arouse 
him,  gently  washing  his  face  with  cold  water  will 
be  effective.  If  there  are  complicating  factors  such 
as  a  cold  bathroom,  darkness  which  the  child  fears 
to  walk  through,  etc.,  a  chamber  pot  or  other  suit- 
able vessel  should  be  provided  in  the  child's  room. 

A  few  cases    will    clear    up    on    this    schedule. 


Most  will  not.  It  then  becomes  necessary  to  em- 
ploy an  alarm  clock  for  the  parent  who  is  to  waken 
the  child,  and  have  it  ring  at  exactly  2  a.  m.  Punc- 
tuality and  regularity  of  the  time  of  awakening 
is  of  the  first  importance  in  overcoming  enuresis. 
The  child  is  now  wakened  at  10  p.  m.,  2  a.  m.  and 
6  a.  m.  In  most  cases  this  will  suffice.  If  neces- 
sary the  alarm  clock  hours  may  be  made  more 
frequent  until  the  child  is  wakened  often  enough 
to  insure  a  "dry"  night.  On  this  schedule  success 
in  overcoming  nocturnal  enuresis  should  be  obtain- 
ed within  a  few  weeks,  but  the  schedule  should  be 
continued  for  at  least  three  months  in  order  for  the 
"dry"  habit  to  become  fixed.  After  that  time  the 
2  a.  m.  wakening  may  be  tentatively  abandoned, 
to  be  resumed  again  at  once  if  the  child  has  any 
"accident." 

For  day-wetting,  special  bladder  training  is  re- 
quired. The  child  if  in  school  should  be  taken  out 
temporarily  to  give  proper  opportunity  for  the 
course  of  training  and  also  to  escape  the  gibes  of 
his  schoolmates  which  make  matters  worse.  He 
should  be  directed  to  void  every  30  minutes  by 
the  clock  if  wettings  are  frequent.  If  infrequent, 
the  intervals  may  be  longer.  After  a  week  of  free- 
dom from  accidents  the  time  may  be  lengthened 
to  40  minutes,  after  another  week  to  50  minutes, 
then  one  hour,  an  hour  and  a  quarter,  an  hour 
and  a  half,  two  hours,  etc.  Some  authorities  rec- 
ommend bladder  exercises,  having  the  child  start 
to  void,  then  stop  before  completing  the  act,  then 
start  again.  All  these  methods  have  as  their 
object  the  gradual  dilatation  of  the  bladder  until 
it  can  accommodate  comfortably  a  normal  amount 
of  urine. 

Punishment  jor  "accidents"  must  never  be  given. 
The  child  must  be  encouraged  to  have  faith  in 
himself,  to  believe  that  he  can  overcome  his  dis- 
ability, and  that  right  early.  He  should  never  be 
told,  "You  will  outgrow  your  trouble  some  day," 
for  that  fixes  in  his  mind  the  idea  of  recovery  in 
some  remote  future  time.  Nor  should  he  be  told 
that  he  has  "weak  kidneys,"  "weak  bladder,  '  etc. 
If  "accidents"  occur,  they  should  be  taken  in  a 
casual  matter-of-fact  way  as  an  indication  for  a 
change  in  schedule,  and  all  emotional  scenes  should 
be  avoided.  Attempts  to  shame  the  child  are  ut- 
terly foolish,  for  he  is  already  suffering  agonies  of 
shame,  and  the  older  the  child  the  more  true  this 
is.  On  the  other  hand,  excessive  "babying"  of  the 
child  is  harmful.  .\  few  children  may  make  no 
effort  to  overcome  enuresis  because  they  like  to 
be  taken  up,  coddled,  and  waited  on  hand  and  foot. 
Prompt  elective  punishment  is  indicated  ij  the 
child  knowingly  breaks  any  of  Ihr  rules  of  diet, 
jluid  intake,  quiet  period  after  4  p.  m.,  etc.,  and  he 


ESSENTIAL  ENURESIS— Taylor 


December,  1936 


should  be  warned  ahead  of  time  of  this. 
Prognosis 
With  adequate  cooperation  of  parents  in  carrying 
out  the  above  method  of  treatment,  cessation  of 
enuresis  should  be  expected  within  a  few  weeks 
to  a  few  months,  and  cure  within  six  months  or 
less.  Without  such  cooperation,  which  demands 
character  and  self-sacrifice  on  the  part  of  at  least 
one  parent,  the  prognosis  is  poor  for  immediate  im- 
provement. Most  patients  do  "outgrow"  the  trou- 
ble, but  it  may  last  well  into  adolescence  and  cause 
untold  suffering  to  the  child  and  his  family  if  ade- 
quate measures  are  not  adopted  to  overcome  it. 
Prophylaxis 
This  is  a  matter  of  training.  This  may  be  be- 
gun as  early  as  6  or  7  months  of  age,  and  should 
never  be  postponed  beyond  the  age  of  1  year,  as 
to  do  so  tends  to  fix  bad  habits  in  the  infant.  He 
should  be  taught  to  use  a  toilet  chair  for  urinating 
and  defecating  and  to  avoid  these  functions  by  day 
when  not  on  the  chair.  This  means  placing  him 
at  frequent  regular  intervals  on  the  chair  until  the 
habit  of  using  it  is  fixed.  At  14  to  18  months 
diapers  should  be  dispensed  with  and  drawers  or 
panties  substituted,  as  these  get  uncomfortably  cold 
when  wet,  and  discourage  wetting.  The  child's 
night-wetting  should  be  forestalled  so  far  as  possi- 
ble, and  he  should  be  trained  early  to  void  just 
before  being  put  to  bed,  then  taken  up  at  10  p.  m. 
and  6  a.  m.  and  also  during  the  night  if  required, 
as  outlined  under  Treatment. 

Bibliography 

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A.,  1924,  txxxin,  1300. 

Amberg,  S.,  and  Grob,  O.:  Effect  of  atropine  on  blad- 
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Beverley,  B.  I.:  Incontinence  in  children.  Jour.  Pediat., 
1933,  n,  718. 

Calvin,  J.  H.:  Enuresis.  J.  A.  M.  A.,  1928,  xc,  820; 
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Chandler,  A.  B.:  Enuresis.  Canad.  Med.  Assn.  Jour., 
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Chmstopherson,  J.  B.,  and  Broadbent,  M.:  Ephedrine 
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CoiMBY,  J.:  Traitement  de  I'incontinence  d'urine  chez 
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XLVin,  282. 

Dreyfus-See,  G.:  L'incontinence  d'urine  chez  I'enfant, 
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Eakl,  C.  J.  C:  Nocturnal  enuresis.  Brit.  Jour.  Child. 
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Fordyce,  a.  D.,  and  others:  Discussion  on  enuresis. 
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Friedell,  a.:  Reversal  of  normal  concentration  of  urine 
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Glaser,  J.,  and  Land.\u,  D.  B.;  A  simple  mechanical 
method  for  treatment  of  enuresis  in  male  children.  Jour. 
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HoRTON,  K.  M.:  Enuresis  in  hospital  practice.  Arch. 
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Hubert,  W.  H.  deB.:  Etiology  of  nocturnal  enuresis. 
Lancet,  1933,  I,  1281. 

Lesne,  E.,  Lievre,  J.  A.,  et  Lievre,  Mme.,  J.  A.:  Les 
facteurs  etiologiques  de  I'enuresie  infantile.  Deductions 
pathogeniques  et  therapeutiques.  Presse  med.,  1935,  xLm, 
1868. 

Lewis,  J.  M.,  and  Ostroff,  J.:  Psychic  enuresis  in 
normal  children,  experimental  study.  Am.  Jour.  Dis.  Child., 
1932,  XLm,  1490. 

Malavazos,  L.:  Effect  of  anterior  pituitary -like  sub- 
stance in  enuresis.  Urol,  and  Cutan.  Rev.,  1935,  xxxrx, 
322. 

Usher,  S.  J.:  Treatment  of  enuresis  in  hospital  practice. 
Canad.  Med.  Assn.  Jour,  1931,  xxiv,  665. 

WooLEY,  H.  T.:  Enuresis  as  a  psychological  problem. 
Ment.  Hyg.,  1926,  x,  38. 


Narcosis  Ther.\py  in  Psychoses 
(G.  H.  Alexander,  Providence,  in  R.  1.  Med.  Jl.,  Oct.) 
In  the  manic  phase  of  the  Manic  Depressive  Psychosis, 
or  in  the  catatonic  excitement  of  Schizophrenia,  it  becomes 
imperative  at  times  to  diminish  excessive  physical  activity. 
For  a  certain  number  the  continuous  bath,  or  packs,  insure 
only  physical  restraint,  which,  in  itself,  further  excites  the 
patient ;  and  too  frequently  sedatives  in  the  commonly 
used  dosage  hkewise  fail  to  produce  the  desired  result. 

At  Butler  Hospital  during  the  past  6  months,  this  routine 
technique  has  been  utilized  in  5  cases,  in  1  of  which  dis- 
continuance of  the  therapy  was  forced  on  the  4th  day, 
because  of  potentially  dangerous  physical  complications. 
Of  the  remaining  4  cases,  2  patients  were  well  enough  to 
leave  the  hospital  approximately  1  week  following  narcosis 
therapy,  and  have  remained  entirely  well  for  periods  of  4 
and  6  months,  respectively.  In  all  of  the  cases,  sodium 
amytal  was  used  exclusively  as  the  narcotizing  agent,  and 
in  most  of  the  cases  reported  in  the  literature  this  drug, 
or  a  member  of  the  same  barbital  group,  has  been  em- 
ployed. 

The  amounts  of  sodium  amytal  administered  varied  from 
9  to  15  grains,  and  were  repeated  as  frequently  as  the 
patient  showed  signs  of  restlessness  and  emergence  from 
narcosis.  Twice  during  each  24-hour  period,  the  patient 
was  allowed  to  emerge  into  sufficiently  Ught  narcosis  to 
take  nourishment  and  fluids  by  mouth,  or  to  be  safely 
artificially  fed,  if  necessary.  At  this  time,  also,  dejections 
and  voiding  were  encouraged,  and  bathing  and  general 
hygienic  measures  were  carried  out.  In  the  event  of  failure 
to  void  for  12  to  15  hours,  with  evidence  of  bladder  disten- 
tion, catheterization  was  employed,  and  enemata  were 
given  routinely  every  second  day,  to  insure  satisfactory 
fecal  elimination.  Fluid  nourishment  of  at  least  2,000  c.c, 
representing  at  least  2,000  calories,  was  given  in  each  24- 
hour  period,  and  adequate  vitamin  intake  was  assured  by 
the  inclusion  of  fruit  juices  and  haliver  oil,  with  viosterol, 
in  the  diet.  A  high-carbohydrate  diet  was  employed  and, 
following  each  feeding,  5  units  of  insulin  were  adminis- 
tered. To  counteract  the  usual  slight  depression  of  b.  p. 
associated  with  the  action  of  sodium  amytal,  3/Sths  grain 
doses  of  ephedrin  sulphate  were  administered  from  time  to 
time.  When  mucus  in  the  throat  proved  troublesome  small 
doses  of  atropin  were  given. 


Can  any  suitable  activities  be  afforded  (D.  H.  Lee, 
Singapore,  in  Malayan  Med.  Jl.,  June)  our  women-folk  to 
alleviate  the  cloying  eternal  golf  and  bridge,  activities 
which  could  afford  mental  satisfaction  and  yet  not  impose 
a  burden  upon  their  health  and  status? 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Auricular  Fibrillation* 

A.  B.  Choate,  M.D.,  Charlotte,  North  Carolina 


1^  ECAUSE  of  the  frequency  with  which  auric- 
r^  ular  tibrillation  is  encountered,  the  difficulty 
we  have  in  its  diagnosis  and  the  influence  it 
has  on  the  prognosis,  I  feel  that  a  discussion  of 
this  form  of  cardiac  condition  is  very  appropriate 
at  this  time. 

Perhaps,  it  is  academic  for  me  to  review  the  phy- 
siology of  auricular  tibrillation.  However,  it  is  an 
abnormal  physiologic  cardiac  condition  in  which 
the  auricles  have  lost  their  normal  contractability; 
hence,  the  auricular  musculature  is  in  a  state  of 
librillary  twitching,  a  complete  and  full  contrac- 
tion of  the  auricle  does  not  take  place,  resulting  in 
the  auricles  not  emptying  completely  and  the  blood 
often  clotting  there. 

Several  theories  have  been  advanced  as  to  why 
the  auricles  behave  in  such  a  manner.  Sir  Thomas 
Lewis  has  advanced  the  theory  which  he  calls  "the 
circus  movement  in  the  auricles."  This  is  a  con- 
dition in  which  a  stimulus  arises  in  an  ectopic  focus 
and  pursues  a  very  rapid  course  about  the  venous 
openings  in  the  right  auricle  causing  small  waves 
of  contraction  to  be  sent  out  into  the  auricular  mus- 
culature. 

To  me,  the  most  plausible  theory  is  that  although 
the  sinoauricular  node  is  the  normal  pace-maker 
of  the  heart,  its  role  is  taken  over  by  the  auricles 
when  they  are  irritated  and  one  or  more  ectopic  foci 
are  set  up  at  the  point  of  irritation  within  the 
auricular  muscle  which  give  rise  to  impulses  at 
the  rate  of  200  to  400  per  minute.  These  impulses 
are  relayed  to  the  ventricle  at  irregular  intervals 
which  responds  by  a  contraction  at  a  rate  of  from 
40  to  180  per  minute. 

Auricular  fibrillation  is  found  as  a  complicating 
abnormal  physiological  condition  in  various  t.vpes 
of  heart  disease,  the  most  frequent  type  of  disease 
being  that  of  rheumatic  mitral  stenosis.  Drs.  Graff 
and  Lingg  found  in  their  series  of  402  rheumatic 
patients  with  mitral  stenosis,  that  50.5  per  cent, 
developed  auricular  fibrillation.  Stone  and  Feil 
report  53.  Weiss  and  Davis  report  57  per  cent. 

It  has  been  shown  by  Chapelle  that  the  occur- 
rence of  auricular  fibrillation  bears  no  relation  to 
the  grade  of  mitral  stenosis,  but  stenosis  or  organic 
insufficiency  of  the  mitral  valve  is  necessary  for 
the  development  of  persistent  auricular  fibrillation 
in  rheumatic  heart  disease.  Auricular  fibrillation 
in  this  condition  is  encountered  with  greater  fre- 


•Presented  to  the  Mecklenburg;  County  Medical   Society,  May  IDth. 


quency  in  persons  past  middle  life. 

Xe.xt  in  frequency  is  hypertensive  vascular  dis- 
ease in  which  auricular  fibrillation  develops  after 
years  of  high  blood  pressure.  Ne.xt  follows  thyro- 
to.xicosis. 

However,  it  has  been  estimated  that  from  10  to 
IS  per  cent,  of  the  cases  are  extracardiac  in  origin. 
In  this  group  fall  the  cases  due  to  poisons  of  many 
different  kinds,  including  alcoholic  excesses,  infec- 
tious diseases,  tobacco,  food  poisoning,  and  some- 
times trauma.  Auricular  fibrillation  once  it  has 
developed  may  be  of  two  types:  Paroxysmal  and 
Chronic.  The  chronic  type  is  the  most  frequently 
detected.  It  is,  however,  usually  preceded  by  the 
paroxysmal  type  which  often  escapes  observation. 
The  diagnosis  of  auricular  fibrillation  can  often 
be  made  by  a  simple  clinical  examination.  Often 
the  pulse  arouses  our  suspicion.  It  is  totally  irreg- 
ular as  to  rate,  rhythm  and  force,  and  there  is  a 
pulse  deficit  of  from  10  to  40  beats.  On  taking 
the  blood  pressure,  we  find  that  one  beat  comes 
through  loudly  and  the  next  one  weakly,  but  each 
cne  different  from  its  fellow. 

-Auscultation  at  the  apex  shows  a  total  lack  of 
rhythm  in  the  irregularity  of  the  force,  rate  and 
rhythm. 

In  the  differential  diagnosis  we  must  consider 
sinus  arrhythmia  and  extrasystoles.  Auricular  flut- 
ter, especially  where  the  ventricular  rate  is  irreg- 
ular, is  very  confusing.  If  the  patient  can  exercise, 
the  irregularity  will  not  diminish  if  it  is  auricular 
fibrillation,  but  will  often  be  accentuated. 

In  other  types  of  irregularity  which  I  have  men- 
tioned, the  irregularity  often  disappears  with  exer- 
cise. However,  the  electrocardiogram  is  the  final 
court  of  judgment  and  we  must  often  rely  upon  it 
for  diagnosis. 

-As  to  the  clinical  significance  of  auricular  fibril- 
lation we  find  that  the  extracardiac  cases  are  usual- 
ly not  serious.  As  a  rule,  when  we  remove  the 
cause,  the  fibrillation  will  terminate,  and  the  effi- 
ciency of  the  heart  that  has  been  lowered  by  the 
fibrillation  will  return  to  normal. 

As  for  the  intracardiac  conditions,  the  prognosis 
is  more  grave.  In  the  rheumatic  cases  the  signs  of 
valvular  lesion  are  often  obliterated  by  the  devel- 
opment of  auricular  fibrillation  as  the  murmurs  are 
obliterated  or  softened  in  intensity  by  the  ineffi- 
ciency of  the  muscular  contraction.     It  is  at  this 


A  URICULAR  FIERI LLA TlON—ChoaU 


December,  1936 


Stage  that  cardiac  decompensation  begins.  If  the 
patient  is  under  twenty-five,  the  prognosis  is  even 
more  grave. 

.Auricular  fibrillation  in  hjrpertensive  cases  usual- 
ly occurs  after  years  of  high  blood  pressure.  It  is 
in  this  type  of  case  that  we  most  often  see  the  cases 
of  embolism,  thrombi  having  a  tendency  to  form 
in  the  incompletely  contracting  auricles,  and  break- 
ing off  at  intervals. 

In  thyrotoxicosis  the  fibrillation  will  usually  tend 
to  disappear  on  removal  of  the  goiter.  Should  the 
auricular  fibrillation  not  occur  until  after  the  re- 
moval of  the  goiter,  as  is  sometimes  the  case,  it  can 
usually  be  reverted  to  a  regular  sinus  mechanism 
by  quinidine. 

Paroxysmal  fibrillation  implies  that  the  patient 
will  develop  the  chronic  form  if  not  treated. 

In  general  the  prognosis  of  auricular  fibrillation 
is  serious,  because  it  usually  develops  in  the  end- 
stage  of  any  type  of  cardiac  disease.  The  man  with 
valvular  disease  who  develops  auricular  fibrillation 
is  near  the  end  of  his  road. 

The  prognosis  of  auricular  fibrillation,  therefore, 
depends  upon  the  extent  of  the  basic  underlying 
pathology  upon  which  the  auricular  fibrillation  is 
superimposed. 

Digitalis  was  for  a  long  time  the  accepted  treat- 
ment of  auricular  fibrillation.  Wenckebach,  in 
1914,  found  that  quinine  would  cure  auricular 
fibrillation.  Von  Frey,  in  1917,  found  that  quini- 
dine had  the  same  effect. 

Closely  following  on  these  reports  came  the  cry 
that  quinidine  caused  thrombosis,  causing  consider- 
able fear  about  the  use  of  the  drug. 

Dr.  Paul  White  of  Boston  then  began  a  study  of 
the  cases  of  emboli  and  found  that  the  percentage 
of  deaths  from  embolic  accidents  was  as  high  among 
patients  who  had  not  received  quinidine  as  it  was 
in  those  who  had  received  it. 

At  one  time  it  was  common  practice  to  hospital- 
ize all  patients  who  were  to  receive  quinidine,  fully 
compensate  them  with  digitalis  then  run  in  quini- 
dine, beginning  with  a  small  test  does  and  then 
increasing  the  dosage  gradually  until  the  patient 
would  be  receiving  as  much  as  100  grs.  per  day 
sometimes.  If  the  heart  did  not  revert  to  normal 
mechanism  in  a  short  time,  then  stop  the  use  of  the 
drug. 

The  present  trend  of  the  use  of  quinidine  in  cases 
of  auricular  fibrillation  is  to  give  it  in  tablets 
of  3  grs.  each,  one  tablet  every  six  hours,  awak- 
ing the  patient  at  night  and  continuing  the  use  of 
it  over  a  period  of  several  months,  as  it  sometimes 
takes  this  long  for  conversation  to  take  place.  The 
use  of  this  method  abolishes  the  danger  of  intoxi- 
cation by  quinidine. 


In  cases  of  decompensation,  digitalis  is  some- 
times used  and  is  desirable,  but  practice  shows  that 
cases  of  auricular  fibrillation  tend  to  revert  more 
quickly,  and  the  percentage  of  converts  is  higher,  if 
the  patient  can  be  properly  treated  without  digi- 
talis. It  is  thought  by  Maher  and  others  that 
digitalis  tends  to  maintain  the  fibrillation  if  it  is 
used  before  the  mechanism  is  converted  to  normal. 

In  the  cases  where  a  conversation  to  normal 
mechanism  has  taken  place,  a  maintenance  dose  of 
quinidine  may  be  given  over  an  indefinite  period 
of  time.  Other  drugs  such  as  opiates,  diuretics, 
etc.,  may  be  used  with  quinidine  whenever  indi- 
cated. 

The  effect  of  quinidine  is  one  of  sedation,  having 
a  sedative  influence  upon  the  auricular  muscula- 
ture, tending  to  decrease  the  number  of  foci,  until 
the}'  are  all  removed  allowing  the  sinoauricular 
node  to  resume  its  normal  role  as  pace-maker. 


.\  Proposed  State  Law  Concerning  the  Sale  of 

Harmful  Drugs 

(Bui.   St.   Louis   Med.   Soc,  Oct.   2nd) 

On  April  7th.  1Q36,  the  Society  passed  a  resolution  to 
recommend  that  the  Missouri  State  Medical  Association 
support  adequate  legislation  for  the  control  of  the  sale  of 
certain    drugs. 

.\  draft  on  this  order  will  shortly  be  presented  to  the 
State  Association  for  action: 

The  sale  or  gift  of  barbituric  acid  (diethylbarbituric 
acid)  chloral,  paraldehyde,  sulphonal  (sulphonemethane), 
thyroid  extract,  dinitrophenol,  dinitrocresol,  cinchophen 
(phenyl-quinoline  carbonic  acid),  or  derivities  and  com- 
pounds thereof  under  any  registered,  copyrighted,  trade- 
marked  or  chemical  name  except  by  manufacturers  or 
chemical  houses  to  wholesale  drug  houses  or  to  hospitals 
or  retail  pharmacies,  and  by  retail  pharmacies  except  on 
the  prescription  of  a  legally  qualified  physician,  dentist  or 
veterinarian,  is  hereby  prohibited.  All  orders  or  prescrip- 
tions shall  be  kept  on  file.  No  copy  or  duplicate  of  such 
order  or  prescription  shall  be  made  and  the  original  shall 
not  be  refilled  except  prescriptions  for  phenobarbital  may 
be  refilled  for  epileptics  when  the  words  epilepsy  or  epilep- 
tic shall  be  written  plainly  thereon  by  the  prescribing  phy- 
sician or  veterinarian   (sic). 


CoNVLiLSioNS   During    Ether    Anesthesia 


The  convulsions  manifest  themselves  usually  after  the 
patient  has  been  under  the  influence  of  ether  for  some 
time.  The  latest  researches  tend  to  point  to  alkalosis  with 
a  subsequent  diminution  in  the  serum  calcium  as  the  cause. 

Calcium  gluconate  given  intravenously  in  two  of  the 
cases  reported,  stopped  the  convulsions  within  a  few  min- 
utes. It  is  possible  that  in  calcium  gluconate  we  have  a 
life-saving  measure  when  used  in  cases  of  convulsions  dur- 
ing ether  anesthesia  or  in  tetany  from  any  other  cause. 


The  Wasserman  test  should  be  done  (H.  N.  Cole, 
Cleveland,  in  Col.  Med.,  Nov.)  the  same  as  a  urine  test  on 
every  new  patient.  Every  pregnant  woman  should  have  a 
test  in  the  3rd  month  of  pregnancy,  again  at  the  6th  month 
and  at  the  Sth  month. 


December,   1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Surgical    Observations 

A  Column  Conducted  by 

The  Staff  or  the  Davis  Hospital 
Statesville,  N.  C. 


Conditions  Often  Overlooked  in  Aged  Women 

Aged  women  are  generally  very  sensitive  about 
any  probably  serious  impairments  of  their  health, 
and  so  often  conceal  evidences  of  such  impairments 
from  members  of  their  families  and  their  closest 
friends;  and  this  is  a  common  explanation  of  the 
advanced  stage  at  which  cancer  is  often  found 
when  such  a  patient  first  consults  her  doctor. 
Sometimes  less  serious  but  very  disabling  conditions 
are  found  which,  had  they  been  in  the  doctor's 
hands  soon  after  their  first  manifestations  present- 
ed themselves,  could  have  been  corrected  and  the 
individual  been  saved  much  suffering. 

Sometimes,  even  when  these  patients  are  induced 
to  consult  a  doctor,  they  withhold  information  on 
the  symptoms  about  which  they  are  most  appre- 
hensive, and  so,  if  a  complete  examination  is  not 
made  grave  conditions  are  overlooked. 

The  rectum  is  the  seat  of  many  troubles.  Fis- 
sures, hemorrhoids  and  various  growths  are  often 
found.  Many  cases  of  carcinoma  of  the  rectum 
advance  far  beyond  the  operable  stage  without  be- 
ing so  much  as  suspected  by  members  of  the  fam- 
ily, the  patient  saying  not  a  word  about  her  suf- 
ferings until  forced  to  call  in  a  doctor.  Among 
less  serious  conditions,  but  very  troublesome  and 
annoying,  are  fungus  infections  about  the  rectum. 
Often  these  infections  cause  excoriations  of  the  skin 
and  intense  itching.  I  believe  this  in  some  cases, 
especially  in  weakened  individuals,  has  caused  tem- 
porary mental  disease.  Feces  impacted  in  the  rec- 
tum is  sometimes  overlooked  and  may  become  se- 
rious if  not  given  attention.  Fistulae  and  perirectal 
abscesses  should  always  be  carefully  looked  for. 
together  with  any  disease  of  the  lower  rectum. 

The  vulva  may  be  the  site  of  various  parasitic 
infections,  esjjecially  that  of  trichophyton.  Growths, 
varicosities  and  old  inflammations  of  Bartholin's 
glands  should  always  be  looked  for  and  hypertro- 
phic and  atrophic  conditions  noted. 

The  urethra  is  very  often  the  seat  of  trouble.  A 
caruncle  may  produce  bleeding  and  cause  the  pa- 
tient to  think  she  has  a  cancer;  besides  the  loss  of 
blood  may  be  great  and  prove  a  serious  strain  upon 
the  patient's  strength.  Prolapse  of  the  urethra, 
growths  about  the  urethra,  inflammation  of  Skene's 
glands,  relaxation  of  the  vesical  sphincter  with 
leakage  and  cystocele  causing  retention  and  tend- 
ing to  produce  cystitis — all  these  are  possible 
sources   ijf    much    trouble.      .An   old    perineal    tear 


permitting  a  large  rectocele  to  form  may  be  a 
great  factor  in  causing  severe  constipation.  Stric- 
tures of  the  urethra  should  always  be  looked  for. 

Vaginitis  may  be  very  troublesome.  The  inves- 
tigation of  vaginitis  and  cervicitis  should  always  be 
careful  and  exact  as  accurate  diagnosis  is  here  es- 
sential for  effective  treatment. 

The  cervix  should  be  examined  by  palpation  and 
inspected  by  aid  of  good  light.  Old  tears,  cervi- 
citis, cystic  glands  and  any  growths  present  can  be 
readily  seen.  Recently  we  have  seen  a  number  of 
fairly  early  cases  of  carcinoma  of  the  cervix  in 
which  there  has  been  no  bleeding,  pain  or  leucor- 
rhea  sufficient  to  attract  the  patient's  notice. 

The  uterus  may  be  involved  in  any  number  of 
ways.  Within  the  past  week  we  have  seen  two  very 
aged  women,  each  of  whom  had  a  very  severe  pyo- 
metria.  In  each  case  dilatation  of  the  cervix  al- 
lowed the  escape  of  much  foul-smelling  purulent 
material.  Apparently  there  was  no  cancer  present 
in  either  case.  These  patients  had  doubtless  suf- 
fered a  great  deal  and,  of  course,  did  not  suspect 
the  cause  of  the  trouble.  The  examination  of  the 
uterus  for  growths  should  be  thorough,  and  the 
other  pelvic  contents  should  not  be  neglected. 

Herniae,  especially  femoral  herniae,  are  often 
overlooked  by  their  victims,  and  in  very  aged  wo- 
men, who  are  often  prone  to  conceal  such  things,  a 
femoral  hernia  may  exist  for  a  long  time  before  be- 
ing discovered  by  members  of  the  family.  In  our 
records  are  a  number  of  cases  of  femoral  and  other 
herniae  in  aged  women  which  were  not  found  until 
after  gangrene  had  occurred.  The  loop  of  the  in- 
testine or  a  part  of  the  loop  may  be  caught  by  an 
internal  ring  and  the  obstruction  go  unrelieved, 
yet  the  hernia  be  reduced  so  far  as  one  can  tell 
from  the  external  examination.  This  should  always 
be  kept  in  mind. 

Not  long  ago  we  operated  upon  an  aged  woman, 
who  had  a  femoral  hernia  which  was  reduced  an 
hour  before  admission  to  the  hospital.  Operation, 
however,  revealed  that  the  intestine  was  caught  in 
the  ring  and  half  the  circumference  of  the  intestine 
was  very  dark  and  presumably  gangrenous.  In 
this  case  it  was  possible  to  suture  the  healthy  por- 
tion over  the  gangrenous  portion,  invaginating  't 
after  a  fashion.  This  was  done  without  a  resec- 
tion and  the  patient  made  a  very  rapid  recovery. 
A  resection  would  have  been  much  more  serious. 

Tumors  of  the  breast  and  malignant  growths 
about  on  various  parts  of  the  body  are  often  over- 
looked in  the  aged.  These  present  one  of  our 
greatest  problems  and  no  examination  is  complete 
•vithout  a  careful  survey  with  the  idea  of  locating 
any  growths  which  are  to  be  found  by  the  usual 
means  of  examination. 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


Most  conditions  amenable  to  surgical  proce- 
dures in  the  young,  feeble  and  aged  people  can 
undergo  without  much  danger  when  the  procedures 
are  carried  out  with  special  indications  well  in 
mind.  Often  x-ray  and  radium  may  be  used  to 
great  advantage.  The  endotherm  knife  will  often 
enable  one  to  remove  malignant  growths  under  lo- 
cal anesthesia — if  they  are  found  early. 

Prostatic  Resection  Results 

After  several  years  of  experience  with  trans- 
urethral prostatic  resections,  a  careful  review  of 
more  than  300  cases  yields  much  of  interest. 

The  operation  has  a  very  low  mortality,  still  it 
is  not  the  best  operation  for  all  cases  of  prostatic 
hypertrophy  by  any  means.  For  best  results  some 
patients  must  have  a  regular  prostatectomy,  either 
perineal  or  suprapubic.  In  many  of  the  cases,  for 
which  prostatectomy  is  more  suitable,  a  trans- 
urethral resection  will  give  relief  from  the  obstruc- 
tion and  allow  the  patient  to  void  freely,  but  with 
such  frequency  of  micturition  by  day  and  by  night 
as  to  be  extremely  distressing,  especially  to  a  sen- 
sitive patient.  Fortunately,  this  tends  to  lessen  as 
time  goes  on  and  the  inflammation  in  the  bladder, 
trigone  and  prostatic  area  gradually  subside. 

In  the  majority  of  cases  of  prostatic  hypertro- 
phy treated  by  transurethral  resection,  nycturia 
decreases  to  the  point  that  it  is  but  little  bother- 
some. In  many  cases  it  finally  disappears  or  be- 
comes so  infrequent  that  the  patient  pays  no  at- 
tention to  it  at  all.  In  a  large  number  of  cases 
nycturia  never  develops.  Many  of  these  old  men 
void  just  before  retiring  and  on  arising  in  the 
morning  and  have  no  urge  between  these  times. 
Others  void  once  or  twice  during  the  night.  Even 
this,  however,  as  a  rule,  is  not  very  troublesome. 

Even  where  the  resection  has  given  practically 
perfect  removal  of  the  mechanical  obstruction  there 
may  be  frequency  of  urination  due  to  irritation 
from  inflammation,  possibly  with  thickening  of  the 
wall  of  the  bladder  following  long-continued  pros- 
tatic obstruction  and  infection — a  condition  which 
will  give  a  great  deal  of  trouble  no  matter  what  is 
done  for  the  relief  of  the  obstruction. 

The  cases  of  prostatic  hypertrophy  which  do  not 
do  well  after  operation  are  those,  as  a  rule,  in  which 
the  kidney  impairment  is  excessive.  After  long- 
continued  back  pressure  has  produced  dilatation 
of  the  ureters  and  the  kidney  pelves,  and  hydro- 
nephrosis, chronic  pyelitis  and  pyelonephritis  with 
great  impairment  of  the  kidney  function,  removal 
of  the  obstruction  will  probably  not  prolong  the 
psitient's  life  to  any  extent. 

Borderline  cases  are  very  difficult  to  manage. 
Days  or  even  weeks  of  drainage  of  the  bladder  by 
an    indwelling    catheter,    or    possibly    suprapubic 


drainage,  may  be  required,  before  it  can  be  deter- 
mined whether  or  not  the  patient  will  be  benefited 
by  an  operation.  A  great  deal  of  patience  is  required 
on  the  part  of  doctor  and  patient.  The  family,  too, 
should  be  acquainted  with  the  reason  for  the  pro- 
longed primary  treatment  so  that  they  may  not 
complicate  things  by  insisting  upon  something  be- 
ing done  right  away. 

It  is  useless  to  do  a  transurethral  resection  upon 
a  patient  whose  kidney  function  remains  so  low 
that  there  is  no  hop>e  of  a  return  of  sufficient  func- 
tion to  permit  life  to  continue  for  some  time.  In 
such  cases  prolonged  catheter  drainage  is  advisable, 
even  though  nothing  else  be  done. 

A  functional  test  of  the  kidneys  together  with 
repeated  blood  tests  for  nitrogen  retention  and  ex- 
amination of  the  circulatory  system  will  usually 
determine  the  advisability  of  surgical  procedures 
in  these  cases. 

Transurethral  prostatic  resection  is  far  preferable 
to  prostatectomy  in  about  85  to  90%  of  the  cases; 
in  the  remaining  10  or  15%  a  prostatectomy  or 
possibly  no  surgical  procedure  at  all  will  be  best. 

Enormous  enlargements  of  the  prostate  gland, 
especially  of  the  subvesical  type  with  elongation 
of  the  prostatic  urethra,  may  be  best  treated  by 
prostatectomy,  although  even  these  may  have  me- 
chanical relief  by  transurethral  resection. 

Obstruction  by  cancer  may  be  removed  and  tem- 
porary relief  afforded  by  one  resection  or  by  re- 
peated resections  at  intervals  of  a  few  months. 

