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Full text of "Southern medicine and surgery [serial]"

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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 
J n a cute abscess the onset is sudden, with severe 
abdominal pain, which appears to be worse at night. 
The commonest location of the pain is in the liver, 
although it may be in the epigastrium or shoulder. 
Pain may come on so suddenly and violently as to 
imitate gallstone colic, or perforated peptic ulcer 
with subphrenic abscess formation. Fever is high 
and irregularly intermittent, the decline being ac- 
companied by profuse sweating. Remissions in the 
temperature may mean secondary infection. Chills 
are frequent, and taken with the fever, may sug- 
gest malaria. Enlarged liver may seem to develop 
rather suddenly, but the enlargement probably has 
been in process for several days. Nausea and vom- 
iting may be marked. The skin generally is sallow, 
but jaundice is uncommon. Acute liver abscess due 
to Entamoeba histolytica may be so violent as to 
result fatally in a few days. Dyspnea suggests 
invohement of the pleura or lung, a complication 



which is more apt to go unrecognized until autopsy 
than is abscess of the liver. Leucocytosis ranges 
from 15,000 to 30,000. The polymorphonuclear 
count ordinarily is low in pure amebic abscess and 
high when mixed infection is present. 

The chronic variety may exist for many months 
or years, with alternating appearance and subsi- 
dence of symptoms from time to time. There is 
apt to be cough, night sweats and weakness, and 
tuberculosis is suspected. Roentgen-ray is a val- 
uable aid in diagnosing either the acute or chronic 
form. If the liver is not definitely enlarged, it is 
remarkable how many cases of liver abscess are 
diagnosed by roentgenology as pulmonary or pleural 
lesions. Lateral as well as antero-posterior views 
should be made, the former bringing out the full 
curve of the diaphragm, and thus differentiating 
between lesions below and above the diaphragm. 
In chronic liver abscess, after recognizing enlarged 
liver, the problem may be to eliminate syphilis, 
carcinoma and cirrhosis. Positive Wassermann re- 
actions in the Negro race are of little significance 
in our community, since 40 per cent, of the colored 
population give such reactions. 

The incidence of appendicitis as a complication 
of amebiasis is stated by various authors as be- 
tween 7 and 40 per cent., the former figure prob- 
ably being more accurate. The symptoms more 
nearly resemble the chronic form, although acute 
appendicitis may be simulated. It is essential to 
recognize the nature of the lesion, if possible, since 
amebicidal medication is indicated rather than 
operation. Gallbladder and urological sequelae are 
seldom met in amebiasis, but constipation and in- 
testinal obstruction may result from peritonitis. 

Ochsner and DeBakey, in a recent paper," pre- 
sent a discussion of the pleuropulmonary complica- 
tions of amebiasis, in which they report 153 collect- 
ed cases and 15 personal cases. Such complications 
occurred in 15 per cent, of 2500 cases of liver ab- 
scess. They take place as a rule as a result of an 
extension of amebic hepatic abscess. Perforation 
of the abscess seldom occurs into the free pleural 
space, but more frequently into the lung or bron- 
chus. Exceptionally hematogenous pulmonary ame- 
bic abscesses may develop. The clinical manifesta- 
tions of pleuropulmonary amebiasis consist chiefly 
of cough and expectoration, fever, dysentery, en- 
larged and tender liver, pain in the chest and 
cachexia. The expectoration of chocolate-colored 
pus is indicative of a communication between a 
liver abscess and a bronchus, and is of diagnostic 
importance. Pulmonary manifestations consist of 
consolidation and cavitation. Roentgen examina- 
tions shows elevation and fixation of the diaphragm 
and a shadow at the right base, particularly in 
those cases in which a pulmonary abscess extends 



SURGICAL COMPLICATIONS OF AMEBIASIS—Boland 



January, 1936 



from a liver abscess. The shadow may show a 
characteristic triangular shape with the base below 
and the apex above. Diagnosis can be definitely 
established by the typical chocolate-colored pus and 
finding amebas in the sputum and aspirated mate- 
rial, ^lortality in the collected cases was 41 per 
cent. 

Abscess of the brain due to amebiasis furnishes 
less than 1 per cent, of complications. Infestation 
takes place in the brain through the blood stream, 
one or both cerebral hemispheres being involved, 
with symptoms of headache, nausea, vomiting, de- 
lirium and convulsions. Fever may be absent, and 
the cerebrospinal fluid may be clear. Death gen- 
erally ensues in a few days. 

Treatment and Results 

Emetine or one of the newer drugs, as treparsol 
or chiniofon, is believed to be specific for amebia- 
sis and its complications. Emetine, however, is 
generally recommended in the treatment of liver 
abscess and other complications. The dose is one 
grain daily, hypodermically, for not more than ten 
or twelve days. Some patients seem to possess an 
idiosyncrasy for emetine, so that its administration 
must be watched carefully. Nausea, vomiting, 
cramps and prostration may develop. The irriga- 
tion of abscess cavities with any kind of amebicidal 
drug is of doubtful efficiency. 

Rogers and other authorities insist that the safest 
and most effectual treatment for hepatic and other 
amebic abscesses is by aspiration and the adminis- 
tration of emetine. In a series of 2661 cases of 
liver abscess treated by open drainage the mortal- 
ity rate was 56 per cent.; in 111 cases treated by 
aspiration and emetine the mortality was 14 per 
cent. Ochsner collected a series of 4035 cases of 
liver abscess treated by open operation, with a 
mortality of 47 per cent., and 459 cases treated by 
aspiration and emetine, with a mortality of 6.9 per 
cent. 

The patients in these groups who were treated 
by aspiration were supposed to have pure amebic 
infestation, with no bacterial infection. If mixed 
infection is found to be present all authors agree 
that open operation and drainage should be insti- 
tuted. Naturally patients with mixed infection are 
more seriously sick, and a higher death rate would 
be expected. The argument put forward by Rogers 
and others in advocating treatment by aspiration 
is that open operation converts a bacteriologically 
sterile abscess into one with mLxed bacterial infec- 
tion. The treatment and the results of treatment 
of hepatic abscess and other complications is some- 
what analogous to the situation in regard to em- 
pyema in the army cantonments during the World 
War. The mortality rate in this fearful epidemic 
did not depend so much upon the therapy adopted, 



whether by aspiration or by open operation and rib 
resection, as it did upon the virulence of the infec- 
tion. In amebic abscess, therefore, is it not fair 
to say that the mortalitj- rate depends to some 
extent upon the resistance of the patient as well as 
upon the method of treatment employed? The pa- 
tients included in the large numbers of cases re- 
ported lived in tropical and semitropical countries 
where amebiasis is very common, and has been 
present for a long time. Is it not possible that 
such patients could develop an immunity to the 
disease which would keep the death rate low, in 
spite of the choice of treatment? 

I mention the choice of treatment and the results 
somewhat in explanation of the high mortality rate 
reported by surgeons in regions removed from the 
centers of amebiasis, where cases are seen only spo- 
radically, and where patients could not have gen- 
erated such a possible immunity. While all the 
patients in our series were not studied bacteriologi- 
cally as thoroughly as they should have been (and 
will be in the future), they were all critically ill, 
and it is difficult to conceive of achieving in them 
a mortality rate as low as 7 or 14 per cent, by any 
method of treatment. Probably the emetine was 
not given a fair trial. It was used in a few cases 
but did not seem to affect the course of the disease, 
so was abandoned. Another explanation for the 
apparently poorer results obtained by members of 
the profession who in a life-time treat only a few 
patients with amebic abscess lies in the fact that 
they cannot be expected to diagnose such cases as 
early as men who treat them by the hundreds. 

Rogers found the pus sterile in 86 per cent of 
his cases, which must have been seen early in the 
disease. He is of the opinion that in large thick- 
walled amebic abscesses destruction of the liver 
does not progress, although the liver may get larger 
and compress the the liver substance. If, however, 
the abscess cavity becomes secondarily infected, 
which invariably occurs if open drainage is insti- 
tuted, the microorganisms are apt to penetrate the 
limiting wall, with resulting extension beyond the 
abscess itself into the surrounding liver parenchyma. 
It is on account of this invasion of the uninvolved 
portions of the liver that the patients may develop 
a severe, frequently a fatal, toxemia. The infec- 
tion of such a sterile abscess with its deleterious 
effects has been compared to the change which 
occurs in a tuberculous abscess that has been 
drained and in which secondary infection takes 
place. Whereas the majority of amebic abscesses 
of the liver are surgically sterile, there may be bac- 
teria in the pus, which, however, are not virulent. 
Only exceptionally are virulent organisms obtained 
from the abscess at the time of drainage. The sec- 
ondary infection occurs following open drainage in 



Januan-, 1936 



SURGICAL COMPLICATIONS OF AMEBIASIS— Boland 



spite of meticulous care being exercised to prevent 
contamination. 

In aspirating a liver abscess for diagnosis and 
treatment it is advised that the needle enter the 
tenth intercostal space in the anterior axillary line, 
and be directed upward, medially and backward. 
In performing such an operation it is understood 
that there is always danger of entering the perito- 
neum or pleura. If the abscess can be entered post- 
peritoneally such a risk may be avoided. Some- 
times it may become necessary to introduce a trocar 
into the abscess cavity because the pus is too thick 
to pass through an aspirating needle. Gessner" 
warns of the danger of hemorrhage from puncture 
of an acutely inflamed and excessively hyperemic 
liver, while Ochsner tells of aspiration being per- 
formed upon a 72-year-old man without previous 
treatment with emetine resulting in death from 
hemorrhage. In aspirating a patient with multiph 
hepatic abscesses, the procedure is more valuable 
as a diagnostic than as a therapeutic means. How- 
ever, cure of the patient depends more upon the 
administration of emetine than upon aspiration. 
The drug should be given both before and after 
aspiration or open operation. It is advised to give 
emetine intramuscularly immediately after aspira- 
tion because following the release of the tension 
within the abscess there is believed to take place an 
exudation into the abscess of lymph containing the 
injected emetine which destroys the amebas. 

Noland, in his discussion of Gessner's paper, 
sfwke of the work of Herrick in Panama, and 
stated that no surgeon had secured better results 
in the treatment of amebic liver abscess. He be- 
lieved that Herrick "s success was due largely to the 
fact that he had abandoned exploratory aspiration 
of the liver transpleurally far earlier than did most 
surgeons. He gave up aspiration largely because 
of two complications: first, on account of the num- 
ber of secondary pleural infections following leak- 
age from abscesses into the pleural cavity, and sec- 
ond, because of the fact that in many cases multiple 
abscesses were missed. He first located the abscess 
accurately through laparotomy, and then closed the 
abdomen and opened the abscess through the dia- 
phragm, the diaphragm being sutured to the inter- 
costal muscles before the abscess was opened. No- 
land affirmed that exploratory aspiration of the 
liver in suspected cases of abscess is a dangerous 
and unwarranted procedure in the majority of 
cases. 

Pleuropulmonary abscess may disappear spon- 
taneously by rupture through a bronchus. This 
abscess is treated on the same principles as liver 
abscess. Open drainage should not be done except 
in cases with secondary infection. In his series of 
pleuropulmonary abscess Ochsner states that 100 



per cent, of his patients treated with emetine recov- 
ered, whereas only 43 per cent, of those not so 
treated recovered. 

In a previous article' the details of fourteen cases 
of amebic liver abscess were put on record from the 
Grady Hospital, Atlanta, from 1925 to 1930, all in 
Negro patients. From 1930 to 1935 two more pa- 
tients were treated, as follows: 

Report of Cases 
No. 15.— .\ man, aged 28, admitted June 29th, 1931, 
complaining of cramping pain in the right lower quadrant 
of abdomen, which had existed for the past three months. 
Severe diarrhea developed after two months (one month 
before admission) with from IS to 20 stools daily, no 
nausea or vomiting. Temperature on admission 102, which 
dropped to normal after operation. Leucocytes 15,000 — 
polys. 84%. Laparotomy was performed the day after 
admission, and what was thought to be a distended gall- 
bladder proved to be an enlarged liver, containing an ab- 
scess which was opened and drained of chocolate-colored 
pus. Entamoeba histolytica was not recovered from the 
pus, but later was found in the stoob. Patient left hospital 
in one month, apparently well. 

No. 16. — Man, aged 43, admitted April 12th, 1933, gave 
history of having had five attacks of severe pain in past 
lew months, worse at night, involving the epigastrium and 
right shoulder. He drank one pint of whiskey a month. 
Weight had dropped from 186 to 146 pounds during the 
past 18 months. There was no history of dysentery, but 
blood was found in the stools, without amebas. The first 
diagnosis was pleurisy, later changed to cholecystitis, a 
diagnosis which was strengthened by the appearance of a 
shadow in the region of the gallbladder which looked like a 
stone, but which later proved to be a calcified mass in the 
liver. The liver did not appear especially enlarged on 
roentgenogram. Right rectus incision over liver showed 
abscess which was packed off, and opened the ne.xt day, 
when it discharged thick yellow pus. Four days later there 
was a discharge of 1500 c.c. typical chocolate-colored pus, 
from which amebas were recovered. The case ran a septic 
course during the patient's two-months' stay in the hos- 
pital, with temperature from 99° to 102° and leucocytes 
from 11,000 to 17,000. He left the hospital with sinus still 
discharging; returned in a few days, and had the ninth 
rib secected for better drainage. The septic course con- 
tinued to fatal termination in the hospital four months 
later. 

SUIVIMARY 

Of the total of 16 cases in the series^ there were 
13 males and three females, the ages from 17 to 47 
years. Five cases were classed as acute and 11 as 
chronic. Eight patients gave no history of dysen- 
tery. Entamoeba histolytica, or its encysted form, 
was recovered from 13 patients; three patients pre- 
sented such typical clinical findings of amebic ab- 
scess that the diagnosis seemed warranted. The 
abscess invariably was located in the right lobe, 
in three cases multiple abscesses. In eight patients 
the approach to the liver was through the abdomi- 
nal wall; in six the liver was reached through rib 
resection. One patient refused operation, and one 
was too near death for operation. The pleura was 
incised in three patients, once accidentally, with a 



SURGICAL COMPLICATIONS OF AMEBIASIS— Boland 



January, 1936 



fatal outcome. Two-stage operations were em- 
ployed in four cases. In the first stage the liver 
was sutured to the abdominal or thoracic wall, or 
the wound packed, so as to isolate an area for open- 
ing the abscess 24 hours later. There were six 
deaths, a mortality of 3 7.5 per cent. 

Bibliography 

1. Rogers, L.: Amoebic Liver .i^bscess: Its Pathology, 
Prevention and Cure. Lancet, vol. i, pp. 463, 569, 677, 
March 11th, 18th, 25th, 1922. 

2. Cr-UG, C. F.: Amebiasis and Amebic Dysentery, 1934. 
Charles Thomas, PubUsher. 

3. OcHSNER, A., and DeBakey, M.: Diagnosis and Treat- 
ment of Amebic Abscess of the Liver. Amer. Jour. 
Digestive Diseases and Nutrition, vol. n, no. 1, pp. 47- 
51, 1935. 

4. WiLLiAiis, p.: .Amebic Abscess of the Liver: Report 
of Fatal Case in Which Etiology Was First Demon- 
strated in Tissue Sections of Diaphragm, Following .Au- 
topsy. Sou. Med. Jour., vol. xxvin, pp. 902-905, Oct., 
1935. 

5. OcHSNER, A... and DeB.\kev, M.: Pleuropulmonar>' 
Comphcations of .Amebiasis. Unpublished paper read 
before the .\mer. .\ssn. for Thoracic Surgery, New 
York, 1935. 

6. Gessner, H. B.: Abscess of the Liver. Trans. Sou. 
Surg. Assti., vol. XLV, pp. 455-464, 1932. 

7. BoL.\ND, F. K.: Abscess of the Liver. Annals of Surg., 
Oct., 1931. 



Fn^E Stubborn Skin Diseases 
(Wm. J. MacDonald, Boston, in Urol. & Cuta. Rev., Dec.) 

A. Rosacea caused by the Demodex Folliculorum. One 
of the characteristics is the presence of pin-head size pus- 
tules. With a small knife transfer the entire pustular con- 
tent to a glass slide and examine with the low power micro- 
scope. Usually at least 1 or 2 and not infrequently more 
demodeces folliculorum will be found. This parasite is 
cigar shaped. The cephalic end is blunt and four very 
active legs on each side. I say active, for if the mite is 
now gazed at under the high power lens, very energetic 
movement of the limbs will be observed. The caudal end 
tapers to a point. 

I suggest a condemnation of the beauty parlor products 
and the substitution of a specific ointment. Women gener- 
ally are emphatic about the irritability of soap and water 
upon their skin. The first shot to be fired is right at the 
soap and water bugbear. The face having been washed 
vigorously at night is then briskly rubbed with the oint- 
ment. At first it will be mildly irritative. Gradually, how- 
ever, this passes off and with the improvement that in- 
evitably follows, this sense of irritation wears away. The 
ointment I suggest with certain variations at times is 

I. Beta-naphthol 



B. Sycosis Vulgaris. Everj' physician meets this disease 
with moderate frequency. It is a staphylococcal infection 
of the chin or upper lip and less frequently the whole 
mandibular region. The pustular lesions superimposed 
upon an erythematous and, at times, quite painful base, are 
readily recognized. ."An ointment containing chlorhydroxy- 
quinoline, benzoyl peroxide, eucalyptol and oil of thyme 
can be obtained now as Unguentum Quinolor Compound. 

In my own personal experience it has been undeniably 
satisfactory. Where my patients have persisted with its 
use, they have promptly recovered. 

C. Perleche. Have you ever noticed a fissured painful 
lesion at the angles of the mouth? This simple disease is 
called Perleche. It is quite common and is due to infection 
with Monilia albicans or an allied type of yeast organism. 
It is often very stubborn. A confrere of mine being af- 
flicted most stubbornly with the disease suggested radium. 
.\ brief exposure of 5 minutes with half strength plaque, 
with no filtration, caused a slight erythema. Following 
this the lesion completely disappeared for the first time in 
several years. It is an apparently quite useful procedure. 

D. Dioxyanthranol 1-S in Psoriasis. Psoriasis of the 
scalp is very resistant to any remedy. Yet, here we possess 
an agent which does achieve remarkable results. Of 29 
cases IS underwent complete involution. The remainder 
improved to a greater or less extent. Its use in psoriasis 
in other parts of the body is equally satisfactory. It is' 
especially valuable in ver\- obstinate crusted cases. The 
ointment is obtainable as Anthralin Ointment. It is dis- 
pensed in three strengths, 0.1, 0.25 and 0.5%. 

Dio.xyanthranol 1-8 in Other Dermatoses. My own ex- 
perience is that it is the most valuable form of medication 
for stubborn and chronic fungus lesions on the fingers, 
hands and feet. Mycotic disease of the hands appears to 
be definitely and seriously on the increase today. It is 
very resistant, by virtue of the hyperkeratotic condition 
present, to Whitfield's ointment, x-ray or any other remedy. 
In clinic work and private practice I find Dio.x>-anthranol 
1-S more than satisfactor^^ Some patients cannot tolerate 
the drug, but the majority are cured, temporarily at least. 
I have not used it in the vesico-pustular type of the erup- 
tion (epidermophytosis) preferring milder remedies. But 
its value in the hyperkeratotic and resistant type of mycotic 
disease cannot be gainsaid. 

This drug has been used in various other dermatoses. 
Some quote its value in ."Mopecia Areata, Parapsoriasis, Fol- 
liculitis, Seborrheic Eczema and Pityriasis Rosea. I have 
not used it in these diseases. 

My object in emphasizing the value of Dioxyanthranol 
1-8 is principally to stress its use in psoriasis and certain 
forms of fungus infection. 



Rectified Spirits 

Mb; 

II. Balsam Peru 

01. Olivi 

Mix 

III. Sulph. Praecip 

Ung. Aq. Rosae, ad 

MLx 

I & II are mixed thoroughly, then III is added. It is 
essential in rosacea to make a correct diagnosis. Eczema 
of the face, lupus er>-th. and other skin diseases rebel if so 
treated. 



gr- 


ui 


m 


m 


m 


XX 


.m 


XX 


-gr 


. V 


^1 


oz. 