It  is  unfortunate  that  the  public  has  come  to  re- 
gard transurethral  resection  as  a  perfect  operation 
without  danger  to  life  or  capacity  for  evil.  Even 
though  in  the  majority  of  cases  excellent  results 
are  obtained,  in  some  cases  perfect  results  do  not 
follow,  no  matter  how  carefully  the  resection  is  done 
and  no  matter  how  good  the  pre-  and  post -operative 
care. 

The  improvements  in  the  technique  of  resections 
have  been  many  and  great.  Better  methods  of 
diagnosis,  better  cutting  current  and  better  aid  to 
the  control  of  hemorrhage  after  op>eration,  together 
with  careful  management  before  and  after  opera- 
tion have  added  greatly  to  the  popularity  and  use- 
fulness of  this  boon  to  man  in  his  declinin?  vears. 


Infections  of  tke  Urethra 

(R.  W.   McKay,  Charlotte,  in   Dean   Lewis'   Practice  of 

Surgery) 

Many  of  the  interdictions  which  the  physician  usually 
places  upon  the  patient  are  foolish,  as  it  is  inconceivable 
that  they  in  any  way  miUtate  against  antibody  production. 
Such  things  as  prohibiting  the  patient  from  ingesting  fried 
foods,  certain  vegetables,  carbonated  beverages  (provided 
they  do  not  contain  alcohol),  tea,  coffee,  sweets,  salts  and 
various  combinations  of  proteins,   carbohydrates  and   fats. 


NovocAiNE  may  cause  a  very  itchy  vesicular  eruption. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


653 


DEPARTMENTS 


HOSPITALS 

R.  B.  Davis,  M.D.,  M.S.,  F.A.C.S.,  Editor,  Greensboro,N.  C. 

Who  is  .\t  Fault? 
At  the  meeting  of  the  hospital  division  of  the 
American  College  of  Surgeons  in  Philadelphia  last 
month  the  writer  heard  a  prominent  hospital  ad- 
ministrator make  this  remark,  "Surgeons  will  then 
stop  operating  on  requisition  from  medical  men." 
After  hearing  the  paper  from  which  this  state- 
ment was  read  I  was  forced  to  the  conclusion  that 
a  larger  responsibility  lies  upon  the  trustees  of  a 
hospital  than  is  generally  considered  when  one  ac- 
cepts such  an  appointment. 

The  standardization  of  hospitals  by  the  Ameri- 
can College  of  Surgeons  has  been  a  godsend  to  pa- 
tients all  over  the  United  States  and  wherever  the 
A.  C.  S.  operates;  however,  the  hospitals  in  the  land 
are  still  far  from  their  goal. 

There  are  few  hospital  trustees  who  do  not  form- 
ulate and  adopt  rules  and  regulations  for  the  con- 
duct of  the  medical  staff.  After  these  rules  and 
regulations  are  adopted  they  lose  their  importance 
in  a  great  number  of  institutions.  Thereafter  the 
most  important  phase  of  the  hospital  program  is 
that  of  keeping  the  hospital  in  good  financial  con- 
dition. As  important  as  this  might  be  it  is  second- 
ary to  that  of  operating  the  institution  according 
to  the  by-laws  adopted  for  the  conduct  of  the  med- 
ical staff. 

In  the  quotation  mentioned  above  the  word 
•then''  represented  some  time  in  the  future  when 
some  certain  thing  would  take  place.  Since  opera- 
tions must  be  done  in  the  hospitals  it  is  obvious 
that  the  surgeon  must  have  the  privilege  of  oper- 
ating in  an  intitution  before  the  lay  public  will 
accept  his  services  to  any  great  extent.  What  then 
must  happen  to  stop  surgeons  from  operating  on  a 
requisition  from  the  medical  man?  Surely  some- 
thing must  happen  to  the  surgeon,  to  the  hospital, 
or  to  both.  What  must,  of  necessity,  happen  to 
the  surgeon  should  be  discussed  by  the  editors  of 
the  surgical  department  of  the  various  medical  mag- 
azines. Suffice  it  here  to  say  that  a  radical  refor- 
mation is  necessary  if  the  hospital  administrator 
quoted  above  is  correct  in  his  assumption. 

Now  let  us  turn  to  the  responsibility  of  the 
hospital,  said  responsibility  being  first  to  the  pa- 
tient, and  not  to  the  surgeon  or  to  the  profoundly 
economic  trustee.  How  can  the  hospital  therefore 
fulfil  this  responsibility  in  regard  to  surgery  don2 


within  its  walls.  The  writer  suggests  that  every 
trustee  read  and  digest  the  by-laws  and  rules  for 
the  conduct  of  the  medical  staff  of  his  institution. 
.After  he  has  done  this  let  him  have  courage  and 
conviction  sufficient  to  demand  that  the  hospital 
administrator  require  the  staff  to  adhere  strictly 
to  these. 

The  best  rule  that  was  ever  made  is  of  no  value 
unless  it  is  put  into  operation.  Timidity  on  the 
part  of  the  operator  of  the  hospital  should  not  be 
tolerated,  and  it  is  an  admission  of  weakness  cou- 
pled with  mercenary  desire  when  found  existing 
in  a  director  or  trustee.  When  David  Crockett 
said,  "Be  sure  you  are  right  and  then  go  ahead," 
he  gave  the  best  advice  possible  for  any  trustee. 

Let  us  now  be  a  little  more  specific  and  come 
down  to  the  heart  of  the  discussion  which  is,  who 
shall  be  allowed  to  operate  upon  human  beings  in 
your  institution?  I  dare  say  that  this  question  will 
be  promptly  answered  by  95  per  cent,  of  the  hos- 
pital trustees  in  the  following  manner: 

No  one  shall  be  allowed  the  privilege  of  the 
operating  room  unless  he  is  a  graduate  of  a  rec- 
ognized medical  college,  holds  a  license  to  practice 
medicine  in  the  State,  is  a  member  in  good  stand- 
ing of  the  county  and  State  medical  societies,  is 
qualified  to  practice  the  specialty  of  surgery,  and 
last  but  not  least,  is  morally  fit  and  temperate  in 
habits.  And  also  only  those  who  will  agree  espe- 
cially not  to  split  fees  in  any  guise  with  the  re- 
ferring doctor,  and  who  promises  by  signing  the 
application  for  membership  on  the  staff  to  abide 
by  the  rules  and  regulations  of  the  hospital. 

So  far  so  good,  but—.  But  what?  How  many 
surgeon-general  practitioners  who  have  never  had 
any  special  training  are  now  operating  in  your  hos- 
pital? How  many  men  are  there  who  have  been 
known  to  do  numerous  D.  and  C.  operations  with- 
out consultation?  How  many  are  there  who  are 
known  to  have  repeatedly  performed  emergency 
appendectomies  when  the  patients  had  normal 
blood  counts  and  the  pathologist  reported  normal 
appendices?  How  many  are  neglecting  to  write 
their  histories  and  physical  examinations  before 
operating,  stating  their  preoperative  diagnosis  at 
that  time?  How  many  in  one  way  or  another  are 
dividing  the  fees  with  the  referring  doctor  without 
the  knowledge  of  the  patient?  How  many  are  there 
who  will  dare  to  differ  in  the  diagnosis  with  the 
referring  doctor  when  agreeing  with  him  will  mean 
an  operation  and  disagreeing  will  mean  no  opera- 
tion? 

I  am  constrained  before  finishing  this  paper  to 
urge  that  some  drastic  step  be  taken  by  hospital 
authorities  to  deny  the  privilege  of  the  operating 
room  to  those  men  who  disqualify  themselves  by 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


woefully  and  willfully  breaking  the  rules  and  reg- 
ulations for  their  professional  and  moral  conduct, 
for  in  the  final  analysis  there  is  only  one  way.  Be 
straight  or  be  nothing. 


How  Doctors  May  Get  Income  Tax  Reduction 

(Letter  nf  K.  W.   Ney,  N.  T..  in   Bui.  St.   Louis   Med.  Soc, 

Sept.    25th) 

If  a  record  of  the  charitable  work  done  in  each  institu- 
tion were  made,  a  value  set  upon  this  service  and  a  certifi- 
cate given  by  the  institution,  or  the  social  service,  to  the 
effect  that  this  service  had  been  definitely  rendered,  I  see 
no  reason  why  it  should  not  be  attached  to  your  income 
tax  return  and  the  deduction  made,  up  to  15%,  on  the 
basis  that  it  is  a  charitable  contribution,  which  it  actually 
is.  If  this  be  generally  done,  no  doubt  it  will  have  to  be 
recognized  and  interpreted  as  a  legitimate  reduction.  In 
charitable  services  not  rendered  in  hospitals,  a  certificate 
from  the  social  service  bureau  could  be  used  to  this  end. 

After  this  recognition  has  once  been  obtained  and  pub- 
licity given  to  the  e.xtent  of  the  charitable  work  of  physi- 
cians, the  reaction  would  undoubtedly  be  strongly  favor- 
able and  perhaps  further  credits  might  be  obtained. 


UROLOGY 

For  this  issue,  J.  W.  Frazier,  M.D.,  Salisbury,  N.  C. 


On  the  Care  of  the  Prostatic* 
In  several  periods  of  progress  throughout  med- 
ical history  this  subject  has  engaged  the  attention 
of  all  who  come  in  contact  with  the  sick.  In  the 
last  few  years  much  has  been  added  to  the  methods 
of  relief  but  little  to  the  underlying  principles  of 
relief,  which  are  well  established. 

Endoscopic  removal  of  the  obstructing  tissue  is 
a  great  forward  step.  Used  rightly  and  not  over- 
looking the  established  underlying  principles  of  the 
care  of  the  prostatic,  it  is  proving  a  boon  to  those 
unfortunate  enough  to  require  such  help.  Pecu- 
liarly this  procedure  is  almost  wholly  a  personal 
one.  It  can  be  learned  in  only  one  way.  Actual 
performance  is  the  only  teacher.  One  gets  little 
help  from  the  more  experienced  men.  It  seems 
impossible  to  pass  along  the  actual  working  knowl- 
edge. The  amount  and  type  of  gland  is  different 
in  each  case.  The  posterior  urethra  and  bladder 
neck  distortion  is  different.  One  feels  that  possibly 
there  will  never  be  a  so-called  expert  in  all  cases. 
Through  the  trial-and-error  method  some  have  ar- 
rived at  a  greater  percentage  of  satisfactory  results. 
Their  trials  and  errors  were  in  bigger  volume. 

With  this  in  view  it  behooves  all  of  us  doing 
this  type  of  work  to  arrive  at  that  state  of  near 
perfection  with  the  least  wear  and  tear  on  the  pa- 
tients and  ourselves.  This  can  be  done  in  several 
ways.     One  is  the   selection   of   the  patient;    the 


•Abstract   of  a   paper   read   before    the    North   Carolina 
Urological  Society  meeting  at  Sedgefield  in  October. 


Other,  and  perhaps  the  most  important,  is  to  under- 
stand and  use  the  principles  underlying  prostatism, 
the  principles  which,  before  the  advent  of  resection, 
had  brought  the  mortality  of  open  operation  down 
to  a  minimum.  Much  adverse  criticism  and  many 
poor  results  of  resection  have  been  due  to  the  for- 
getting of  these  established  principles  worked  out 
over  a  period  of  years  and  just  as  important  now 
as  then. 

Through  numerous  trials  and  tribulations  the 
urologist  learned  long  ago  that  adequate  drainage, 
subsidence  of  infection  and  recovery  of  kidney  func- 
tion were  necessary  before  any  procedure  for  per- 
manent relief  could  be  undertaken  with  safety. 
They  were  made  to  realize  that  temporary  relief 
from  prostatism  was  afforded  by  adequate  drainage 
over  a  f>eriod  of  time.  If  this  relief  was  not  ob- 
tained, and  the  patient's  general  condition  did  not 
improve,  operation  on  the  prostate  by  any  method 
was  useless.  Often  prolonged  drainage  is  neces- 
sary to  lessen  infection  and  improve  kidney  func- 
tion. This  drainage  can  not  be  accomplished  by 
the  indwelling  catheter  in  the  large  boggy,  badly 
infected  prostates.  Infection  is  enhanced;  epididy- 
mitis complicates. 

The  long-continued  catheter  drainage  distorts 
the  posterior  urethra  and  bladder  neck  in  an  al- 
ready difficult  case.  This  means  a  poor  operative 
risk  with  the  many  complications  following.  These 
are  the  cases  which  give  the  resection  procedure  a 
black  eye.  How  much  better  it  is  to  drain  prop- 
erly. A  suprapubic  drain,  whether  a  small  catheter 
placed  through  a  trocar,  or  a  pezzar  catheter 
through  a  small  incision,  makes  a  marked  differ- 
ence. Infection  is  reduced  to  a  minimum  and  gen- 
eral health  improves  without  the  attendant  difficul- 
ties of  the  indwelling  catheter.  Preparation  time  is 
extended  as  long  as  necessary  and  instead  of  re- 
secting a  large,  boggy,  edematous,  badly  infected 
prostate  of  an  old  individual  in  poor  health,  we 
now  have  a  fairly  firm  gland  with  infection  re- 
duced to  the  minimum,  no  edema  of  the  posterior 
urethra  and  bladder  neck  to  distort  the  parts,  and 
a  patient  in  so  improved  general  condition  as  to 
make  of  him  a  comparatively  good  risk. 

By  application  of  these  principles  many  of  the 
cases  formerly  unsuitable  for  resection  can  be 
brought  into  the  suitable  class,  much  difficulty  in 
the  border-line  ones  can  be  avoided  and  our  per- 
centage of  indicated  resections  increased  from  per- 
haps 75  to  perhaps  90%.  It  behooves  us  to  re- 
member that  these  principles  have  been  worked  out 
over  many  years,  that  pathological  conditions  now 
are  little  different  from  formerly  and  that,  to  do 
the  most  for  our  patients,  these  principles  must 
not  be  forgotten. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Tke  Old  Man  and  His  Prostate 
(G.  R.  Livermore,  Memphis,  in  W.  Va.  Med,  Jl.,  Nov.) 
For  patients  who  refuse  all  operative  interference,  and 
for  those  who  have  had  a  resection  and  still  have  some 
residual  urine  and  frequency,  there  is  a  palliative  method 
which  is  quite  satisfactory.  The  obstruction  may  be  mark- 
edly reduced  and  the  patient  greatly  relieved  by  the  injec- 
titon  of  boiling  water  into  the  prostate,  with  the  prostatic 
needle  through  the  panendoscope  and  by  applying  the  cut- 
ting current,  using  the  blade  electrode  to  the  obstructing 
nodules  in  the  internal  meatus  or  prostatic  urethra.  It 
may  be  done  in  the  office  and  the  patient  is  not  confined 
to  bed  following  the  treatment.  It  is  not  recommended 
except  in  such  cases.  I  began  the  use  of  this  method  - 
years  ago  and  am  much  gratilied  at  the  results  obtained. 


-s.  M.  &  s.- 


INTERNAL  MEDICINE 

Paul  H.   Ringee,  A.B.,  M.D.,  F.A.C.P.,  Editor 
Aiheville,  N.  C. 


Present  Status  of  the  Problem  of  "Rheuma- 
tism" AND  Arthritis 

In  the  Annals  oj  Internal  Medicine  for  January, 
Philip  S.  Hench  (Rochester,  Minn.),  Walter  Bauer 
(Boston),  A.  Almon  Fletcher  (Toronto),  David 
Christ  (Los  Angeles),  Francis  Hall  (Boston),  and 
T.  Preston  White  (Charlotte,  N.  C.)  go  into  all 
phases  of  arthritis  and  review  the  American  and 
English  literature  for  1934.  This  is  a  monumental 
article  which  it  is  difficult  to  abstract  satisfacto- 
rily, but  one  which  brings  the  whole  subject  very 
much  up  to  date. 

The  authors  claim  that  rheumatic  disease  is 
on  the  increase.  In  Massachusetts  of  the  total 
population  over  40,  one  person  in  every  10  had 
rheumatism;  and  in  the  age  group  between  70  and 
80,  one  in  every  4  was  affected. 

Traumatic  arthritis  may  result  from  either  acute 
or  chronic  trauma,  by  the  former  being  meant  from 
injury  from  without,  and  the  latter  incident  to 
abnormal  use  of  joints  because  of  either  occupa- 
tion or  poor  posture.  The  latter  accounts  most 
commonly  for  the  affection  of  the  lumbar  portion 
of  the  spine. 

Gonorrheal  Arthritis:  In  many  cases  spontane- 
ous healing  occurs,  but  the  disease  may  become 
progressive  with  joint  destruction  and  ankylosis. 
There  is  mild  fever  and  variable  leukocytosis.  Most 
cases  are  polyarticular.  Fever  therapy  is  recom- 
mended, raising  the  temperature  to  105  or  106  for 
five  hours,  repeated  at  four-day  intervals  for  from 
two  to  six  doses.  [The  authors  make  no  mention 
of  treatment  by  insufflation  of  air,  highly  recom- 
mended by  W.  B.  Porter,  of  Richmond,  and  oth- 
ers.— Ed.\ 

Tuberculous  Arthritis  is  on  the  decline,  as  one 
would  expect  with   the  decline  of   tuberculosis   in 


general.  The  arthritis  is  always  secondary  to  a 
lesion  elsewhere  in  the  body  and  the  joints  most 
commonly  affected  are  the  spine,  knees,  hips,  el- 
bows, ankles  and  shoulders.  [While  doubtless  there 
is  always  a  tuberculous  focus  elsewhere  in  the 
body,  most  probably  in  the  lungs,  it  does  not 
have  to  be  clinically  active  in  any  sense  for  tuber- 
culous arthritis  to  develop. — Ed.\  The  symptoms 
are  those  of  arthritis  in  general — rubor,  tumor, 
color,  dolor.  Occasionally  roentgenograms  are  very 
typical;  at  other  times  they  are  not  diagnostic. 
.'\rthrodesis  is  the  treatment  of  choice. 

Pneumococcic  Arthritis  is  rare,  occurring,  accord- 
ing to  the  authors,  once  in  every  800  to  1,000  cases, 
and  characterized  by  an  acute  and  generally  puru- 
lent arthritis,  the  knees  being  most  commonly  in- 
volved and  diagnosis  being  based  on  examination 
of  the  fluid  aspirated  from  the  joint. 

Symmetrical  Serous  Synovitis  (also  known  as 
Clutton's  joint)  is  the  most  common  affection  of 
congenital  syphilis.  "It  is  characterized  by  a  rela- 
tively painless,  simple,  serous  or  gummatous,  bilat- 
eral synovitis  lasting  for  months  or  years  without 
bony  changes,  commonly  affecting  both  knees.  It 
is  associated  with  the  secondary  eruption.  The 
process  may  subside  spontaneously  and  is  little 
affected  by  anti-syphilitic  therapy." 

"Haverill  Fever  (erythema  arthriticum  epidemi- 
cum)  has  an  associated  multiple  arthritis  appearing 
with  the  secondary  rise  of  fever  on  the  third  to 
the  fifth  day.  The  joints  become  painful,  swollen 
and  red.  Hydrops  of  the  knee  may  develop  and 
occasionally  Haverhillia  multiformis  is  isolated. 
The  arthritis  lasts  about  four  weeks." 

Rheumatic  Fever:  Its  incidence  depends  much 
on  factors  of  climate  and  environment.  The  dis- 
ease rarely  occurs  in  the  tropics  and  is  very  prev- 
alent in  the  temperate  zones,  especially  during  the 
cold  months  of  the  year.  It  has  a  predilection  for 
cities  and,  like  so  many  physical  evils  of  this  life, 
is  more  prone  to  attack  the  poor.  Heredity  plays 
a  factor,  as  history  of  the  disease  in  the  family 
can  be  elicited  in  a  third  of  the  cases.  In  addition 
to  the  arthritis,  the  onset  may  be  with  tonsillitis 
or  upper-respiratory-tract  infection,  and  cutaneous 
eruptions  and  purpura  may  set  in.  The  onset  in 
adults  is  more  sudden  than  in  children.  The  heart 
is  more  apt  to  be  attacked  in  a  child,  [Dr.  Olchin, 
the  famous  British  clinician  of  three  decades  ago, 
said  that  in  adults  rheumatic  fever  was  a  disease 
of  the  joints  with  heart  symptoms  secondary,  while 
in  children  it  was  a  disease  of  the  heart  with  joint 
symptoms  secondary. — Ed.\  "Aortic  stenosis  is 
more  common  in  females,  aortic  valvulitis  in  males 
and  the  mitral  valve  is  involved  in  83  per  cent. 
*    *    •*    Lesions   in    the   coronary   arteries  are   not 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


uncommon,  and  when  the  heart  is  involved  inter- 
stitial nephritis  may  be  found."  Many  organisms 
have  been  held  responsible  for  the  disease,  but  it 
is  at  present  believed  that  Streptococcus  haemoly- 
ticus  is  the  prime  offender. 

Chronic  Arthritis  is  that  type  which  is  subdivid- 
ed into  atrophic  and  hypertrophic.  "Regardless  of 
etiology,  these  two  are  separate  entities  and  not 
merely  different  manifestations  of  the  same  process 
among  persons  of  different  age  groups."  The  au- 
thors consider  a  multitude  of  causative  factors, 
such  as  infection,  under  which  they  group  bactere- 
mia, toxemia  or  allergy,  metabolic  abnormality, 
circulatory  imbalance  and  endocrine  disturbance. 
In  about  SO  per  cent,  of  the  cases  heredity  is  a 
factor.  Definite  proof  of  the  infective  nature  of 
the  disease  is  as  yet  lacking,  and  the  entire  subject 
of  etiology  and  pathogenesis  is  unsettled.  It  is 
important  to  remove  the  foci  of  infection  and,  this 
having  been  done,  vaccines,  foreign  proteins,  diet 
low  in  carbohydrate  and  calories  but  rich  in  vita- 
mins, physical  therapy  and  hyperthermia  have  been 
the  methods  of  treatment. 

"Recent  roentgen  and  pathologic  evidence  indicates  that 
hypertrophic  arthritis  is  universally  present  among  persons 
over  45  but  is  symptomatically  evident  in  only  about  5  per 
cent,  of  those  affected.  The  most  obvious  causal  agents  are 
tissue  age  and  prolonged  trauma.  Because  of  the  age  inci- 
dence, general  absence  of  infection,  presence  of  tissue  sen- 
iUty  and  degenerative  nature  of  the  process,  it  is  believed 
that  it  results  from  'altered  metabolism'  incident  to  age. 
Therapeutically,  removal  of  any  foci  of  infection,  diet  lovif 
in  carbohydrate,  mecholin  iontophoresis,  physical  and  fever 
therapy  are  the  methods  of  choice." 

"Gouty  arthritis  is  a  chronic  disease  characterized  by 
acute,  recurrent  attacks  with  complete  remissions  and  res- 
titution of  articular  function.  Joints  other  than  the  big 
toe  may  be  involved,  and  the  degree  of  hyperuricemia  does 
not  parallel  the  activity  of  the  gout." 

As  Stated  at  the  beginning  of  this  review,  the 
article  is  so  exhaustive  as  to  make  it  very  difficult 
to  condense.  It  is  an  extremely  satisfactory  con- 
tribution to  read  as  a  general  introduction  to  the 
entire  subject  of  arthritis,  not  only  because  of  the 
wealth  of  material  that  is  to  be  found  in  the  text 
itself,  but  also  because  of  the  comprehensive  bibli- 
ography given  at  the  end. 


was  kept  from  all  company  of  men  and  if,  having  some 
such  disease,  she  were  found  to  be  with  child,  she  with  her 
brood  were  buried  alive." 


A  Discussion  of  Burton's  Anatomy  of  Melancholv 
<Jos.   L.    Miller,  Chicago,  in  Annals  of  Med.   History,  Vol 

8,   No.   1) 

He  discusses  the  hereditary  nature  of  melancholy:  "A 
child  is  as  well  inheritor  of  his  infirmities  as  of  his  lands." 
He  refers  to  the  frequency  with  which  this  heredity  skips 
one  generation,  "and  doth  not  always  produce  the  same, 
but  some  like  and  is  a  symbolizing  disease."  He  quotes 
an  early  writer  who  speaks  of  a  practice  in  Scotland  which 
has  bearing  on  this  point:  "If  any  were  visited  with  the 
falling  sickness,  madness,  gout,  leprosy,  or  any  such  dan- 
gerous disease  which  is  likely  to  be  propagated  from  the 
father   to    the   son,   he   was  instantly   gelded.     A   woman 


THERAPEUTICS 

J.  F.  N.\sii,  M.D.,  Editor,  Saint  Pauls,  N.  C. 


Vaginal  Specula  of  1850 

Dr.  Don  Smith  practiced  medicine  in  this  com- 
munity for  several  decades.  His  word  was  gospel, 
for  he  was  a  man  of  education  and  intelligence,  a 
graduate  of  Princeton  and  the  University  of  Penn- 
sylvania. He  was  a  very  popular  practitioner  and 
for  20  miles  around  he,  his  gray  horse  and  his 
saddlebags  were  known  to  practically  every  house- 
hold. He  was  so  competent  that  many  young  men 
read  medicine  under  him,  but  he  would  present  no 
one  with  any  credentials  until  he  took  a 
final  year  in  a  medical  college.  The  following  pas- 
sages are  copied  from  Churchill  on  Diseases  of 
Wojjicn  of  1852,  which  a  nephew  of  his  used  as  a 
textbook  at  the  University  of  Pennsylvania. 

(Note  the  interest,  ingenuity  and  the  lack  of 
asepsis! ) 

A  few  words  upon  the  mode  of  making  a  vaginal 
examination.  If  the  disease  be  one  involving  the 
position  of  the  pelvic  contents,  .  .  .  that  the  patient 
should  be  in  the  upright  position  ...  is  preferable 
in  almost  all  cases,  as  the  parts  come  better  within 
reach.  The  labia  are  first  to  be  separated,  and 
the  forefinger  (previously  well  oiled)  is  to  be  passed 
from  behind  forward,  until  it  enters  the  vagina.  It 
is  then  to  be  passed  from  before,  backwards  and 
upwards,  until  it  reaches  the  os  uteri. 

This  deficiency  in  our  means  of  diagnosis  {viz., 
the  not  being  able  to  see  the  part  affected)  is  to  a 
great  extent  supplied  by  the  use  of  the  speculum, 
to  which  we  undoubtedly  owe  much  of  the  recent 
extension  of  our  knowledge  of  uterine  and  vaginal 
diseases.  However,  it  requires  greater  exposure, 
and  is  more  offensive  to  feminine  delicacy  than  ex- 
amination by  the  finger.  In  some  cases  it  is  much 
more  painful.  The  information  it  affords  is  also 
more  limited. 

It  enables  us  to  ascertain  accurately  the  length 
and  thickness  of  the  cervix  uteri,  to  detect  the  va- 
riations from  the  natural  color  of  the  mucous  mem- 
brane, slight  erosions  which  might  be  passed  over 
by  the  finger,  elevations  on  the  cervix  uteri  or  walls 
of  the  vagina  too  little  raised  to  impress  the  sense 
of  touch;  and  we  are  enabled  to  discover  the  color 
of  the  surface  of  an  ulcer.  It  will  also  confirm 
many  characters  recognized  by  the  touch.  On  the 
other  hand,  we  must  be  careful  that  we  do  not 
mistake    for    morbid    changes    those    appearances 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


657 


which  are  caused  by  the  instrument  itself.  For 
instance,  pressure  on  the  outer  end  of  the  instru- 
ment may  change  the  elevation  and  position  of  the 
uterus,  and  produce  swelling  and  puffiness  of  the 
cervix. 

There  can  be  no  doubt  of  the  great  value  of  the 
speculum,  both  for  the  detection  of  disease  and 
the  application  of  remedies;  but  I  fear  that  its 
employment  has  been  too  indiscriminate,  and  that 
injury,  beyond  the  violation  of  delicacy,  has  not 
unfrequently  been  occasioned  by  it.  It  should  never 
be  used  if  it  be  possible  to  avoid  it,  in  virgins,  or 
when  there  is  any  alteration  of  tissue,  involving  its 
greater  liability  to  laceration,  and  as  rarely  as  pos- 
sible with  nervous  women. 

Several  species  of  speculum  have  been  invented. 

I  believe  Mr.  Fenner  was  the  first  to  propose  a 
cylinder  of  equal  diameter,  with  an  additional  im- 
provement. He  observes:  "For  the  purpose  of 
using  a  tube  of  the  requisite  size  with  the  facility 
and  without  pain,  I  attach  an  air-cushion  in  such 
a  manner  that  its  soft  elastic  projection  might  pre- 
viously produce  dilation  and  by  overlapping  might 
protect  the  parts  from  the  pressure  of  the  edges  of 
the  tube.  Small  bladders,  or  the  crops  oj  poultry, 
partly  distended  with  air,  and  disguised  by  being 
stained  with  orchel,  answer  the  purpose  of  the 
cushions,  and  can  readily  be  procured.  The  cush- 
ion is  formed  by  the  twisting  of  the  depending  por- 
tion of  the  bladder,  so  as  to  force  the  air  into  its 
superior  part,  and  then  tying  it  with  a  silken  cord 
in  a  slip  not,  leaving  the  end  long  enough  to  ex- 
tend below  the  bottom  of  the  tube.  When  fairly 
introduced  the  air  is  to  be  evacuated  by  pulling 
the  cord,  and  the  cushion  may  then  be  removed." 

Some  time  ago,  I  caused  a  speculum  to  be  made 
of  metal,  but  instead  of  an  air-cushion,  I  had  the 
top  of  the  inner  end  turned  over,  so  as  to  avoid 
the  contact  of  an  edge  with  the  orifice  of  the  va- 
gina and  I  found  it  to  answer  very  well. 

Dr.  Ferguson  has  greatly  improved  the  cylindri- 
cal glass  speculum,  by  covering  it  externally  with 
a  brilliant  metallic  coating  and  this  again  with  a 
thin  layer  of  India  rubber.  The  reflecting  power 
internally  is  much  increased,  and  the  instrument  is 
much  strengthened,  so  that  there  is  but  little  dan- 
ger of  its  breaking,  which  has  happened  with  the 
plain  glass  speculum. 

Dr.  Protheroe  Smith  has  invented  a  speculum, 
by  which  a  visual  and  digital  examination  can  be 
made  at  the  same  time.  It  consists  of  two  cylin- 
ders, the  outer  of  metal  and  the  inner  of  glass  and 
in  the  former  of  these  there  is  a  fenestrum.  When 
the  instrument  is  introduced,  the  inner  speculum  is 
partially  withdrawn,  and  the  finger  passed  into  the 
vagina  posteriorly,  and  through  the  fenestrum  can 


reach  the  cervix  uteri. 

The  Palin  cylindrical  specula  are  the  best  when 
the  OS  uteri  is  to  be  scarified,  as  the  blood  escapes 
through  them  at  once. 

In  order  to  facilitate  the  application  of  leeches 
an  obturator  is  used,  fitting  tight  like  a  piston,  but 
pierced  so  as  to  allow  the  escape  of  air.  With  such 
an  instrument,  it  is  easy  to  push  up  the  leeches  to 
the  OS  uteri,  and  by  leaving  it  in  the  cylinder,  to 
prevent  their  escape. 

The  bivalve  speculum  of  M.  Jobert  of  Paris  con- 
sists of  two  half  cylinders,  joined  together  by  a 
hinge  on  one  side,  about  one-third  distant  from  the 
inner  end  of  the  instrument.  When  introduced  as 
the  hinge  passes  into  the  vagina,  the  pressure  of  the 
orifice  above  the  hinge  expands  the  inner  extrem- 
ity. 

Madame  Boivin's  speculum  consists  of  two  half 
cylinders  joined  at  their  outer  extremities  to  trans- 
verse limbs  of  brass,  the  one  hollow  and  the  other 
solid.  The  solid  part  passes  into  the  hollow  limb 
and  is  moved  backwards  and  forwards  (thus  open- 
ing or  closing  the  blades  of  the  speculum)  by  a 
small  wheel  with  teeth,  turned  by  a  key. 

Mr.  Coxeter's  bivalve  speculum  is  a  very  useful 
one;  the  two  blades  are  separated  by  a  screw  at 
the  outer  end,  by  which  the  expansion  required 
can  be  regulated  and  maintained. 

I  procured  some  time  ago  a  three-bladed  specu- 
lum; but  who  invented  it  I  do  not  know;  the  third 
blade  folds  over  the  others  when  the  instrument  is 
closed,  but  when  the  bivalves  are  expanded,  the 
third  blade  covers  the  space  between  them,  and 
forms  a  complete  cylinder. 


PyRETHRirM  FOE  SCABIES 
(S.   E.  Sweitzer,  Minneapolis,  in  Jl.-Lan.,  Sept.) 

The  principal  points  in  diagnosis  are  the  location  of  the 
eruption,  the  finding  of  the  burrow,  and  the  symptoms  of 
itching  on  going  to  bed.  Scabies  is  essentially  a  front- 
sided  disease  and  the  anterior  surface  of  the  body  and  the 
buttocks,  the  wrists,  web  of  the  fingers  and  axillary  spaces 
are  the  common  sites.  In  cleanly  patients  the  burrow  is 
often  very  hard  to  find  and  in  some  obscure  cases  a  diag- 
nosis may  be  made  tentatively  from  the  history  of  other 
cases  in  the  family  or  itching  at  night. 

Our  treatment  of  scabies  for  many  years  has  been  Wilk- 
inson's ointment.  In  nearly  every  case  it  was  necessary  to 
give  treatment  for  a  post-scabetic  dermatitis.  Wilkinson's 
ointment  is  also  dirty  and  smelly,  so  we  were  glad  to  try 
Pyrethrum  when  it  was  offered;  100  gm.  of  the  ointment 
used  represents  83  gm.  of  pyrethrum  flowers. 

We  believe  that  an  ointment  of  this  strength  need  not 
have  exfoliative  qualities  for  it  apparently  readily  pene- 
trates the  burrows  and  kills  the  eggs  without  the  dangers 
of  exfoliation. 

Scabctic  patients  are  handed  a  printed  slip  with  these 
directions: 

First  night  a  warm  soapy  bath  for  at  least  20  minutes, 
scrubbing  vigorously,  preferably  with  a  brush.     Dry  with 


658 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


rough  towel  and  apply  the  ointment  to  the  entire  body 
from  the  neck  to  the  feet.  Use  the  ointment  every  night 
for  from  5  to  7  days,  then  take  the  2nd  bath  and  report 
to  clinic.  Change  clothing  and  bed  clothes  at  beginning 
and  end  of  treatment. 

We  treated  1,213  cases  in  all;  878  required  from  5  to  7 
days,  and  283  took  from  7  to  14  days  to  complete  the 
treatment.  It  was  necessary  to  go  over  to  the  use  of 
Wilkinson's  ointment  in  52  cases — either  on  account  of 
pustular  involvement  or  poor  co-operation. 

Only  5  cases  were  found  sensitive  to  the  Pyrethrum  oint- 
ment. 

s.  M.  &  B. 

PEDIATRICS 

G.  W.  KuTSCHEB,  M.D.,  F.A.A.P.,  Editor,  AsheviUe,  N.  C. 


Pediatric  Ramble 

It  would  be  impossible  in  the  space  allotted  this 
column  to  give  proper  credit  for  the  sources  of  the 
following  impressions  gained  during  a  recent  tour 
of  the  hospitals  of  the  North  and  East,  concluding 
with  the  Southern  Medical  Association  meeting  at 
Baltimore.  An  air  conditioned  room  kept  at  85 
degrees  F.  temperature  and  a  humidity  of  65,  for 
premature  infants,  was  observed.  With  this  equip- 
ment it  would  seem  that  all  premature  babies  should 
live.  Oxygen,  carbon  dioxide  and  oxygen,  and  alpha 
lobelin  and  coramin  were  used  as  stimulants  when 
indicated. 

Cases  of  infantile  paralysis  and  cases  of  menin- 
gococcic  meningitis  were  admitted  to  the  general 
wards  without  fear  of  cross  infection.  The  beds  in 
these  wards  were  separated  by  glass  partitions  and 
the  nurses  were  trained  to  prevent  cross  infections. 
Records  fail  to  show  a  failure  in  carrying  out  such 
technique.  Meningococcus  antitoxin  has  not  re- 
placed the  old  standard  anti-meningococcus  serum 
in  the  hospitals  visited. 

One  institution  conducting  research  studies  on 
nephritis  believed  that  there  are  only  three  kinds 
of  nephritis:  acute,  and  chronic  glomerulonephritis, 
and  nephrosis.  There  is  not  therapy  that  even 
approaches  a  specific  for  any  of  these  conditions. 
Not  only  during  the  course  of,  but  again  in  two 
weeks  following,  each  and  every  attack  of  tonsillitis, 
a  careful  urinalysis  should  be  done.  Only  in  such 
a  way  can  the  increasing  high  mortality  rate  in 
nephritis  be  reduced  by  recognizing  the  disease  in 
its  earliest  stages.  Cases  of  nephrosis  are  still 
shown  as  exhibits  everywhere  they  are  treated.  The 
removal  of  all  possible  foci  of  infection  was  the 
best  known  treatment  for  both  acute  nephritis  and 
nephrosis.  Certainly  drugs  have  no  influence  on 
these  diseases. 

Sonne  type  of  dysentery  was  frequently  encoun- 
tered this  past  summer.  Urinary  and  stool  cultures 
must  be  negative  before  discharge,  as  the  disease  is 


known  to  be  spread  by  carriers. 

Acrodynia,  common  in  the  South,  was  displayed 
as  a  curiosity  in  the  North.  Hemophilia  was  treat- 
ed everywhere  by  transfusions.  Snake  venom  and 
ovarian  extract  have  fallen  into  disrepute  due  to 
their  failure  to  produce  results.  Placental  extract, 
by  mouth,  is  being  tried  but  no  one  seemed  pre- 
pared to  announce  their  results  with  enthusiasm  as 
yet.  Hyperthyroidism  in  adolescent  children  was 
being  treated  almost  entirely  by  complete  bed  rest. 
Iodine  was  used  in  the  rare  case,  but  surgery  was 
looked  upon  as  contraindicated. 

Everyone  seemed  most  enthusiastic  over  their 
successes  in  the  use  of  amniotin  suppositories  for 
gonorrheal  vaginitis.  Only  the  suppository  use  of 
the  drug  gives  best  results.  One  institution  was 
enthusiastic  over  the  results  obtained  by  lactos; 
suppositories  per  vaginam.  In  one  place  amniotin 
suppositories  produced  cures  in  one  hundred  per 
cent,  of  cases  within  twenty-seven  days.  Chorea 
was  being  successfully  handled  by  typhoid-para 
typhoid  intravenous  injections  and  without  unto- 
ward reactions.  Extensive  studies  on  the  use  of 
specific  sera  for  pneumococcic  pneumonia  were  un- 
der way.  Although  statistics  are  not  available, 
those  in  charge  of  the  studies  were  very  enthusias- 
tic over  their  results.  A  study  as  to  the  possibilities 
of  immunizing  children  against  pneumococcus  pneu- 
monia showed  much  progress. 

The  surgical  treatment  of  bronchiectasis  was 
strongly  emphasized  in  most  of  the  larger  hospitals. 
The  improvements  in  the  mortality  rate  from  sur- 
gical intervention  was  attributed  to  earlier  opera- 
tion. Heretofore,  the  operation  was  carried  out  as 
a  last  resort.  Apparently  surgery  has  made  little 
advance  in  the  treatment  of  hydrocephalus  in  the 
past  few  years.  Less  surgery  and  more  careful 
study  for  acute  mastoiditis  was  the  principle  gener- 
ally followed  wherever  the  subject  was  being 
studied.  Early  operation  seemed  to  have  more 
complications  attended  with  it  than  delayed  opera- 
tion. 

The  origin  of  blood  platelets  in  the  lungs  is  an 
interesting  discovery  made  by  Dr.  Howell  of  Bal- 
timore, now  over  seventy  years  of  age.  An  alarm- 
ing increase  in  the  number  of  suipestifer  blood 
stream  infections  was  reported  in  Baltimore. 

And  finally,  the  psychiatrist  has  just  as  much 
trouble  handling  the  spoiled  child  as  does  any  other 
physician. 

S.  M.  &  s. 

.\  Critical  Evaluation  of  Recent  Advances  in 

CoNT.iGious  Diseases 

(J.  A.  Toomey,  Cleveland,  in  Jl.  Indiana  State  Med.  Assn., 

Nov. ) 

Susceptibility  to  scarlet  fever  is  determined  by  the  Dick 
te?t ;  injecting  intradermally  in  the  forearm  a  small  amount 
of  scarlet  fever  streptococcus  toxin.     In  24  hours  a  suscep- 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


6S9 


tible  individual  will  have  a  local  inflammaton'  reaction, 
0.5  cm.  or  so  at  the  site  of  the  injection.  Occasionally 
delayed  reaction?  48  hours  .-V  person  with  a  negative  Dick 
test  may  again  become  susceptible  just  as  a  patient  who 
has  had  scarlet  fever  may  again  contract  the  disease.  One 
susceptible  to  scarlet  fever  may  be  protected  by  injecting 
weekly  for  5  weeks  increasing  numbers  of  skin-test  units 
of  the  toxin  that  causes  the  disease.  .\  Dick  test  should 
be  repeated  a  month  or  so  after  the  last  injection.  Occa- 
sionally a  few  more  injections  of  the  last  dose  are  needed. 
On  the  other  hand,  if  a  Dick  test  is  done  after  the  4th  dose 
it  often  will  be  found  negative  and  the  5th  dose  can  be 
dispensed  with  The  immunity  obtained  is  said  to  last  from 
3  to  7  years. 

It  is  believed  that  this  method  should  be  utilized  for 
individuals  caring  for  patients  ill  with  scarlet  fever,  for 
children  in  orphanages,  preventoriums,  nursery  schools. 
One  hesitates  at  the  present  time  to  urge  this  procedure  as 
a  general  public  health  measure.  Reactions  are  sometimes 
very  severe. 

Of  7,000  cases  of  scarlet  fever  that  we  have  cared  for  75 
have  died.  Over  90%  had  nasal  passages  plugged  with 
secretion,  secondar.-  sinusitis,  and  often  ear  and  lymph 
gland  infections.  Many  physician  seem  to  think  that  giving 
antitoxin  is  all  that  is  necessary.  They  forget  that  sepsis 
secondars'  to  localized  infection  in  the  nose  may  come  on 
at  a  time  even  when  there  has  been  plenty  of  antitoxin 
present  in  the  blood  stream.  //  /  had  to  choose  between 
antitoxin  and  other  therapies,  I  would  content  myself  with 
keeping  the  nasal  passages  free  by  suction  and  gentle  swab- 
bing. However,  in  patients  who  are  desperately  ill,  I 
would  not  withhold  its  use.  On  the  other  hand,  /  have 
a  great  deal  of  faith  in  convalescent  serum,  and  give  from 
50  c.c.  to  100  c.c.  intramuscidarly . 

What  about  the  individual  who  is  exposed  to  the  dis- 
ease? Why  follow  a  procedure  that  may  produce  serum 
sickness  and  make  the  injected  individual  sicker  than  the 
person  ill  with  scarlet  fever  to  whom  he  has  been  exposed? 

To  prevent  diphtheria  adults  are  supposed  to  be  given 
toxin-antitoxin  because  they  react  to  toxoid;  and  children, 
toxoid  or  precipitated  toxoid  because  they  have  few  or  no 
reactions  to  this  material  and  because  they  are  not  sensi- 
tized to  horse  serum  as  they  would  be  if  toxin  antitoxin 
were  used. 

I  think  it  best  to  learn  how  to  use  and  to  know  the 
advantages  and  disadvantages  of  one  type  of  prophylaxis 
for  all  groups  There  may  be  reactions,  but  you  can  avoid 
most  of  them  by  increasing  the  number  of  doses  and  de- 
creasing the  amount  injected  at  any  one  time.  With  alum- 
precipitated  toxoid,  I  did  not  find  that  one  dose  immunized 
our  susceptible  nurses,  nor  did  I  find  injections  were  un- 
accompanied by  reactions.  At  the  present  time  I  am  using 
toxoid  exclusively.  Toxoid  material  is  clear.  The  physi- 
cian can  tell  at  a  glance  whether  he  should  or  should  not 
use  the  material. 

All  adults  should  be  tested  before  immunization  and 
both  children  and  adults  should  be  Schick  tested  some 
months  after  immunization  in  order  to  determine  whether 
immunity  has  been  established.  If  the  test  is  still  positive 
after  6  months,  another  course  of  injections  should  be 
started.     Active  immunity  lasts  a  long  time. 

Measles  may  be  prevented  by  the  use  of  convalescent 
measles  serum ;  but  one  should  not  wish  to  prevent  measles, 
but  to  attenuate  its  severity  so  that  the  patient  will  get  a 
modified  attack  of  the  disease  and.  possibly,  permanent 
immunity.  Five  or  6  c.c.  of  convalescent  measles  serum 
injected  6  or  7  days  after  initial  exposure  usually  modifies 
the  attack. 


From  20  to  30  c.c.  of  convalescent  mumps  serum  injected 
intramuscularly  may  be  used  to  prevent  mumps  or  to  mod- 
ify the  complications. 

Erysipelas  vaccine  is  given  to  patients  who  have  been 
ill  with  erysipelas  since  these  are  the  individuals  that  are 
apt  to  have  recurrences.  I  do  not  use  the  vaccine,  since  I 
do  not  believe  that  it  has  been  proved  that  erysipelas  is  a 
toxic  disease  in  the  same  sense  that  scarlet  fever  is.  / 
believe  that  it  is  a  form  of  allergy.  Most  individuals  who 
contract  erysipelas  have  plenty  of  antitoxin  in  their  blood 
serum  at  the  very  time  they  contract  the  disease. 

I  don't  think  you  can  promise  that  the  patient  will  not 
get  whooping  cough  if  you  employ  either  of  these  antigens. 
We  have  seen  patients  who  developed  whooping  cough 
within  6  months  after  a  full  course  of  injections.  After 
a  otudy  of  1,500  proven  cases  in  our  wards  and  elsewhere,  I 
would  hesitate  to  accept  any  comments  on  modifications 
since  the  disease  itself  is  so  variable.  Giving  from  10  to 
20  c.c.  of  convalescent  whooping  cough  serum  seems  to  do 
some  good.  We  have  never  seen  the  slightest  benefit  ob- 
tained from  the  use  of  commercial  vaccines  after  the  patient 
has  contracted  the  disease. 

In  meningitis  recently  I  have  had  excellent  results  with 
the  antitoxin  made  by  Parke,  Davis  &  Company.  Many 
of  our  cases  have  been  treated  intravenously  and  intramus- 
cularly with  complete  cure.  It  is  not  good  practice  to 
give  meningitis  antitoxin  or  antiserum  to  exposures,  since 
the  number  of  exposures  who  contract  the  disease  are  few. 

Encephalitis:  There  is  no  known  method  by  which  sus- 
ceptibles  can  be  recognized.  Since  the  morbidity  rate  and 
the  contagious  index  are  low,  it  is  not  practicable  to  inject 
those  exposed. 

Tetanus:  You  can  now  immunize  against  tetanus  by  the 
use  of  tetanus  toxoid  given  the  same  way  as  diphtheria 
toxoid. 

Poliomyelitis:  No  vaccine  should  ever  be  used  which  is 
not  safe,  and  my  opinion  is  that  the  latter  (Kolmer's)  at 
least  is  unsafe.  The  consensus  is  that  convalescent  serum 
should  be  used,  but  in  larger  amounts  than  heretofore — 
from  SO  to  100  c.c.  intramuscularly.  Alum  or  tannic  prep- 
arations are  now  being  injected  into  the  noses  of  those  ex- 
posed. Believing  as  I  do  that  the  virus  enters  by  way  of 
the  gastrointestinal  tract,  I  do  not  see  how  intranasal  sprays 
will  prevent  the  occurrence  of  this  disease  in  human  beings. 

Smallpox:  No  evidence  presented  thus  far  indicates  that 
any  vaccine  is  better  than  the  calf  vaccine.  One  need  not 
worry  about  the  postvaccinal  encephalitis;  it  may  be  avoid- 
ed if  vaccination  is  carried  out  during  infancy. 

Typhoid  fever:  A  recent  advance  is  that  paratyphoid  A 
and  B  organisms,  considered  by  many  as  the  material  in 
the  triple  vaccine  which  causes  the  reactions  seen  after  its 
use,  have  been  left  out  and  many  are  now  using  only  the 
straight  typhoid  vaccine  and  giving  an  injection  each  year 
at  the  end  of  spring. 

Rabies:  Vaccination  may  not  always  protect  and  post- 
rabies  paralysis  may  occur  as  a  result  of  the  treatment, 
but  such  cases  are  so  few  we  should  not  hesitate  to  use  this 
material  when  needed. 

Acne  and  boils:  Staphylococcus  is  now  used  to  immunize 
individuals  who  have  acne  or  boils  caused  by  that  organ- 
ism. A  staphylococcus  antitoxin  is  now  in  the  market  for 
the  treatment  of  individuals  having  staphylococcus  septice- 
mia, but  its  value  has  not  been  established. 

Chickenpox:  The  best  procedure  to  follow  is:  after  the 
original  patient  has  remained  in  bed  for  a  day  or  so,  let 
him  out  and  expose  all  of  his  brothers  and  sisters  so  that 
they  will  contract  the  disease  also.    This  is  what  happens 


660 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


anyway  in  practice,  and  I  don't  see  why  we  shouldn't 
admit  that  quarantine  for  this  disease  is  a  waste  of  time, 
effort  and  money. 

B.  M.  b  6. 

CLINICAL  PSYCHIATRY 

Claude  A.  Boseman,  M.D.,  Editor,  Pinebluff,  N.  C. 


The  Depressions 

To  a  general  practitioner  of  medicine  visiting  a 
hospital  for  the  mentally  diseased  for  the  first  time, 
the  bizarre  character  of  the  behavior  and  menta- 
tion of  some  of  the  patients  is  so  striking  that  he 
would  generally  fail  to  note  the  normal  behavior 
and  conversation  of  many  others.  We  are  struck 
by  th-e  bizarre  rather  than  the  usual.  And  yet  one 
of  the  most  interesting  types  and  most  promising 
as  to  therapy  is  that  type  which  we  call  a  depres- 
sion. 

All  of  us,  doctors  and  laymen,  are  acquainted 
with  depression.  We  have  experienced  depression 
in  ourselves,  in  our  relatives  and  in  our  friends. 
We  all  have  fjeriods  of  the  blues,  lasting  a  few 
hours  or  a  few  days,  or  maybe  longer,  and  consider 
this  a  normal  state  of  being.  When  these  periods 
are  more  extensive  or  more  intense,  they  become 
pathological,  and  it  is  necessary  that  the  patient 
seek  medical  aid.  Hence,  the  depressions  as  diag- 
nosed clinically  in  psychiatry  differ  not  in  kind,  but 
in  degree  from  that  which  we  all  consider  normal. 
The  depressions,  therefore,  offer  an  excellent  ap- 
proach to  clinical  psychiatry  because  there  is  noth- 
ing bizarre  or  mysterious  about  them,  and  a  com- 
mcn-sense  and  practical  approach  suggests  itself. 

Pathological  depressions  may  be  of  the  simple 
type,  or  there  may  be  a  depression  with  somewhat 
more  disturbed  mental  activity,  or  a  depression  with 
agitation  occurring  in  the  involutional  period,  or  de- 
pression alternating  with  elation. 

Probably  the  most  understandable  typ>e  of  all 
nervous  disorders  is  a  depression  of  the  simple  type. 
I  present  a  case  history  of  this  1)^56: 

A  man,  aged  33,  came  to  the  hospital  the  31st 
of  last  May  complaining  chiefly  of  being  "nervous, 
scared  to  death  about  myself,  despondent." 

In  September  of  the  preceding  year  he  devel- 
oped prostatitis,  and  was  kept  in  bed  for  two  weeks. 
During  that  time  he  was  scared  about  his  physical 
condition,  nervous,  worried  and  blue.  On  two  oc- 
casions he  cried  when  he  saw  his  family.  Later, 
he  was  advised  that  he  suffered  from  deficiency  of 
thyroid  extract  and  was  given  this  extract  over  a 
period  of  three  months  with  no  improvement  that 
he  could  detect.  He  remained  at  his  mother's  home 
during  this  period.  His  mother's  home  was  in  a 
neighboring  town  to  his  own  home.  During  this 
time  he  said  that  he  could  not  be  satisfied  for  15 


minutes.  He  was  unable  to  eat  or  sleep,  or  occupy 
himself.  At  this  time  he  was  examined  at  an  ex- 
cellent hospital  clinic  where  he  was  advised  that 
he  was  not  suffering  from  a  physical,  but  from  a 
nervous  disorder.  His  basal  metabolic  rate  was 
within  normal  limits.  He  was  advised  to  take  a 
rest  either  in  a  mental  hospital,  or  on  a  trip.  He 
elected  a  trip  to  Florida  with  his  wife  and  sister. 
Here  he  discarded  all  medication  and  improved  so 
much  that  he  returned  home  in  three  weeks.  He 
immediately,  however,  developed  his  old  symptoms, 
was  unable  to  work,  unable  to  concentrate  on  any- 
thini,  and  had  frequent  crying  spells.  He  returned 
to  Florida  with  his  wife  and  a  sister-in-law.  This 
time  he  did  not  become  better,  consulted  a  chiro- 
practor with  no  results,  and  after  three  weeks  be- 
came worse,  experienced  a  panic  of  fright,  fearing 
that  he  might  injure  his  wife  and  decided  to  enter  a 
hospital. 

The  family  history  was  negative  for  gross  mental 
or  nervous  disease.  The  mother  and  sister  were 
said  to  be  nervous.  The  father  and  two  brothers 
were  successful  business  men  and  took  prominent 
parts  in  the  economic  and  civic  life  of  their  city. 

The  patient  was  the  third  in  a  fraternity  of  five. 
His  childhood  had  been  uneventful  as  far  as  re- 
called. The  patient  had  always  been  a  lover  of 
his  home  and  very  devoted  to  all  the  family,  espe- 
cially the  elder  brother  on  whom  he  still  leaned. 

He  had  measles,  mumps,  whooping  cough  in 
childhood.  He  had  had  a  fracture  of  the  leg  and 
two  of  the  arm  in  his  teens;  appendectomy  at  24; 
influenza  at  26;  nervous  indigestion  lasting  three 
weeks  at  29.  The  patient  was  always  fearing  some 
severe  illness  and  frequently  consulted  doctors. 

He  is  a  high-school  graduate  and  attended  college 
for  three  years.  He  had  always  been  an  average 
student,  and  took  some  part  in  extra-curricular  ac- 
tivities. (The  patient  was  really  much  above  the 
average  mentally.) 

After  leaving  school  he  had  engaged  in  business 
with  his  brother,  and  prior  to  his  illness  was  man- 
ager of  a  local  branch  of  the  organization.  Here, 
he  had  proven  to  be  a  successful  and  competent 
manager  in  every  respect. 

He  had  married  at  26  a  woman  five  years  his 
senior,  who  had  been  married  and  divorced.  She 
had  always  worked  and  was  employed  in  her  hus- 
band's office.  There  were  no  children,  though  no 
contraceptives  had  been  used. 

He  looked  his  age,  was  of  excellent  physique 
and  would  have  been  conspicuous  in  any  crowd  for 
his  splendid  physical  condition.  No  abnormalities 
of  any  sort  were  found. 

Mental  examination  revealed  rather  marked  de- 
pression, somewhat  retarded  muscular  activity,  and 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


a  slow,  listless  manner  of  talking.  His  appetite 
was  poor  and  he  was  unable  to  sleep  without  the 
aid  of  sedatives. 

He  was  given  a  schedule  of  activity  which  he 
followed  closely  during  his  stay  in  the  hospital. 
The  major  part  of  his  treatment  consisted  of 
psychotherapy  for  one  hour  a  day  during  the  period 
of  his  hospital  residence.  This  lasted  five  months. 
The  patient  was  asked  to  lie  down  on  a  couch,  relax 
as  much  as  possible,  and  to  talk  about  the  things 
that  were  in  his  mind.  Here,  as  in  all  psycho- 
therapy, the  treatment  consisted  not  in  the  physi- 
cian pouring  ideas  into  the  patient,  but  the  patient 
letting  out  ideas  to  the  physician.  The  patient 
talked  freely  and  frankly,  and  the  physician  gener- 
ally listened.  In  a  brief  space  it  is  impossible  to 
give  all  the  material  that  the  patient  presented 
during  five  months.  Only  a  few  salient  ideas  can 
be  given. 

During  the  first  few  weeks  he  constantly  asked 
for  and  received  reassurance  that  his  difficulty  was 
nervous  and  not  physical  and  that  he  would  re- 
cover. He  felt  that  possibly  the  diagnosis  was 
wrong.  As  he  came  to  feel  more  confidence  in  the 
physician,  he  gradually  accepted  the  diagnosis. 

From  the  beginning  it  was  apparent  that  he  felt 
a  distressing  sense  of  guilt,  and  that  he  punished 
himself  by  suffering.  This  was  his  expiation.  He 
expressed  early  his  feelings  that  masturbation  was 
really  the  cause  of  the  trouble,  that  had  caused  the 
prostatitis,  and  prostatitis  was  the  beginning  of  the 
trouble.  Masturbation  had  not  only  caused  phy- 
sical damage,  but  had  wrought  psycho-sexual  havoc 
as  well.  He  felt  that  he  was  impotent  and  that  all 
manly  vigor  had  left  him  forever.  He  had  experi- 
enced premature  ejaculations  and  at  times  impo- 
tence in  the  past,  and  he  felt  that  he  would  never 
be  able  to  engage  in  intercourse  again.  He  was 
reassured  that  masturbation  was  rather  the  usual 
and  not  the  unusual  thing,  and  that  these  calami- 
ties did  not  follow. 

He  then  expressed  feelings  of  guilt  about  his 
character  traits,  that  he  was  a  coward,  yellow,  a 
weakling,  and  that  his  sickness  was  really  not  a 
sickness,  but  a  weakness.  If  he  were  really  a  man 
he  would  go  home,  make  a  living  for  himself  and 
his  wife,  and  live  normally.  He  was  asked  if  he 
would  feel  guilty  if  he  had  had  pneumonia  and 
assured  that  his  nervous  condition  was  no  more  his 
fault  than  pneumonia  would  be. 

Early  in  the  patient's  treatment  his  extreme  de- 
votion to  his  wife  was  emphasized  and  seemed  to 
be  an  overdetermined  affect.  He  said  that  he  did 
n  ;t  want  to  get  well  if  he  would  not  feel  toward 
his  wife  as  he  always  had.  He  definitely  felt  that 
she  was  superior.     She  was  older,  was  more  ex- 


perienced, and  was  a  better  business  man  than  he. 
.Any  resentment  that  he  might  have  felt  he  had 
stifled  completely.  He  felt  that  he  must  be  com- 
pletely a  part  of  her  if  he  were  to  receive  any  love 
from  her  whatsoever.  He  felt  that  he  must  love 
her  in  every  aspect,  and  resent  nothing,  or  he  would 
lose  her  entirely.  He  felt  that  she  thought  him  a 
weakling  and  this,  for  one  thing,  he  did  resent,  but 
he  could  not  feel  this  resentment,  certainly  not  ex- 
press it.  He  must  either  love  completely  or  hate 
completely.  He  could  do  neither.  Gradually,  he 
came  to  feel  that  emotions  are  ambivalent,  and  that 
he  might  be  irritated  a  little  and  still  love  his  wife. 

This  failure  of  the  aggressive  mstinct  in  the 
patient  was  apparently  the  chief  symptom.  He 
could  take  it  out  only  on  himself.  His  impotence, 
feelings  of  inferiority,  suppression  of  hostility  and 
need  for  reassurance  were  all  expressions  of  this. 
As  he  gradually  became  able  to  express  his  irrita- 
tion, and  later  anger,  with  the  physician,  he  became 
more  tolerant  of  these  emotions. 

He  finally  began  to  feel  that  he  was  better  in 
the  hospital,  and  then  spent  the  last  month  talking 
about  the  difficulties  he  feared  when  he  arrived  at 
home.  These  he  was  somewhat  able  to  experience 
in  anticipation  and  to  overcome.  His  dependence 
on  the  physician  was  more  difficult  to  overcome. 
He  did  this  partly  by  several  visits  home  before 
he  was  finally  discharged,  and  by  several  visits  to 
the  hospital  afterwards. 

No  effort  was  made  in  this  case  to  delve  into 
deeply  repressed  childhood  memories,  because  of 
the  time  involved.  The  patient  dealt  only  with 
present  material  and  his  underlying  emotional  re- 
actions. The  physician's  contribution  was  mainly 
why  or  wherefore.  In  a  sense  the  patient  adminis- 
tered psychotherapy  to  himself  with  the  physician 
as  an  audience. 

He  was  discharged  October  30th,  condition  im- 
proved, and  at  the  present  time  is  able  to  carry  on 
his  business  activities. 


-s.  M.  &  s.- 


PsYCHOAffALYSis  is  a  diagnostic  and  psychotherapeutic 
measure  employed  in  a  very  limited  number  of  mild  mental 
disorders.  It  bears  about  the  same  relation  to  Ps\chi,itry  as 
does  the  x-ray  to  the  general  practice  of  medicine.  When 
used  by  qualified  physicians,  both  psychoanalysis  and  the 
x-ray  are  valuable  although  limited  adjuncts  to  the  practice 
of  medicine.  When  placed  in  non-professional  hands  both 
psychoanalysis  and  the  x-ray  are  equally  menacing.  Every 
qualified  psychiatrist  has  a  knowledge  of  psychoanalysis, 
and  employs  it  in  those  cases  wherein  its  use  is  indicated, 
but  he  also  recognizes  its  limitations.  Psychoanalysis  is 
a  specialty  of  neither  medicine  nor  psychiatry,  it  is  a  diag- 
nostic and  psychotherapeutic  measure  whose  greatest  value 
seems  to  be  in  the  unmasking  of  a  limited  number  of  sexual 
perversions. — Exchange. 

8.  M.  &  s. 

Agranulocytose;. — A  fatal  case  is  reported  caused,  ap- 
parently, by  one  10-gr.  dose  of  pyramidon. 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


SURGERY 

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


Regional  Differences  in  the  Mortality  Rate 
OF  Appendicitis  in  the  United  States 

In  the  American  Journal  of  Surgery  for  October, 
1933,  Dauer  and  Lilly  of  Tulane  reported  a  statis- 
tical study  of  the  mortality  rates  from  appendicitis 
in  the  various  geographical  areas  of  the  United 
States.  These  finds  are  of  special  interest  to  mem- 
bers of  the  Tri-State  Medical  Association,  for  Vir- 
ginia and  the  Carolinas  have  the  lowest  rates  in 
the  entire  nation.  The  study  was  based  upon  fig- 
ures obtained  from  the  mortality  statistics  reports 
of  the  United  States  Bureau  of  the  Census  of  the 
1920  and  1930  enumerations  and  was  confined  to 
the  years  1922  to  1929  inclusive.  Only  data  of 
the  36  States  which  were  continuously  in  the  death 
registration  area  for  these  years  could  be  used. 

An  interesting  fact  is  that  the  mortality  rate  for 
the  Rocky  Mountain  States  is  highest  and  for  th? 
South  Atlantic  States  is  lowest  in  the  study,  the 
former  being  23. S  and  the  latter  only  11.1  per 
100,000 — less  than  half  as  high.  In  the  South  only 
figures  for  the  white  population  are  considered.  If 
figures  for  Negroes  were  included  the  discrepancy 
would  be  even  more  striking,  for  the  authors  them- 
selves say  that  the  crude  death  rates  from  appen- 
dicitis reported  for  Negroes  in  the  United  States 
are  lower  than  those  for  the  white  race.  "In  this 
study  it  was  found  almost  without  exception  that 
in  each  age  group  the  Negro  rate  was  below  that 
of  the  white  in  all  the  Southern  States."  The  New 
England,  the  North  Atlantic,  the  North  Central, 
the  South  Central  and  the  Pacific  States  rates  are 
between  those  of  the  Rocky  Mountain  and  the 
South  Atlantic  States. 

Why  this  marked  difference  in  the  various  geo- 
graphical groups  of  States  exists  is  hard  to  under- 
stand. From  such  authority  the  findings  must  be 
accepted  as  being  true.  It  is  hard  to  conceive  of 
the  difference  being  from  climatic  influence,  for 
diarrhea  and  intestinal  infection  are  greater  every- 
where in  hot  weather  and  the  writer  believes  that 
appendicitis  is  more  common  and  more  severe  in 
summer.  Difference  in  occupation  and  in  habit 
can  not  explain  it  nor  can  difference  in  diet. 

The  study  does  not  include  the  incidence  of  the 
disease  so  that  it  is  hard  to  determine  what  bearing 
treatment  may  have  on  the  mortality  rate  per  100,- 
000  p>opulation.  No  doubt  giving  cathartics  for 
abdominal  pain  and  delay  in  operation  until  per- 
foration of  the  appendix  has  occurred  are  material 
factors  in  the  mortality  here  as  elsewhere.  The 
writer  feels  that  the  teaching  and  the  practice  of 


Horsley,  of  Royster  and  of  Guerry,  in  the  States  of 
Virginia,  North  Carolina  and  South  Carolina,  are 
to  a  great  degree  responsible  for  the  low  rates  of 
10.4,  10.4  and  8.3  per  100,000  population  for  their 
respective  States.  It  should  be  the  ambition  of 
physicians  in  these  three  States,  through  education 
of  both  doctor  and  layman  as  to  the  danger  of 
delay  in  acute  appendicitis,  to  still  further  reduce 
these  figures. 

In  conclusion,  it  is  of  interest  to  note  the  mor- 
tality rate  as  it  varies  with  the  age  of  the  patient. 
In  appendicitis  "the  case  fatality  rate  decreases 
from  the  first  year  of  life  until  about  20  years  when 
the  lowest  point  is  reached.  After  the  third  decade 
the  fatality  rate  again  increases,  and  a  mortality 
of  SO  per  cent,  or  more  has  been  reported  for  groups 
over  60  years  of  age."  "The  greatest  percentage  of 
cases  occurs  in  the  ages  when  the  case  fatality  rates 
are  lowest,  i.e.,  between  15  and  30  years;  and  the 
lowest  percentage  occurs  when  the  fatality  rates  are 
highest."  Dauer  and  Lilly  have  given  us  in  their 
report  certain  interesting  aspects  of  appendicitis 
mortality  which  have  hitherto  received  little  atten- 
tion. 


The   Use  of  P.^pain   in   the   Prevextion-   of   Peritone.^ 

Adhesions 
(B.  W.  Ward,  T\i\sa.  in  Jl.  Okla.  State   Med.  Assn.,  Nov.) 

Papain  is  a  vegetable  product  obtained  from  the  paw 
paw  tree  or  carica  papaya,  which  has  a  proteolytic  action. 
It  is  available  commercially  as  a  powder  but  in  the  ordi- 
nar\-  form  is  not  sterile.  Since  heat  could  not  be  used  it 
was  destructive  to  the  enzyme  action,  the  problem  of 
sterilization  was  a  real  one,  but  was  worked  out  by  Wal- 
ton. The  sterile  product  used  by  the  essayist  was  supplied 
generously  by  Parke  Davis  and  Company. 

Papain  was  introduced  in  1922  by  Kubota.  Ochsner 
and  his  coworkers  have  been  responsible  for  the  vast 
amount  of  the  experimental  and  clinical  work. 

The  essayist  has  had  the  opportunity  in  2  cases  of  re- 
entering abdomens  and  nothing  the  good  effect. 

Two  cases  alone  prove  little  but,  added  to  similar  obser- 
vations by  others,  at  least  justify  continued  use  of  papain 
if  not  premature  enthusiasm  as  to  its  value. 

Dr.  Ochsner  and  Storck  report  231  cases  in  which  papain 
had  been  used.  Of  these  122  patients  had  an  average  of 
lYz  operations  per  patient.  In  this  group  one  patient  had 
been  operated  on  22  times,  another  IS  times,  and  2  others  8 
times.  In  the  series  were  37  cases  which  had  reoperation 
subsequent  to  the  employment  of  papain.  In  94.5%  of 
these  cases  papain  was  effective  in  either  completely  elimi- 
nating or  materially  relieving  adhesions.  The  mortality 
rate  was  1.8%,  an  exceedingly  low  figure  for  this  type  of 
surgery,  constituting  strong  proof  of  the  harmlessness  of 
papain  properly  prepared  and  used.  Dr.  Ochsner  now  ad- 
vocates a  1-20,000  solution  of  papain,  using  Hartman's 
solution  as  a  diluent.  Fifty  mgms.  of  papain  to  each  1,000 
c.c.  of  solution  is  employed.  It  was  found  convenient  to 
inject  the  diluent  through  the  rubber  stopper  into  the 
vial  of  papain  and  shake  vigorously,  after  this  withdrawing 
the  solution  with  a  needle  and  adding  it  to  the  diluent  to 
be  used. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


GENERAL  PRACTICE 

WiNGATE  M.  Johnson,  M.D.,  Editor,  Winston-Salem,  N.  C 


The  Southern   Medical  Meeting 

The  Fifth  Regiment  Armory  in  Baltimore  fur- 
nished an  ideal  setting  for  the  thirtieth  annual 
meeting  of  the  Southern  Medical  Association,  which 
met  November  17th  to  20th.  An  excellent  pro- 
gram had  been  arranged — the  difficulty  being  that 
experienced  in  trying  to  enjoy  all  three  rings  of  a 
circus  at  the  same  time.  Even  the  medical  ses- 
sions were  split  up  into  two  sections,  both  goin-j 
at  the  same  time,  so  that  one  had  to  choose  the 
more  attractive  program. 

During  the  two  days  of  my  attendance  I  was 
fortunate  in  my  selections — with  a  few  exceptions. 
Let  me  give  briefly  the  papers  that  most  appealed 
to  me,  with  the  qualification  that  omission  of  any 
paper  does  not  mean  that  it  was  not  of  a  high 
order. 