Aenor^ialities ix Feminixity Corrected by Surgery 
(From Current Recordings in Med. Rec, Dee. 4th) 
Dr. Frank HLnman, San Francisco, listed aversion to 
marital relationship, despondency, suicidal tendency and a 
general tendency toward masculine traits, hirsutism and 
deepened voice changes brought about either by a tumor 
in the cortex of the adrenal glands or by overactivity of 
the cortex. By a new surgical technique, the normal ap- 
pearance, as well as feminine traits is restored to the pa- 
tient, either by the removal of the tumor, or if there is 
none, by the excision of about 2/3rds of the 2 adrenal 
glands. Dr. Hinman said that l/'3rd left is sufficient to 
carry on the normal processes, but if an insufficiency re- 
sults, it is remedied by the occasional injection of cortin, 
the hormone secreted by the adrenal cortex. 



Januar>-, 1936 



SOUTHERN MEDICINE AND SURGERY 



Osteomyelitis of the Vertebrae 

G. C. Dale, IM.D., Goldsboro, North Carolina 



OSTEOMYELITIS in this discussion is lim- 
ited to the disease produced by pus-form- 
ing organisms. There is a paucity of cases 
of such types of osteomyelitis, due perhaps to some 
lack of dissemination of knowledge of the condition 
and to the infrequency of its discussion in Amer- 
ican literature. 

Important communications made by Hahn in 
1895 and 1899 listed one case of vertebral osteo- 
myelitis in 661 compiled cases of osteomyelitis in 
general. The development of the x-ray has made 
diagnosis simpler and more certain. It is agreed 
that diagnosis is difficult, that there is great danger 
in the disease because of complications within the 
spinal canal, and that this form of osteomyelitis is 
a part of a general infection, pyemia. 

The disease is somewhat more common in males 
than in females varying from SS to 72 per cent, in 
favor of males. It is most frequently seen in adol- 
escence, rarely appearing beyond 30 years of age. 

The lesion is a metastatic lesion associated di- 
rectly with a bacteremia, which has as its focus 
bacterial infection somewhere in the body, possi- 
bly even in the alimentary or genito-urinary tract. 
The focus may be a boil of the skin, a tonsillar 
or pharyngeal infection, an infection in the genito- 
urinary or any other system. The lesion is the 
result of a subsidiary and secondarily infected 
thrombus which has been transplanted by the cir- 
culating blood into an end artery. Bone tissue is 
peculiarly prone to this process because of its vas- 
cular structure. Trauma is a factor in facilitating 
metastatic lesions. The effect of the invasion is a 
nutritional disturbance of the bone cells and sub- 
sequent necrosis. Vertebral lesions are relatively 
few and follow no particular plan, because of the 
arrangement of local blood vessels and because of 
essential anatomical conditions. 

Unlike other bones, the vertebrae have no defi- 
nite membranous periosteum. The function of the 
periosteum is largely taken over by tendinous, 
tibrous and ligamentous structures, all of which 
are essential in supporting a flexible spine and in 
maintaining its strength. The anatomical arrange- 
ment of these structures determines in large meas- 
ure the planes along which infection spreads. 

The vertebral bodies have a more abundant vas- 
cular arrangement than have the pedicles and 
laminae. By a large number of vessels correspond- 
ing generally in number with the spinal t.egment 
and derived from the basilar in the neck, the inter- 
costal and other branches in the thorax, and the 



lumbar vessels in the loin, they are supplied in a 
double manner. One group of vessels perforates 
the bodies from the outer side, breaks up into a 
network and supplies the adjacent bone with blood. 
These vessels anastomose with branches which have 
entered the spinal canal. The lateral spinal 
branches enter the spinal canal through the inter- 
vertebral foramina and divide into two branches, 
one of which supplies the spinal cord and its mem- 
branes, the other dividing into branches which an- 
astomose with similar branches from above and 
below to form two lateral chains on the posterior 
surface of the bodies. From these the periosteum 
and bodies are supplied and branches anastomose 
above and below to form a central chain on the 
posterior surfaces of the bodies. The pedicles, 
laminae and processes are principally fed from ter- 
minal anastomosing vessels from the spinal arteries 
inside the canal and their blood supply is much 
less abundant than that of the bodies. 

The disease more frequently involves the arches 
and processes in the lumbodorsal region and the 
bodies in the cervical region. The initial lesion is 
of small size, usually superficial, but occasionally 
penetrates into deeper bone structure. Sequestra 
are rarely formed, due to abundant vascular anas- 
tomoses. Abscess formation is the rule and sup- 
puration follows fascial planes and in directions 
according to anatomical configurations. 

In the cervical spine the bodies of the vertebrae 
are most frequently involved. Suppuration on the 
anterior body surface travels beneath the preverte- 
bral fascia upward toward the skull or downward 
into the mediastinum. This is one of the causes 
of retropharyngeal abscesses. When the abscess 
develops in the lateral pedicles it points in the pos- 
terior triangle of the neck, being diverted there by 
the prevertebral fascia. An abscess developing on 
the anterior surface of the transverse process is 
similarly diverted into the posterior triangle of the 
neck. One developing in the posterior aspect of 
the transverse process, the laminae, or the spinous 
processes, spreads backward and is reached deeply 
in the muscle spaces of the neck. 

In the thoracic spine foci of infection develop 
most frequently in that part of the spine posterior 
to the bodies. Suppuration of the anterior portions 
of the pedicles and lateral processes usually follows 
the fascial sheath of the iliopsoas muscle and ap- 
pears as an iliopsoas abscess. It may appear in the 
posterior mediastinum or retropleurally. Suppura- 
tion of the posterior portions of the transverse 



OSTEOMYELITIS OF THE VERTEBRAE— Dale 



Januar>', 1936 



processes, the laminae or the spinous processes, 
appears in the space between the spine and the 
bend of the ribs and is deep-seated. Suppuration 
arising in the exterior surfaces of the bodies of the 
vertebrae accumulates in the posterior mediastinum, 
where it may localize or spread into the pleural sac 
or produce a suppurative pericarditis. 

In the lumbar spine osteomyelitis most commonly 
affects the transverse processes, the arches and 
the spinous processes. Abscess formation on the 
anterior surface of the transverse processes, on the 
pedicles or on the anterior portions of their bodies, 
may locahze here and may be felt by abdominal 
palpation, or may spread out under the diaphragm 
to form a subphrenic abscess, or may appear fur- 
ther down as a perinephritic abscess. 

Foci of infection developing along the posterior 
parts of the arches, transverse and spinous proc- 
esses appear as suppurations in the spinal muscles 
in the small of the back. 

Osteomyelitis of the posterior sacrum or coccyx 
appears as a subcutaneous abscess and is easily 
accessible. Osteomyelitis of the anterior sacrum 
and coccjTi suppurates into the hollow of the sacrum 
and points either in the space between the coccyx 
and anus, in the gluteal muscles, or as a paraanal 
abscess; or it may follow along the crest of the 
ileum upward and point above Poupart's ligament. 
Suppuration breaking into the spinal canal may 
accumulate between the bone and dura mater com- 
pressing the cord or may localize as a subperiosteal 
abscess or may rupture the dura and produce a 
spinal meningitis. 

The symptoms of osteomyelitis of the vertebrae 
are markedly varied. These are made complex 
frequently because of the fact that the spinal pic- 
ture is overshadowed by the picture of a generalized 
infection. The average clinical picture is that of a 
piofound toxemia with sepsis. This may rapidly 
progress to a fatal termination. Especially is this 
the case where organisms from the spinal focus are 
being rapidly liberated into the blood stream. The 
condition may be confused with typhoid fever, cere- 
brospinal meningitis or some unknown infection. 

Milder forms appear in which there is no bac- 
teremia and without clinical signs of a general in- 
fection, the bacteremia having disappeared with 
the subsiding vertebral focus. In such cases there 
is tenderness and rigidity of the affected portion 
of the spine, spontaneous or provoked pain and a 
tendency of the patient to assume a supine position. 
All cases eventually show local signs which point 
to the seat of infection, provided the patient is not 
overwhelmed by the toxemia before they appear. 
The great majority of cases in a short time pre- 
sent the signs and symptoms of abscess formation. 
When lesions develop in the posterior portions of 



the vertebrae there is swelling, local edema, cen- 
trifugal induration and finally central softening 
along the posterior aspects of the back. Abscesses 
of the anterior portions of the vertebrae are deep- 
seated and are difficult to diagnose. One is guided 
in these cases by the general condition of the pa- 
tient and by local spinal rigidity. Lesions devel- 
oping deeply in the vertebral arches present the 
neurological evidences of cord compression and de- 
generation or of inflammation of the meninges. 

Complications arising from local extension of 
the disease are: 1) abscess of the neck, 2) retro- 
pharyngeal abscess, 3) extrapleural or retropleural 
abscess, 4) mediastinal abscess, S) pleurisy with 
and without effusion, 6) empyema of the thorax, 
7) pericarditis of various forms, 8) iliopsoas and 
intraabdominal abscesses, 9) pelvic abscesses — 
ischiorectal, paraanal and gluteal abscesses, 10) 
many forms of disease of the spinal canal, 11) 
complications associated with the general infection 
— including osteomyelitis in other bones, infections 
of joints, peritonitis, pericarditis, meningitis, endo- 
carditis, lung abscess, renal infarct, etc. 

The average mortality of vertebral osteomyelitis 
is 53 per cent. 

Prognosis is dependent upon the location of the 
infection in relation to the spinal canal and vital 
organs, the direction of extension and the speed of 
interference. 

Treatment in the vast majority of instances is 
purely surgical. Suppuration which can be easily 
located requires only simple incision and drainage. 
It is neither safe nor practical to resort to radical 
bone surgery. No attempt at removal of sequestra 
should be made because of the fact that so often 
sequestra do not form and simple drainage of a 
subperiosteal abscess is quite sufficient. It is also 
very difficult to demarcate diseased bone from 
healthy bone and in the spine all healthy bone is 
essential for preservation of strength and contour. 
If sequestration does occur it is usually small and 
when completely separated it will extrude itself or 
can be readily lifted out. Intrathoracic and ab- 
dominal accumulations, pelvic abscess and their ex- 
tensions are handled according to best surgical 
judgment. Suppurations into the spinal canal in- 
volving the meninges and cord are too often be- 
yond control and one is lost in the neurological 
manifestations. A case, however, is reported in 
which an abscess of the vertebrae was opened, the 
wound later exuding cerebrospinal fluid, with spon- 
taneous closure of the fistula without any untoward 
manifestations. 