Dr.  Thomas  B.  Futcher's  excellent  paper  on  Dis- 
turbances of  Pituitary  Function  gave  a  clear  re- 
sume of  the  modern  conception  of  the  pituitary. 
When  his  paper  is  published  in  the  Southern  Med- 
ical Journal  it  will  bear  careful  reading.  Drs.  Har- 
rop  and  Whitehill  discussed  the  new  protamine  in- 
sulin, particularly  their  modification  of  it  by  the 
addition  of  zinc.  I  am  not  yet  ready  to  abandon 
the  old  insulin  until  the  newer  preparation  is  better 
understood. 

Dr.  Uhlenluth  discussed  The  Interrelations  be- 
tween Thyroid  and  Hypophysis,  showing  how  the 
thyroid  gland  is  stimulated  by  the  secretion  from 
the  anterior  lobe  of  the  pituitary.  The  Etiology  of 
Exophthalmic  Goiter,  by  Dr.  John  T.  King,  dem- 
onstrated rather  clearly  the  effect  of  upper  respira- 
tory infections  in  this  disease. 

The  Management  of  Psychoneurotic  Patients,  by 
Dr.  L.  F.  Barker,  was  scholarly,  clear  and  practi- 
cal; though  the  criticism  may  be  offered  that  the 
treatment  presupposed  more  wealth  than  most  of 
these  unfortunates  possess. 

Dr.  Perrin  H.  Long  made  a  very  good  case  for 
Prontosil,  a  product  of  the  Winthrop  Company,  as 
"a  specific  chemotherapeutic  agent  for  the  treat- 
ment of  Beta  Hemolytic  Streptococcal  Infections": 
but  while  he  was  enthusiastic,  his  paper  was 
strangely  reminiscent  of  the  claims  made  for  mer- 
curochrome  a  few  years  ago.  I  hop>e  that  this 
will  prove  the  long-sought  remedy  that  will  destroy 
germs  in  the  bloodstream  without  injury  to  the 
host,  but  have  been  disappointed  tod  many  times 
to  accept  it  without  further  trial. 

Of  extreme  interest  was  the  repxirt  on  Melitensis 
Infection:    Treatment   with    Neoarsphenamine,   by 


Dr.  Charles  \V.  VVainwright.  In  half  a  dozen  cases 
Dr.  Wainwright  had  found  neoarsphenamine  quite 
effective.  He  usually  began  with  .3  gram,  then  .6, 
then  .9,  until  a  total  of  from  2.5  to  4  grams  had 
been  given. 

Dr.  Warfield  T.  Longcop>e  read  an  excellent  pa- 
per on  Pyelonephritis.  Dr.  Maurice  Pincoffs  dis- 
cussed Varieties  of  Hypertension.  Dr.  Louis  Ham- 
man  reported  two  cases  of  subacute  gonococcal  en- 
docarditis, as  evidence  that  this  disease  may  be 
prolonged  for  months,  and  progress  much  more 
slowly  than  is  thought:  though  both  these  cases 
ended  fatally,  true  to  its  malignant  nature 

Dr.  Lloyd  \V.  Ketron's  paper,  Skin  Disease  and 
Internal  Medicine,  suggested  that  while  the  mod- 
ern trend  is  more  and  more  to  regard  skin  disorders 
as  manifestations  of  focal  infection,  endocrine  dis- 
turbance, allergy,  psychoneurosis,  or  other  deep- 
seated  cause,  it  should  not  be  forgotten  that  there 
are  many  diseases  of  the  skin  itself  which  should 
be  treated  in  situ. 

Dr.  Charles  Hendee  Smith  gave  an  exceedingly 
practical  talk  on  infant  feeding,  which  was  a  plea 
for  simple  methods  and  a  protest  against  overfeed- 
ing by  the  use  of  concentrated  formulas. 

Dr.  Russell  Cecil  showed  the  striking  improve- 
ment in  the  treatment  of  lobar  pneumonia  by  anti- 
pneumococcus  serum.  Dr.  B.  R.  Kirklin  gave  the 
clinical  indications  for  roentgenologic  examination 
of  the  thorax.  Among  other  interesting  points  he 
called  attention  to  the  tendency  of  lung  tumors  to 
metastasize  early  to  the  brain — hence  in  brain  tu- 
inors  it  is  always  well  to  examine  the  chest  by  x- 
rays. 

Dr.  ().  H.  Perry  Pepp>er,  who  is  always  stimu- 
lating, gave  some  Comments  on  Disease  of  the  Eso- 
phagus, which  called  attention  to  the  importance 
of  considering  that  part  of  the  digestive  tract  in 
parasternal  pain.  Of  special  interest  to  me,  because 
it  explained  a  case  1  had  long  puzzled  over,  was 
his  report  of  a  patient  who  had  persistent  pain  be- 
tween the  right  border  of  the  sternum  and  the  right 
breast,  which  came  on  soon  after  the  death  of  a 
relative  from  cancer  of  the  breast.  Dr.  Pepper's 
patient  came  to  him  with  a  cancer  phobia.  Flu- 
oroscopic examination  of  the  esophagus  showed 
only  a  momentary  hesitation  at  the  point  of  pain, 
but  the  esophagoscope  revealed  an  inflammatory 
area  at  that  [X)int.  Phenobarbital  and  atropine, 
with  reassurance,  relieved  the  condition,  but  it  re- 
turned several  times,  always  under  emotional  stress. 
Dr.  Pepper  stated  that  emotional  strain  could  cause 
a  painful  spasmodic  contraction  of  the  esophagus, 
just  as  it  could  of  the  colon  or  of  the  duodenum. 

Dr.  \V.  S.  Newcomet.  in  Results  Obtained  in  the 
Treatment  of  Angiomata,  made  a  point  of  partic- 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


ular  interest  to  me,  because  I  had  just  learned  it 
from  Dr.  J.  P.  Rousseau — that  the  angiomata  of 
infants  commonly  known  as  birthmarks  should  be 
treated  as  soon  as  discovered,  even  in  the  first  week 
of  life,  for  they  can  be  obliterated  with  one  or  two 
light  doses  of  x-rays,  whereas  if  one  waits  for  some 
months  they  are  much  harder  to  destroy. 

One  of  the  most  carefully  worked-out  reports 
was  that  of  Drs.  Ruffin  and  Smith,  of  Duke  Uni- 
versity, on  the  treatment  of  pellagra  by  liver  ex- 
tracts, with  evaluation  of  the  various  preparations. 
Those  from  the  whole  liver  gave  the  best  results, 
as  the  pellagra-preventing  factor  was  evidently  lost 
in  refining  the  concentrated  extracts  for  intramus- 
cular injection.  Another  interesting  observation 
of  these  authors  was  that  the  exposure  of  one  arm 
to  the  sunlight  for  a  few  minutes  was  a  depend- 
able criterion  of  the  cure  of  a  patient.  If  not 
cured,  this  exposure  would  bring  about  a  relapse. 

A  feature  not  on  the  program,  but  intensely  in- 
teresting, was  the  exhibition  for  the  first  time  of 
motion  pictures  of  fluoroscopic  examinations  of  the 
chest  and  abdomen,  by  Dr.  Stewart,  of  New  York. 
Pictures  were  shown  of  a  normal  heart;  of  mitral 
stenosis  and  regurgitation;  of  aortic  aneurism;  of 
a  normal  esophagus,  of  a  cardiospasm,  and  of  a 
basal-cell  carcinoma  of  the  esophagus  before  and 
after  radiation.  Several  cases  of  artificial  pneu- 
mothorax were  shown,  and  one  of  spontaneous 
pneumothorax  that  developed  after  an  artificial  one 
was  produced.  A  bullet  in  the  lungs  was  shown, 
bobbing  up  and  down  with  respiration.  Its  owner 
had  kept  it  for  twenty  years  without  knowing  it. 
Peptic  ulcers  were  shown,  a  normally  emptying 
gallbladder  and  the  normal  movements  of  the  liver 
and  kidneys  on  respiration.  Finally  the  gradual 
filling  up  of  the  kidneys,  ureters  and  bladder  after 
the  injection  of  intravenous  dye  was  demonstrated. 

Dr.  Stewart  stated  that  this  method  of  getting  a 
permanent  record  of  the  movements  of  the  various 
viscera  is  practical  and  has  many  advantages.  The 
films  can  be  filed  to  be  compared  with  future  pic- 
tures; they  can  be  mailed  to  distant  points  for  con- 
sultation; and  they  permit  of  leisurely  and  pro- 
longed study  of  the  organs  without  overexposing 
the  patient  or  the  doctor  to  the  x-rays. 

The  exhibits,  both  commercial  and  scientific. 
were  of  a  high  order.  It  should  be  a  source  of 
peculiar  pride  to  North  Carolinians  that  the  first 
prize  was  awarded  to  Dr.  Deryl  Hart  and  his  asso- 
ciates for  the  exhibition  of  "sterilization  of  the  air 
in  the  operating  room  by  bactericidal  radiant  en- 
ergy." 

S.    M.    &   6. 

The  Elliott  Machixe  in  the  Treatment  of  Prostatitis 
(L.  W.  Riba,  Chicago,  in   III.  Med.  Jl.,  Nov.) 
Because  such  good  results  were  obtained  in  female  pelvic 


infections  it  was  felt  that  this  method  merited  a  trial  in 
the  treatment  of  prostatic  disorders.  Through  the  co- 
operation of  the  Treatment  Regulator  Corporation,  many 
different  sized  bags  were  devised  and  used  in  this  series  of 
82  cases.  A  distensible  rubber  bag  inserted  into  the  rectum 
and  attached  to  the  Elliott  machine  was  the  treatment 
used  in  these  cases. 

The  Elliott  treatments  are  particularly  adaptable  to  acute 
infections  of  the  prostate,  especially  where  local  therapy 
is  contraindicated. 

-\rthritic  pains  due  to  a  prostato-vesicular  focus  can  be 
relieved  in  the  majority  of  cases  and  the  original  focus 
improved. 

Daily  treatments  of  30,  45  and  60  minutes  are  prefer- 
able. 

S.   M.   &   S. 

Certain  Newer  Methods  of  Treating  Peptic  Ulcer 

(A.   B.  Rivers,  Rochester.  Minn.,  in  Amer.  Jl.  Dig.   Dis.  & 
Nutri.,  Nov.) 

Metaphen  may  at  times  be  useful  as  an  adjuvant  to 
other  treatment  of  the  infected  stomach  with  erosions  or 
ulcers.  Mucin  therapy  is  reasonable  and  may  at  times 
help  when  other  methods  of  treatment  fail.  Duodenal  or 
jejunal  alimentation  is  occasionally  successfully  employed 
to  control  the  symptoms  of  intractable  ulcer.  It  seems 
especially  useful  in  the  control  of  night  distress. 

The  parenteral  methods  of  treatment  seem  to  possess  no 
definite  claim  to  merit  except  in  so  far  as  they  may  initiate 
or  accelerate  the  process  of  tissue  repair.  It  is  doubtful 
whether  this  occurs  regularly  with  greater  facility  than  can 
be  accomplished  by  the  older  approved  methods  of  ulcer 
therapy. 

It  is  consoling  still  to  have  several  things  to  try  when 
the  patient  is  not  doing  well  on  pet  methods  of  treatment. 
In  such  an  instance,  however,  it  is  better  to  concentrate 
on  the  method  under  trial,  to  work  a  little  more  exten- 
sively to  get  the  patient  to  co-operate  in  treatment,  rather 
than  jump  from  one  method  to  another,  which  is  expensive, 
destroys  the  patient's  confidence,  and  in  the  end  usually 
results  in  failure. 

S.   M.   &   S. 

Cancer  of  the  Cervix 

(Francis   Reder,  St.  Louis,  in  Weekly   Bui.  St.   Louis   Med. 

See,  Nov.  13th) 

Malignancy  of  the  virginal  cervix  I  have  not  as  yet  en- 
countered. Malignancy  of  a  lacerated  cervix,  when  prop- 
erly repaired,  is  almost  as  rare. 

I  marvel  at  our  lack  of  insistence  on  having  neglected 
lacerations  of  the  cervix  repaired  before  they  show  evidence 
of  malignancy.  Every  lacerated  cervix  should  be  repaired. 
I  have  watched  the  repair  of  many  a  cervix  and  so  far  as 
I  was  able  to  judge  only  about  50%  were  properly  re- 
paired. The  entire  plug  of  scar  tissue  involving  the  lac- 
eration must  be  removed,  and  this  involves  frequently  the 
entire  thickness  of  the  cervical  canal.  The  apposition  of 
the  incised  cervical  lips  must  be  well-nigh  perfect. 


RADIOLOGY 

Wright  Clarkson,  M.D.,  and  Allen  Barker,  M.D., 
Editors,  Petersburg,  Va. 


Danger  of  the  Use  of  Mineral  Oil  in  the 
Respiratory  Tr.4ct 

The  use  of  various  preparations  containing  min- 
eral oil  in  treating  respiratory  diseases  is  common 
practice.     It  is  generally  assumed  that  such  prep- 


December.  1936 


SOUTHERN  MEDICINE  AND  SURGERV 


665 


arations  can  be  used  without  danger,  and  there  is 
little  in  the  literature  to  contradict  this  assump- 
tion. The  earlier  reports  of  lung  injuries  were  those 
in  which  an  accidental  aspiration  of  oil  had  oc- 
curred in  young  and  debilitated  infants.  Most  of 
those  cases  were  clinically  diagnosed  as  broncho- 
pneumonia. The  correct  diagnosis  was  made  only 
at  autopsy. 

Up  to  the  present  time  only  a  very  few  adults 
with  preliminary  changes,  due  to  oil,  have  been 
reported.  The  most  recent  of  these  consist  of  thre? 
cases  reported  by  Davis. ^  In  each  of  these  he  had 
the  opportunity  to  observe  them  both  clinically  and 
roentgenographically.  Two  of  his  patients  died. 
On  one  of  these  an  autopsy  was  permitted.  Th? 
third  patient  is  still  living. 

One  patient  complained  of  fever,  malaise,  and  a 
severe  nonproductive  cough:  another,  of  a  chronic 
nasal  discharge  and  a  chronic  sore  throat;  the  third, 
of  pain  in  his  chest,  cough,  and  blood-tinged  spu- 
tum. Before  the  onset  of  symptoms,  two  of  these 
patients  had  received  ten  intratracheal  instillations 
of  mineral  oil,  and  the  third  had  been  advised  to 
use  nasal  douches  of  mineral  oil  three  or  four  times 
daily. 

The  roentgenograms  of  those  patients  who  have 
aspirated  rather  large  quantities  of  mineral  oil  are 
quite  distinctive.  In  the  early  phase  the  changes 
simulate  a  fibrotic  obliterating  bronchiolitis,  show- 
ing miliary  mottling  in  the  involved  areas,  due  to 
an  accentuation  of  the  finer  lung  markings.  As  a 
result  of  the  anatomic  arrangement  of  the  main- 
stem  bronchi,  the  earliest  and  most  marked  changes 
are  seen  in  the  right  lung.  In  one  patient  that  Da- 
vis followed  with  serial  chest  roentgenograms  over 
a  period  of  six  years,  there  was  a  progressive  con- 
traction of  the  involved  lobe  with  increasing  solidi- 
fication of  the  areas  involved.  The  final  roentgen- 
ograms of  this  patient  showed  only  fibrous  remnants 
of  the  involved  areas. 

In  all  of  these  cases,  sputum  examinations  re- 
vealed the  presence  of  oil  droplets  even  though  one 
patient  had  had  no  oil  administered  for  more  than 
fix  years.  This  same  patient  came  to  autopsy  and 
large  quantities  of  oil  were  found  in  the  lung,  its 
mineral  nature  being  determined  by  chemical  tests. 

The  report  of  such  cases  immediately  leads  one 
to  question  the  wisdom  of  the  present-day  use  of 
iodized  vegetable  oils  in  the  diagnostic  and  thera- 
peutic procedures  performed  in  various  pulmonary 
conditions.  Although  it  is  known  that  iodized  vege- 
table oils  may  remain  in  the  chest  for  weeks  or 
months  after  instillation,  Pinkerton-  found  that 
vegetable  oils  produced  but  little  reaction  in  the 
lungs.  In  animals  these  oils  occasionally  caused 
minute  abscesses  in  areas  in  which  there  had  been 


bronchial  obstruction,  but  in  most  of  his  animals 
no  changes  were  produced.  The  wide  experience 
of  innumerable  workers  who  report  no  serious  se- 
quelae following  repeated  instillations  of  the  vege- 
table oils  reassures  us  that  we  need  not  expect  the 
serious  changes  which  occur  after  the  use  of  mineral 
oil. 

With  the  present  extensive  use  of  intratracheal 
and  intranasal  oil  medication,  it  is  probable  that  in 
the  future  more  of  these  serious  sequelae  will  be 
reported.  It  is,  therefore,  important  for  the  clini- 
cian and  the  radiologist  to  remember  the  possibility 
of  these  complications,  particularly  in  patients  with 
pulmonary  fibrosis.  It  is  also  important  in  taking 
the  history  of  these  patients  to  determine  whether 
or  not  oil  medication  has  been  used. 

The  present  extensive  use  of  mineral  oil  in  the 
treatment  of  nasal  and  other  respiratory  diseases 
should  be  discouraged,  and  whenever  practicable, 
oil  of  sesame  or  of  poppy  seed,  or  some  other  bland 
vegetable  oil  should  be  used  rather  than  mineral 
oil. 

References 

1.  Davis,  K.  S.:  Roentgenographic  Changes  Following 
the  Introduction  of  Mineral  Oil  in  the  Lung.  Radi- 
ology,  Feb.,  1936,  26:131-137. 

2.  Pinkerton,  H.:  Oils  and  Fats:  Their  Entrance  into 
and  Fate  in  the  Lungs  of  Infants  and  Children:  A 
Clinical  and  Pathologic  Report.  Am.  Jour.  Dis.  Child., 
Feb.,  1927,  33,  259. 

B.   M.   &  6. 

Oil  .'\spir.\tion  Pneumonia 
(Editorial    International    IVled.    Dig.,   Nov.) 

Physicians  should  be  careful  in  the  use  of  nose  drops 
and  should  inform  the  mother  of  the  dangers  incidental  to 
their  use.  It  is  questionable  whetlier  it  is  worth  while  to 
instill  such  drops  into  the  nares  of  a  vigorously  resisting 
baby  or  young  child.  Certainly  this  aspiration  pneumonia 
is  a  definite  entity.  The  mother  should  be  instructed  to 
exercise  as  much  care  as  possible  when  she  administers 
cod-liver  oil,  and  it  would  probably  be  better  to  use  one 
of  the  several  efficient  concentrated  sources  of  vitamin  D 
in  those  babies  or  children  who  register  their  objection  to 
the  bulkier  doses  of  oil. 

It  is  reasonable  to  believe  that  many  cases  of  oil  pneu- 
monia have  been  overlooked  inasmuch  as  an  accurate  diag- 
nosis can  be  made  only  at  autopsy.  In  any  event  it  has 
already  occurred  sufficiently  often  to  justify  the  precautions 
suggested. 


CLINICAL  CHEMISTRY  &  MICROSCOPY 

C.  C.  Carpenter,  B.A.,  M.D.,  F.A.C.P.,  Editor 
Wake  Forest,  N.  C. 


The  Cancer  Cell 

In  a  paper  read  before  the  section  on  Pathology 
and  Physiology  at  the  meeting  of  the  A.  M.  A.  in 
Kansas  City  on  Identification  of  the  Cancer  Cell, 
Dr.  William  C.  MacCarty  of  the  Mayo  Clinic  offers 
a  suggestion  for  earlier  diagnosis  of  cancer  by  path- 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


ologists.  This  pai>er  was  published  in  the  Journal 
of  the  A.  M.  A.  of  September  12th  and  abstracted 
in  the  October  issue  of  Southern  Medicine  &  Sur- 
gery. 

This  paper  offers  a  suggestion  that  in  order  to 
diagnose  cancer  earlier  and  more  accurately  the 
pathologist  needs  to  improve  his  technique  which 
is  antiquated,  and,  more  particularly,  he  should 
study  fresh  tissue.  He  offers  as  a  point  that  may 
aid  the  fact  that,  by  a  study  of  unfixed  fresh  tissue, 
the  nucleolus  was  found  to  be  considerably  larger 
in  the  cancer  cells.    He  also  says, 

"As  pointed  out  by  Balfour,  Harrington  and  Rankin, 
only  25  per  cent,  of  the  cancers  of  the  stomach,  SO  per  cent, 
of  the  cancers  of  the  breast,  and  58  per  cent,  of  the  cancers 
of  the  large  intestine  are  operable  when  seen  by  surgeons." 

"The  cancer  cell  has  identifying  characteristics.  Histolog\' 
of  the  past  and  present  and  modem  cytology  are  two  very 
different  sciences  with  quite  different  technics  requiring  a 
somewhat  different  training,  yet  to  be  recognized  by  general 
pathologists  and  taught  by  them  in  a  routine  way  to 
modern  medical  students. 

"Until  medical  students  are  taught  this  newer  method. 
we  cannot  expect  cancer  to  be  recognized  early." 

Let  US  assume  that  the  suggestion  made  by  Mac- 
Carty  is  of  value  to  the  pathologist.  It  would  ap- 
pear to  me  that  some  of  the  things  he  suggests  are 
the  problems  of  the  pathologist.  As  such  a  large 
percentage  of  the  cancers  are  inoperable  when  first 
seen  by  the  surgeon  one  with  ordinary  ability  would 
have  little  difficulty  in  diagnosing  the  case  either 
clinically  or  pathologically.  No  matter  how  well 
trained  and  equipped  the  pathologist  or  surgeon 
may  be,  he  most  certainly  cannot  make  an  early 
diagnosis  unless  he  gets  to  see  the  patient.  It  is 
unlikely  that  the  pathologist  will  see  the  patient  be- 
fore the  surgeon,  and  certainly  the  pathologist  does 
not  get  the  tissue  until  the  surgeon  has  taken  the 
biopsy.  Therefore,  it  would  seem  obvious  to  me 
that,  according  to  his  own  statement,  the  problem 
centers  more  around  getting  the  patient  early  than 
it  does  having  the  pathologist  fussing  around  meas- 
uring nucleoli. 

It  is  interesting  to  note  how  one  who  is  well 
trained  occasionally  becomes  very  enthusiastic 
about  some  minor  point  in  medicine  allowing  it  to 
become  over-emphasized  to  the  point  of  overshad- 
owing the  major  issue.  As  a  rule  these  minor 
points  are  the  ones  in  which  men  of  experience  do 
not  agree  but  the  fundamental  principles  live  in 
the  minds  of  all  forever. 

A  case  recently  seen  in  our  own  laboratory  has 
demonstrated  this  point  of  the  identification  of  the 
cancer  cell.  The  clinical  history  was  not  in  keep- 
ing with  the  appearance  of  malignancy  in  the  lymph 
node.  It  was  seen  by  Dr.  R.  P.  Morehead  and 
me  in  our  laboratory  and  from  the  slide  we  made  a 
diagnosis  of  Hodgkin's  disease,  calling  attention  on 


our  report  to  the  fact  that  this  gland  showed  under 
the  microscop>e  all  the  characteristics  given  for  the 
diagnosis  of  Hodgkin's  disease.  The  clinicians  in 
Raleigh  and  Baltimore  who  had  seen  the  case,  in 
spite  of  this  beautiful  description  by  us,  doubted 
the  diagnosis.  .\.  slide  of  the  lymph  node  was  sent 
to  the  Baltimore  clinicians,  who  had  it  studied  by 
one  of  the  leading  pathologists  there,  who  agreed 
that  it  was  malignant  but  suggested  that  he  would 
favor  the  diagnosis  of  lymphosarcoma.  The  clini- 
cian in  Raleigh  asked  that  a  third  pathologist  see 
the  slide  and  give  his  opinion.  We  had  the  good 
fortune  at  that  critical  time  of  having  Dr. 
William  Boyd,  Professor  of  Pathology  at  the  Uni- 
versity of  Manitoba  and  author  of  the  textbook 
used  in  the  majority  of  medical  schools,  visit  our 
laboratory.  So  I  asked  Dr.  Boyd  to  serve  as  the 
third  pathologist.  After  studying  the  slide  and  the 
history  of  the  case  Dr.  Boyd  suggested  that  in  his 
opinion  it  was  not  a  malignant  lymph  node  but 
the  patient  would  be  entirely  well.  When  Dr. 
Boyd  was  asked  his  explanation  for  the  presence 
of  the  supposedly  identifying  cells  he  expressed  the 
opinion  that  no  tumor  should  be  diagnosed  by  the 
cell  alone,  but  that  the  type  cell  should  be  used  as  a 
link  in  the  chain  of  evidence  for  or  against  a  diag- 
nosis, along  with  the  clinical  record  of  the  case. 
This  case  serves  beautifully  in  my  opinion  to  illus- 
trate the  old  adage:  When  the  laboratory  and  the 
clinical  disagree,  stick  to  the  clinical.  So  no  mat- 
ter how  important  the  nucleolus  may  prove  to  be 
for  the  proper  interpretation  of  the  cancer  cell,  it 
will  not  serve  as  a  final  and  infallible  characteristic 
and  we  will  need  to  continue  to  get  the  patient 
early  and  study  him  as  a  whole. 

The  suggestion  that  medical  students  be  taught 
to  identify  the  cancer  cell  would  probably  be  worth 
our  time  and  the  time  of  the  student  if  we  were 
training  men  to  be  only  pathologists.  As  a  matter 
of  fact  the  trend  is  in  the  opposite  direction  in  the 
teaching  of  pathology.  The  medical  schools  exist 
to  train  men  for  a  general  practice  of  medicine  and 
not  to  train  specialists.  Our  efforts  are  directed 
toward  training  the  student  to  visualize  pathologi- 
cal processes  in  tissue  so  that  he  may  be  able  to 
understand  pathological  manifestations  at  the  bed- 
side. Along  with  this  obviously  we  hope  that  he 
learns  some  cytology  and  the  identification  of  can- 
cer cells.  In  my  opinion  it  would  be  folly  to  re- 
quire the  students  to  become  proficient  in  any  one 
of  the  specialties. 

Dr.  MacCarty  has  made  an  observation  that  we 
hope  will  be  a  help  to  the  pathologist  in  identifying 
the  cancer  cell,  but  the  pathologist  must  continue 
to  think  clinically  and  the  clinician  must  think 
pathologically  if  the  mortality  and  morbidity  from 
disease  is  to  be  reduced. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


HUMAN  BEHAVIOR 

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


Anthony  Comstock  Comes  to  Town 

Although  his  mortal  structure  lost  its  vital 
spark  twenty-odd  years  ago,  Anthony  Comstock 
has  come  in  spirit  to  this  town,  founded  by  the 
most  famous  of  the  several  William  Byrds.  And 
the  coming  of  Comstock  to  this  town,  which  he 
probably  never  visited  while  in  physical  life,  is  all 
the  more  curious,  because  William  Byrd,  our  found- 
ing-father, was  not  at  all  Puritanical  either  in 
speech,  spoken  or  written,  or  in  behaviour. 

I  have  not  personally  seen  Comstock  since  he 
came  to  town,  but  the  newspaper  boys  have  given 
him  a  cordial  welcome,  and  they  are  apparently 
delighted  with  his  old-time  garrulity  and  general 
damnatory  attitude.  He  was  probably  invited  to 
this  city  by  one  of  our  ministers.  I  think  I  recall 
that  a  pastoral  statement  vocalized  the  fear  that 
the  youth  of  the  city  might  be  corrupted  by  read- 
ing the  lecherous  and  licentious  literature  liberated 
each  week  by  certain  purveyors  and  sellers  of  the 
salacious  and  the  pornographic  page.  The  citizens 
of  our  city  were  moved.  And  so  were  some  of 
our  municipal  officials.  The  clerici  convened  and 
demanded.  The  sale  and  the  distribution  of  de- 
basing and  demoralizing  literature  must  cease.  But 
such  unworthy  publications  must  first  be  discover- 
ed, read,  analysed,  branded,  condemned,  publicly 
denounced,  withdrawn  from  sale  and  castigated. 

Such  responsible  and  judicious  and  highly  moral 
activity  called  for  the  selection  and  organization 
of  a  committee — a  committee,  too,  that  could  be 
shocked  but  neither  corrupted  nor  demoralized  by 
the  scrutinization  of  the  vulgar  and  the  obscene. 
Several  of  the  leading  citizens  of  the  city,  no  one 
of  them  a  constituent  of  any  special  school  of  lit- 
erature, were  selected  by  the  Municipal  Depart- 
ment of  Public  Safety  as  a  Citizens'  Censorship 
Committee.  Why,  the  very  entitlement  of  the  or- 
ganization is  even  more  alliterative  than  the  Society 
for  the  Suppression  of  Vice  of  the  years  gone  by, 
and  made  famous  and  otherwise  by  the  crusading 
zeal  of  its  incorruptible  secretary,  Anthony  Com- 
stock. 

Why  shouldn't  our  visual  food  be  examined, 
approved  or  condemned,  according  to  its  deserts? 
.Almost  all  purchases  bear  an  inspection  tag.  The 
gasoline  with  which  we  propel  our  death-dealing 
chariots  is  tested,  not  once  only,  but  perhaps  many 
times.  The  lumber  we  buy  is  inspected.  So  is 
the  guano  that  makes  our  crops  grow.  The  liquor 
we  drink  is  inspected.  When  our  children  enter 
school  they  are  inspected  inside  and  out     Our  live- 


stock is  inspected,  the  milk  is  examined,  graded 
and  labeled;  and  all  meat  that  we  buy  must  first 
be  inspected.  The  movies  on  which  we  feast  our 
eyes  and  with  which  we  rejuvenate  our  emotions 
are  all  rigidly  inspected  by  a  bi-se.xual  state  cen- 
sorship commission.  There  are  few  things  left  on 
which  we  can  afford  to  risk  our  untutored  and 
infirm  individual  judgment.  All  opinions  today 
must  be  group-formed  and  passed  down  to  the 
individual.  We  are  living  in  an  age  of  censorship. 
There  is  little  left  for  a  plain  person  to  do  save  to 
comply  and  to  complain. 

But  I  have  been  informed  from  behind  the  veil 
that  the  members  of  the  Citizens'  Censorship  Com- 
mittee are  having  an  exceedingly  busy  and  risible 
time  of  it  in  reading  and  in  condemning  as  unfit 
for  juvenile  eyes  so  many  entertaining  and  grip- 
ping publications.  And  as  soon  as  the  ungodly 
weekly  and  monthly  publications  have  all  been  read 
and  reread  and  catalogued  and  condemned  and  cas- 
tigated, more  ponderous  volumes  will  be  tackled, 
destroyed,  or  radically  expurgated.  William  Shake- 
speare will  be  ripped  out  here  and  there;  many 
passages  of  Holy  Writ  will  be  deleted;  old  Juvenal 
will  be  thrown  to  the  wolves;  Voltaire  will  be  used 
as  kindling  material,  and  Rabelais  will  go  into  the 
furnace.  Little  Boy  Blue  will  surely  be  spared,  but 
When  Willie  Wet  the  Bed  will  undoubtedly  be 
thought  too  uriniferous  for  jejune  noses;  and  I  fear 
that  The  Snakes  that  Rowdy  Saw  and  the  Clink  of 
the  Ice  in  the  Pitcher  will  be  thought  too  bibulous 
even  for  these  post-arid  times. 

We  are  living  in  censorious  days.  If  the  maga- 
zines may  be  censored  and  withdrawn  by  municipal 
edict  for  the  protection  of  the  morals  of  our  chil- 
dren, why  may  not  our  daily  and  weekly  news- 
papers and  other  publications  be  censored  also  and 
be  condemned  and  damned  as  unfit  mental  pabu- 
lation  for  adult  eyes  and  minds?  And  if  printed 
opinion  may  be  condemned  and  made  to  cease, 
why  may  not  spoken  opinion  later  be  hushed  unless 
it  accord  with  the  censor's  wishes?  Much  of  the 
world's  population  has  been  made  muni.  Isn't  the 
municipality  in  which  Thomas  Jefferson  and  Pat- 
rick Henry  once  resided  getting  out  from  under 
their  tutelage  when  it  sends  a  group  of  its  citizens 
in  official  capacity  out  upon  the  streets  with  a 
moral  sieve  through  which  to  pass  all  print;d  mat- 
ter so  that  the  fit  may  be  separated  from  the  unfit? 
Will  the  citizen  fmally  have  no  chance  to  exercise 
individual  judgment  ? 

Lately,  one  of  my  patients  remarked  to  me  in 
my  office,  and  he  may  have  dementia  praecox,  that 
he  would  prefer  to  manage  his  own  affairs  ineffi- 
ciently than  to  permit  another  to  manage  them 
efficiently.     I  observed  that  he  might  be  exercising 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


bad  judgment,  but  that  his  aphorism  crystallized 
my  conception  of  ancient  democracy. 

A  Civic  Incineration 

I  have  not  the  slightest  doubt  that  John  Coates 
is  dead.  He  is  as  dead  as  Marley,  and  even  old 
Scrooge  signed  a  statement  that  Marley  was  dead. 
The  final  asseveration  was  that  Marley  was  as 
dead  as  a  door  nail.  John  Coates  is  as  dead  as 
Hector,  the  son  of  a  king  and  a  queen,  and  to  be 
as  dead  as  Hector  means  to  be  dead  entirely.  The 
integrity  of  the  somatic  structure  of  Hector  was 
preserved,  and  his  enraged  killer  dragged  the  dead 
Hector  again  and  again  around  the  city  in  whose 
defense  he  had  given  his  life.  But  the  dead  body 
of  John  Coates  could  not  have  been  dragged  around 
by  Achilles  nor  by  any  other,  for  the  body  of  John 
Coates  was  suddenly  transformed  into  a  little  heap 
of  ashes,  and  no  indignity  can  be  heaped  upon 
ashes. 

On  account  of  some  minor  infraction  of  the  civic 
rules  and  regulations  of  the  ancient  and  dignified 
Commonwealth  of  Virginia,  John  Coates  was  ap- 
prehended by  some  proper  arresting  officer  and 
lodged  in  the  municipal  jail  of  Colonial  Beach  on 
or  about  November  ISth.  I  am  not  acquainted 
with  the  kind  or  the  magnitude  of  his  civic  infrac- 
tion. Perhaps  he  had  exhibited  evidences  of  hav- 
ing ingested  too  generous  a  quantity  of  liquor  sold 
to  him  by  his  native  Commonwealth.  At  any  rate, 
he  was  housed  in  the  local  hoosegow.  At  a  late 
hour  of  the  night,  soon  afterwards,  the  place  of 
civic  detention  was  seen  by  some  ambulatory  citi- 
zen to  be  aflame.  Within  a  few  minutes  Colonial 
Beach  was  jailless  and  John  Coates  was  lifeless. 

After  such  a  civic  catastrophe  there  is  always  a 
solemn  investigation.  The  rule  was  not  disregard- 
ed in  the  instant  case.  Such  a  survey  must  be 
made  slowly,  solemnly,  carefully,  deliberately,  with- 
out fuss  and  feathers,  judiciously,  dispassionately, 
and  comprehensively.  This  complicated  and 
weighty  responsibility  devolved  upon  the  State's 
Commissioner  of  Public  Welfare.  The  investiga- 
tion was  made;  the  report  was  transmitted  to  the 
Honourable  George  Campbell  Peery,  for  the  mo- 
ment Governor  of  the  Commonwealth.  The  nucleus 
of  the  report  was  that  John  Coates  was  burned  to 
death  while  locked  in  a  cell  in  the  jail  of  Colonial 
Beach,  Westmoreland  County,  Virginia.  The  jail 
and  John  Coates  were  both  destroyed  by  the  same 
municipal  fire.  John  Coates  was,  of  course,  at 
that  late  hour  of  the  night,  his  own  keyless  jailer. 
No  Sheriff  or  Deputy  or  Turn  Key  could  be  ex- 
pected to  sit  up  all  night  long  and  listen  to  John 
Coates  sleep  and  keep  away  fire.  John  Coates  was 
locked  in,  and  left  to  sleep  and  to  burn  alone. 


Even  though  the  jailer  of  Colonial  Beach  may 
have  been  in  his  own  home  asleep  on  that  fateful 
night,  the  Commonwealth  of  Virginia  never  sleeps. 
It  slumbers  not  nor  sleeps.  Almost  before  the  ashes 
of  John  Coats  and  the  walls  of  his  cell  were  cool, 
an  investigation  of  the  tragedy  was  under  way, 
and  a  thorough  report  of  the  pyric  disaster  was 
within  the  two  hands  of  His  Excellency,  the  Gov- 
ernor, even  before  two  weeks  had  elapsed.  The 
results  of  the  post-incinerative  survey  were  two: 
the  Governor  of  the  Commonwealth  made  use  of 
the  catastrophe  to  point  to  the  more-than-a-cen- 
tury-old  fact  that  the  citizens  of  Virginia  enjoy 
local  self-government,  and  that  even  the  Governor, 
with  all  of  his  puissance,  has  nothing  to  do  with  a 
village  jail,  even  though  it  may  be  on  fire.  And 
the  state's  Commissioner  of  Public  Welfare  in- 
formed the  state's  citizenship  that  their  jail  system 
is  outmoded,  discredited,  Elizabethan.  Why  once 
a  school-teacher,  and  later  a  lawyer,  if  one  is  not 
to  use  language? 

No  one  who  moves  about  over  the  State  of  Vir- 
ginia with  open  eyes  stands  in  need  of  the  state- 
ment of  the  Commissioner  that  forty-eight  of  the 
state's  one  hundred  and  sixteen  jails  are  left  un- 
guarded at  night,  and  that  thirty-odd  of  them  are 
fire-traps.  The  maintenance  of  many  of  them  as 
they  are  constitutes  a  continuing  crime.  And  such 
crimes  are  not  confined  to  the  State  of  Virginia.  I 
recall  that  a  few  years  ago  a  couple  of  youths  lost 
their  lives  by  fire  in  a  village  jail  in  North  Caro- 
lina into  which  they  were  thrust  and  locked  on 
account  of  some  raucous  outburst  of  behaviour. 
Many  wrong-doers  undoubtedly  escape  incarcera- 
tion, thank  God,  otherwise  I  should  be  even  more 
frequently  in  jail.  But  no  one  who  spends  even  so 
little  time  as  one  night  in  any  average  jail  escapes 
punishment.  Even  such  temporary  incarceration 
constitutes  lasting  punishment. 

John  Coates,  burned  to  death  locked  in  a  cell  in 
a  jail  in  the  county  made  memorable  as  the  place 
of  nativity  of  George  Washington,  many  of  the 
Lees,  James  Monroe,  the  father  of  John  Marshall, 
and  other  dignitaries  of  lesser  degree,  may  be  able, 
wherever  his  ashen  remains  may  be,  to  be  com- 
forted by  the  Gubernatorial  statement  that  a  jail 
is  a  mechanism  of  localized  democracy;  and  John 
Coates'  spirit  may  be  made  glad  by  the  Commis- 
sioner's renaissant  remark  that  many  of  our  jails 
are  just  like  those  in  existence  in  the  gay  days  of 
the  "V'irgin  Queen  and  William  Shakespeare  and 
Francis  Bacon  and  William  Harvey  and  Sir  Walter 
Raleigh  et  al;  but,  despite  investigation  and  reports 
and  local  democracy  and  the  Renaissance,  John 
Coates  is  dead — and  he  was  burned  to  death  while 
locked  and  left  uncared  for  in  a  jail  in  Virginia. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


669 


And  that  catastrophe  and  the  carelessness  which 
begot  it  is  a  disgrace  to  the  state  and  to  that  civic 
fabrication  which  we  miscall  civilization. 


PUBLIC  HEALTH 

N.  Thos.  Ennett,  M.D.,  Editor,  Greenville,  N.  C. 
Pitt  County  Health  Officer 


A  Brief  Report  on  the  67th  A.  P.  H.  A.  Meet- 
ing IN  New  Orleans,  Oct.  20th-23rd 

It  was  estimated  that  more  than  1,500  persons 
were  present  at  this  meeting.  They  included  pub- 
lic health  officials  of  States  and  cities,  sanitary  en- 
gineers, school  physicians,  State  laboratory  direc- 
tors, directors  of  public  health  nursing  and  officers 
of  the  U.  S.  Public  Health  Service. 

There  were  delegates  from  nearly  every  State  in 
the  Union  and  also  Cuba  and  Mexico. 

In  addition  to  the  eight  sections  where  scientific 
papers  were  read,  there  were  also  extensive  scientific 
and  commercial  exhibits. 

Of  course,  the  aggressive,  recently  appointed 
Surgeon  General,  U.  S.  P.  H.  S.,  Doctor  Thomas 
Parron,  now  president  of  the  A.  P.  H.  A.,  held  the 
spotlight.  Doctor  Parran's  address  before  the  Gen- 
eral Session  was  the  main  event  of  the  meeting. 
The  gist  of  this  address  appears  in  the  following 
quotation  taken  from  one  of  the  New  Orleans  pa- 
pers: 

"Public  health  in  the  light  of  present  scientific  knowl- 
edge goes  far  beyond  environmental  sanitation.  It  must 
necessarily  be  concerned  with  all  factors  which  make  for 
healthful  living:  The  prevention,  alleviation  and  cure  of 
disease  by  all  methods  known  to  science;  the  promotion 
of  the  physical  and  mental  status  of  the  race;  the  pro- 
vision of  decent  housing,  healthful  working  conditions,  fa- 
cilities for  recreation,  food  adequate  in  amount  and  kind 
lor  proper  nutrition;  a  standard  of  living  compatible  with 
normal  family  life  and  the  upbringing  of  children." 

"In  addition  to  those  generally  accepted  health  measures 
which  are  provided  directly  by  a  health  department,  com- 
munity effort  concerned  directly  and  indirectly  with  public 
health  may  be  considered  broadly  in  two  groups. 

1.  Those  measures  of  direct  concern  to  a  health  depart- 
ment but  not  necessarily  provided  by  it,  such  as  bedside 
nursing,  medical,  dental  and  hospital  services  for  the  pop- 
ulation groups  in  need  of  them. 

2.  General  health  measures,  such  as  better  housing,  rec- 
reation facilities,  and  a  useful  job  at  a  fair  wage,  which 
have  a  direct  influence  upon  health  but  in  this  country 
have  been  unrelated  to  health  agencies." 

Citing  the  coordinated  campaign  against  pneu- 
monia launched  last  year  by  the  organized  medical 
profession  of  New  York  State  and  the  New  York 
State  Department  of  Health  and  the  cancer  cam- 
paign in  Massachusetts,  Dr.  Parran  said: 

"Mass  attacks  upon  these  and  similar  diseases  is  rela- 
tively new,  however,  in  a  majority  of  States.  We  have 
been  looking  at  them  through  the  microscope  for  so  long 
that  it  is  difficult  to  refocus  for  a  telescopic  view.   Yet  both 


views  are  necessary  if  we  are  to  see  them  in  their  entirety, 
and  both  the  individual  and  the  mass  attacks  are  neces- 
sary." 

One  of  the  most  interesting  scientific  exhibits 
was  that  of  the  x-ray  trailer  owned  by  the  State 
of  Louisiana  and  used  in  the  rural  sections  in  the 
State's  tuberculosis  field  clinics. 

Dr.  O'Hara,  State  Health  Officer,  referred  to  it 
as  "a  mobile  tuberculosis  laboratory,  to  be  sent  to 
all  the  parishes  that  invite  us,"  and  added,  "the 
consent  of  the  parish  medical  societies  is  obtained 
before  a  parish  is  visited.  The  x-ray  pictures  are 
made  and  developed  free  of  charge  and  the  pictures 
turned  over  to  the  local  authorities  in  each  parish." 

The  trailer  is  18  feet  long  and  equipped  with  an 
80,000-volt  machine.  The  machine  is  hooked  on 
to  outside  power  lines  in  places  where  it  stops  for 
examinations. 

.According  to  visiting  physicians,  this  x-ray  trailer 
idea  is  one  of  the  most  important  ever  undertaken 
by  the  medical  profession  in  the  war  against  tuber- 
culosis. 

If  the  general  medical  profession  approves  the 
x-ray  trailer  idea,  it  is  our  opinion  that  every  State 
in  the  Union  will  rapidly  adopt  this  practical  meth- 
od of  combatting  tuberculosis  through  early  diag- 
nosis. 

s.  M.  &  8. 

The  Over-crowdinc  of  the  Medical  Profession 


One  of  the  most  important  problems  now  confronting 
the  medical  profession  of  this  country  is  over-crowding 
so  great  that  it  has  become  a  menace  both  to  the  pro- 
fession and  to  the  public.  It  is  a  menace  to  the  profession 
in  that  due,  in  part,  at  least,  to  this  over-crowding  it  is 
difficult  for  a  large  number  of  medical  men  to  make  a 
living.  It  is  a  menace  to  the  public  in  that  the  fierce 
competition  has  had  a  tendency  to  commercialize  the  pro- 
fession and  lower  the  standards  of  medical  practice.  If 
this  rate  of  increase  is  allowed  to  continue,  the  over-crowd- 
ing will  become  a  greater  and  greater  menace  to  both  the 
profession  and  the  public. 

The  practical  solution  would  seem  to  be  for  the  medical 
schools  to  reduce  the  number  of  students  in  their  entering 
classes  by  S%  each  year  for  the  next  5  years. 

We  must  elevate  the  standards  of  requirements  demanded 
to  secure  a  medical  education  and  a  license  to  practice 
medicine.  This  should  not  mean  an  increase  in  the  length 
of  the  medical  course  but  a  decrease  in  the  number  of 
medical  students  by  an  increase  in  the  educational  stand- 
ards and  the  standards  of  personal  fitness. 

Although  Jews  compose  only  3.5%  of  the  entire  pop- 
ulation 17%  of  all  the  medical  students  in  the  country  are 
Jewish. 

3.  M.  *  8. 

Glaucoma. — All  ophthalmologists  see  cases  which  re- 
semble glaucoma,  but  are  not ;  and  other  cases  which  seem 
not  to  be  glaucoma,  but  later  develop  into  glaucoma. — 
Moulton. 

8.   M.   JE  8. 

The  quickest  and  most  effectual  way  of  conquering  a 
fever,  is,  in  most  cases,  by  early  submission  to  it. — Rush. 


670 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


Southern  Medicine  and  Surgery 

Official  Organ  of 

Tei-State  Medical  Association  of  the 

Carolinas  and  Virginia 

Medical  Society  of  the  State  or 

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 
Eye,  Ear  and  Throat  Hospital  Group Charlotte,  N.  C. 

Ortliopedcc   Surgery 

O.  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 ,  I 

Internal    Medicine 
P.  H.  Ringer,  M.D Asheville,  N.  C. 


Geo.  H.  Bunch,  M.D 


Columbia,  S.  C. 


Obstetrics 
Henry  J.  Langston,  M.D. Danville,  Va. 

Gynecology 
Chas.  R.  Robins,  M.D.  Richmond,  Va. 

Pediatrics 
G.  W.  Kutscheb,  jr.,  M.D. 


.Asheville,  N.  C. 

General   Practice 

Wingaie  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.  Lee  Moose,  Ph.G. Asheville,  N.  C. 

Cardiology 
Clyde  M.  GiLiioRE,  A.B.,  M.D. Greensboro,  N.  C. 

Public   Health 

N.  Thos.  Ennett,  M.D Greenville,  N.  C. 

Radiology 
Allen  Barker,  M.D.         I  Petersburg,  Va. 

Wright  Clarkson,  M.D. ) 

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

Clinical    Psychiatry 
C.  A.  BosEM.^v,  M.D Pinebluff,  N.  C. 


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. 


Toward  Keeping  Others  and  Ourselves  From 
Being  Killed  by  Automobiles 

Doctors  have  to  be  out  on  the  roads  when  they 
are  wet  or  covered  with  sleet;  they  must  go  about 
their  work  on  Saturday,  on  Circus  Day,  on  Christ- 
mas Eve,  on  Fourth  of  July — whenever  their  pa- 
tients need  them.  We,  along  with  all  others,  have 
a  right  to  take  our  families  over  the  roads  we  pay 
for  and  that  there  he  will  be  safe  in  life  and  limb. 

Speed  laws  on  the  statute  books  do  no  good. 
Highway  patrolmen  are  decorative  and  expjensive, 
but  useless. 

Speed  is  the  chief  element  in  the  highway  slaugh- 
ter. 

There  is  a  certain  and  cheap  way  of  assuring 
that  cars  will  not  exceed  the  speed  limit.  Tha 
onh^  argument  against  it  is  that  it  will  accomplish 
its  purpose.  Do  the  legislators  and  the  courts  want 
the  speed  laws  enforced?  If  so.  here  is  the  way  to 
do  it: 

Pass  a  law  requiring: 

( 1 )  That  every  motor  vehicle  using  the  public 
roads  of  the  State  be  equipped  with  a  governor — 
a  mechanism  for  controlling  the  speed  of  machin- 
ery— set  at  the  legal  speed  limit  for  that  vehicle; 
any  such  vehicle  found  on  any  public  road  not  so 
equipped  to  be  confiscated  to  the  State. 

(2)  That  two  lines  be  drawn  on  the  road  sur- 
face instead  of  one,  these  lines  12  inches  to  either 
side  of  the  middle. 

(3)  That  every  hard-surface  road  be  paralleled 
by  a  good  cheap  walking  path  at  least  three  feet 
from  the  edge  of  the  hard  surface. 

After  these  provisions  are  made  when  any  one 
sees  a  car  going  at  60  to  90  miles  per  hour  he  will 
know  that  the  car  furnishes  prima  facie  evidence  of 
serious  law-breaking:  and  he  will  have  every  rea- 
son to  believe  that  the  drive:-  is  a  reckless  and 
very  likely  generally  lawless  menace  to  all  who  use 
the  road.  These  considerations  would  greatly  re- 
duce the  number  of  robberies,  as  would-be  robbers 
would  stage  their  hold-ups  where  the  sight  of  a 
car  traveling  at  top  speed  would  attract  no  atten- 
tion. 

A  great  number  of  those  who  sit  under  steering- 
wheels  believe  that  they  are  driving  just  right  when 
their  inside  wheels  are  running  right  on  the  center 
mark,  that  unless  these  inside  wheels  are  over  to 
the  left  of  the  line  they  are  not  violating  any  law 
nor  incurring  any  risk.  Observe  as  you  go  along 
the  roads  and  see  what  you  about  this. 

It  is  an  outrage  that,  in  building  hard-surfaced 
roads,  the  road-builders  have  torn  up  the  good, 
comfortable,  safe  walking  paths  alongside  our 
roads,  and  provided  nothing  instead.  Try  it  your- 
self.    Walk  along  a  road  at  night  and  note  how 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


your  life  is  menaced  by  every  car  that  passes.  And 
Its  hard  on  the  nerves  of  decent  drivers,  too.  Num- 
bers of  our  people  have  been  killed  as  they  walked 
along  their  own  roads  to  attend  church  services,  to 
visit  neighbors,  or  to  purchase  necessaries  at  the 
neighborhood  store.  Provision  should  be  made  by 
which  these  rights  could  be  exercised  in  safety  and 
tranquillity  of  mind. 

The  passage  and  enforcement  of  these  laws  will 
greatly  increase  tourist  travel  in  the  State,  and 
a  good  many  of  the  best  of  these  tourists  will 
decide  to  stay  with  us  permanently,  desiring  to  live 
among  people  who  have  sense  enough  and  will 
enough  and  decency  enough  to  deal  rigorously  with 
all  who  would  make  our  highway  travel  perilous. 

Appeal  to  your  legislators  on  the  grounds  of 
safety  and  peace  of  mind  for  those  who  drive  care- 
fully, of  safety  of  occupants  and  car  when  a 
young  member  of  the  family  has  the  car  out,  of 
safety  for  those  who  need  to  walk  along  the  high- 
ways, of  helping  in  preventing  robberies,  and  even 
on  the  ground  of  making  money  by  attracting  tour- 
ists to  a  State  that  makes  it  roads  safe  for  all  the 
law-abiding. 

s.  M.  &  s 

No  Slur  on  General  Practitioners 
One  of  the  morning  papers  of  October  28th 
brought  to  our  eye  an  A.  P.  article,  of  the  day  be- 
fore, from  Richmond  which  contained  this  sen- 
tence: "Dr.  John  B.  Hawes,  2nd,  of  Boston, 
Mass.,  told  members  of  the  American  Clinical  and 
Climatological  Association  today  that  through  the 
ignorance  of  general  practitioners,  many  cases  of 
lung  and  throat  trouble  are  diagnosed  as  silicosis 
and  attributed  to  dusts  breathed  in  industrial 
plants." 

Long  e.xperience  of  how  hard  newspaper  folks 
find  it  to  quote  accurately  led  us  to  inquire  of 
Dr.  Hawes  before  making  comment,  and  his  reply, 
made  up  largely  of  long,  exact  quotations  from  his 
paper,  puts  an  entirely  different  face  on  the  matter. 
These  quotations  show  that  he  did  give  "igno- 
rance on  the  part  of  doctors"  as  one  of  the  causes 
of  trouble,  but  never  did  he  mention  general  prac- 
titioners, or  say  a  word  to  indicate  that  he  re- 
garded this  ignorance  as  inexcusable  or  as  confined 
to  any  group  of  doctors.  Rather,  it  seems  that  we 
doctors,  pretty  generally,  are  tarred  with  the  same 
stick. 

Other  parts  of  Dr.  Hawes'  letter  show  that  he 
shares  our  own  high  regard  for  the  abilities  of 
general  practitioners  and  our  fixed  opinion  that, 
since  specialists  must  rise  or  fall  with  general  prac- 
titioners, whoever  destroys  public  confidence  in  the 
family  doctor  digs  the  foundation  from  under  the 
whole  structure  of  Medicine. 


671 

It  is  plain  that  the  reporter,  not  being  able  to 
conceive  of  the  existence  of  ignorance  among  spe- 
cialists, made  a  free-hand  interpretation  of  "igno- 
rance on  the  part  of  doctors"  as  "ignorance  on  the 
part  of  general  practitioners,"  thus  manifesting  his 
own  ignorance  and  putting  newspaper  men  down 
in  the  ditch  with  doctors. 

Out  of  this  experience  we  may  get  two  ideas  of 
some  value:  1)  that  it  is  well  to  continue  in  the 
habit  of  ascertaining  what  a  man  really  said  before 
forming  an  opinion;  and  2)  that  newspaper  folks 
need  to  be  impressed  with  the  fact  that,  taking  all 
doctors  of  medicine  into  consideration,  general 
practitioners  grade  pretty  well. 

S.    M.    &   S 

The  Coming  Tri-State  Meeting 
February  22nd  and  23rd 

Our  president  has  been  working  out  his  plans 
for  our  meeting  for  many  months  and  now  arrange- 
ments are  taking  definite  form. 

An  excellent  meeting  is  assured.  We  are  letting 
our  applicants  into  the  secret  that  this  is  the  friend- 
liest organization  of  doctors  to  be  found  an3rwhere, 
that  its  members  are  so  regular  in  their  attendance 
as  to  make  of  each  meeting  a  sort  of  family  re- 
union; so  you  must  not  allow  any  consideration- 
meeting  of  Deans  of  Medical  Colleges  or  of  the 
Society  of  the  Cincinnati,  possible  bad  weather,  or 
anything  whatsoever— to  prevent  your  attending. 

We  will  greatly  miss  Dr.  Southgate  Leigh,  but 
Dr.  Leigh's  mantle  has  fallen  on  the  shoulders  of 
a  son  who  takes  up  his  father's  work  in  our  organ- 
ization as  elsewhere. 

Many  other  ties  bind  the  Tri-State  to  Norfolk 
and  the  Tidewater,  and  these  ties  will  be  renewed, 
strengthened  and  multiplied. 

The  secretary  again  reminds  that  ours  is  not  a 
body  that  is  perpetuated  automatically,  as  are  our 
State  medical  societies,  and  you  will  find  enclosed 
an  application  blank  which  you  are  requested  to 
place  in  the  hands  of  a  doctor  whom  you  would 
like  to  have  as  one  of  us.  Don't  neglect  to  say 
that  our  applicants  are  welcomed  to  our  meetings. 

S.    M.   &  s 

Public  Health  as  Defined  by  Surgeon  General 
Parr AN 
Last  summer  to  the  headship  of  the  United 
States  Public  Health  Service  came  a  new  surgeon 
general,  Dr.  Thomas  Parran,  formerly  Commis- 
sioner of  Health  of  the  State  of  New  York;  and 
immediately  the  dust  from  the  sweeping  of  the 
new  broom  began  to  rise  and  swirl.  Over  many 
years  Dr.  I'arran  has  noted  with  grave  concern 
ihat  little  was  being  accomplished  in  the  way  of 
deterring  our  people  from  exposing  themselves  to 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


syphilis,  and  many  times  has  his  voice  been  raised 
in  warning.  Surely  the  gravity  of  the  situation  as 
to  syphilis  amply  justifies  concern,  study  and  ear- 
nest and  sustained  effort  to  remedy. 

Dr.  Parran  has  published  on  this  subject  in 
many  journals  and  many  organizations  of  doctors 
in  private  practice  and  in  public  health  work  have 
lent  sympathetic  ear,  whether  or  not  they  could 
share  his  optimism.  It  was,  possibly,  the  thing  to 
do  to  take  his  cause  to  the  public  direct;  although 
many  doctors  deplore  his  use  of  the  Survey  Graphic 
(issue  of  July,  1936)  as  a  medium;  for  private 
practitioners  of  medicine  remember  the  Survey 
Graphic  as  a  decided  non-friend. 

It  would  seem,  too,  that  Surgeon  General  Parran 
could  have  chosen  a  more  reasonable  title  than, 
"Why  Don't  We  Stamp  Out  Syphilis?",  although 
it  is  doubtful  if  he  could  have  picked  one  which 
would  have  got  his  piece  reprinted  more  widely. 
Even  the  not  very  sensational  Reader's  Digest  car- 
ried a  condensation,  of  which  it  made  reprints  to 
be  spread  far  and  wide,  at  "1,000  or  more  $12.50 
per  thousand." 

The  readiest  answer  to  the  question — assuming 
that  it  is  meant  as  something  more  than  a  bit  of 
rhetoric — is:  Because  we  can  not;  but  the  answer 
given  us  by  a  high  official  in  the  Medical  Corps 
of  the  Navy  was  more  pungent,  far. 

If  anybody  can  show  us  a  plan  which  holds  out 
any  half-way  reasonable  prospect  of  stamping  out 
syphilis,  we  are  confident  that  at  least  95  per  cent, 
of  doctors  will  give  hearty  and  enthusiastic  sup- 
port. 

Dr.  Parran  blames  our  alleged  hush-hush  meth- 
ods for  the  prevalence  of  venereal  diseases  and 
thinks  the  diffusion  of  information  in  the  high 
schools  would  have  prevented  epidemics  of  such 
diseases  in  certain  of  these  schools.  Our  own  ob- 
servation is  that  there  is  no  longer  any  hush-hush 
about  such  things,  and  that  20  or  30  years  back, 
when  the  hush-hush  did  prevail,  venereal  disease 
in  a  school  child  was  a  rarity,  indeed.  Maybe 
shaking  "the  dangling  legs  of  tabes  and  the  mum- 
bling mask  of  paresis"  before  the  eyes  of  school 
children  would  have  a  happy  effect;  but  our  faith 
in  fear  of  remote  and  uncertain  punishment  is 
weak.  Not  through  Fear,  not  through  Religion, 
not  even  through  JNIorality,  but  by  home  and  school 
inculcation  of  Decency  is  this  grave  situation  to  be 
met;  and  it  will  prove  a  long  and  laborious  process. 

It  would  appear,  though,  that  this  modern  Saint 
George  counts  this  Dragon  as  already  slain,  for  he 
promptly  takes  on  all  the  other  enemies  of  man- 
kind. On  the  word  of  the  Editor  of  the  Depart- 
ment of  Public  Health  of  this  journal  we  have  it 
that,  last  October,  the  new  Surgeon  General  told 


the  American  Public  Health  Association: 

(See  p.  669,  this  issue.) 

Now,  if  the  prevention,  alleviation  and  cure  of 
disease  by  all  methods  known  to  science  by  Public 
Health  officials  would  not  automatically  do  away 
with  the  private  practice  of  medicine,  then  words 
have  no  meaning  and  there  is  no  such  thing  as 
reason.  And  the  further  features  of  the  program 
are  far  more  astounding:  provision  of  housing, 
healthful  working  conditions,  facilities  for  recrea- 
tion, food — everything!  In  short,  in  the  opinion 
of  the  Surgeon  General  of  the  U.  S.  P.  H.  S.,  Pub- 
lic Health  officials  should  take  over  all  the  work 
now  being  done  by  doctors  of  medicine,  by  states- 
men and  by  economists!  Nobody  can  say  it  is 
not  an  ambitious  program. 

Over  and  over  we  are  told  that  Public  Health  is 
a  specialty.  There's  a  tale  of  a  sign  being  exhib- 
ited which  read: 

"Doctor  Josiah  Spratt, 
Specialist  in  Acute  and  Chronic  Diseases 
of 
Men,  Women  and  Children. 
Animals  treated  on  Wednesdays  and  Saturdays"; 
but  Doctor  Spratt  was  a  narrow  specialist  as  com- 
pared with  a  specialist  who  could  cover  the  field 
of  Public  Health  as  defined  by  Dr.  Parran. 

There  is  no  reason  to  believe  that  other  PubLc 
Health  folks  entertain  any  such  grandiose  ideas. 
Certainly  those  in  this  State  and  Section  have  no 
wish  to  thus  enlarge  their  field.  The  worst  that 
can  come  of  such  ill-considered  pronouncement  is 
that  confidence  in  Public  Health  activities  gener- 
ally will  be  shaken.  However,  in  all  human  prob- 
ability, such  an  all-inclusive  program  will  fall  of 
its  weight,  and  promptly. 


How  Much  We  Know  that  Isn't  So 

This  journal  has  suggested  in  times  past,  we  be- 
lieve at  least  once  as  a  New  Year  thought,  that  it 
would  be  well  for  everyone  to  bring  each  of  his 
fixed  ideas  under  critical  scrutiny  at  least  once  in 
each  twelve-month. 

Anyone  who  will  allow  his  mind  to  wander  back 
over  the  years  and  recognize  and  bring  forward 
unpleasant  instances  which  show  how  mistaken  one 
may  be  when  he  feels  most  assured,  will  find  it  a 
chastening  and  humbling  process,  but  wholesome 
withal. 

As  an  extreme  illustration  is  cited  the  abstract 
in  this  issue  an  article  tending  to  prove  that  a 
child  of  delicate  constitution  is  no  more  prone  to 
develop  the  disease,  tuberculosis,  than  is  the  robust 
child.  Of  course,  it  is  possible  that  this  may  be  a 
mistaken  idea;  but  it  looks  as  though  a  good  case 
is  made  out  for  it. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


673 


How  glibly  and  confidently  have  we  said  that 
typhoid  is  a  disease  of  infection,  tuberculosis  a 
disease  of  resistance.  And  there  was  no  shadow 
of  question  in  our  mind  as  to  the  truth  of  our  state- 
ment. Our  satisfaction  was  akin  to  that  of  the 
man  who  loves  to  say  those  who  do  not  agree  with 
him  are  "like  the  ostrich  who  hides  his  head  in  the 
sand,"  when  it  is  obvious  that  such  a  bird  would 
be  promptly  suffocated  or  devoured,  and  so  these 
hatchings  from  addled  eggs  would  have  died  out 
long  before  man  invented  language  and  wrote  down 
stupid  lies. 

The  authors  of  the  tuberculosis  article  conclude. 
With  suck  facts  established,  we  should  immediately 
discontinue  some  of  the  tuberculosis  work  of  to- 
day, and  re-establish  it  on  the  fundamental  princi- 
ples that  we  have  used  in  other  communicable  dis- 
eases.   That  is  a  wise  specific  resolution. 

We  can  add  the  wise  general  resolution  not  to 
identify  ourselves  so  firmly  with  any  general  con- 
ception as  to  make  it  impossible  for  us  to  abandon 
it  gracefully  when  it  becomes  necessary  to  take 
higher  and  firmer  ground. 

It  is  generally  said — and  that  may  not  be  true 

that  one  may  remove  from  the  walls  of  a  rented 
house  any  article  which  he  attaches  by  the  aid  of 
screws,  but  that  anything  he  nails  on  becomes  a 
part  of  the  realty  and  must  not  be  removed. 


Dr.  G.  D.  McGregor 

While  this  section  was  on  the  press  the  sad  news 
of  the  death  of  Dr.  ^McGregor  was  brought  to  the 
office.  In  his  usual  good  health  he  attended  the 
annual  joint  meeting  of  the  Board  and  the  Staff  of 
St.  Peter's  Hospital  last  evening  and  this  morning 
(Dec.  9th)  he  was  found  dead  in  the  yard  outside 
his  window.  Death  is  attributed  to  his  having 
fallen  from  the  open  window  while  sleep-walking. 

Dr.  :\IcGregor  was  one  of  the  most  useful  and 
popular  members  of  the  profession  in  Charlotte, 
and  his  death  has  cast  a  gloom  over  the  holiday 
season. 


American  Association  for  the  Study  of  Goiter  again 
offers  the  Van  Meter  Prize  Award  of  .S300  and  two  honor- 
able mentions  for  the  best  esays  submitted  concerning  e,\- 
perimental  and  clinical  investigations  relative  to  the  thy- 
roid gland.  This  award  will  be  made  at  the  discretion  of 
the  Society  at  its  next  annual  meeting  to  be  held  in  De- 
troit, June  14th  to  16th.  The  competing  manuscripts 
which  should  not  exceed  3.000  words,  must  be  presented 
in  English  and  a  typewritten  double  spaced  copy  sent  tcj 
the  Corresponding  secretary.  Dr.  W.  Blair  Mosscr,  133  Bid- 
die  street.  Kane.  Pennsylvania,  not  later  than  April  1st. 
1937.  Manuscripts  received  after  this  date  will  be  held  for 
competition  the  following  year  or  returned  at  the  author's 
request. 


CASE  HISTORY 
By  GROESBECK  WALSH 
On  ^Monday  when  it  all  began 
I  simply  ducked  my  head  and  ran. 
I  flung  myself  upon  the  bed 
And  jammed  my  knuckles  in  my  head 
Through  tight  shut  eyes  and  tumbled  clothes. 
\\'hat  happened  Thursday  night  arose 
Again  and  yet  again  that  scene 
Like  phantoms  on  a  movie  screen. 
I  dared  not  go  upon  the  street 
To  chance  the  people  I  might  meet 
I  know  the  very  words  they  say 
Those  beldames  of  the  P  .T.  A. 

And  yet  I  dared  not  boldly  shirk 
The  stark  reality  of  work. 
I  know  with  all  that  wealth  of  choice 
I  should  have  said  I'd  lost  my  voice. 
With  every  sort  of  pain  to  choose 
I  took  the  one  that  women  use 
(And  thereby  made  a  bad  mistake) 
I  said  I  had  the  stomach  ache. 

The  whole  campaign  was  crystal  clear 
The  moment  that  they  had  me  here. 
"Appendicitis,  its  the  truth 
It  saps  them  in  the  bloom  of  youth." 
My  parents  sat  with  bated  breath 
And  heard  the  rustling  wings  of  Death. 
A  parlous  moment  touch  and  go 
And  up  to  me  to  stage  the  show. 

I  carried  on  like  one  possessed 

By  souls  at  Lucifer's  behest. 

They  heard  me  screaming  down  the  hill 

Three  nurses  could  not  hold  me  still 

And  when  they  questioned  me  I  said 

The  pain  had  shifted  to  my  head. 

The  other  day  at  seven  bells 
The  ward  still  ringing  with  my  yells 
(The  nurses  had  me  firmly  packed 
Which  marks  the  ending  of  my  act.) 
A  doctor  with  an  evil  face 
Who  talked  as  if  he  owned  the  place 
Game  in  and  sat  beside  my  bed 
I  relished  every  word  he  said. 

"When  little  sister  strikes  a  lull 

I'll  put  a  gimlet  in  her  skull 

And  make  the  outline  .sharp  and  clear 

Hy  pumping  in  some  atmosphere. 

.An  .\-ray  picture  will  e.xplain 

The  cause  of  pressure  on  her  brain." 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


Go  find  a  doctor  in  this  town 

Who  knows  it's  life  that  has  me  down 

A  single  one  to  understand 

Or  learn  to  recognize  the  brand. 

They  cut  and  purge  and  bake  and  look 

For  answers  in  a  printed  book. 

Oh  teach  them  Lord  to  seek  and  find 

Redemption  through  the  human  mind. 

I  have  no  tumor  of  the  brain 
My  flesh  and  blood  are  right  as  rain 
And  yet  I  am  forever  through 
With  all  the  things  I  planned  to  do. 
To  rise  and  watch  those  children  stare 
Once  more;  far  rather  would  I  dare 
The  lofty  window's  pleading  breath 
To  learn  how  merciful  is  Death. 

Could  I  but  take  my  parent's  hand 
To  say,  'Sometime  you'll  understand 
The  torment  I  am  passing  through 
Is  all  the  shield  I  know  for  you. 
The  little  animal  you  gave 
The  world  Our  Lord  came  down  to  save 
Will  hold  this  body  in  the  flame 
Before  her  sin  be  given  name.' 


Treatment  oe  Eye  Diseases  by  the  General  Practitioner 
(R.  E.  Russell,  Ocala,  in  Jl.  Fla.  Med.  Assn.,  Nov.) 
It  is  the  purpose  of  this  paper,  in  a  general  way,  to 
help  the  general  practitioner  to  recognize  those  conditions 
of  the  eye  that  he  should  not  attempt  to  treat,  and  also 
give  some  helpful  advice  on  treatment  for  certain  diseases 
of  the  eye,  and  temporary  handling  of  emergencies. 