A few cases, as the one reported here, in which 
the focal process subsides or becomes dormant as a 
result of clearing the blood stream of infection, can 



January-, 1936 



OSTEOMYELITIS OF THE VERTEBR.\E—Dale 



IS 



be handled by simple orthopedic measures for fixa- 
tion or by absolute rest in bed. 

Case Report 

A married woman, aged 27 years, was admitted to the 
hospital with a chief complaint of weakness of back and 
hips. She was well until January, 1934, when, following 
the birth of a child, she had chills and fever every other 
day. There were no symptoms at this time referable to 
the genital organs and no abdominal tenderness. She was 
treated by her physician for malaria, but to no avail and 
was admitted after a few weeks to a large hospital in the 
State where a diagnosis of septicemia was made. After 
three weeks' stay in this hospital during which time she 
received nine blood transfusions she was discharged and 
was told that she had had a severe illness. 

Upon discharge she and other members of her family 
noticed that she showed stiffness of the spine. When she 
sat down she was perfectly erect; when she arose she stood 
rigidly ; if she stooped she would fall and, having fallen, 
she was unable to get up without assistance. There was 
no sign of severe pains in the back, certainly no more than 
few pains in the legs and sacral region. She has been ex- 
tremely nervous and sleepless. No drug that she has taken 
has produced sleep. She has lost ten pounds after having 
gained ten pounds with the rest in the hospital. 

These episodes of back pain with rigidity having been 
repeated somewhat frequently, in alarm she returned to 
the hospital, where she was examined and told that her 
ailments were purely of an imaginary character and was 
directed to get out of bed at any cost and to assume other 
interests in life for combatting her depressive state. All 
this was futile and she went to an osteopath who advised 
rest in bed. This gave some improvement. 

Upon entering our hospital she was very emotional and 
cried at the least provocation. Her digestion apparently 
was good ; constipation was moderate. There were no 
symptoms referable to the urinary system, no cough, no 
pleuritic pain. Menstrual periods had been regular and 
normal. She is the mother of two children, both breech 
deliveries. The last was not unusually long. The past 
medical and family histories are unessential. Physical ex- 
amination revealed a heart normal in size, p. 146, b. p. 
104/74, abdomen negative. Vaginal examination dis- 
closed nothing abnormal. On examination of the back there 
was found to be tenderness in the lumbar region on a level 
with the third and fourth lumbar vertebrae, the patient 
could not iJex the spine without pain ; after stooping half 
way to a chair she would fall the remainder of the distance 
and was unable to rise from this position without assist- 
ance. Tenderness did not extend to hips or legs. Extrem- 
ities were negative throughout. The blood Wassermann 
reaction, tuberculin skin test and catheterized urine speci- 
men were negative; w. b. c. 6,000; hgb. 90% and r. b. c. 
4,300,000. 

X-ray examination of the spine revealed osteomyelitis of 
third and fourth lumbar vertebrae. 

The patient was referred to Dr. Donnell B. Cobb, who 
applied a body cast with the spine slightly extended. This 
was removed in about six weeks and examination made. 
Considerable improvement was observed. Patient felt a 
great deal better and there was evidence in the x-ray plate 
of further ankylosis and another cast was applied, the pa- 
tient being allowed to be about her normal duties. Eight 
or ten weeks later when the last cast was removed she 
could walk with ease and could almost touch the floor 
with hands without pain. Other x-ray plates showed a 
great deal of callus formation which appeared to be suffi- 
cient to produce a stable ankylosis. The intervertebral 
space v.as obliterated. 



References 

Wileksky: Annals of Surgery, vol. Lxxxix, no. iv, p. 
561, April, 1929. 

Wilensky: Annals of Surgery, vol. Lxxxn, no. v, p. 
731, May, 1929. 

Henry: The Journal of Bone and Joint Surgery, vol. 
No. m, p. 536, July, 1929. 

Carson: The British Journal of Surgery, vol. xvni, no. 
71, p. 400, Jan., 1931. 



The Effect of Exercise on Menstruation 



We are taught to believe menstruation is a physiological 
function, that it should not be attended with pain. Here 
are the results of the study of 500 girls over a 2-year period. 

At this time all students were permitted to participate 
in activity on the gymnasium floor during the menstrual 
period with the exception of 3 students who had prolonged 
menstrual flow of S to 12 days. No student fainted during 
any class period or immediately after. 

Medications that were employed when necessary consisted 
of bronsalLzol, viburnum, acetylsalicylic acid and occasion- 
ally atropine. The medicine was given infrequently. Four 
hundred and twenty-sLx reported as feeling better because 
of taking exercise, 52 as seeing no change and 22 claimed 
to have felt worse after exercise; 310 claimed there was no 
noticeable change in flow, 106 claimed there was an appre- 
ciable increase the first 2 days, 32 claimed the flow was 
lengthened and more profuse up to 4 days' length and 3 
napkins increased first 2 days; 41 showed no increase first 
2 days, but the period lasted more profusely the last 2 or 3 
days; 11 showed decrease in length of time, but increase 
of flow during period. 

It was definitely concluded that the patient felt more fit 
if she exercised during her menstrual period. The fact that 
so httle increase in metrorrhagia was noticed makes this 
factor seem practically negUgible. Therefore, through our 
study we conclude that exercise during the menstrual period 
is beneficial to the young woman. 



Headache From Tobacco, Drugs, etc. 

(Alex. Lambert, New York, in Bui. N. Y. Academy of 

Med., Aug.) 

As far as smoking the tobacco is concerned, the delete- 
rious effect on the human organism is more due to some 
element in the tobacco, other than nicotine, than to the 
nicotine itself. 

There is no question that the blood pressure rises during 
smoking, and in animal experimentation, small amounts of 
nicotine cause a rise in the blood pressure, and the coro- 
nary, pulmonary and hepatic vessels are constricted there- 
by. 

The work of Sulzberger and Harkavy, and others, has 
produced ver\' strong evidence that the clinical effects of 
tobacco are due to hypersensitization by some substance 
in the tobacco itself, more than in the smoke. 

Many headaches which are laid to smoking are unques- 
tionably due to other substances, they may be due to other 
solids or fluids taken the night before, and are blamed on 
the tobacco. But headache from tobacco does occur, and 
is dependent for its occurrence on the quantity taken, and 
on the sensitiveness of the person indulging in it. We 
cannot gauge these two factors, we cannot say how fre- 
quent it is. It is quickly evident in some, it is never evi- 
dent in others. It may be produced by the nicotine, it 
may have nothing to do with the nicotine, we do not 
know. 

An individual may be sensitive to only one kind of to- 
bacco, not to other kinds. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



The Management of Nervous Indigestion* 

Paul F. Whitaker, ^I.D., F.A.C.P., Kinston, North Carolina 



THE treatment of nervous indigestion, in 
fact the treatment of nervous disorders in 
general, is much neglected. When one gets 
away from time to time to take ward rounds or 
attend clinics or meetings in the larger medical cen- 
ters of the country, seldom does he hear anything 
on the subject, and the curricula of the medical 
schools have little to offer the student along this 
line. JNIedical students at present are splendidly 
trained in the science of medicine, but are woefully 
lacking in the art. This is, indeed, an unfortunate 
situation — unfortunate for the young practitioner 
who starts out under the severe handicap of having 
not even a general idea of handling the nervous 
patient, and unfortunate for the suffering individual 
with a functional digestive condition who wanders 
from one physician to another and then more often 
than not into the field of quackery. 

That the subject is an important one no one can 
deny. By their very number these patients de- 
mand consideration. Leading gastroenterologists 
estimate that more than half the patients that con- 
sult them for chronic indigestion belong in the so- 
called functional class. In our war-time army at 
least one-third of the men hospitalized because of 
digestive complaints suffered from neurosis. That 
the field is often a disappointing one, no one with 
even a moderate experience will deny, but the sat- 
isfaction obtained by getting one good result more 
than outweighs many disappointments. In twelve 
years of clinical practice with especial interest in 
gastroenterolog}' I am more convinced each year 
that the medical student, the practitioner, the spe- 
cialist and the consultant should take more time 
with these people who make up a large percentage 
of clinical practice, and should work out a rational 
line of procedure to follow in their management. 
Sometimes, even with the best of care, a cure is 
not obtained; but all too often the patient's failure 
to progress is because of ignorance or lack of inter- 
est on the part of the doctor, or because the doctor 
shows his feeling that, as a neurotic's troubles or- 
iginate within himself, he should correct them un- 
aided. 

The term nervous indigestion is used to include 
all those gastrointestinal disturbances for which no 
organic cause can be found. They can be either 
motor, sensory or secretory in nature. One should 
make the diagnosis only after a careful and pains- 
taking history, a thorough physical examination 
and proper laboratory and x-ray procedures, and 



often the opinion of a specialist in various fields is 
necessary. Many conditions cause disturbed diges- 
tion. Gallbladder disease, ulcer, appendicitis, 
cancer and parasitic infestation are common 
causes within the gastrointestinal tract, and eye- 
strain, cardiovascular-renal disease, brain and cord 
tumors, arthritis of the spine, diseases of the thy- 
roid gland, tuberculosis and allergy frequently 
cause indigestion. It is also well to remember that 
functional and organic disease can be found to- 
gether. All too often is a diagnosis of neurosis 
made and later, to the detriment of the patient and 
the regret and humiliation of the physician, it is 
found that organic disease is present and accounts 
for the symptoms. 

The one fundamental principle in dealing with 
patients with nervous indigestion is to treat the 
patient behind the disease. In an organic condition . 
we focus our attention directly on the lesion in 
question; in a functional condition we must include 
the whole patient — his mental and physical state, 
and in so far as possible his environment. It is 
hoped in this paper to bring out certain fundamen- 
tal principles underlying the management of these 
neuroses, realizing at the same time the futility of 
attempting to discuss all the possible useful meas- 
ures in combatting them. Under the first heading 
may be considered the attitude of the physician to 
the patient. 