There  are  many  times  when  the  burden  of  all  treatment 
falls  ppon  the  family  physician. 

The  average  case  of  acute  conjunctivitis  will  result  in 
spontaneous  recovery,  whether  in  spite  of.  or  on  account 
of,  the  various  eye  drops  and  lotions  that  are  used.  An 
excellent  rule  is  to  use  only  two  drugs  in  the  treatment  of 
acute  conjunctivitis.  Protargol  is  fairly  stable  and  avail- 
able practically  everywhere.  From  3  to  S%  solution  used 
in  the  eye  every  2  or  3  hours  is  very  efficacious  and  well 
tolerated  by  the  patient.  Another  excellent  drug  is  zinc 
sulphate.  A  solution  containing  1  or  2  grains  to  the  ounce 
of  water  or  boric  acid  solution  will  be  found  extremely 
valuable  in  conjunctivitis  that  tends  to  become  chronic,  or 
those  which  in  the  early  stages  show  signs  of  e.xcoriation 
around  the  outer  angle  of  the  eye.  It  is  a  safe  guess  that 
any  type  of  conjunctivitis  will  recover  in  half  the  usual 
time  if  the  proper  treatment  is  carried  on  intensively  every 
2  or  3  hours  day  and  night.  Medication  should  never  be 
put  in  an  eye  until  that  eye  is  thoroughly  cleansed  of  all 
purulent  exudate.  Normal  saline,  boric  acid  solution,  so- 
dium borate  solution,  are  excellent  cleansing  agents  and 
should  be  used  freely  and  often  and,  contrary  to  popular 
belief,  an  ice  cold  solution  is  more  efficacious  and  gratify- 
ing to  the  patient  than  a  hot  solution.  Heat  is  used  for 
diseases  of  the  lids  only  when  there  is  a  definite  cellulitis 
of  the  deeper  lid  structures.  Many  cases  of  acute  gon- 
orrheal conjunctivitis  have  been  quickly  and  thoroughly 
curel  with  nothing  more  than  cold  saline  irrigations  every 


30  minutes  24  hours  a  day. 

The  common  sty  may  be  the  indirect  result  of  a  re- 
fractive error  that  only  the  proper  glasses  will  permanently 
correct,  but  often  it  is  primarily  a  local  infection  of  a  hair 
follicle.  Heat  should  always  be  used  and  I  use  a  3% 
ammoniated  mercur>'  ointment  and  believe  it  to  have  more 
antiseptic  value  than  the  yellow  oxide.  The  medication 
does  not  cure  the  sty  that  is  already  present,  but  it  pre- 
vents the  development  of  others,  and  so  should  be  used 
for  several  days  after  the  patient  presumes  that  the  first 
infection  is  well. 

Foreign  bodies  loose  beneath  the  lids  are  fairly  simple  to 
remove.  Clean  cotton  wrapped  around  a  match  or  tooth- 
pick is  the  best  instrument,  and  it  is  wise  to  cleanse  the 
eye  afterward  with  some  mild  irrigating  solution.  Very 
few  except  ophthalmologists  are  equipped  to  remove  bodies 
that  are  imbedded  in  or  penetrate  the  eye.  Many  violent 
corneal  ulcers  are  caused  by  clumsy  and  denuding  efforts 
to  remove  foreign  body  from  the  cornea  with  a  poor  light 
and  improper  instruments.  Eye  injuries,  with  or  without 
foreign  bodies,  should  be  handled  by  the  ophthalmologist 
if  possible.  However,  in  most  cases  it  is  the  general  prac- 
titioner who  must  administer  first  aid.  It  is  practically 
impossible  to  see  a  minor  abrasion  of  the  cornea  without 
staining  with  some  dye.  Never  look  at  an  eye  and,  be- 
cause the  eye  looks  all  right  and  no  foreign  body  is  seen, 
dismiss  the  patient  with  a  laugh  and  a  pat  on  the  shoulder. 
The  best  and  safest  first-aid  in  practically  every  eye  injury 
is  to  cleanse  the  eye  with  a  mild  irrigating  solution,  im- 
mobilize the  lids  with  a  bandage,  and  let  the  ophthalmolo- 
gist take  the  responsibility.  In  extremely  painful  injuries, 
morphine  hypodermically  should  be  used.  Because  of  its 
devitahzing  influence  cocaine  should  not  be  used  in  the  eye 
following  injury.  Butyn,  2%,  or  pantocaine,  yifo,  will  re- 
lieve pain  temporarily  and  are  not  harmful. 

None  but  a  qualified  specialist  should  ever  use  atropine 
in  the  eye.  In  my  own  practice  during  the  past  2  years,  I 
have  seen  3  patients  with  eyes  that  were  absolutely  ruined 
by  the  use  of  atropine.  These  3  patients  had  been  treated 
by  a  general  practitioner  for  acute  iritis.  Each  one  was 
suffering  from  a  violent  attack  of  inflammatory  glaucoma 
that  was  greatly  exaggerated  and  the  eye  irreparably  dam- 
aged by  the  mydriatic  effect  of  atropine. 

This  disease,  of  practically  unknown  etiology,  may  attack 
all  ages,  all  races,  of  either  sex  and,  contrary  to  popular 
opinion  among  physicians,  it  is  one  of  the  common  diseases 
of  the  eye.  It  is  an  insidious  disease.  It  is  a  treacherous 
disease.  It  may  come  on  suddenly  with  excruciating  pain, 
loss  of  vision,  and  violent  congestion  of  the  eye,  or  it  may 
develop  slowly,  without  warning,  without  pain.  There  may 
be  only  a  gradual  diminution  of  vision  which  the  patient 
may  think  is  due  to  age  or  need  of  glasses.  It  may  be 
present  in  its  first  stages  without  symptoms,  without  di- 
minution of  vision,  and  one  drop  of  atropine  solution  may 
be  the  spark  to  start  a  violent  conflagration  of  inflamma- 
tory reaction  that  leaves  the  patient  with  a  marble-hard, 
hopelessly  blind  eye.  There  are  many  diseases  of  the  eye 
that,  to  the  casual  observer  and  at  times  the  trained  oph- 
thalmologist, very  closely  resemble  glaucoma.  The  decid- 
ing points  in  the  diagnosis  are  often  fine  as  well  as  techni- 
cal. Acute  glaucoma  may  have  even,-  physical  finding  of 
acute  iritis  or  acute  keratitis  and  the  only  deciding  factor 
be  the  intraocular  pressure.  A  sensitive  and  trained  finger 
can  usually  detect  this  by  palpation,  but  only  the  tonometer 
in  the  hands  of  the  ophthalmologist  should  be  relied  upon. 
In  iritis  and  many  other  diseases  of  the  eye,  atropine  is  the 
backbone  of  the  treatment  but  in  glaucoma  it  is  a  poison- 
ous and  destructive  agent. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


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There  have  been  ten  reductions  in  the  price 
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SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


BOOK  REVIEWS 


THE  PRACTICE  OF  MEDICINE,  by  Jonathan  Camp- 
bell Meakins,  M.D.,  LL.D.,  Professor  of  Medicine  and 
Director  of  the  Department  of  Medicine,  McGill  Univer- 
sity; Physician-in-Chief,  Royal  Victoria  Hospital,  Mon- 
treal; Formerly  Professor  of  Therapeutics  and  Clinical 
Medicine,  University  of  Edinburgh.  Fellow  of  the  Royal 
Society  of  Edinburgh;  Fellow  of  the  Royal  Society  of 
Canada;  Fellow  of  the  Royal  College  of  Physicians,  Lon 
don;  Fellow  of  the  Royal  College  of  Physicians,  Edinburgh, 
Honorary  Fellow  of  the  Royal  College  of  Surgeons,  Edin- 
burgh; Fellow  of  the  Royal  College  of  Physicians,  Canada; 
Fellow  of  the  American  College  of  Physicians.  With  505 
illustrations  including  35  in  color.  The  C.  V.  Mosby  Com- 
pany, St.  Louis.     1936.     $10.00. 

The  author  is  an  unusually  clear-headed,  practi- 
cal doctor.  He  recognizes  the  facts  that  symptoms 
cause  persons  to  consult  physicians  and  that  symp- 
toms are  the  most  important  clues  to  disease  rid- 
dles; so  he  writes  at  length  about  symptoms.  No 
therapeutic  nihilist,  he  covers  treatment  adequate- 
ly. No  believer  in  mass  production  in  medicine,  he 
puts  his  chief  dependence  in  family  doctors,  and 
for  these  family  doctors  he  has  written  a  book  that 
no  one  of  them  can  afford  to  do  without. 


DISEASES  OF  THE  NOSE,  THROAT  AND  EAR  for 
Practitioners  and  Students,  edited  by  A.  Logan  Turner, 
M.D.,  LL.D.,  F.R.C.S.E.,  Consulting  Surgeon,  Ear  and 
Throat  Department,  Royal  Infirmary,  Edinburgh;  with  the 
collaboration  of  J.  S.  Eraser,  M.B.,  F.R.C.S.E.,  Surgeon 
Ear  and  Throat  Department,  Royal  Infirmary,  Edinburgh; 
Douglas  Guthrie,  M.D.,  F.R.C.S.E.,  Consulting  Surgeon, 
Ear  and  Throat  Department,  Royal  Edinburgh  Hospital 
for  Sick  Children;  Charles  E.  Scott,  M.B.,  F.R.C.S.E., 
Aural  Surgeon,  Royal  Edinburgh  Hospital  for  Sick  Chil- 
dren; J.  D.  LiTHGOW,  M.B.,  F.R.C.S.E.,  Surgeon,  Ear  and 
Throat  Department,  Royal  Infirmary,  Edinburgh;  G. 
Ewart  Marten,  M.B.,  F.R.C.S.E.,  Assistant  Surgeon,  Ear 
and  Throat  Department,  Royal  Infirmary,  Edinburgh,  and 
John  P.  Stewart,  M.D.,  F.R.C.S.E.,  Assistant  Surgeon, 
Ear  and  Throat  Department,  Royal  Infirmary,  Edinburgh. 
Fourth  edition,  revised  and  enlarged  with  243  illustrations 
in  the  text  and  21  plates,  of  which  S  are  in  colour.  William 
Wood  and  Company,  Baltimore.     1936.     $6.00. 

Each  section  has  been  thoroughly  revised  to  ex- 
press the  advances  made  since  the  third  edition  was 
put  out.  The  anatomy  of  each  part  is  reviewed  in 
so  far  as  applies  to  the  clinical  case.  Excellent 
directions  are  given  on  methods  of  examination, 
symptoms  and  general  treatment.  The  dealing  with 
affections  of  the  paranasal  sinus  is  particularly  ef- 
fective. The  examination  of  the  air  passages  with 
various  scopes  is  described  in  detail.  The  whole 
subject  of  diseases  of  these  special  parts  is  covered 
in  thorough  Scottish  fashion. 


MODERN  TREATMENT  AND  FORMULARY,  by 
Edward  A.  Mullen,  P.D.,  M.D.,  F.A.C.S.,  Assistant  Pro- 
fessor Pharmacology  and  Physiology,  Philadelphia  College 
of  Pharmacy  and  Science,  Lieutenant  Commander,  Medical 
Corps,   U.   S.   Naval   Reserve.     Foreword   by   Horatio   C. 


Wood,  jr..  Professor  of  Therapeutics  in  University  of  Penn- 
sylvania, Graduate  School  of  Medicine,  Professor  of  Phar- 
macology and  Physiology,  Philadelphia  College  of  Phar- 
macy and  Science.  F.  A.  Davis  Company,  Philadelphia. 
1936.     S5.00. 

For  a  time  treatment  was  neglected  and  formu- 
laries derided.  A  great  and  beneficent  change  com- 
ing about  in  this  regard  in  the  past  few  years  makes 
this  book  quite  opportune.  For  practically  every 
condition  which  a  doctor  may  be  called,  the  book 
recommends  drugs  and  other  remedies.  Diet  Lists, 
a  Table  of  Differential  Diagnoses,  Miscellaneous 
Emergencies,  Physician's  Interpreter  (in  5  lan- 
guages) ;  Poisons  and  Antidotes  and  many  other 
special  features  contribute  to  the  value  of  the  vol- 
ume. 


ALLERGIC  DISEASES:  Their  Diagnosis  and  Treat- 
ment, by  Ray  M.  Balyeat,  M.A.,  M.D.,  F.A.C.P.,  Associate 
Professor  of  Medicine  and  Lecturer  on  Diseases  Due  to 
Allergy,  University  of  Oklahoma  Medical  School;  Chief  of 
the  Allergy  Clinic,  University  Hospital ;  Consulting  Physi- 
cian to  St.  Anthony's  Hospital  and  to  the  State  University 
Hospital;  Consulting  Physician  to  St.  Anthony's  Hospital 
and  to  the  State  University  Hospital ;  President  of  the 
Association  for  the  Study  of  Allergy,  1930-1931;  Director, 
Balyeat  Hay  Fever  and  Asthma  Clinic,  assisted  by  Ralph 
BowEN,  B.A.,  M.D.,  F.A.A.P.,  Chief  of  Pediatric  Section, 
Balyeat  Hay  Fever  and  Asthma  Clinic,  Oklahoma  City. 
Illustrated  with  132  engravings,  including  S  in  color,  fourth 
edition,  revised  and  enlarged.  F.  A.  Davis  Company,  Phil- 
adelphia.    1936.     $6.00. 


Anal-  Sed 


Analgesic,    Sedative    and    Antipyretic 

.Affords  relief  in  migraine,  headache,  sciatica  and 
neuralgia.  Rheumatic  symptoms  are  frequently  re- 
lieved by  a  few  doses. 

Description 
Contains   i'/z    grains   of   Amidopyrine,    14    grain    of 
Caffeine  Hydrobromide  and  15  grains  of  Potassium 
Bromide  to  the  teaspoonful. 

Dosage 
The  usual  dose  ranges  from  one  to  two  teaspoonfuls 
in  a  little  water. 

How  Supplied 
In  pints  and  gallons  to  physicians  and  druggists. 


Burwell  &  Dunn  Company 


Manufacturing 
Established 


Pharmacists 
in   1887 


CHARLOTTE,  N.  C. 

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


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Balyeat's  name  stands  for  authority,  in  so  far  as 
there  can  be  any  authority  on  so  rapidly  developing 
and  so  extensive  a  subject  as  allergy. 

The  author  keeps  his  feet  on  the  ground  and  does 
not  become  carried  away  by  an  exaggerated  idea  of 
the  prevalence  of  the  disease  condition  and  the  im- 
portance of  the  subject. 

This  edititon  continues  the  series  of  reliable 
guides  for  doctors  in  dealing  with  their  allergic  pa- 
tients. 


DR.  COLWELL'S  D.^MLY  LOG.  Colwell  Publishing 
Co.,  Cliampaign,  III.     $6.00. 

The  main  reason  why  few  doctors  keep  accurate 
and  reliable  professional  and  business  records  is 
that  the  keeping  of  such  records  is  not  made  easy 
for  them.  The  Daily  Log  makes  easy  the  keeping 
of  such  records  to  the  immense  advantage  of  the 
doctor  in  the  care  of  his  patients,  in  the  develop- 
ment of  his  professional  knowledge,  in  the  collec- 
tion of  his  accounts,  in  his  making  a  creditable  ap- 
pearance when  called  into  court,  and  when  the  time 
comes  to  make  out  income  tax  reports. 


THE  1936  YE.4R  BOOK  OF  GENER..\L  SURGERY: 
Edited  by  Ev.\rts  \.  Graha^i,  A.B.,  M.D.,  Professor  of 
Surgery-,  Washington  University  School  of  Medicine;  Sur- 
geon-in-Chief  of  the  Barnes  Hospital  and  of  the  Children's 
Hospital,  St.  Louis.  The  Year  Book  Publishers,  Inc.,  Chi- 
cago.   §3.00  postpaid. 

U.  S.  P.  ether  from  drums  has  been  found  as 
satisfactory  as  from  small  tins.  Cyclopropane,  and 
spinal  analgesia,  have  many  friends.  A  mixture  of 
honey  and  cod  liver  oil  has  been  found  to  acceler- 
ate wound  healing.  Cirrhosis  of  the  liver  is  high 
among  Malays,  who  consume  little  or  no  alcohol. 
Roentgen  therapy  of  cancer  is  being  more  used 
now  than  ever  before.  Information  is  given  on 
better  management  of  facial  wounds.  Patients  with 
heart  disease  are  fairly  good  surgical  risks.  There 
is  a  report  of  fatal  hemorrhage  from  puncture  of 
the  epigastric  artery  during  paracentesis  for  ascites. 
Intussusception  in  adults  is  not  as  uncommon  as 
is  generally  supposed.  Hockworm  disease  may 
closely  simulate  appendicitis.  The  injection  treat- 
ment of  hernia  is  finding  favor.  A  good  deal  of 
the  pain  of  gallbladder  disease  comes  from  pan- 
creatitis. A  new  procedure  for  lumbar  puncture  is 
introduced.  A  splint  which  preserves  function  in 
broken  clavicles  is  described. 


APPLIED  DIETETICS  for  Adults  and  Children  in 
Health  and  Disease,  by  Sanford  Blum,  A.B.,  M.S.,  M.D., 
Head  of  Department  of  Pediatrics,  and  Director  of  Re- 
search Laboratory,  San  Francisco  Polvclinic  and  Po'^t 
Graduate  School.  F.  A.  Davis  Company,  Philadelphia 
1036.     $4.75.  ■ 

Dietaries  are  presented  which  the  author  has 
found  to  meet  the  needs  of  his  patient.s  over  20 
years,  and  which  can  be  readily  modified  to  meet 


individual  needs  elsewhere.  The  author  bears  in 
mind  the  essential  point  that  a  diet  should  be  such 
that  a  patient  can  and  will  folow  it.  No  food-fad- 
dist compilation,  the  book  is  made  up  of  sound 
directions  for  supplying  various  food  needs  and 
.generally  reasons  are  given. 


NEWS  ITEMS 


Forty-first  annual  meeting  of  the  Seaboakd  Medicai.  As- 
sociation OF  Virginia  and  North  Carolina  was  held  at 
Tarboro,  N.  C,  December  1st  to  3rd,  under  the  presidency 
of  Dr.  Spencer  P.  Bass,  of  Tarboro. 

Guests  from  outside  the  two  States  were  Asst  Surg 
Gen'l.  of  the  U.  S.  P.  H.  S.,  R.  A.  Vonrferteher ;  Dr.  How- 
ard A.  Patterson,  New  York;  Dr.  C.  H.  Mavo,  Rochester, 
Minn.;  and  Dr.  J.  P.  Hennessey,  New  York. 

New  officers:  Dr.  P.  L.  Moncure,  Norfolk,  president; 
Dr.  R.  J.  Walker,  Tarboro,  first  vice  president;  Dr.  F.  C. 
Rinker,  Norfolk,  second  vice  president;  Dr.  Tom  Watson, 
Greenville,  third  vice  president,  and  Dr.  A.  A.  Creecy,  New- 
port News,  Va.,  fourth  vice  president.  Dr.  Clarence  Por- 
ter Jones,  Newport  News,  was  re-elected  secretar\--treas- 
urer. 


The  third  annual  meeting  of  the  Southeastern  Branch 
Society  of  the  American  Urolocical  Assocmtion  was 
held  at  Charlotte,  Dec.  4th  and  5th.  The  Arrangements 
Committee  consisted  of  Dr.  Claude  B.  Squires  (chairman), 
Dr.  Raymond  Thompson,  Dr.  Robt.  W.  McKay,  Dr.  Ham- 
ilton W.  McKay. 

All  scientific  and  business  sessions  were  held  at  Hotel 
Charlotte.  A  golf  tournament  was  held  at  the  Charlotte 
Country  Club,  prizes  were  awarded,  luncheon  at  1  p.  m. 
both  days  at  Hotel  Charlotte,  and  on  the  afternoon  of  the 
4th  a  bridge  luncheon  and  other  entertainment  for  the 
ladies. 

An  elaborate  banquet  was  given  at  the  Charlotte  Country 
Club  the  evening  of  the  4th,  with  dancing  and  a  high  class 
floor  show. 

Dr.  Hamilton  W.  McKay,  Charlotte,  is  the  new  presi- 
dent. 


The  regular  monthly  meeting  of  the  Row.\n  County  (N. 
C.)  Medical  SociEr\-,  held  at  the  Court  House  at  Salisbury 
at  8  p.  m  ,  December  3rd,  had  as  guest  speaker  Dr.  Win- 
gate  M.  Johnson,  of  Winston-Salem,  who  spoke  to  a  large 
attendance  on  The  Trend  Toward  Socialized  Medicine  in 
the  United  States. 

Officers  of  the  society  are:  J.  C.  Eagle,  M.D.,  president  • 
W.  L.  Tatum,  M.  D.,  vice  president;  B.  W.  McKenzie 
M.D.,  secretary;  1.  E.  Shafer,  M.D.,  treasurer. 


The  Charlotte  Mental  Hygiene  Sochcty  and  the  Civic 
Education  Committee  of  the  Parent-Teacher  Council,  joint- 
ly, held  a  panel  discussion  of  mental  health  conditions  in 
the  State  at  the  Central  High  School  auditorium  the  even- 
ing of  December  7th.  Those  who  took  part  in  the  discus- 
sion were  Dr.  P.  H.  Gwyn,  of  Davidson  College;  Dr  Harry 
Crane,  of  Chapel  Hill;  Dr.  C.  E.  Boseman,  of  Pine  Bluff'; 
Miss  Helen  Taylor,  Director  of  the  Children's  Service  Bu- 
reau .Charlotte;  Miss  Margaret  Thomp.son,  of  the  City 
Schools;  Dr.  Allyn  Choate,  Treasurer  of  the  Charlotte  Men- 
tal Hygiene  Society  and  Vice  President  of  the  State  So- 
ciety; Miss  Elsie  Larsen,  Executive  Secretary  of  the  State 
Mental  Hygiene  Commission,  and  Graham  Davis,  of  the 
Duke  Foundation. 


678 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


The  semi-annual  meeting  of  First  Disiric  (S.  C.)  Med- 
ical Association  was  held  at  Ridgeland,  Nov.  18th,  at  4 
p.  m.    Program: 

Treatment  of  Open  Wounds,  Dr.  W.  H.  Prioleau,  Char- 
leston; Painful  Lesions  of  the  Eye,  Dr.  F.  R.  Price;  Treat- 
ment of  Congestive  Heart  Failure,  Dr.  G.  P.  Richards; 
The  Grading  of  Malignant  Tumors,  Dr.  T.  W.  Peery. 

Officers  elected::  Dr.  C.  P.  Ryan,  Ridgeland,  president; 
Dr.  Riddick  Ackerman,  Walterboro,  vice  president;  Dr. 
John  van  de  Erve,  jr.,  Charleston,  secretary  and  treasurer. 


At  the  meeting  of  the  Sullivan  and  Johnson  County 
(Tenn.)  Medical  Society,  held  November  11th,  Dr.  Ro- 
derick Heeffron,  Boston,  read  a  paper:  Serum  Treatment 
of  Lobar  Pneumonia;  and  Dr.  Jas.  K.  Hall,  Richmond: 
The  Value  of  Truth  in  Diagnosis  and  in  Therapy. 


The  GuLLFORD  County  Medical  Society,  meeting  in  the 
King  Cotton  Hotel,  Dec.  8th,  was  addressed  by  Dr.  George 
F.  CahiU,  of  the  Squier  Urologic  Clinic  of  the  Medical 
Center,  New  York  City.  Dr.  Cahill  used  for  his  subject 
The  Present  Value  of  Roentgenograms  in  Urinary  Tract 
Injuries.  Supper  was  served  at  6:30  o'clock  and  the  in- 
stallation of  the  new  officers  for  the  incoming  year  fol- 
lowed. The  new  officers  are  Dr.  P.  W.  Flagge,  president ; 
Dr.  W.  L.  Jackson,  vice  president;  Dr.  E.  T.  Harrison, 
secretar}',  and  Dr.  Philip  B.  Davis,  treasurer.  The  offices 
alternating  yearly,  all  officers  are  from  High  Point. 

The  retiring  officers,  who  were  commended  for  their  un- 
tiring service,  are  Dr.  J.  W.  Tankersley,  president;  Dr.  R. 
0.  Lyday,  vice  president,  and  Dr.  Norman  C.  Fox,  secre- 
tary. 


Dr.  H.  H.  H.arrison,  Dr.  L.  W.  Ellas,  of  Asheville,  and 
Dr.  F.  H.  Riqhardson  of  Black  Mountain  were  injured 
Nov.  16th  in  an  automobile  accident  as  they  were  passing 
through  Greensboro,  on  the  way  to  Baltimore  to  attend  a 
meeting  of  the  American  Pediatric  Society.  Dr.  Harrison, 
hurt  the  most  severely,  suffered  a  fractured  hip  and  right 
arm.     Dr.  Elias  received  chest  injuries  and  lacerations. 


Dr.  Harold  W.  Miller,  Woodstock,  has  been  named 
coroner  of  Shenandoah  County,  Va.,  by  Judge  Williams  of 
the  Circuit  Court.  He  succeeds  Dr.  William  C.  Ford,  who 
is  retiring  because  of  his  health,  after  having  been  county 
coroner  eight  years. 


Dr.  James  G.  Pate,  Gibson,  was  elected  president  of  the 
Fifth  District  Medical  Society  at  the  annual  fall  meeting 
at  Sanatorium,  October  21st.  He  succeeds  Dr.  A.  B. 
Holmes  of  Fairmont,  who  presided  at  the  meeting.  Dr. 
0.  L.  McFadyen  of  Fayetteville  was  re-elected  secretary- 
treasurer. 


Dr.  R.  a.  Schoonover,  Greensboro,  was  the  speaker  at 
the  weekly  luncheon  of  the  Kiwanis  Club  of  his  city  on 
November  12th.  Discussing  the  subject,  Old  Age  De- 
ferred, he  mentioned  the  early  50's  as  a  danger  period  and 
warned  against  youth-renewing  transplantations. 


Dr.  Beverley  R.  Tucker,  of  Richmond,  attended  the 
annual  meeting  of  the  Association  of  the  Seaboard  Air  Line 
Railway  Surgeons  in  Havana,  Cuba,  on  December  2nd  to 
5th. 


Dr.  E.  T.  Harrison-,  High  Point,  has  joined  the  staff  of 
the  Burrus  Memorial  Hospital,  succeeding  Dr.  Howard 
Sparling,  who  will  practice  at  Winston-Salem. 


Dr.  Tom  A  Willlajus,  formerly  of  Washington  and 
Florida,  and  a  former  Fellow  of  the  Tri-State  Medical  As- 
sociation, is  a  neurologist  member  of  the  recently  enlarged 
International  Clinic  at  Sherwood  Park,  Tunbridge  Wells, 
England.  In  the  winter  Dr.  Williams  engages  in  practice 
in  his  specialty  at  Bordighera,  Italy.  Rare  Tom  Williams 
sends  this  information  and  concludes  thus:  "I  regret  the 
loss  of  the  delightful  associations  of  my  former  Society.  A 
visit  from  any  member  would  be  welcomed  by  myself  and 
my  associates." 


Dr.  E.  C.  Bennett,  Elizabethtown,  recently  sustained 
severe  bruising  when  the  auto  in  which  he  was  returning 
to  Elizabethtown  from  Lumberton  overturned. 


Dr.  John  Donnelly.  Superintendent  of  the  Mecklenburg 
County  Sanatorium,  at  Huntersville,  was  elected  president 
of  the  Southern  Sanatorium  .Association  at  the  annual 
meeting  of  the  group  held  at  Hot  Springs,  Arkansas,  in 
November.  Dr.  Donnelly  was  unable  to  attend  the  meet- 
ing, but  was  advanced  for  that  honor  by  friends  in  spite 
of  his  absence. 


Dr.  J.  E.  CoPELAND,  of  Round  Hill,  Loudoun  County, 
Va.,  celebrated  his  Plst  birthday  December  3rd.  He  was 
born  in  Loudoun  County  and  has  spent  most  of  his  life 
there.  He  served  in  the  War  Between  the  States  and  is 
the  only  Confederate  veteran  in  the  county.  He  practiced 
medicine  after  the  close  of  the  war  until  about  the  age  of 
75,  when  he  retired.  He  and  Mrs.  Copeland  will  reach 
their  57th  wedding  anniversarj'  in  February. 


ARTHRITIS 

Prompt  and 
Sustained 


Relief 


SULPHOGEn 


U 


THERAPEUTIC  ACTION 

Pain    checked,    reduction    in    swelling    hastened, 
joint  mobility  definitely  increased. 
Therapeutic  doses  produce  no  toxic  symptoms. 
Non-irritating,  painless  and  no  "protein  shock." 

FORMULA: 

.\  5%  solution  of  Dipeptyl-Amino  Thiol.  Con- 
tains the  special  determinants  obtained  from  the 
protein  molecule  complex  and  organic  sulphur 
molecularly  combined  in  the  form  of  disulphide — 
S:S — and  sulphydryl — S  H — groups,  so  that  each 
2  c.c.  will  contain  the  equivalent  of  10  mgms.  of 
available  sulphur. 

.AVAILABLE:  2  c.c.  ampuls,  boxes  of  12,  25,  lOO. 

"Write  for  complete  literature. 


HYPO-MEDICAL 


490  BROADWAY  .  NEW  YORK,  N.Y. 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


Actual  Practice  in  Surgical  Technique 


v^ 


Method  of  Holding  Connel  Stitch.  From  Princi- 
ples of  Operative  Surgerv,  bv  A.  V.  Partip'lo 

M.D. 
Special  instruction  and  practice  in  the  technique  of  one 
or  more  operations  is  available  to  surgeons   who  wish  to 
review  the  anatomy  and  technique  of  certain  operations 
This  IS  an   especially  valuable  feature  of   our  institution! 


The  Laboratory  of  Surgical 
Technique  of  Chicago 

(incorporated  not  for  profit) 

offers  Instruction  and  Practice  in  Surgical 
Technique.  The  regular  two-weeks  course 
combines  Clinical  Teaching  with  actual  prac- 
tice by  the  students.  A  review  of  the  nec- 
essary Surgical  Anatomy  is  embraced  in  the 
work. 

Special  Courses 

Urology  and   Cystoscopy 
Proctology 

Ear,  Nose,  and  Throat 
Orthopedic  Surgery 
Gynecology  and  Obstetrics 
Larj-ngology  and  Bronchoscopy 
Surgical  Pathology 
Surgical  Anatomy 

passed. 


information 
Requi 


3S    to    Courses,    Fees,    Registration 
--lents.    Etc.,    Address 


A.  V.    PARTIPILO,  M.D.,  Director 

PhT.   t°"*'    °f '"    ^"'-    '"'^"^   ^°°'^    ^°""*y    Hospital) 
Phone   Haymarket  7044  visitors  Always   Welcom 


Dr.  B.  B.  Daltox,  Health  Officer  of  Richmond  County, 
North  Carolina,  has  resigned  to  enter  upon  the  private 
practice  of  medicine  at  Liberty,  in  Randolph  County. 

Appropriations  totaling  815,000  by  the  boards  of  super- 
visors of  Northampton  and  Accomac  Counties  have  been 
made  recently  to  the  Northampton-Accomac  Memoriaj, 
Hospital  at  Nassawado.x.  Both  boards  of  supervisors 
voted  unanimously  to  appropriate  $7,500  each,  and  nego- 
tiations resulted  in  the  indebtedness  being  cancelled  for  60 
per  cent,  of  the  principal  sum. 

The  Memorial  Hospital,  dedicated  to  the  Eastern  Shore 
men  who  sen-ed  in  the  World  War,  opened  in  1928  with 
a  superintendent,  three  undergraduate  nurses  and  '  three 
physicians,  Dr.  Don  S.  Daniel,  Dr.  John  R.  Hamilton  and 
Dr.  W.  Carey  Henderson.  In  1929  Dr.  H  .L.  Denoon  jr 
succeeded  Dr.  Daniel,  who  resigned  to  affiliate  with  a 
Richmond  hospital. 


From  Dr.  A.  E.  Baker,  Charleston 
Comparing  the  development  of  public  roads  and  public 
health,  Dr.  Reginald  Fitz,  Boston  internist  and  principal 
speaker  at  the  Founder's  Day  celebration  of  the  Medical 
College  of  the  State  of  South  Carolina,  on  Nov  6th  told 
approximately  100  physicians  and  surgeons  from  through- 
out South  Carolina  that  "if  we  continue  to  follow  the  path 
that  we  have  lately  been  following,  it  is  difficult  to  escape 
the  belief  that  before  long  some  form  of  State  medicine 
wUl  become  as  generally  acceptable  in  this  country  as  are 
the  State  roads."  The  celebration  opened  with  'a  series 
of  specialized  lectures  in  the  Roper  Hospital  clinics  and 
ended  with  a  banquet  at  the  Fort  Sumter  Hotel  where 
Dr.  Fitz  delivered  his  main  address  of  the  day  The  clinic 
lectures  were  given  by  Dr.  F.  Hoshall,  Dr.  W    A    Smith 


Dr.  A.  Johnston  Buist,  Dr.  Joseph  I.  Waring,  all  of  Char- 
teton,  and  Dr.  George  R.  Wilkinson,  of  Greenville,  and 
Dr.  Roger  G.  Doughty,  of  Columbia.  Dr.  Fitz  spoke  first 
at  a  luncheon  given  by  the  Medical  History  Club  at  the 
Fort  Sumter  Hotel,  on  Early  History  of  Lead  Poisoning 
m  Boston^  In  1723,  Dr.  Fitz  said,  a  law  was  passed  for- 
biddmg  the  distillation  of  rum  through  lead  pipes  The 
question,  he  said,  is  how  anyone  then  knew  the  poisonous 
properties  of  lead. 

Addressing  the  medical  men  on  the  subject.  From  Cow 
Path  to  State  Road:   An   Historic   Ramble,  Dr    Fitz   con- 
rasted   the  development   of   medicine   in    Charieston   with 
that  m  New  England.     The  original   New   Engenders,  he 
said,   were  culturally   far  behind   the  people   of   Charieston. 
The  beginnings  of  medicine  in  New  England  were  largely 
made  by  clergymen  and  it  was  not  until  after  the  Revolu- 
tion that  any  system  of  medical  education  was  established. 
Af  er  the  war,  however,  all  over  New  England  small  med- 
ical schools  became  established  in  appropriate  centers.     In 
I?50  or  thereabouts,   when   railroads   were   making  trans- 
portation  simpler,  the  stronger  schools  became  concentrat- 
ed m   large  centers  of  population   where  there  were  large 
hospitals    the  smaller  schools   being   driven   out    of   exist- 
ence^    The   War  Between   the   States,   if  anvthing,   was  :, 
handicap    to    the    development    of    medical    knowledge,    h-^ 
raid.    The  Spanish  War.  on  the  other  hand,  focused  public 
auent.on  upon  the  importance  of  infectious  diseases.    Dur- 
ing the  last  few  years,  he  declared,  it  has  been  shown  how 
difficult  1    may  be  in  times  of  depression  for  endowed  hos- 
pitals and  medical  schools  to  finance  themselves,  while  the 
State,  regarding  health  as  a  public  utility,  can  carry  for- 
ward public  health  programs  as  they  seem  indicated.    "Jult 
as  now  roads  have  been  developed,"  he  said,  "by  State  or 
government  funds,  so  also  have  the  by-paths  in  medicine 
tfiat  seemed  of  essential  importance  to  public  health  been 


680 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1Q36 


developed  by  State  or  government  funds." 

Dr.  Fitz  was  introduced  by  Dr.  Robert  Wilson,  Dean  of 
the  Medical  College,  who  acted  as  toastmaster.  Dr.  Fitz 
is  director  of  the  Massachusett's  Memorial  Hospital  and  a 
former  associate  professor  of  medicine  at  Harvard  Univer- 
sity. 

Funeral  services  for  Dr.  H.  M.  Brabham,  70-year-old 
physician  of  Erhardt,  who  died  Nov.  19th  after  breaking 
both  hips  in  a  fall  at  his  home,  were  conducted  at  the 
residence  on  Nov.  20th.  Interment  followed  in  the  Kearse 
Brabham   cemetery  near  there. 

Among  the  physicians  from  South  Carolina  who  attend- 
ed the  meeting  of  the  Southern  Medical  Association  in 
Baltimore  were  Drs.  Robert  Wilson,  jr.,  J.  H.  Cannon,  J. 
I.  Waring,  F.  B.  Johnson,  D.  L.  Maguire,  O.  B.  Chamber- 
lain, K.  M.  Lynch,  all  of  Charleston,  and  Dr.  Riddick  Ack- 
erman,  sr.,  of  Walterboro. 

Funeral  services  for  Dr.  James  Avery  Finger,  who  died 
Nov.  23rd,  were  held  at  the  Grace  Protestant  Episcopal 
Church  on  Nov.  24th.  A  native  of  Charleston,  Dr.  Finger 
was  S3  years  old.  He  was  graduated  from  the  Medical 
College  of  the  State  of  South  Carolina  and  was  affiliated 
with  several  fraternities. 

Dr.  O.  B.  Chamberlain,  of  Charleston,  was  taken  sud- 
denly ill  in  Baltimore  while  attending  the  meeting  of  the 
Southern  Medical  Association.  He  is  doing  nicely  in  Johns 
Hopkins  Hospital. 

Dr.  Francis  G.  Cain,  of  Charleston,  has  announced  that 
after  Dec.  1st  he  will  confine  his  work  to  surgery. 


Deaths 


Miss  Maud  Paine  Winborne  and  Dr.  Southgate  Leigh, 
jr.,  both  of  Norfolk,  Va.,  November  3rd,  at  St.  Paul's 
Church,  Richmond. 


Dr.  John  McKamie  Harry,  of  Concord  and  FayetteviUe, 
and  Miss  Sarah  Katherine  Currie,  of  Parkton,  were  married 
on  November  7th. 


Dr.  Ralph  Bernard  Garrison,  of  Glen  Alpine,  and  Miss 
Evelyn  Louise  Blackley,  of  Hamlet,  were  married  on  No- 
vember 14th.     They  will  live  in  Hamlet. 


Dr.  Herbert  Potts,  of  Goldsboro,  and  Miss  Sophia  Har- 
gett,  of  Mt.  Olive,  were  married  on  November  7th. 


Miss  Frances  Middleton,  of  Aberdeen,  Maryland,  and 
Dr.  James  H.  Bunn,  of  Henderson,  N.  C,  and  Baltimore, 
November  26th. 


Dr.  John  J.  Nelson,  jr.,  Columbia,  Va.,  died  suddenly  at 
the  home  of  his  mother,  December  4th. 


Dr.  Herbert  Potts,  Goldsboro,  and  Miss  Sophia  Hargett, 
Mt.  Olive,  were  married  November  7th. 


The  wedding  of  Miss  Lois  Griswold,  of  Wendell,  and 
Dr.  Robert  Boone  Outland,  of  Elm  City,  was  solemnized 
November  5th  in  the  Methodist  Church  at  the  home  of 
the  bride. 


Dr.   Greer   B.^ucHii.-ix,   Richmond,   has  been   appointed 
chief  surgeon  to  the  Richmond  Fire  Department. 


Dr.  Francis  Marion  Davis,  Greenville,  N.  C,  was  kill- 
ed instantly,  along  with  two  others,  on  November  15th, 
when  a  tire  blew  out  and  his  automobile  was  wrecked. 
Dr.  Davis  was  i2  years  of  age  and  a  graduate  of  Chapel 
Hill  and  Harvard. 


Dr.  William  McKim  Marriott,  Dean  of  the  School  of 
Medicine  of  the  University  of  California  at  Berkeley,  died 
there  at  the  age  of  51,  November  11th.  He  had  been,  for 
several  years  prior  to  last  .August,  Dean  of  the  School  of 
Medicine  of  Washington  University,  St.  Louis.  He  was 
an  academic  graduate  of  the  University  of  North  Carohna. 


Dr.  Robert  W.  Petrie,  60,  owner  of  the  Petrie  Hospital  at 
Murphy,  N.  C,  died  suddenly  of  a  heart  attack  the  after- 
noon of  November  17th,  as  he  entered  the  operating  room 
to  examine  a  patient.  Dr.  Petrie  practiced  first  at  Lincoln- 
ton,  where,  with  Dr.  L.  A.  Crowell,  he  was  one  of  the 
founders  of  Lincoln  (now  Gordon  Crowell  Memorial)  Hos- 
pital. Later  he  practiced  his  specialty  of  diseases  of  the 
eye,  ear,  nose  and  throat  at  Charlotte,  still  later  going  to 
Lenoir,  where,  again  with  Dr.  L.  A.  Crowell,  he  established 
the  Caldwell  Hospital.  Three  years  ago  he  built  the  Petrie 
Hospital  and  since  that  time  has  practiced  at  Murphy. 


Dr.  Edward  S.  Lester,  62,  died  November  15th  at  Memo- 
rial Hospital,  Danville,  Va.,  after  an  illness  of  two  months. 
He  was  widely  known  as  a  practitioner  and  he  had  been  a 
member  of  the  teaching  faculty  at  Hargrave  Military  In- 
stitute for  the  past  10  years. 


Dr.  C.  M.  Fauntleroy,  55,  for  28  years  in  the  U.  S.  P.  H. 
S.,  died  at  Charleston,  December  3rd,  while  driving  his 
automobile. 


AS  AC 

ELIXIR    ASPIRIN    COMPOUND 


Contains  five  grains  of  Aspirin,  two  and  a  half 
grains  of  Sodium  Bromide  and  one-half  grain  Caf- 
feine Hydrobromidc  to  the  teaspnonful  in  stable 
Elixir.  ASAC  is  used  for  relief  in  Rheumatism,  Neu- 
ralgia, Tonsillitis,  Headache  and  minor  pre-  and  post- 
operative cases,  especially  the  removal  of  Tonsils. 

Average  Dosage 
Two  to  four  teaspoonfuls  in  one  to  three  ounces  of 
water  as  prescribed  by  the  physician. 

How  Supplied 
In  Pints.  Five  Pints  and  Gallons  to  Physicians  and 
Druggists. 


Burwell  &  Dunn  Company 

Manufacturing  <^^^^  Pharmacists 


CHARLOTTE,  N.  C. 

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


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


The   Tulane   UniVersiti^  of  Louisiana 
GRADUATE  SCHOOL  of  MEDICINE 

Postgraduate  instruction  offered  in  all  branches  of  medicine. 

Special  Courses: 

Surgery,  Gynecology  and  Obstetrics — May  10  to  June  5,  1937. 
Tropical  Medicine  and  Parasitology — June  14  to  July  24,  1937. 

Courses  leading  to  a  higher  degree  are  also  given. 

A  bulletin  furnishing  detailed  information  may  be  obtained  upon  application  to 

THE  DEAN,  GRADUATE  SCHOOL  OF  MEDICINE 

1430  Tulane  Avenue,  New  Orleans,  La. 


Dr.  Charles  Metcalf  Byrnes  died  suddenly  in  his  office 
in  Baltimore  while  in  conversation  with  a  friend  on  the 
afternoon  of  November  2Qth.  He  was  SS  years  of  age. 
He  leaves  a  widow  and  a  little  girl.  Dr.  Byrnes  was  a 
native  of  Natchez,  Mississippi.  He  came  to  North  Caro- 
lina for  his  academic  work  and  he  was  graduated  from 
the  University  in  1902.  His  medical  education  was  ob- 
tained at  Johns  Hopkins  University,  from  which  he  was 
graduated  in  1906.  .\fter  having  served  an  interneship 
there  he  was  called  by  Dr.  Richard  H.  Whitehead,  the 
dean,  to  a  chair  in  the  School  of  Medicine  in  the  University 
of  Virginia.  From  there  he  returned  to  Baltimore,  where 
he  practiced  neurology  to  the  moment  of  his  death.  For 
many  years  he  had  been  a  member  of  the  faculty  of  the 
Medical  School  of  Johns  Hopkins  University.  Dr.  Byrnes 
had  many  friends  in  North  Carolina.  He  was  one  of  the 
great  neurologists  of  the  United  States. 

s.  M.  &  s. 


Our  Medical  Schools 


Medical  College  or  Virginia 


Armistice  Day  e.xercises  were  held  the  morning  of  No- 
vember 11th  at  Monumental  Church,  the  student  body, 
faculty  and  guests  present.  Dr.  W.  Lowndes  Peple,  emer- 
itus professor  of  clinical  surgery,  who  was  a  member  of 
the  McGuire  Unit,  Base  Hospital  45,  during  the  World  War 
was  the  speaker. 

A  grant  of  $100,636.00  has  been  made  to  the  college  by 
the  Public  Works  .Administration  for  the  construction  of  a 
new  dormitory  and  staff  house.  This  will  provide  living 
quarters  for  14S,  a  cafeteria  and  other  important  facilities. 
The  cost,  equipped,  will  be  $250,000.00. 

Dr.  Fred  J.  Wampler,  professor  of  preventive  medicine, 
and  Miss  Lillian  M.  Bischoff,  director  of  the  public  health 
nursing  course.  Saint  Philip  Hospital,  attended  the  meeting 
of  the  Southern  Branch  of  the  .American  Public  Health  As- 
sociation in  Baltimore,  November  17th  and  ISth. 

Dr.  I.  A.  Bigger,  Dr.  William  B.  Porter,  Dr.  Lee  E.  Sut- 
ton, jr..  Dr.  H.  Hudnall  Ware,  Dr.  H.  Page  Mauck  and 
Dr.  W.  T.  Sanger  were  among  those  who  attended  the 
meeting  of  the  Southern  Medical  Association  in  Baltimore, 
November  17th-20th.  Doctor  Sanger  discussed  Dr.  O.  W. 
Hyman's  paper  on  The  Number  and  Distribution  of  Phy- 
sicians in  the  Southern  States  as  Bearing  upon  the  Policies 
of  Southern  medical  colleges. 

The  R.  O.  T.  C.  classes  which  were  discontinued  as  an 
economy  measure  a  few  years  ago,  have  been  re-establish- 
ed this  year.  Under  this  plan  graduates  of  a  Class-A  med- 
ical school  after  taking  the  four  years'  work  with  the  R.  0. 


T.  C.  unit  are  awarded  a  first  lieutenancy  in  the  medical 
unit  of  the  Reserve  Officers'  Training  Corps. 

Dr.  J.  H.  Scherer  and  Dr.  Paul  Kimmelstiel  have  been 
appointed  joint  coroners  for  the  City  of  Richmond  to  suc- 
ceed the  late  Dr.  James  M.  Whitfield. 

Dr.  George  Z.  Williams,  a  graduate  of  the  University  of 
Colorado,  has  been  appointed  associate  in  pathology.  Doc- 
tor Williams  for  the  past  four  years  has  been  a  fellow  and 
an  instructor  in  pathology  in  the  School  of  Medicine  at 
the  LIniversity  of  Colorado. 

Dr.  Frederick  B.  Mandeville,  professor  of  radiology,  at- 
tended the  annual  meeting  of  the  Roentgen  Ray  Society  in 
Cleveland  recently. 

Dr.  Frederick  W.  Shaw,  professor  of  bacteriology,  has 
prepared  a  supplement  to  Physician's  Library  on  suipestifer 
infections  and  human  necrobacillosis. 

Dr.  Lewis  E.  Jarrett,  superintendent  of  the  hospital  divi- 
sion, attended  the  meetings  of  the  .American  Hospital  .As- 
sociation in  Cleveland  recently. 

The  Secretary  of  the  Interior,  Honorable  Harold  L. 
Ickes,  was  the  principal  speaker  at  Founders'  Day  of  the 
ninety-ninth  session  of  the  College  on  Tuesday,  December 
1st.  At  these  exercises  two  PW.A-aided  projects — a  new 
central  power  plant  and  tunnel  system  connecting  the  va- 
rious units  of  the  Hospital  Division,  and  a  laundry  with 
sewing  facilities — were  dedicated,  and  the  cornerstone  of 
the  new  clinic  and  laboratory  building,  also  PWA-aided, 
was  laid  with  Masonic  ceremonies.  .Another  PWA-aided 
project,  a  dormitory  to  house  the  hospital  house  staff  and 
the  senior  medical  class,  will  shortly  go  under  construc- 
tion. 

Others  who  spoke  briefly  on  Founders'  Day  were:  Hon. 
George  C.  Peery,  the  Governor  of  Virginia;  Dr.  J.  Fulmer 
Bright,  the  Mayor  of  Richmond;  Colonel  Robert  T.  Bar- 
ton, jr..  Vice  Chairman  of  the  Board  of  Visitors  of  the 
College;  Mr.  G.  .A.  Peple,  jr..  consulting  engineer;  Mr. 
Coleman  Baskerville.  architect,  and  Dr.  W.  T.  Sanger, 
President  of  the  College,  who  presided.  .A  considerable 
number  of  distinguished  guests  were  present  including  rep- 
resentatives of  the  Federal  and  State  Public  Works  .Ad- 
ministration, State  and  City  officials,  college  presidents, 
and  other  prominent  citizens.  The  program  was  broadcast 
over  WR\'.A,  Richmond. 

The  present  building  program  of  the  college  of  over  a 
million  dollars  is  being  financed  by  grants  from  the  Fed- 
eral government  of  appro.ximately  .'j;400,000,  a  gift  to  the 
institution  of  .'?300,000,  and  the  sale  of  self-liquidating  bonds 
of  approximately  $300,000. 

Wake  Forest 
Dr.  William   Boyd,  Professor  of  Pathology  at  the  Uni- 
versity of  Manitoba,  visited  the  school  October  29th  and 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


THE  CHILD'S  HEALTH  TODAY  IS  THE 
NATION'S  HEALTH  TOMORROW 


BUY 


CHRISTMAS 
SEALS 


The  National,  State  and  Local  Tuberculosis  Associations  of  the  United  States 


December,  1936 


SOUTHERN  MEDICINE  AND  SURGERY 


683 


lectured  to  the  student  body  and  invited  physicians  of 
surrounding  territon,-  on  Bronchogenic  Carcinoma. 

Doctors  C.  C.  Carpenter  and  H.  M.  Vann  attended  the 
meeting  of  the  American  Association  of  Medical  Colleges 
in  Atlanta  October  26th-2Sth.  On  the  trip  Dr.  Vann,  who 
is  district  counselor  for  the  Phi  Rho  Sigma  Fraternity, 
visited  the  chapters  at  Emory  University,  University  of 
Georgia  and  the  Medical  College  of  South  Carolina. 

Dr.  C.  C.  Carpenter.  Professor  of  Pathology,  attended 
the  meeting  of  the  Southern  Medical  Association  in  Balti- 
more November  16th-lPth. 

Dr.  Hubert  A.  Royster,  Professor  of  Surgery,  and  Dr. 
Ivan  Procter,  Professor  of  Obstetrics,  attended  the  meetine 
of  the  American  College  of  Surgeons  in  Philadelphia  Octo- 
ber lQth-23rd. 

Dr.  Thurman  D.  Kitchin,  President  of  the  College,  ad- 
dressed the  Eighth  District  Medical  Society  at  Leaksvillc 
on  November  24th. 

DUIE 

On  October  30th,  Dr.  A.  Graeme  Mitchell,  of  the  Chil- 
dren's Hospital,  Cincinnati,  Ohio,  lectured  at  Duke  Hospital 
on  the  Various  Phases  of  Endocrinology. 

On  November  3rd,  Dr.  Sanders  L.  Christian,  of  the  Unit- 
ed States  Public  Health  Ser.'ice,  Washington.  D.  C,  gave 
a  Resume  of  the  Hisfon.-  of  United  States  Pubhc  Health 
Service  and  Various  Functions  of  each  department. 

On  November  7th,  Dr.  George  W.  McCoy,  of  the  United 
States  Public  Health  Service,  Washington,  D.  C,  gave  a 
lecture  on  the  Recent  Advances  in  Epidemiology. 

UinvEFsmr  of  Virginia 

At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  October  IQth  Dr.  E.  P.  Lehman  read  a  paper 
on  The  Endocrines  in  Surgery  and  Dr.  J.  Edwin  Wood 
spoke  on  the  subject  of  Diuretics. 

The  third  Post-Graduate  Course  in  Ophthalmology  and 
Oto-Laryngology  was  held  at  the  University  of  Virginia 
on  October  27th-30th.  Lectures  and  clinics  were  given  by 
Dr.  Gabriel  Tucker,  University  of  Pennsylvania;  Dr.  Perry 
Goldsmith,  University  of  Toronto;  Mr.  E.  B.  Burchell, 
Eno  Laborator>',  New  York  City;  Dr.  John  R.  Richardson, 
Boston;  Dr.  Bernard  Samuels,  Cornell  University;  Dr. 
Webb  W.  Weeks,  New  York  University  and  Bellevue  Hos- 
pital Medical  College;  Dr.  Harry  S.  Gradle,  Northwestern 
University;  Dr.  James  W.  White,  New  York  University; 
anad  Dr.  H.  S.  Hedges,  University  of  Virginia. 

On  October  29th  Dr.  E,  C.  Drash  spoke  before  the  Mer- 
cer County  Medical  Society  at  Princeton,  West  Virginia, 
on  the  subject  of  The  Present  Status  of  Thoracic  Surgery. 
On  November  18th  Dr.  Maximilian  Ehrenstein,  Research 
Associate  in  Organic  and  Physiological  Chemistry  at  the 
University  of  Virginia  Medical  School,  gave  a  report  on 
Recent  Advances  in  the  Field  of  Male  Sex  Hormones  be- 
fore the  Section  on  Urology  of  the  Southern  Medical  Asso- 
ciation in  Baltimore. 

Dr.  William  R.  Houston,  of  Austin,  Texas,  addressed  the 
fall  meeting  of  Alpha  Omega  Alpha  on  October  29th.  He 
spoke  on  The  History  of  Medical  Thoucht. 

On  October  27th  Dr.  H.  B.  Mulholland  spoke  before  the 
American  Clinical  and  Climatological  Societv  in  Richmond 
on  the  subject  of  Weil's  Disease. 

The  eighteenth  Post-Graduate  Medical  Clinic  was  held 
at  the  University  Hospital  on  November  6th.  Forty-five 
physicians  registered  for  the  course. 

On  November  22nd  Dr.  H.  B.  Mulholland  spoke  to  the 
Academy  of  Medicine  in  Lynchburg  on  Recent  Advances 
in  Medicine. 


At  the  meeting  of  the  University  of  Virginia  Medical 
Society  on  November  16th  Dr.  T.  L.  Squier,  of  MUwaukee, 
Wisconsin,  spoke  on  the  subject  of  Bone  Marrow  Insuffi- 
ciency with  Especial  Reference  to  Granulocytopenia  and 
Thrombocytopenia. 

• S.    U.    &   B. 


POSTPAETITII    HB3HORRHAGE    IN    OUTPAnENT   OBSTETRICS 

(H.  Buxbaum  and   I.  C.   Udesky,  Chicago,  in   III.   Med.  Jl.. 

Nov.) 

Good  obstetrics  can  be  done  in  homes  under  seemingly 
unsurmountable  obstacles. 

Operative  obstetrics  should  be  done  only  when  strictly 
indicated. 

Uterine  exhaustion  in  the  first  stage  of  labor  should  be 
avoided  by  the  administration  of  large  quantities  of  fluids 
and  carbohydrates,  plus  morphine  sulphate  alone  or  in 
combination  with  a  synergist  to  give  the  patient  plenty  of 
rest.  Morphine  should  not  be  given  within  3  hours  of  the 
expected  birth  of  the  child. 

In  the  3rd  stage  of  labor  avoid  all  meddlesome  manip- 
ulations. 

Blood  transfusions  in  amounts  not  less  than  700  c.c. 
should  be  given  early  and  freely. 


-a.   M.   Ic  8.- 


FouRTH    Biennial   Report   of   the   North   Carolina 
Industrial  Commission 

North  Carolina  workers  or  their  dependents  in  seven 
years  have  received  6'/^  million  dollars  in  compensation 
benefits,  plus  3  1/3  million  dollars  in  medical,  hospital 
and  nursing  care— a  total  of  $9,747,775  in  all  benefits  under 
the  Workmen's  Compensation  Act. 

Without  counting  days  lost  due  to  death  or  permanent 
partial  disability,  North  Carolina  workers  actually  lost 
during  the  seven  years  nearly  2  million  days  from  work 
due  to  the  over  200,000  accidents. 

For  the  fiscal  year  ending  July  1st,  32,568  compensation 
claims  were  filed,  and  $1,356,962  were  paid  for  compensa- 
tion and  medical  care. 

The  last  fiscal  year  the  commission  handled  next  to  the 
largest  number  of  claims  since  its  organization  in  1929, 
being  surpassed  only  by  the  first  year. 

In  addition  to  the  claims  for  accidental  injuries,  216 
claims    were    filed    under    the    newly-enacted   Occupational 


FOR 

PAIN 

The  majority  of  the  phy- 
sicians  In  the   Carollnas 
art  prescribing  our  new 
tablets 


AND 


751 


AmlieiU  Md  Sedatlva     7  parti      5  pirti       I  Dtrt 


Aiplrln   PhenaaetiB  Ctff«li 


STe  will  mail  professional  samples  regularly 
with  nur  comjAiments  if  you  desire  them. 
Carolina   Pharmaceutical    Co.,    Clinton,   S. 


rrly  I 

•OT.  I 


6S4 


SOUTHERN  MEDICINE  AND  SURGERY 


December,  1936 


Disease  Amendment,  with  a  total  cost  of  $6,138  and  2,418 
days  lost  from  work. 

Last  year  763  cases  went  to  a  hearing  before  an  indi- 
vidual commissioner,  and  105  were  appealed  to  the  Full 
Commission. 

Since  1920  there  have  been  298  appeals  to  Superior  Court 
from  decisions  of  the  Full  Commission,  of  which  the  court 
affirmed  151,  reversed  40,  and  107  have  not  been  heard  for 
various  reasons,  including  abandonment  of  appeal. 

Since  1929  there  have  been  99  compensation  cases  ap- 
pealed to  the  Supreme  Court.  Of  this  number  the  Supreme 
Court  affirmed  79  commission  decisions  and  reversed  20. 


Specific  Food  Sensitiveness 


Although  there  are  more  disappointments  than  miracles 
in  the  search  for  and  the  curing  of  severe  manifestations 
of  food  sensitiveness  the  miracles  are  so  gratifying  that, 
each  time,  the  clinician  will  resolve  to  spend  more  time 
looking  for  them.  The  field  is  still  much  neglected;  more 
diets  must  be  fitted  and  fewer  handed  out  ready  made. 

A  good  history  will  often  show  that  the  diet  is  probably 
not  the  cause  for  the  patient's  discomfort.  Patients  must 
not  be  left  too  long  on  narrow  elimination  diets;  such 
diets  are  for  testing  and  not  for  treatment. 

Some  cases  of  diarrhea  and  pseudo-ulcer  are  due  to  the 
milk  that  is  taken  by  way  of  treatment,  and  not  infre- 
quently certain  foods  irritate  or  greatly  depress  the  brain. 
Somnolence  after  meals  can  be  due  to  a  particular  food, 
and  canker  sores  in  the  mouth  can  be  produced  by  food. 

Efforts  to  use  an  elimination  diet  are  often  instructive  in 
showing  the  physician  that  he  is  dealing  with  an  unreason- 
able, overly  fussy,  querulous,  or  psychopathic  person. 

Food  sensitiveness  is  not  necessarily  allergic  or  due  to 
protein.  Perhaps  partly  for  this  reason,  skin  tests  are  of 
little  help  in  finding  the  foods  that  cause  indigestion. 


The  Ow'nt:rshtp  of  X-ray  NEC^mfES 

(Leslie  Childs,  Atty.,  Indianapolis,  in  Clin.   Med.  iS.  Surg., 

Nov.) 

X-ray  negatives,  in  a  sense,  differ  little,  if  at  all,  from 
microscopic  slides  of  tissue  made  in  the  course  of  diagnosis 
or  treating  a  patient  but  it  would  hardly  be  claimed  that 
such  slides  were  the  property  of  the  patient.  A  recent 
court  decision: 

".\l50,  in  the  event  of  a  malpractice  suit  against  a  phy- 
sician or  surgeon,  the  x-ray  negatives,  which  he  has  caused 
to  be  taken  and  preserved,  incident  to  treating  the  patient 
might  often  constitute  the  unimpeachable  evidence  which 
would  fully  justify  the  treatment  of  which  the  patient  was 
complaining. 

"In  the  absence  of  an  agreement  to  the  contrary,  there 
is  every  good  reason  for  holding  that  x-ray  negatives  are 
the  property  of  the  physician  or  surgeon,  rather  than  of 
the  patient  or  party  who  employed  such  physician  or  sur- 
geon, notwithstanding  the  cost  of  taking  the  x-ray  pictures 
was  charged  to  the  patient  or  to  the  one  who  engaged  the 
physician  or  surgeon,  as  a  part  of  the  professional  service 
rendered " 


-s.  M.  &  s.- 


PoisoNiNG  BY  PoTASSitrM  CHLORATE.— A  case  is  reported 
by  H.  L.  Robinson,  in  the  Chinese  Medical  Journal  for 
August.  Death  ensued  on  the  9th  day  after  taking  an 
ounce  of  the  chlorate  which  he  said  he  had  bought  for 
Epsom  salts. 


CHUCKLES 

So  I  returned  and  went  to  "'Heaven"  where  Luellin  and 
I  dined.  .  .  .  Then  we  went  to  a  sport  called  "selling  a 
horse  for  a  dish  of  eggs  and  herrings." — Samuel  Pepys. 

.Another  thing  that  helps  to  keep  this  country  in  a  tur- 
moil is  the  peculiar  attraction  that  strong  lungs  have  for 
weak  heads. — Thomastoti   (Ga.)   Times. 

"An  exclusive  vegetable  diet  will  make  you  beautiful," 
asserts  a  woman  columnist.  Lady,  did  you  ever  take  a 
good  look  at  a  hippopotamus? — Thomaston   (Ga.)   Times. 

Physician  recommends  for  the  middle-aged  light  exercise 
and  a  siesta  each  day.  Daily  dozen  and  daily  dozing. — 
.Arkansas  Gazette. 

A  noted  lung  specialist  says  that  a  man  who  sings  at  the 
top  of  his  voice  for  an  hour  a  day  won't  be  troubled  by 
chest  complaints  in  his  old  age. 

He  probably  won't  be  troubled  with  old  age. 

Student  (holding  test  tube  up  to  his  ear) :  "The  chem- 
istry book  says,  'Introduce  ferrous  sulphate,  then  slowly 
add  sulfuric  acid  and  note  the  ring.'  Blamed  if  I  can  hear 
a  sound." 

''You  are  a  little  goose,"  remarked  a  young  M.D.  to  his 

"Of  course,  I  am,"  was  the  laughing  response.  "Haven't 
I  got  a  quack?" — Ex. 

Visitor:     "How  old  are  you,  sonny?" 

Boston  Boy:  "That's  hard  to  say,  sir.  .According  to  my 
latest  school  tests,  I  have  a  psychological  age  of  11  and  a 
moral  age  of  10.  Anatomically,  I'm  7 ;  mentally,  I'm  9. 
But  I  suppose  you  refer  to  my  chronological  age.  That's 
8 — but  nobody  pays  any  attention  to  that  these  days!" — 
Christian  Science  Monitor. 

"Leishmaniasis,"  I  muttered  to  myself. 

The  eyes  of  Mrs.  Cohen  spat  fire. 

"What  do  you  know  about  Mr.  Lysman  and  myself? 
And  furthermore  it's  none  of  your  business,  and  nobody 
else's."    And  out  she  went. 

My  meditations  were  suddenly  interrupted  by  an  elderly 
woman,  an  inquisitive  visitor:  "My  good  man,  do  you 
like  it  here?"  When  informed  that  I  am  one  of  the  physi- 
cians she  apologized  profusely,  then  turned  to  her  lady 
companion.  "Martha,  this  will  be  a  good  lesson  for  me. 
Never  judge  a  man  by  appearance." 

Lawyer:     "Then  your  husband,  I  take  it,  is  elderly?" 

Client:  "Elderly?  Why,  he's  so  old  he  gets  winded 
placing  chess." — Mutual  Magazine. 

Sympathizer:     "How's  your  insomnia?" 

Incurable:  "Worse  and  worse.  I  can't  even  sleep  when 
it's  time  to  get  up." — Answers. 

The  witness  was  nervous  on  the  stand  and  tried  to  pass 
it  off  with  some  racy  testimony.  At  one  time  he  mentioned 
"a  coupla  quartsa  Scotch." 

"What  is  Scotch?"  asked  the  magistrate. 

"Not  wot  it  used  to  be,  yer  honor,  not  arf." — Humorist. 

"Did  you  have  a  local  anaesthetic?'' 

"No,  I  went  to  a  hospital  in  Boston." 

He — Mar>',  here's  a  hair  in  this  pie  crust. 

She — Well,  it  looks  like  one  of  yours,  Henry.  It  must 
have  come  off  the  roUingpin. 

It's  money,  money,  money  all  the  time.  Do  you  think 
I'm  the  goose  that  lays  the  golden  eggs? 

No,  not  that  one. 

Son — Mother,  what  does  it  mean  when  the  paper  says 
some  man  went  to  a  convention  as  a  delegate-at-large? 

Mother — It  means  his  wife  didn't  go  with  him,  son. 


SOUTHERN  MEDICINE  AND  SURGERY 

INDEX  1936 

--^DRESSES,  ORIGINAL  ARTICLES  AND  CASE  REPORTS 

Adenitis,  Acute  Mesenteric,  A  Filtrable-Virus  Disease    cT~IFAVr, "^ 

After  Body,  Soul  and  Spirit-What?,  /.  5   BarkTde "^ 

Amebiasis,  Surgical  Complications  of,  ;=■   K   Boland  ^''^ 

•'""w/J"' '''!!li^^^:!"*^!j:°  '^^^^^^^^^^^^'^^^^^^^^^^^  ' 

Ano-rectal  Hemorrhage,  C.  C.  Massey    L                            19 

Antisepsis,    Chemical,   Soulhgate   Leigh   ^     Zi                                      " 36S 

Appendicitis,  The  Diagnosis  and  Treatment'of  AcutTlTW  T^^t "' 

Appendicitis,  Mortality  in  1.7S6  Cases  of  Acut e   pZrZ.   '  ^  J/       r~-~, "3 

Arsphenamine  Poisoning,  FnigUity  of  the  Veins'  as  a  Fartt^  ^.^  W '♦aS 

Walsh  &  C.  S.  Stickley  __  ^'""^  ""  ^^^  Production  of,  Groesbeck 

Art  of  Practice  and  Healing,  C   C   Orr                  ~                ' — -  363 

Auricular  Fibrillation,  A.  B.  Choa'te ;; ■ US 

Backache,  D.  W.  Holt  ._.„ 649 

Backache— Pain,  A   .A.  Barron  _I1    1  1__Z                             ^27 

Bacterial  Vaccine  Therapy,  J    T    Wolfe                               '*^'* 

Beyond  the  Veil  (Poem),  Groes'beck  Wals'h\_                 ^ " -■-  ^^^ 

Blood  Transtusion— A  New  Method,  /.  Elliott  '  "■  ^^  Koyner,  jr 633 

Case  History   (Poem),  Groesbeck   Walsh  ,  ^'^^ 

Carcinoma  of  the  Rectum:  Stricture  of  the  Rectum,  fl-'ssione ^^-^ 

Cardiac  Hypertrophy-Hypertension-Nephrosclerosis,'  F.  E    Zem J, 

Card  ovascu  ar  Diagnosis,  Common-sense  in,  E.  J.  G   Beardskv  " ^°^ 

Cardiovascular  Syphilis,  T.  R.  Littlejohn  1 i       i^eardsley 264 

Cartilaginous  Growths,  A    .E.   Baker ' 314 

Chemical  Antisepsis,  Southgate  Leigh  Z J! ""  269 

'''"Ky'-'-Stili^JSe^^r'r^^^^^^^  "' 

Chondroiibroma  of  the  Trachea,  E.  T.  Gatewood  ^  " 

Coccygeal  Region  of  a  Babv,  Abnormal  Growth  From7hrR^~P~^F "* 

'°"^^z^:jx^-^'  ^-"-'°-'  ^~  of;^h:Teg^wVsp^-r^re„e7io77.T. "' 

Cystm  Stones,  R.  W.  McKay ^ .    371 

Cysts,  Sarcococcygeal,  J.  B.  Jones  _J  _      _  — 367 

""'"VI'a, J''  ^pp°:^-_"""^  °f  j-«'i"  Throughou7^;":^„~thrT;;;^;;;;;^";^"wr^-: '" 

Diagnosis  and  Treatment  of  Acute  Appendicitis,  The," ^  H  Tr^t f° 

Diarrhea  m  Children,  IF.  /.  iflciey  ,  n-  n.  irout  . j23 

Diphtheria  Case,  Report  of  General  Lymphadenitis  in'  a"p~T^JZ::^ '*^^ 

Doctor,  What  Life  Teaches  the,  E.  J.  G.  LSv       '  ^"'^"^" 2S0 

Economics  and  State  Medicine,  A.  P   Willis ~ *^^ 

Enuresis  Essential,  F.  R.  Tavlor  '  361 

Epilepsy  Treated  by  Antirabic  Vaccine,  A  Case  of  Idinmth,v""/l""K'"n/""-^^^^ ^'^^ 

Eugenics,  Medicine's  Need  of,  Wm.  Allan  _!  __     _!!   _        "  ^"«*' ^99 

Fear,  The  Dominance  of,  L.  G.  Beall Zl__l  ^^^ 

^'^t  T^t^i:y  ^_^^-_';^^-ductio^  ofArsphenaminT^^ningZ^^tl^rS^S^    '" 

Francisco,  Peter,  /.  K.  Hall "_  ■ — 363 

Glomus  Tumor,  G.  W.  Horsley  _ ~  — 5*2 

Goitre,  J  .P.  Munroe ~SZ. — -—        S 

Gout— The  Modern  Disease,  A.  Cohen     "        „  1"""' " ~- S79 

Growth  From  the  Coccygeal  Region  of  a  Baby,  Abnormal'  IT^Prl^'^ter^^ ^H 

Growths,  Cartilaginous,  A.  E.  Baker _         _  Itmmerman igg 

Heart  Disease,  A  Sudden  Death  Not  Caused  By   J  F  NoTh  '  "^ ^*' 

Heart  Massage  A^aFinal^rt  for  Resuscitating  Hearts  Fl^n71j;;;^7:;,-;ti^^;Yrc.    ''' 

Hemorrhage,  Ano-rectal,  C.  C.  Massey ~ 4S9 

Hemorrhage.  Spontaneous  Subarchnoid,  /   H    McNeil  ~  ~ 36S 

Hypennsulinism    A  Simple  Approach  to  the  Diagnosis  of",  G.  J^ "  ira'wo«'"AT''R   "p.T; aI^ 

Hypertension-Cardiac  Hypertrophy-Nephrosclerosis,  F.  E    Zemfi  '  ^'"''^—    ^" 

Hypothyroidism  in  Children,  Mild,  /.  R    Ashe ^ • 202 

Indigestion,  Nervous,  P.  F.  Whitaker ' — " ^^^ 

Infections,  The  Upper  Respiratory,  Page  Norlhington '~       ~ ~~ '* 

influenza— Some  Observations  and  Impressions,  W.  M   Johnson    I i 


SOUTHERN  MEDICINE  AND  SURGERY 

Institutional  Treatment  of  the  Negro  With  Special  Reference  to  Collapse  Therapy,  John  Don- 

Insulin,  Protamine,  Harold  Glascock,  jr S31 

Insulin  Through  the  Day  in  the  Treatment  of  Diabetes,  The  Apportionment  of,  W.  R.  Jor- 
dan   _ 420 

Interesting  Case?,  What  Constitutes  an,  P.  H.  Ringer 245 

Internal  Medicine,  The  Common  Field  of  Psychiatry  and,  C.  A.  Baseman 469 

Intestinal  Obstruction,  An  Analysis  of  70  Cases  of  Acute,  Edgar  Angel  &  Alex.  Kizinski S9S 

Jurisprudence,  Medical,  C.  A.  Douglas 6S 

Kidney  Tuberculosis,  Management  of,  A.  J.  Crowell 133 

Larj'ngeal  Stenosis  in  Children,  Acute,  E.  W.  Carpenter 423 

Lateral  Sinus  Thrombosis  With  Recovery,  Furman  &  Edgar  Angel 479 

Life  Teaches  the  Doctor?,  What,  E.  J.  G.  Beardsley 177 

Lumbosacral  Fusion  in  Low  Back  Disorders,  Apparent  Indications  For,  O.  L.  Miller S33 

Lymphadenitis  in  a  Diphtheria  Case,  Report  of  General,  A.  E.  Turman 2S0 

Medical  Jurisprudence,  C.  A.  Douglas 6S 

Medicine's  Need  of  Eugenics,  Wm.  Allan . 416 

Meningococcus  Meningitis  and  Some  Related  Problems,  The  Incidence  of,  W.  B.  Blanton 373 

Meningo-enchephalitis  a  Complication  of  Undulant  Fever,  C.  E.  Ervin  „...  478 

Menopause.  The  Psvchotic  Disturbances  Incidental  to  Pregnancy,  the  Puerperal  State  and, 

R.  H.  Long      ' 310 

Mental  Disease,  Maladjustment  As  a  Cause  of,  D.  C.  Wilson S21 

Mesenteric  Adenitis — ,  Acute,  A  Filtrable-virus  Disease,  C.  S.  White S23 

Mortality  in  1,786  Cases  of  Acute  Appendicitis,  Furman  &  Edgar  Angel  _i 428 

Narcotic  Drug  Addictions.  Evaluation  of  Various  Treatments  For,  W.  C.  Ashworth 200 

Negro,  Institutional  Treatment  of  the.  With  Special  Reference  to   Collapse  Therapy,  John 

Donnelly  „  -  - 7S 

Nervous  Indigestion,  The  Management  of,  P.  F.  Whitaker 16 

Nephroptosis,  The  Diagnosis  and  Treatment  of,  /.  D.  Highsmith  &  C.  J.  Albright ^_..  192 

Obstetrical  Anesthesia  With  Special  Reference  to  Local  Infiltration,  The  Selection  of,  W.  Z. 