Physici.\x .\nd Patient 

Neurotic people are as a rule sensitive, high- 
strung and emotional and their first impression of 
a doctor often decides his usefulness to them. As 
the management of the nervous patient begins with 
the examination it is highly important that the 
proper relationship be established at this time. It 
is obvious that the examination and the history 
must be thorough and painstaking, also sympathetic 
and reassuring to gain the patient's confidence and 
faith which is so essential to success in treatment. 
Once established, this relationship should be care- 
fully fostered by the physician on every occasion. 

FSVCHVOTHER.^PY, INSTRUCTIONS IN MeNT.41, .\ND PhYSIC.W. 

Hygiene 
Just as in organic disease we try to spare a dis- 
eased organ by rest of its function, it is important 
in functional disease to put the patient's mind at 
rest. In some cases this is readily accomplished 
by giving the patient a proper insight into his con- 
dition. !Many develop symptoms and consult us 
when thev hear of the illness of some friend, neigh- 



♦Presented to the Seaboard Medical Association, meeting at Old Point Comfort. Va., December 3rd to 5th, 1935. 



Januan-, 1936 



.UAXAGF.MEXT OF XERVOUS INDIGESTION— WhUaker 



bor or kinsman being diagnosed ulcer or cancer. 
This type of patient usually loses interest in his 
digestive tract when, after a careful study, no or- 
ganic basis for his sj'mptoms is found. Far 
less simple is the management of the case in 
which the basis of the neurosis is some circum- 
stance beyond the ability of any physician to con- 
trol. The constitutionally inadequate individual, 
the person harassed beyond measure by financial 
insecurity, domestic unhappiness, or vain regrets — 
each is an individual problem requiring individ- 
ual guidance. The mental purgation of pouring 
his troubles into the ear of an understanding 
person is in itself of value. I often tell these 
people that most everyone has a cross to bear in 
life and if their problem cannot be solved at pres- 
ent they will have to accept it in the best manner 
possible and live with it as best they can. It is 
both useless and foolish to tell them not to worry. 
Tell them to worry as little as possible and do the 
best that they can with a bad situation. So much 
for the purely psychic element in the problem. 
Where the neurosis is brought about by sheer men- 
tal or physical exhaustion, then much is to be 
gained by rest. Here again judgment and tact 
must be used. It is foolish to tell the bread-winner 
of a family that he must stop work entirely and 
go to some expensive resort or sanatorium for a 
rest. There could certainly be no mental rest un- 
der a situation like that. Have him rest an hour 
each day after the midday meal, remain in bed on 
Saturday afternoons and Sundays, or have him 
leave his work two afternoons a week for fishing 
or golf or whatever he enjoys doing. Certain severe 
cases require hospital care with complete bed rest, 
forced feedings and isolation. The value of order, 
px)ise and moderation can often be inculcated in the 
classically unstable neurotic by the practice of con- 
sistent hygienic habits. They must be taught the 
futility of wearing themselves out and induced to 
cultivate an attitude of calm and tranquillity. 
Often a few more hours sleep than the patient is 
getting may greatly aid in relieving his symptoms. 
One person may get along very well with five or 
si.\ hours sleep, whereas it will take eight to ten 
hours for another. If they cannot sleep without 
them, then, sedative drugs such as phenobarbital 
or bromides should be unhesitatingly given in suf- 
ficient dosage to get the proper effect. 

Phvsiother.\py, E.xercise and Massage 
These are at times valuable adjuncts in the treat- 
ment of nervous indigestion. In the patient with 
enteroptotic habitus certain orthopedic exercises are 
of distinct value in improving posture and giving 
tone to flaccid abdominal muscles. Where consti- 
pation exists massage downward over the course 
of the colon by the patient or a massuer t.ften gives 



marked benefit. I am firmly convinced that a 
properly fitted abdominal support benefits and 
gives a sense of well-being to the enteroptotic typ)e 
of individual. Ultraviolet radiation seems in some 
cases to improve the appetite, increase resistance 
to infection and increase the weight. A good coat 
of tan improves the appearance of the patient and 
makes him think that he has a healthier look. In 
addition to the actual benefit derived from these 
measures, they have the psychic effect upon the 
patient of making him think that something is be- 
ing done to help him. 

Diet and Manner of Eating 

I am convinced that the tv-pe of diet prescribed 
is not as important as the manner of eating. Swal- 
lowing our food whole, eating while discussing some 
business problem or when emotionally disturbed, 
eating amid wrangling and argument or when thor- 
oughly fatigued — neither is conducive to good di- 
gestion. If the patient is guilty of any of these 
practices he should be told how the emotions may 
affect digestion and urged to take plenty of time 
with his meals, chew his food thoroughly and put 
away care and worry while he is partaking of food. 
Regular hours of eating should be insisted upon 
and maintained. If the patient be guilty of glut- 
tony he should be told to eat more sparingly. On 
the other hand many a functional dyspeptic will be 
found to have eliminated one article of diet after 
another because he fancies that it disagrees with 
him. Such a patient should be vigorously taken 
in hand and made to retrace his steps until he is 
again eating with relish and impunity everything 
that he could use before the onset of the symptoms. 

Since the time of Hippocrates a smooth diet has 
been found to help many sufferers with indigestion. 
.Alvarez, in his classic book. Nervous Indigestion, 
emphasizes the virtues of such a diet and outlines 
it in detail. It has been quoted practically ver- 
batim in the latest edition of Beckman's Treatment 
in General Practice, and it would be well worth 
while for one interested in the management of di- 
gestive neuroses to thoroughly familiarize himself 
with it. The scientific basis for it is: first, that it 
leaves a low residue; second, that cellulose is indi- 
gestible; and third, that the normal gradient of 
bowel irritability and rhythmicity is often reversed 
in places, and that liquids will flow through re- 
versed places while solids will not. 

On the other hand I have seen functional dyspep- 
tics with faulty elimination markedly benefited by 
bran and prunes, and I respectfully submit that 
Alvarez has possibly too vigorously denounced this 
at-times-valuable substance. For the underweight 
patient a pint of cream a day will usuallj' promptly 
bring about the desired increase. 



MANAGEMENT OF NERVOUS INDIGESTION— Whitaker 



January, 1936 



Drugs 

Many cases of digestive neurosis are due to in- 
somnia resulting from an anxiety neurosis and the 
relief of this condition will of itself produce a cure. 
It is necessary, however, that sleep-producing drugs 
be continued over a sufficient period of time, for 
weeks and at times for months. The various prep- 
arations of bromides and barbiturates may be used. 
Bromides if used over prolonged periods will often 
produce a rash. The barbiturates are with certain 
people both objectionable and dangerous; at times 
instead of soothing the patient they make him 
highly unstable. Particularly, have I noted this 
with amytal and sodium amytal. Switching from 
the bromides to the barbiturates and back again 
often serves the purpose. The best of the barbi- 
turates in my experience, the one that gives a more 
restful sleep without an unpleasant hangover, is 
ipral. The ordinary preparation of triple bromide 
is as good a bromide preparation as we have, if 
given in some unobjectionable vehicle. Another 
excellent preparation is sulfotone, containing sul- 
phur and a ^ of a grain of phenobarbital in each 
tablet. If given one tablet three times a day and 
at bedtime it seems to take the edge off a sensitive 
nervous system without any depressing effect. 

The various digestants are of doubtful value and 
tonics and bitters are probably useless. One-half 
to one ounce of whiskey taken before the midday 
and evening meal certainly stimulates the appetite, 
relaxes the patient and produces that sense of well- 
being conducive to a good digestion. Insulin in 
from 10- to 20-unit doses before each meal usually 
produces, a. splendid appetite and quickly enables 
the overwrought and underweight individual to put 
on needed pounds. Particularly is the drug of 
value in the patient hospitalized for a rest cure. 

SirMTiIARY 

In the management of cases of nervous indiges- 
tion, I would emphasize: first, be sure of the diag- 
nosis; and second, every doctor into whose hands 
he falls treat every such patient with the same 
respect that we treat a patient with organic disease. 
Add to this sympathy and understanding and the 
ordinary common sense in the selection of sugges- 
tions and procedures to follow and the percentage 
of satisfactory results will be gratifying. 

Bibliography 

1. Beckm.\n: Treatment in General Practice, Second Edi- 
tion. 

2. Alvarez: Nervous Indigestion. 

3. Kantor: Treatment of Common Disorders of Diges- 
tion. 

4. NoYES: Modern Clinical Psychiatry. 

5. Powe; Food Allergy. 

6. Henry: Psychopathology. 



The Pediatrician Looks at the Tonsil 
(R. M. Pollitzer, Greenville, in Jl. S. C. IVIed. Assn., X-ag.) 
Commonly in groping about for some cause of malnutri- 
tion, loss of appetite, enuresis, epilepsy or what-not, the 
doctor suggests that the tonsils should be removed. 

.\ complete examination is time consuming and costs 
money. The mother only too often is over-anxious to find 
a short cut to the child's health. She wants something 
done now. So the doctor then and there says "The tonsils 
must come out." 

Not enough judgment or discrimination is used in the 
condemnation of tonsils. 

Tonsillitis is common to all ages, especially so in child- 
hood. .\t times there is abdominal pain, which often leads 
to a mistake in diagnosis. Albumin in the urine is not 
uncommon, and blood microscopically is not rare. 

In my practice tonsillitis in infants between 7 months and 
1 year has been extremely frequent. The diagnosis of ton- 
sillitis, in my opinion is missed oftener by the doctor and 
the mother, than any other with the possible exception of 
otitis media. Where there is vomiting or diarrhea, and 
even with abdominal pain not infrequently calomel or 
castor oil has already been given. 

Repeated attacks of tonsillitis are a menace to the child's 
health, and probably the chief factor in hypertrophy of the 
tonsil. Diseased or obstructive tonsils, not merely large 
tonsils should be removed. "Repeated attacks of tonsillitis, 
increasing in severity, with or without systemic disturbance 
indicate disease." There is no evidence to support the 
common practice of removal of tonsils for a susceptibility 
to head colds, frequent sore throat, croup or asthma. 
.\sthma is often thereby aggravated. Mere enlargement or 
prominence without disturbance of breathing, without 
glandular enlargement, and no history of disease is a con- 
traindication to removal. 

Where an infant has had several attacks of otitis media, 
an adenoidectomy must be done. There is no reason why 
one must operate on both tonsils and adenoids. Little ones 
if possible should retain their tonsils for several years. 

The operation should not be done during an acute illness, 
or attack of tonsillitis, nor until at least 2 weeks have 
elapsed. The best season is that time of the year when we 
are free from cold weather, from much rain or strong 
winds; for the little patient is going to be more exposed to 
these for several weeks, and sinus involvement is not an 
uncommon sequel. Where the child is being seriously dam- 
aged or delay is considered dangerous, the tonsils may be 
removed even during the first year. But where it is advis- 
able three years is the minimum age for tonsillectomy. 

I have known of 2 children who died in diabetic coma, 
because the urine was not examined prior to the anesthetic. 
Further there have been some deaths from hemorrhage, 
which might have been prevented. Children with leukemia 
have had their tonsils removed, and then soon after had 
that diagnosis made. Minimum requirements are' a careful 
history, a thorough physical examination of the whole 
child, along with a urinalysis and a blood-study. This 
last includes a leucocyte count, a differential count, a hemo- 
globin estimation, and test for coagulability. After a ton- 
sillectomy for several days, say 3 at least, the patient 
should be kept in bed, and for several weeks after that, 
he should be carefully protected from undue exposure, and 
guarded from acute infections. Parents should be warned 
that improvement will not be evident within a few days, 
perhaps not for several months. 

Nor should they be led to expect the cure of idiocy, 
epilepsy, enuresis, and many other chronic ills. 



(Continued on p. 22) 



Januan', 1936 



SOUTHERN MEDICINE AND SURGERY 



The Selection of Obstetrical Anesthesia with Special Reference 
to Local Infiltration* 

W. Z. Bradford, :M.D., F.A.C.S., Charlotte, North Carolina 



THE judicious choice of anesthesia is of 
great importance in obstetrics. While the 
role of anesthetics as a factor in infant and 
maternal morbidity and mortality is difficult to 
evaluate, certain baneful results of their misuse are 
evident. Among these are the possible harm of 
deep general anesthesia to the respiratory center 
of an unborn infant prior to a difficult operative 
delivery, particularly when that infant is already 
partially asphyxiated; the influence of ether or 
chloroform upon the maternal organs when in a 
state of acidosis as is found in the toxemias of 
pregnancy, or in the dehydration and exhaustion 
state of prolonged labor; and the irritation with 
resulting dissemination of infection from the use 
nf these agents in the presence of acute or chronic 
respiratory infections complicating labor. 

For a number of years the influence of the Chi- 
cago Lying-in, and more particularly of Dr. De- 
Lee through his annual year book, has been af- 
fecting medical thought in calling the attention 
of the profession to the need of proper selection 
of obstetrical anesthesia, and especially to the safe- 
ty and wide field of application of local infiltra- 
tion. The subject has grown to be of such im- 
portance that, at the recent meeting of the Amer- 
ican ^ledical Association, the section on Obstetrics 
and Gynecology devoted an entire morning to a 
symposium on anesthesia in obstetrics. 

The passage of responsibility in this matter to 
the anesthetist is begging the issue. The trained 
anesthetist is available to only a limited number 
of patients. In 1933 of the more than 75,000 
births in North Carolina only 8 per cent, were in 
iiospitals and in many of these institutions trained 
anesthetists were not available. The problem of 
evaluation and discrimination in the prevention of 
pain at delivery is the responsibility of every phy- 
sician assisting at childbirth. 

There is no presumption that the discussion of 
anesthetics which follows represents the last word 
on the subject. This is a paper of personal experi- 
ences and many of the conclusions are those of an 
individual. 

Ether 
.\ wide margin of safety and low toxicity justi- 
fies for this agent an extensive usage. This is 
especially true when the physician is dependent 
upon a nurse or an entirely untrained attendant 



for administration. For relaxing a tonic uterus 
where a slow fetal heart indicates anoxemia, ether 
greatly improves the prognosis of the instrumen- 
tally delivered infant. Its limitations are briefly 
as follows; a long latent period prior to uncon- 
sciousness forbids its prolonged use in the second 
stage of labor, also the tendency to uterine inertia 
inhibits the bearing-down effort of the perineal 
stage; the irritating effect upon the respiratory sys- 
tem prohibits its use in any infection of the upper 
or lower respiratory tract; acting as a protoplas- 
mic poison and increasing glycogen consumption, 
its use in large quantities in the dehydrated and 
exhausted state following a prolonged labor is open 
to serious question. Our chief use for this drug 
has been late in the first stage of a prolonged labor 
— usually due to an occiput-posterior position — 
by rectal instillation analgesia is obtained lasting 
from 2 to 4 hours. With the odor of ether on the 
patient's breath in S to 10 minutes, excellent an- 
algesia and amnesia results, and the injection may 
be safely repeated within a few hours. 

Chloroform 
The universal use of chloroform in obstetrical 
anesthesia, from the days of Sir James Y. Simpson 
where the sponsorship of royalty gave an impetus 
which grew for many decades, makes any critic 
of its use substantiate his argument. The late 
John O. Polak said that in his entire experience 
he failed to see harmful effects from chloroform 
though used on thousands of patients on his ser- 
vice. The prompt analgesia following 2-i drops 
on an open mask and the lack of mucous mem- 
brane irritation make it readily adaptable in the 
second stage of labor; under its influence the co- 
operation of the parturient materially shortens the 
duration of labor. Harmful effects upon the child 
have seldom been reported. While uterine inertia 
frequently follows its sustained use over an hour, we 
have employed chloroform by light drop intermit- 
tently with contractions for over three hours upon 
numerous patients without demonstrable injury. 
Dr. Potter, I understand, uses this agent routinely 
in delivery. It is certain that no anesthetic is capa- 
ble of relaxing a uterus as promptly and as com- 
pletely as chloroform and with the ease and success 
of version dependent upon relaxation it follows that 
usually the successful version exponent is a chloro- 
form enthusiast. However, we are in accord with 



•Presented to Seventh District (N. C.) Medical Society, meeting at Wadesboro, Novemljer ]2th, 1935. 



SELECTION OF OBSTETRICAL ANESTHESIA— Bradjord 



January, 1936 



Rucker, that the preHminary administration of 
adrenalin, 1 c.c. of 1:1000 solution, gives prompt 
uterine relaxation and permits a successful version 
under ether or nitrous-oxide anesthesia. 

In the past four years I have seen three fatal 
cases of acute liver necrosis or acute yellow atrophy, 
and two cases of liver injury of an advanced degree 
with recovery. Chloroform was employed for de- 
livery in two of the fatal cases while in the third 
the liver pathology was present prior to delivery. 
In the group with recovery one was delivered under 
low spinal anesthesia by vaginal hysterotomy and 
the other permitted to deliver spontaneously with- 
out relief. All of these women had both hemolytic 
and obstructive jaundice, a high icterus index, and 
were desperately ill. Stander has written exten- 
sively on delayed chloroform poisoning in pregnancy 
and the vulnerability of the liver of a pregnant 
woman is manifest in the high percentage deaths 
from chloroform and arsenic that occur in preg- 
nancy. The low glycogen reserve, the secondary 
anemia, the calcium depletion, the compensated 
acidosis and other changes in body chemistry are 
physiological components of pregnancy which pre- 
dispose to liver injury from any toxic agent. Chlo- 
roform is a protoplasmic jxiison with a predilection 
for liver cells which produces further glycogen de- 
pletion and further reduction in body pH. Chlo- 
roform should never be used in the presence of 
toxemia of pregnancy. The recent investigations 
in the physiological chemistry of the pregnant wo- 
man and the published clinical reports of liver 
injury, from even small amounts of chloroform, 
given to susceptible patients, make the routine em- 
ployment of chloroform in obstetrical anesthesia 
open to valid criticism. 

Nitrous Oxide 
Nitrous oxide with oxygen, administered by a 
competent anesthetist, constitutes one of the joys 
of the practice of obstetrics. The harmlessness of 
the gas and the immediate analgesia permit its 
intermittent use for hours without diminution in 
the force or duration of uterine contractions. The 
stimulating effect of a mixture rich in oxygen upon 
mother and child is especially valuable prior to 
forceps extraction. Maternal rebreathing at the 
time of crowning of the fetal head produces a high 
carbon-dioxide concentration thus stimulating the 
infant's respiratory center and the welcome cry 
usually promptly follows delivery. The expense 
and necessity for a skilled assistant are its only 
disadvantages. Its inability to relax a tonic uterus 
limits is use in the presence of a contraction ring 
or where the uterine cavity must be invaded as in 
an impossible breech presentation, or doing a ver- 
sion. 



Cyclopropane 
Our experience with cyclopropane has been lim- 
ited to 12 to 15 cases. In the early group the high 
oxygen content resulted in a long latent period 
prior to the institution of respiratory effort by the 
infant. One unexplained infant death occurred in 
a section; the fetal heart sounds persisted 30 min- 
utes but no effort at breathing could be initiated. No 
autopsy was performed. The depth of anesthesia 
obtained as well as expense of the gas prohibit its 
intermittent use in the second stage of labor. In 
a second smaller group results have been most satis- 
factory. Cyclopropane requires an anesthetist skill- 
ed in its administration. 

Barbiturates Intravenously 
Several years ago we reported at a staff meeting 
our results on 15 patients given pernoston intra- 
venously. This barbituric acid compound, syn- 
thesized with a bromine radical, has been used 
extensively at the Sloane Maternity Hospital in 
New York and we aided in its experimental use 
on approximately 100 deliveries at Bellevue Hos- 
pital in 1930. The depth of anesthesia obtained 
by this drug does not permit of artificial delivery 
without restraint, but the remarkable analgesia and 
amnesia satisfy the patient's demand for a pain- 
less childbirth. This and all other intravenous de- 
pressants were discontinued following the develop- 
ment of cyanosis and the falling of respiration to 
6 per minute required artificial stimulation for sev- 
eral hours. Intravenous analgesics and anesthetics 
once administered cannot be removed and there is 
no field for their use in the conservative practice 
of obstetrics. 

Splnal Anesthesla 

Prior to our interest in local infiltration we em- 
ployed spinal anesthesia for delivery in the presence 
of a number of obstetrical complications. Contrary 
to the common experience little difficulty was ex- 
perienced in making the spinal puncture, either 
because of the abdominal tumor or the pains of 
labor. Splendid results were obtained in a few 
cases requiring major obstetrical surgery — includ- 
ing cases of preeclamptic toxemia, active pulmonary 
tuberculosis and upper respiratory infections. Fifty 
mg. of novocaine without barbitage results in an- 
esthesia sufficient for forceps, episiotomy and re- 
pair. The only complication was marked uterine 
atony with postparteuni hemorrhage requiring 
packing and blood transfusion in two cases. This 
tendency, and the lack of a trained assistant to 
follow the patient's blood pressure and pulse, re- 
sulted in the experiments in local infiltration and 
local block. 