Bradford 19 

Osteomyelitis  of  the  Vertebrae,  G.  C.  Dale 13 

Ovarian  Cysts  With  Hemorrhage,  Rupture  of,  A.  deT.  Valk 131 

Pain — Backache,  A.  A.  Barron 474 

Pellagra,  B.  R.  Tucker 2S3 

Peptic  Ulcers,  The  Surgical  Treatment  of,  Paul  McBee 71 

Peter  Francisco — Hyperpituitary  Patriot,  /.  K.  Ball S82 

Physician's  Theology,  A,  F.  R.   Taylor 69 

Poliomyelitis?,  Are  Transfusions  Beneficial  in,  C.  U.  Gay 418 

President  of  the  Medical  Society  of  the  State  of  North  Carolina,  Address  of  the,  P.  H.  Rin- 

President  of  the  Tri-State  Medical  Association  of  the  Carolinas  and  Virginia,  Address  of  the, 

C.  C.  Orr lis 

Prostatic  Resorption  and  Resection  in  Early  Prostatism,  Maximilian  Stern 518 

Prostatic  Resection,  More  About,  F  .A.  Ellis 208 

Psychiatn,-  and  Internal  Medicine,  The  Common  Field  of,  C.  A.  Baseman  469 

Psychotic  Disturbances  Incidental  to  Pregnancy,  the  Puerperal  State  and  the  Menopause,  The, 

R.  H.  Long  310 

Protamine  Insulin,  Harold  Glascock,  jr. S31 

Rectum:,  Carcinoma  of  the,  Stricture  of  the  Rectum,  H.  B.  Stone 1 

Respiratory  Infections,  The  Upper,  Page  Narthington 118 

Sacrococcygeal  Cysts,  J.  B.  Jones 411 

State  Medicine  and  Economics,  A.  P.  Willis 361 

Sterility  in  Women  From  the  Functional,  Endocrinal  and  Organic  Viewpoint,  A  Review  of 

sob  Cases  of,  R.  T.  Ferguson 259 

Stones,  Cystin,  R.  W.  McKay 367 

Subarachnoid  Hemorrhage.  Spontaneous.  /.  H.  McNeil 316 

Sudden  Death  Not  Caused  by  Heart  Disease,  J.  F.  Nash 428 

Syphilis,  Cardiovascular.  T.  R.  Litllejohn 314 

Syphilis,  The  Treatment  of  Congenital,  with  Acetarsone,  J.  M.  Arena  &  C.  H.  Gay 73 

Theology,  The  Physician's.  F.  R.  Taylor 69 

Trachea,  Chondrofibroma  of  the,  E.  T.  Gatewood 136 

Transfusions  Beneficial  in  Poliomyelitis?,  Are,  C.  H.  Gay 418 

Tuberculosis,  Management  of  Kidney,  .4.  /.  Crowell 133 

Tumor,  Glomus,   G.   W.  Horsley 5 

Undulant  Fever,  Meningo-encephalitis  a  Complication  of,  C.  E.  Ervin 478 

Upper  Respiratory  Infections,  The,  Page  Narthington 118 

Uterine  Bleeding,  The  Physiology  and  Pathology  of,  Ivan  Procter 303 

Vaccine  Therapy,  Bacterial,  J.  T.  Wolfe 181 

Veil,  Beyond  the  (Poem),  Groesbeck  Walsh 283 

Vertebrae,  Osteomyelitis  of  the,  G.  C.  Dale 13 

Veronal  and  Related   Drugs,   A  Suggestion  for  Their  More  Restricted  Use,  The  Injurious 

Effect  of,  W.  C.  Ashworth 592 

Vertigo — Its  Causes  and  Treatment.  J.  .4.  Shield __._ 61 


SOUTHERN  MEDICINE  AND  SURGERY 

NOTES 
{Uyisigned  Articles  are  by  the  Davis  Hospital  Stag) 

Abdomijlal   Drarag;^'""!'""'''!''""  '^"  Differential  Diagnosis  of  Upper  Right S63 

Appendicitis  in  Infants  and  Small  Children  l.'l "_ ~  Z^ITZZ 31s 

Breast,  Tumors  of  the,  in  Women  in  the  Late  ChUd-Bearing  Period 

Colitis    -  _ 

381 

_ 65 1 

79 


272 


Conditions  Overlooked  in  Aged  Women  

Diphtheria,  The  Treatment  of  Laryngeal  Obstruction  in 

Gallbladder  Disease,  Diagnosis  of 

Gastrointestinal    E.\aminations    !_! \ ~~  ^°^ 

Gynecological    Examinations ~_  "  \^\ 

Hernia  in  Children,  The  Repair  of 

Hookworm  _.  ..  ._ 

Jaundice  Associated  With  Pancreatitis,  Seven  Cases  of  Obstructive  Z. 
Laryngeal  Obstruction  in  Diphtheria,  The  Treatment  of 
Menstrual  Cycle,  The  Investigation  of  Pain  Associated  With  the  .._! 
Narcolepsy 


Hookworm '"  3^^ 

382 

602 

-- -- --.  79 

600 

139 


Operations,  Multiple _   

Osteomyelitis,  Acute,  in  Children  ^     ""  Z 1LZ~ ~  319 

Ovarian  Cyst,  Uterine  Fibroid  and  Pregnancy— Differential  Diagnosrs"B7t^^eii'"ZZZ 

Pyloric  Obstruction  in  Infants 

Pyloric  Ulcer  in  a  Boy  14  Years  of  Age,  Acute  Perforation  of  a  _ 

Practical  Practice  Notes,  C.  C.  Hubbard '"  

Prostate,  The ~ 160 

Prostatic  Resection  Results  '_ ^_  2.  ^^^ 

Spinal  Fluid  in  Surgical  Patients,  Examination  of  _____ 

Spine,  X-ray  Examination  of  the _  1_ 

Tumors  of  the  Breast  in  Women  1..  the  Late  Child-Bearing  Period 

Vagmitis  in  Infancy  and  Childhood,  A.  Hinson 

X-Ray   Examination   of  the   Spine   


601 
319 

44 
600 


601 
210 
318 


EDITORIALS 


228 
670 
446 


.,    ,  .      ^.  {Unsigned  Editorials  are  bv  the  Editor) 

Abstracts  in  this  Issue:  Long-Accepted  and  True  Not  Synonyms  «n4 

Assertmg  Ourselves  in  Elections,  For „          _  _  _ ,„ 

Automobiles    Toward  Keeping  Others  and  Ourselves  from"  being  Killed  by 
Automobile  Wreck  Losses,  Toward  Doing  Something  About 

Beeman:,  Dr.  P.  T.,  He  Fed  Fever   _  __ 

Beware °'-° 

Brush-Up  Course,  The . -  288 

Brush-Up  Course  in  This  Month,  About  Our  _    "     "  ^ 

Brush-Up  Course,  Our  "~ ^06 

Cancer,  A  Lesson  in  Ways  of  Fighting    ____! Z  ~ «nf 

Cancer,  Reasoning  on  Facts  About  _ ~  ' f:. 

Cause,  Injuring  a  Good '   '   ""      "  ^° 

Columbia  Tri-State  Meeting  The U'  _"  '. 1 _~"ZI  ~~ oa   Vl? 

Corporations  to  Practice  Medicine,  Unlawful  for '  "  '  '  ^l 

Correction [2  ' " 

County  Medical  Society,  Publicity  For ^  ~ ^j^ 

Development  of  Roentgenology,  The '. Z ' ta? 

Doctor  of  Medicine  For?,  What's  a  Plain I '  ~ ?! 

Doctors,  The  Public's  Obligation  to  _      ;;;  H 

n°JnTi  ^™,k"'"^.k'''  ^f ''  ^"^  Protesting  the  Rights" of  Regular  Licensed  34! 

Domg  Something  About  Automobile  Wreck  Losses,  Toward    _! ill 

Duke's  Post  Graduate  Course  October  15th  to  17th «a 

Elections,  For  Asserting  Ourselves  in J2  ooa 

Epilepsy,  A  Promising  Treatment  For :,f 

F^a,  Why  We,  C.  C.  Hubbard  ^^     ___    'I '""  "f 

Fever,  He  Fed:  Dr.  P.  T.  Beeman II • "^ 

General  Practitioners,  No   Slur  on _"~  ' ", 

Health  Bulletin  and  Its  Editor,  The  _      I  1 Z_ I'll  ' ^11 

Heart  Disease,  What  to  Tell  the  Patient  With  .'  _Z 47 

Heartening  Incident,  A ~  ' "*'' 

How  Much  We  Know  that  Isn't  So  ...Jl.'. ~     I     ~" ,^^ 

Hubbard,  Dr.,  As  a  Representative  Family  Doctor  11 ILZl  ". '  fif 

Impingement  of  Pubhc  Health  Activities  on  Private  Practice         "      "'  IaI 

Injuring  a  Good   Cause  "  ^^° 

.lennings.   President ]"ZZ_ Zl ■ 55? 

Medical  Schools,  Reconsideration  As  to  Chapel  Hill  and  Wake  Forest 


Medical  Society  of  the  State  of  North  Carolina,  The  President  of  the,  D.  JB."CoTb~ 


164 

47 
344 


SOUTHERN  MEDICINE  AND  SURGERY 

Medicine,   On   Choosing . 619 

Mouse,  Not  Another,  Even  from  That  Mountain S66 

Nash,   Editor 449 

Non  Nocere  S06 

Practical  in  Medicine,  A  Word  For  the 284 

President  Jennings 164 

President  of  the  Medical  Society  of  the  State  of  North  Carolina,  D.  B.  Cobb 344 

Protecting  the  Public  and  Protecting  the  Rights  of  Regular  Licensed  Doctors 348 

PubUc  Health  Activities  on  Private  Practice,  The  Impingement  of 346 

Public  Health  as  Defined  by  S.  G.  Parran  ...-- 671 

Public  Health  Teaching  on  the  Hill . 230 

Public's  Obligation  to  Doctors,  The 98 

Publicity   for  Every   County   Medical  Society 400 

Reasoning  on  Facts  About  Cancer . 448 

Reconsideration  As  to  Chapel  Hill  and  Wake  Forest  Medical  Schools  (Abs.  /.  A.  M  J..) 47 

Representative  Doctor,  Dr.  Hubbard  As  a , 164 

Roentgenology,  The  Development  of 287 

Sanatorium  for  the  Tuberculous,  The  Western  North  Carolina,  L.  G.  Beall 231 

Sugar-Free  Suffice?,  Does  Keeping  the  Urine,  Wm.  Allan  __._ 349 

Sun  Do  Move,"  The  Rev.  John  Hasper  Preached,  "De  _.__ . S06 

Teaching  on  the  Hill,  Public  Health 230 

Tell  the  Patient  With  Heart  Disease,  What  to . 399 

Tri-State   Meeting,   The    Coming    671 

Tri-State  Meeting,  The  Columbia 98,  163 

Tuberculous,  The  Western  North  Carolina  Sanatorium  for  the,  L.  G.  Beall 231 

Two  Hundred  Years  But  As  a  Single  Day S67 

Unlawful  for  Corporations  to  Practice  Medicine 46 

Urine  Sugar-Free  Suffice?,  Does  Keeping,  Wm.  Allan . 349 

What's  a  Plain  Doctor  of  Medicine  For? 99 

Word  for  the  Practical  in  Medicine,  A 284 

DEPARTMENT  EDITORIALS 

(Unsigned  Department  Editorials  are  by  the  Editor  of  the  Department;  in  Departments  in  which 
there  is  more  than  one  Editor,  each  editorial  is  signed) 

HUMAN  BEHAVIOR 

About  Mr.  Polydoron . 82 

Anthony   Comstock   Comes  to  Town  667 

Avoidance   of  Ingratitude,  On 26 

Civic   Financing,   Cyclic . 26 

Community's  Responsibility  for  the  Mentally  Sick,  The 144 

Goldfish,   On   Invisible 393 

Heredity,  Immortality,  Protoplasm 221 

Incineration .   A   Civic   668 

Ingratitude,  On   Avoidance  of . 26 

Inner  Selves,  Our 341 

Invisible  Goldfish,  On  393 

Lawyers  and  Liquor 497 

Laymanized  Psychiatry,  On 393 

Licensing  Lawyers  and   Doctors 499 

Odysseying  in  the  Mountains S60 

Our  Inner  Selves 341 

Physician,  The  True 222 

Polydoron,  About  Mr. 82 

Professional   Progression 442 

Protoplasm,   Heredity,   Immortality 221 

Psychiatric  Mediaevalism,  On . 26 

Psychiatry,  On  Laymanized . 393 

Publicize   Psychotics?,   Why 393 

Regression,   On   . 603 

Responsibility  for  the  Mentally  Sick,  The  Community's 144 

Retrospection,  Mostly  in 280 

True  Physician,  The  222 

Department  Editor — /.  K.  Hall 


EYE,  EAR,  NOSE  AND  THROAT  DISEASES 

General  Conditions  As  Explanations  of  Eye  Smptoms,  F.  C.  Smith 397 

Ophthalmological  Pitfalls,  Some,  N.  H.  Turner 27 

Visual  Requirements  for  Drivers  of  Automobiles,  F.  C.  Smith ISS 

Department  Editors — Charlotte  Eye,,  Ear  and  Throat  Hospital  Group 


SOUTHERN  MEDICINE  AND  SURGERY 


ORTHOPEDIC  SURGERY 


94 

221 

495 

94 

1S4 


A,  B,  C's  of  Fractures  of  the  Long  Bones,  The,  /.  5   Gaul     _          _         _  i  e4 

Colles'  Fracture,  0.  L.  Miller  ~" "™L~Z!'""r"Il"IZZ~" 

Disturbance  of  Growth  in  Long  Bones  as  Result  of  Fractures  That  Include  the  Epiphy^sTf 

Chnical  and  Medicolegal  Interest,  0.  L.  Miller 

Flat  Feet— Painful  Feet,  J.  S.  Gaul ;"_"' ' 

Fracture,  Colles',  0.  L.  Miller \  "__ '_ 

Fractures  of  the  Long  Bones,  The  A,  B,  C's  of,  /  .S.  Gavl         S  J. L  _U      _    _   J 

Fractures  That  Include  the  Epiphysis,  Disturbance  of  Growth  in  Long  Bones  as  "a  Result" of" 

of  Chnical  and  Medicolegal  Interest,  O.  L.  Miller 221 

Giant-Cell  Tumors  of  Long  Bones,  Treatment  of,  O.  L.  Miller   _    __I 440 

Metastatic  Type  of  Osteomyelitis,  The,  J.  S.  Gaul _1_1___  394 

Osteomyelitis,  Chronic,  /.  5.  Gaul _^_ ,. 

Osteomyelitis,  The  Metastatic  Type  of,  /.  S.  Gaul '_ 394 

Tumors  of  Long  Bones,  Treatment  of  Giant-Cell,  0.  L.  MiUer " " J'_  '_  "  "  440 

Department  Editors— 0.  L.  Miller  and  J.  S.  Gaul 

UROLOGY 

Calculus  Resulting  From  Foreign  Bodies  in  the  Urinary  Bladder,  A  Discussion  of,  P   E  Ruth  322 

Diverticulum  of  the  Urinary  Bladder,  P.  E.  Huth 1_  142 

Foreign  Bodies  in  the  Urinary  Bladder  With  an  Unusual  Calculus  Resulting  'Therefrom   P  E 

Huth  „   ,.   ' 

Hydrocele  With  Inflammatory  Changes,  Unusually  i^argi,~N~o'Benson~H~'ZII  212 

Malignancy  in  an  Undescended  Testis,  P.  G.  Fox  &  Harold  Glascock '_    "_UZ  434 

Medical  Treatment  of  Genito-Urinary  Tuberculosis,  P   A    Yoder "_     ~  84 

Nephritis  a  Medical  or  a  Urological  Problem?,  Is,  £;»ier  jyej^  __    Z.               70 

Prostatic,  Care  of  the,  /.   11'.  Frazier  ^       _       _"      ""        _    _  ^Z 

Trigonitis  With  Neoarsphenamine,  The  Treatment  of'Acute  Gonorrheai',">7"o;"Be„yon~ "" 604 

Tuberculosis,  Medical  Treatment  of  Genito-Urinarv-,  P    4    Yoder . 84 

Undescended  Testis,  Malignancy  in  An,  P.  G.  Fox  '&  Harold  Glascock     __ZI""  434 

Urethral  Strictures,  R.  W.  McKav   __ __          _   _~      ITTZ ' SS6 

Urinary  Infections,  The  Influence' of  Stasis  on  Chronic,  ^.W.^cA'ay  ^^^ 

Departmxnt  Editors— fl'.  W.  and  H.  W.  McKay 

INTERNAL  MEDICINE 

Anemia,  Pernicious,  P.  H.  Ringer  .  __ 

Acute  Abdominal  Disease  Simulating  "Coronarv  Occlusion,  W   B   Kinlaw "77  22S 

Coronary  Occlusion,  Acute  Abdominal  Disease  Simulating,  W.  B.  Kinlaw    '  22  S 

Hereditary  Factor  in  Obesity,  The,  P.  H.  Ringer " 

Medical  Post-Operative  Complications,  Some  Early,  W.  B.  Kinlawi^              '"  ifin 

Obesity,  The  Hereditary  Factor  in,  P.  H.  Ringer "'  '"" 

Paroxysmal  Tachycardia,  IF.  B.  Kinlaw •'^^ 

Pernicious  Anemia,  P.  H.  Ringer "'2.  L.  J, 

Pneumonia,  The  Treatment  of,  P.  H  .Ringer  . 1  _'"  i43 

Post-Operative  Complications,  Some  Early  Medical,  W.  B.  Kinlaw'       "        '"  ifin 

Psychoneuroses,  P.  H.  Ringer ~  °" 

■Rheumatism"    and    Arthritis    _.„           ~    __     '    '_ "_    "J  ^^^ 

Streptothrix  and  Monilia  Infections  as  CUnicarEntities,'"/'." J7 "  Rimer                               fil4 

Treatment,  The  Art  of,  P.  H.  Ringer TZITTT SOI 


Department  Editors— P.  H.  Ringer  and  W.  B.  Kinlaw 


395 


Air-Conditioned  Operating  Room,  The 

Anemic,  Operations  Upon  the Z!_Z1 '_ Z~ 

Anoxemia   of  the   Brain _^ "     "  ~  .^'1 

Burns,   George  McCutchen .......1. ]1 '~~.  ISO 

Gallbladder  Surger\-,  Impaired  Liver  Function  As  a  Cause  of  Death  After  ^« 

Hand?.  The  Care  of  the  Surgeon's ''" 

Liver  Function,  Impaired  after  Gallbladder  Surgery Zl 

Peritonitis,  The  Fallopian  Tube  As  a  Portal  of  Entrance  for  the  Causative  Agenr^Tchem" 

Peritonitis,  The  Treatment  of  J 7 ~     ZZ 

Prayer,  The   Surgeon's  ,,° 

Regional   Differences    in    Appendicitis  Deaths   

Retractor,  Abdominal,  Use  and  the  Abuse  of  the  IZ_ ZZ!  71 

Shock,  Modem  Understanding  of '_ 


607 


432 
662 
S44 
279 


Department  Editor— G.  H.  Bunch 


Care,  Simplified  Obstetric  (Abs.),  E.  D    Plass , ccn 

Excuses,  We  Seek '  ^Iz 

3S 


SOUTHERN  MEDICINE  A>n)  SURGERY 

Obstetrical  Hemorrhage  Outside  the  Hospital,  Management  of,  J.  S.  Brewer^ 4S2 

Dep.\rtment  Editor — U.  J.  Langston 


GYNECOLOGY 

Cancer  of  the  Cervix,  A  Summarj'  of  the  Diagnosis  and  Treatment  of,  W.  F.  Martin 89 

Cervicitis,   Chronic  iSl 

Leukorrhea-   _ '. 320 

Department  Editor — C.  R.  Robins 

PEDIATRICS 

Allergy    Simplified . 391 

Gleanings  From  Here  and  There 215 

I  BeUeve 92 

Immunizations,  Prophylactic 327 

Measles    Prophylaxis 149 

Meeting,  The  Georgia  Pediatric 38 

Meeting  of  the  Medical  Society  of  the  State  of  North  Carolina 149 

Meeting,  State  Medical  Society,  May  4th  to  6th 214 

Meeting,  Roaring   Gap SSI 

Milk,    Certified 27S 

Mumps  Pancreatitis 439 

Pediatric    Ramble    6SS 

Pick-Ups 606 

Vincent's  Infection  of  the  Mouth SOO 

Dep.«tment  Editor — G.  W.  Kntscker 


GENERAL   PRACTICE 

American  Foundation,  An  Open  Letter  to  the 87 

Arthritis  Problem,  The  Present  Status  of  the 147 

Books,  Two . 440 

Country  Doctor,  The,  C.  C.  Hubbard 148 

Doctor,    The SS4 

Duke's  Post   Graduate   Course 612 

Hospitals,  Open  Season  For 274 

Meeting,  The  A.  M.  A.,  in  Kansas  City 329 

Meeting,  The   Eighth   District 274 

Naarna   Darrell   214 

Opinion,  A  Cocksure 147 

Physician  and  the  Pharisees,"  "The 388 

Press?,  How  Free  is  the 489 

Public  Health,  Partners  in .. 610 

Security,"  "We  Do  Not  Want 612 

Southern   Medical   Meeting 663 

Tribute,  A.  J.  A.  McMillan 439 

Word,  A  Personal 329 

Department  Editor — W.  M.  Johnson 


clinical  chemistry  and  microscopy 

Autopsy,  The  Incomplete 215 

Cancer  Cell,  The  _- 66S 

Physiology  and  Pathology  in  Gynecology 383 

Sedimentation  of  Red  Blood  Cells,  /.  /.  Combs 32S 

Dep.wtment  Editor — C.  C.  Carpenter 

hospitals 

Advertisement,  The  Best SSI 

Doctor's    Routine,    Tht 338 

For  Whom  Are  Hospitals  Built? 213 

Hospital  Daddy,  A 36 

Noises  and  Odors,   Hospital 273 

Presentation  of  Diplomas  to  a  Class  of  Nurses,  /.  P.  Kennedy 387 

Private   versus  Public   Hospitals 441 

Purchasing  Agent,  Central,  for  a .  387 

Registered  Nurse  and  Hospital  Meetings,  The . ,  1S7 

Spade  a  Spade 606 

Visiting  Hours . .  493 

Waste,    Hospital 93 

Who  is  at  Fault? 653 

Departmejjt  Editor — R.  B.  Davis 


I 


SOUTHERN  MEDICINE  AND  SURGERY 

PHARMACY 

Changes  in  U.  S.  P.  and  N.  F.,  Some  553,  609 

Depariment  Editor — W.  L.  Moose 

HISTORIC  MEDICINE 

Byrd's  Histon.-  of  the  Dividing  Line 500 

Department  Editors — Various 

CARDIOLOGY 

Cardiovascular  Literature,  Recent 390 

Coronary  Disease,  Two  Problems  in  the  Management  of 493 

Coronan.-  Disease,  Two  Questions  in  S47 

Hypothyroid   Heart,   The 278 

Rheumatic  Fever:   Complications,  5.  F.  Ravenel . 86 

Rheumatic  Fever;   Early  Treatment 41 

Rheumatic  Fever,  EUas  Faison  _ 219 

Department  Editor — C.  M.  Gilmore 

PUBLIC  health 

A.  P.  A.  Meeting  669 

Physical  Defects  to  Growth  in  Children,  The  Relation  of 438 

Physician  and  the  Sanitary  Inspector,  The 396 

Preschool   Examination,  The  217 

Rural  Health  Service  in  the  United  States 5.60 

Social  Security  Act  and  Public  Health  Policies,  The 37 

Superintendent  of  Schools  and  the  Health  Officer,  The 492 

Swimming  Pools  and  Bathing  Beaches 340 

Syphilis  Control,  The  Private  Physician  and 279 

Department  Editor — A^.  T.  Ennett 

dermatology 
Eczema  Therapy  (Abs.),  F.  Wise  &  J.  Wolf 


Department  Editor — J.  A.  Elliott 


radiology 


Bronchiectasis 276 

Carcinoma,  Cervical  Metastatic 40 

Dermatology,  Roentgen  Therapy  in 217 

Endocrine   Disorders,   Value   of   Roentgenography   of   the   Epiphyses   for   the   Diagnosis   of 

Preadult 487 

Heart  Disease,  Roentgen  Diagnosis  of 96 

Iso-Iodeikon  or  Diodrast  Any  Therapeutic  Value?  ,Has —  SS5 

Menopausal  Syndrome,  Pituitary  Irradiation  for  the 389 

Mineral  Oil.  Dangers  in  Use  of  - : -664 

Myeloma,  Multiple,  F.  B.  Mandeville  444 

Pitressin  in  Cholec\stography  and  Urography 608 

Pituitary   Basophilism 339 

Radio-Curability  of  Tumors 1S8 

Department  Editors — Wright  Clarkson  and  Allen  Barker 


therapeutics 

Christian  Festschrift,  The,  F.   R.   Tavlor  ^^ 1S3 

Gout,"  "A  Dialog  With  the  (Franklin),  F.  R.  Taylor  ^ 331 

Epitome  of  the  U.  S.  Pharmacopeia  and  National  Formulary,  F.  R.  Taylor SSO 

Obstetrical  Analgesia,  J.  F.  Nash  ^ —  490 

Oxford  Loose-Leaf  Medicine,  High  Spots  From  New  Chapters,  F.  R.  Taylor  — 224 

Prescriptions  in  Some  Common  Ailments,  Some  Useful,  /.  F.  Nash  431 

Pediatric  Problems  of  North  Carolina,  One  of  the,  /.  A.  Shaw — -  549 

Vaginal  Specula   of   1S50,  /.  F.  Nash - 656 

Department  Editors — P.  R.  Taylor  and  /.  F.  Nash 

CLINICAL  psychiatry 

Depressions,   The    660 

Psychiatry,  Attitudes  Toward . . S4S 

Therapy  in  Modern  Psychiatry , —  612 

DEP.iVRTMENT  EDITOR — C.  A.  Boseman 

IN  MEMORLAM 

Anderson,  Dr.  Tom,  /.  M.  Northington  _ 350 

Averitt,  Dr.  Kirby  J.,  J.  F.  Highsjith,  sr —  290 

Babington,  Robert  B.,  0.  L.  Miller  .- - —     48 


SOUTHERN  MEDICINE  AND  SURGERY 


Blair,  Dr.  Alexander  McNeil,  C.  H.  Cocke 

Burrus,  Dr.  John  T.,  J.  M.  Northington 

Gray,  Dr.  Eugene  Price,  W.  M.  Johnson 

Harmon,  Dr.  Samuel  E.,  /.  H.  Mcintosh  

Kluttz,  Dr.  DeWitt,  /.  C.  &  Joshua  Tayloe  

Knox,  Dr.  A.  W.,  H.  A.  Rovster 


Leigh,  Southgate,  /.  M.  Northington  

Dr.   G.  D.  McGregor,  /.  M.  Northington  

Potts,  Dr.  Frederick  L.,  DeWitt  Kluttz  

Robertson,  Dr.  Luther  A.,  H.  J.  Langston 

Redfern,  Dr.  Thomas  Craig,  Wingate  Johnson 

Shuford,  Dr.  J.  H.,  J.  M.  Northington 

Shuford,  Dr.  J.  H.,  A.  C.McCall  

Smith,  Dr.  Z.  G.,  B.  R.  Tucker 


Smithwick,  Dr.  James  Edwin,  /.  M.  Northington 
TRI-STATE  MEDICAL  ASSOCIATION 


290 
401 
S68 
290 
S68 
S78 
231 
673 
292 
292 
624 
294 
294 
294 
507 
289 


Fellows  of  the  Tri-State  Medical  Association 


AUTHORS 

(of  Original  Articles,  See  further  under  Editorials,  Dept.  Editorials,  Notes,  etc.) 


Albright,  C.  J. 

Allan,  Wm. 

Angel,  Edgar 

Angel,  Furman 

Arena,  J.  M 

Ashe,  J.  R. 

Ashworth,  W.  C.  _- 

Baker.  A.  E. 

Barksdale,  I.  S. 

Barron,  A.  A.  

Beall,  L.  G. 

Beardslev,  E.  J.  G. 

Blanton,  W.  B.  

Boland,  F.  K. 

Boseman,  C.  A.  

Bost,  T.  C. 

Bradford,  W.  Z.  _ 

Carpenter,  E.  W 

Choate,  A.  B.  

Cohen,  A 

Crowell,  A.  J. 

Crowell,  L.  A. 

Dale,  G.  C.  


Donnelly,  John 
Douglas,  C.  A.  _ 


Elliott,  J.  

Ellis,  F.  A.  - 
Ervin,  C.  E. 


Ferguson,  R.  T.  _ 

Gatewood,  E.  T. 
Gay,  C.  H. 


192 
416 

_426,  479,  595 

426,  479 

73 

587 

200,  592 

269 

471 

474 

377 

177,  264 

373 

7 

469 

459 

19 


423 
649 
637 
133 
23 

13 

75 
65 

643 
208 
478 

2S9 


Glascock,  Harold,  jr. 
Graham,  A.   S. 

Hall,  J.  K. 

Highsmith,  J.  D. 

Holt,  D.  W 

Horsley,  G.  W. 


-73,  418 
S31 

187 

__  582 
192 

52  7 

5 


Johnson,  W.  M. 

Jones,  J.  B.  

Jordan,  W.  R.  _ 


513 
411 
420 


Kizinski,   Alexander 


Lackey,  W.  J. 

Leigh,  Southgate 
Littlejohn,  T.  R. 
Long,  R.  H. 

Massey,  C.  C.  

Miller,  O.  L 

Munroe,  J.  P. 

McBee,   Paul 

McKav,  R.  W. 

McNeil,  J.  H. 

Nash,  J.  F. 

Northington,  Page 

Orr,  C.  C 


Rainey,  W.  T.  __. 
Ringer,  P.  H. 

Rovster,  H.  A.,  jr. 

Shield,  J.  A. 

Stem,    Maximilian 

Stickley,  C.  S. 

Stone,  H.  B. 


Ta\-lor,  F.  R.  

Timmerman,  W.  P. 

Trout,  H.  H. 

Tucker,  B.  R.  

Turman,  A.  E. 


Valk,  A.  deT. 


595 

477 
129 
314 


_  365 
_  533 
__  579 
_  71 
-_  367 
_  316 


428 
118 

115 

465 
303 

371 
245 
633 

61 
518 
363 


-.69,  646 

199 

123 

253 

250 


Walsh,    Groesbeck 
Whitaker,  P.  F.  _ 

White,   C.   S. 

Wilkinson,  G  .R.  ... 

Willis,  A.  P. 

Wilson,  D.  C. 

Wolfe,  J.  T 

Wright,  O.  E. 

Zemp,  F.  E.  


..283,  363,  673 

16 

523 

465 

365 

521 

181 

599