That the pregnant woman is a poor spinal an- 
esthesia risk has been stated repeatedly, and num- 



Januar)', 1936 



SELECTION OF OBSTETRICAL ANESTHESIA—Bradford 



erous tragic illustrations of this fact have been 
reported. In the Margaret Hague Maternity in 
Jersey City, the largest maternity in this country, 
this method of relief is used in from 40 to SO per 
cent, of all deliveries. Dr. Cosgrove states that 
the safety of spinal anesthesia in the pregnant 
woman depends upon the following details: 1 — 
Xo barbitage. 2 — Low injection. 3 — Novocaine 
crystals. 4 — Nq Trendelenburg. S — Novocaine 
and adrenalin. 6 — Proper selection of cases. The 
anesthesia permits a beautiful abdominal section, 
usually with a minimal blood loss. Our experience 
has been limited to three cases. 

Local Infiltration" and Local Block 
In the past 12 months we have employed local 
infiltration or local block in 29 major obstetrical 
procedures, chiefly complications, in which, for eco- 
nomic or other reasons, nitrous oxide could not 
be satisfactorily obtained. The preliminary anal- 
gesia in the first stage of labor was varied — mor- 
phine and scopolamine, morphine and magnesium 
sulphate, sodium amytal, sodium amytal and scopo- 
lamine, sodium alurate, ether by rectum. The 
harmlessness to mother and child, the adaptability 
to home and hospital delivery, the minimum cost, 
and the lack of need for a trained assistant justify 
a detailed report of this experience. 
Technique 
A small intradermal wheal is made at a point 
midway between the anus and an ischial tuberos- 
ity. With the index finger of the left hand in the 
vagina the needle is inserted in this wheal and, 
while injecting, is advanced toward the ischial spine. 
A slight resistance is felt when the fascia plane is 
encountered, the plunger is withdrawn slightly to 
make sure it is not in a vein, and approximately 
20 c.c. of 1 per cent novocaine is injected in the 
substance of the levator ani in the region of the 
pudendal nerve, the point of the needle lying just 
proximal to the ischial spine. 

.'\ similar injection is made on the opposite side, 
followed by superficial infiltration of the labia. A 
total of approximately three ounces of the solution 
used for the nerve block and the infiltration and 
perineal relaxation and anesthesia are obtained suf- 
ficient for perineal forceps, spontaneous delivery or 
superficial episiotomy. 

In cases requiring more extensive surgical pro- 
cedures, as midpelvic forceps, manual rotation, 
breech extraction, or extensive episiotomy and re- 
pair, the parasacral or antesacral infiltration is used. 
Technique: (After the method of Tucker and Bena- 
ron of Chicago as reported in the June, 1934, issue 
of the American Journal of Obstetrics and Gyne- 
cology.) With the gloved finger in the rectum an 
intradermal wheal is made at the level of the sacro- 



coccygeal joint from lJ/^-2 cm. on either side of 
the midline. The IS cm. needle is grasped by the 
hub and introduced through the wheal. The point 
of the needle is advanced over the edge of the 
last sacral vertebra, and along the anterior aspect 
of the sacrum in contact with the bone and parallel 
to the midline. At a point from 6 to 7 cm. above 
the sacro-coccygeal articulation the second sacral 
foramen is encountered. If blood does not drip 
from the needle, the syringe is attached, and as the 
needle is withdrawn 60-70 c.c. of O.S per cent, 
novocaine solution is deposited between the sec- 
ond and fifth sacral foramina. The needle is then 
withdrawn to the edge of the last sacral vertebra 
and its direction changed to a slight angle up- 
ward. It is advanced parallel to the midline and 
at a point from 9 to 10 cm. above the sacro-coccy- 
geal articulation the first sacral foramen is encoun- 
tered. Approximately 1 ounce is injected here. 
The needle is then withdrawn and approximately 
10 c.c. is injected over the coccyx, between the 
coccyx and rectum, thus blocking the sacro-coccy- 
geal plexus of nerves. The procedure is repeated 
on the right side. 

No attempt is made to hit the individual sacral 
foramina. The injection consumes from IS to 20 
minutes. No difficulty is encountered from the en- 
gaged head. Care should be taken not to perforate 
the rectum. This method of infiltration is contra- 
indicated where immediate extraction is indicated 
because of fetal asphyxia and in the presence of 
local pelvic infection or frank intrapartum sepsis. 

In this group of 29 cases local anesthesia was 
selected of choice in 20 and of arbitrary election 
for investigative purposes in 9. In the latter group 
it was augmented by nitrous oxide in 3 cases and 
by ether in 1. There was complete failure of anes- 
thesia in 1 patient and partial failure in 1, a sup- 
plementary means being used in the other 2 cases 
to produce unconsciousness at the time of delivery. 

Following is a brief summary: 
Total cases: 29 (pathological 21, non-pathological 8). 
Source: Private 22, consultation 4, maternity clinic 3. 
Maternal deaths 0, stillbirths 0, neonatal deaths 2 (pre- 
maturity 1, pyelo-nephritis 1). 
Therapeutic abortions 2. 
Vaginal deliveries 27, abdominal deliveries 2. 
Primipara 27, multipara 2. 
White 27, Negro 2. 

Delivery 
Spontaneous delivery 3. 
Therapeutic abortion 2. 
Low forceps 13. 
Mid-pelvic forceps 5 (all transverse arrests). 

Kielland 7. 

Barton 1. 

Manual rotation and Hawkes-Dennen 2. 
Breech extraction 1. 
Spontaneous breech 1 (Piper forceps). 
Episiotomy and repair 19. 



SELECTION OF OBSTETRICAL ANESTHESIA— Bradford 



January, 1936 



Repair 2. 

Third-degree laceration and repair 1. 

Cesarean section 2. 

Complicating Pathology — 20 cases 
Eclampsia — 3 cases 

No. 1 Induction of labor, convulsion with vertex on 

perineum, fetal heart 200. 
No. 2 Deep transverse arrest of posterior occiput, very 

toxic, no progress for several hours. 
No. 3 No convulsions for 5 days, sloughing of labia, 
purulent vaginitis, cesarean section. 
Pre-eclamptic toxemia — 6 cases 

No. 1 Induction of labor, outlet forceps and episio- 

tomy. 
No. 2 Fetal heart slow to 60, meconium, fetal distress. 
No. 3 Pulse 120, t. 100. Outlet forceps and episiotomy. 
No. 4 Induction of labor. Low forceps and episiotomy. 
No. 5 Induction. Upper resp. infection. Spontaneous 

following episiotomy. 
No. 6 Fulminating pre-eclampsia. Cesarean section. 
Intercurrent Infections — 4 cases 

No. 1 Osteomyelitis of mandible, purulent gingivitis 
with internal drainage, t. 103, disproportion trans- 
verse arrest. 
No. 2 Influenza and asthma. Spontaneous delivery. 
No. 3 Acute upper respiratory infection. Pulse 120. 
Arrest at outlet. Outlet forceps and episiotomy. 
No. 4 Acute upper respiratory infection with pre- 
eclampsia. Spont. delivery. Episiotomy. 
Acidosis and Maternal Exhaustion — S 

No. 1 Labor 60 hours. Pathological contractions. Low 

forceps and epis. 
No. 2 Labor 38 hours, vomiting, pulse 120. Transverse 

arrest. Manual rotation and midpelvic forceps. 
No. 3 Laor 40 hours. Rapid pulse, manual rotation, 

midpelvic forceps. 
No. 4 Labor 48 hours. Persistent vomiting and dis- 
tention, p. 150. Kielland forceps and episiotomy. 
No. S Labor 24 hours. Vomiting, acetone odor to 

breath. Low forceps. 
All of this group were difficult obstetrical problems, all 
occiput posteriors with hard difficult labors, all supported 
with intravenous glucose and saline and analgesia during 
first stage. 
Prematurity — 1 

Extraction following 48-hour labor, no progress for sev- 
eral hours. Breech at inlet. 
Active pulmonary tuberculosis — 1 (D & C) 
Advanced cardiac disease — 1 (D & C) 

No complicating pathology 9 
Spontaneous breech (Piper forceps) No. 1. 
Repair of laceration and episiotomy (vomiting, rapid 

pulse) No. 2. 
Nos. 3, 4, 5, 6, 7 Elective prophylactic forceps and 
episiotomy following anterior rotation of occiput with 

caput crowning. 
No. 8 Episiotomy, spontaneous delivery, repair. 
No. 9 Low forceps, third degree laceration, repair. Dem- 
onstration case. Healing by primary union. 

Summary 
The need of evaluation and discrimination in 
the choice of obstetrical anesthesia together with a 
brief summary of the more popular anesthetics has 
been discussed. The comparative safety and effi- 
ciency of local block and local infiltration has been 



presented through the medium of 29 major pathol- 
ogical cases delivered by this method. 



The Pediatrician Looks at the Tonsil 
(Continued from p. IS) 
Nothing in this paper should be construed or is intended 
as a condemnation of the operation when indicated and 
done by skilled men. 

(Discussion by Dr. D. L. Smith, Spartanburg:) 
No child should have the tonsils removed on one exam- 
ination of the tonsils. The school nurse goes around and 
looks at the tonsils and condemns them, the parents are 
thoroughly educated, and the tonsils are removed. This is 
being done in South Carolina and done frequently. 

I think the tonsil has a definite mission in the body. It 
is very desirable that the child retain his tonsils until the 
second year of school life. 

(Discussion by Dr. C. L. Kibler, Columbia:) 
Whether it is a small tonsil or a large tonsil, whether it 
is imbedded or not, whether it has crypts from which you 
can squeeze out debris, pus, etc., it matters not. But if 
you have a red Hne running all the way down on the ex- 
ternal pillar, the tonsil is diseased. It is evidence of deep 
infection, and I would unhesitatingly say, remove them. 
(Discussion by Dr. J. W. Jervey, jr., Greenville:) 
One thing I do consider as a contraindication for tonsil- 
lectomy, hypertrophy of the lymphatic tissue in the lym- 
phoid ring. When I see hypertrophy of all that tissue I 
do not believe that tonsillectomy will accompUsh the desired 
result. 

(Discussion by Dr. M. R. Mobley, Florence:) 
Let's bring this thing home to ourselves. If your little 
girl comes home from school with a note saying her tonsils 
should come out, do you telephone to an otolaryngologist 
and say: "I want you to take my child's tonsils out"? 
Anyone who advises removal of that tonsil needlessly is 
thoughtlessly jeopardizing the life of that child. But when 
that tonsil becomes so infected that it acts as a focus of 
infection from which bacteria can be disseminated to the 
various organs of the body, then is the time to remove that 
tonsil, and not until then. 



Infliience of Hygroscopic Agents on Irritation From 
Cigarette Smoke 
(W. F. Greenwald, New York, in Med. Rec, Dec. 4th) 
A series of studies pointed to a most surprising fact — 
that the main source of irritation from cigarette smoke 
was not the tobacco but the hygroscopic agent added to 
tobacco to maintain the moisture content. The hygroscopic 
agent commonly used is glycerine. Burning glycerine forms, 
among other smoke products, a highly irritating and toxic 
substance. Diethylene glycol has all the desirable proper- 
ties of a hygroscopic agent but cannot on combustion pro- 
duce an irritant such as that produced by the burning of 
glvcerine. 



Use of Insulin in Non-Diabetic Tuberculous Children 



By the use of insulin an acceleration of the rate of gain 
in weight was obtained in 15 of 17 non-diabetic tuberculous 
children. Of these 15, 13 maintained the gain of weight 
induced by insuhn after the insulin was discontinued. This 
follow-up period in most cases was three months. 

The weight gained after the fourth week of insulin ther- 
apy was too small to warrant its use for a longer period. 
The subjective reaction of the children to the insulin is no 
criterion of its efficacy. 



Januarj', 1936 



SOUTHERN MEDICINE AND SURGERY 



Case Report 



Cholecystostomy in January- Cholecystoduo- 

denostomy in april- drainage of lumbar 

Abscess in :May: Still a Problem 

L. A. Crowell, M.D., F.A.C.S., Lincolnton, N. C. 
Lincoln Hospital 

A MATRON, aged 44, admitted to the Lincoln 
Hospital January 11th, 1935, complained chiefly of 
jaundice, and intense itching all over the body, 
also of loss of weight and energy, and of having 
passed clay-colored stools and, at times, dark red- 
dish-brown urine. Additional factors were loss of 
appetite, indigestion, flatulence, abdominal disten- 
tion, irritability and extreme fatigue — the latter two 
complaints from itching making sleep impossible. 

She states that, with the exception of some at- 
tacks of kidney colic prior to October, 1931, her 
health was good. At this time, after a normal day 
and going to bed feeling well, she awakened about 
3 a. m. aching all over and feverish and vomited 
a large quantity of fluid and undigested food. She 
had three such attacks that fall, about one month 
apart. There was no pain or jaundice with the 
attacks. She felt well iDctween the attacks, had a 
good appetite and her usual weight and strength. 

From December, 1931, to December, 1933, she 
had four or five similar attacks at longer intervals, 
none lasting longer than a day or two. Between 
these attacks, as between the first three, she was 
well. From October, 1931, to December, 1933, she 
was treated at intervals for stomach trouble and 
anemia. During that two-year period the hemo- 
globin fluctuated between 50 and 60 per cent. 

In Christmas week of 1933 the palms and soles 
began to itch. Itching persisted with slight in- 
crease, and April 2nd, 1934, she first noticed jaun- 
dice. From that time on the itching became pro- 
gressively worse, until she was hardly able to rest 
at all. At no time had there been pain. 

On May 7th, 1934, x-ray pictures were taken 
of the gallbladder area following the ingestion of 
dye. The films showed a density of irregular shape 
within the left kidney shadow which was diagnosed 
as a calculus; no gallbladder shadow. 

She had not complained of any pain in the kid- 
ney area or anywhere else, but further questioning 
revealed that she had had typical kidney colic on 
the left in 1923, in 1925 and in September, 1933, 
none lasting over three days, but each so severe 
that morphine was required. 

She continued to lose weight, become more ane- 
mic, and the itching and indigestion became worse 
and worse. In June, 1934, she was seen by a con- 
sulting internist, who advised continuing the medi- 
cal trea'ment. 



Upon admission to the hospital January 11th, 
1935, the following positive physical and laboratory 
findings were recorded: t. 98; p. 88; r. 20; b. p. 
110/70; there was an intense yellow pallor of the 
entire skin with a suggestion of green in the sclerae, 
the facies tired and drawn, tongue heavily coated. 
The heart and lungs appeared normal, the liver 
tender and enlarged to three finger-breadths below 
the costal border. There was no tenderness in the 
lumbar region. The w. b. c. was 16,800 — polys. 
87; lymph. 10; bas. 3; the r. b. c. 750,000; the 
hgbn. 35 per cent., clotting time 7 min. The urine 
was acid and showed 1-plus albumin and ISO pus 
cells to the 1. p. f. A single K. U. B. film showed the 
coral stone in the left kidney to be larger. X-ray 
of the gallbladder region, using the new intensifi- 
cation technique of Illick and Stewart, showed no 
gallbladder shadow. 

The patient's condition growing steadily worse, 
a tentative diagnosis of carcinoma of the head of 
the pancreas was made, and the patient was oper- 
ated on for three seasons: first, to afford tempo- 
rary relief if the trouble should prove to be car- 
cinoma; second, to give the benefit of the possi- 
bility that the obstruction might be due to low- 
grade inflammation of the head of the pancreas; 
third, because of the possibility that the obstruc- 
tion might be due to stone. In this connection. 
Dr. Frank H. Lahey reports a case of persistent 
and silent jaundice in which, on operation, a stone 
was found in the common duct, the removal of 
which cured the patient. 

During the eleven days prior to the operation 
an attempt was made to build up the patient's re- 
sistance and to reduce the clotting time by the 
administration of liver extract, iron and arsenic, 
calcium chloride, and calcium lactogluconate. 
During this period the hemoglobin was raised from 
35 per cent, to 50 per cent., but the clotting time 
remained at 7 minutes. 

On January 21st, under ether anesthesia, an 
oblique incision was made in the upper right abdom- 
inal quadrant, and the liver found symmetrically en- 
larged and soft, the gallbladder slightly distended 
but not diseased, the gallbladder and ducts free of 
palpable stones. The head of the pancreas was 
diffusely enlarged and hard, but not definitely ma- 
lignant. The gallbladder was opened and consider- 
able dark thick bile was evacuated, no stones found. 
A cholecystostomy was done. 

Reaction to the operation was quite satisfactory; 
bile flowed copiously from the wound, the jaundice 
slowly diminished. The itching was less at the end 
of a week and ceased between the third and 
fourth week, but jaundice was apparent for four- 
teen weeks. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



Six days after the operation blood began oozing 
from the wound. Pain appeared in the knee and 
elbow joints the same day. Calcium preparations 
and hemostatic serum were given to no avail. The 
bleeding from the wound increased, the gums be- 
gan to bleed, blood appeared in the urine, was 
vomited and passed by bowel. Pituitrin hypoderm- 
ically, adrenalin and tannic acid solutions locally, 
tight packing of the wound, more calcium and 
hemostatic serum were used. The bleeding around 
the wound was finally checked by searing with the 
actual cautery, and the tannic acid and adrenalin 
applications to the wound and to the gums finally 
stopped the oozing. Between January 28th and 
February 17th eight transfusions of citrated blood, 
averaging 475 c.c. each, and a total of 750 c.c. of 
normal saline solution, were given. The stools were 
clay-colored from February 1st through the 18th, 
except for three or four days after January 30th 
when they were black with blood. 

Digestive disturbance followed which, with the 
dehydration from the loss of fluid from the biliary 
fistula and the rather severe reaction from one of 
the transfusion — the last one — reduced the patient's 
condition almost to extremis. 

After the bleeding was controlled, improvement 
was gradual; the appetite and digestion bettered 
and brought slight gain in strength. March 6th 
the patient was able to sit up in bed and ten days 
later she was out in a rolling chair for a short 
time each day. During February and the early 
part of March the amount of pus in the urine in- 
creased greatly. This was combated with urinary 
antiseptics and frequent bladder irrigations. There 
was no pain in the lumbar region at this time. 

By April 2nd, 70 days after the first operation, 
the patient's condition was considered good enough 
to permit steps to stop the copious drainage of 
bile from the biliary fistula. On that date, under 
local procain anesthesia, a new incision was made 
along the line of the old one, the granulated tissue 
dissected out, the gallbladder separated from 
numerous adhesions and opened. Into this opening 
the small end of a mushroom catheter was inserted 
and fastened, the other end of the catheter being 
pushed into the duodenum, an area of which had 
first been encircled by stitches of catgut and then 
punctured with the cautery. The peritoneal coats 
of the gallbladder and duodenum were next brought 
together by two lines of stitches and a tab of omen- 
tum was tied over the suture line and the abdomen 
closed. Button tension sutures and skin clips were 
used to make the wound approximation more se- 
cure. The patient experienced no pain and left the 
table in good condition. 

We chose to connect the gallbladder to the 
duodenum rather than to stomach, jejunum or any 



other part of the intestinal tract, because it seemed 
sound physiology to revert the bile to that part of 
the intestinal tract into which it normally is emp- 
tied. While it is more difficult to anastomose the 
gallbladder to the duodenum than to the stomach, 
we thought the use of the mushroom catheter 
would more than balance the technical difficulty. 

The use of a mushroom catheter for making this 
anastomosis is ideal. I would be afraid to make 
an anastomosis of this kind without some device 
to keep the passage patent, A ^Murphy button can 
be used but we have no assurance which way the 
button will pass when it sloughs out. 

.Although we realized the poor operative risk, 
something had to be done to stop the loss of fluid 
and to restore the bile to the body economy. With 
an external biliary fistula there is a waste of pig- 
ment for hemoglobin formation; loss of calcium 
with its influence on blood clotting and on harden- 
ing of bone, and the increased tendency to tetany; 
loss of sodium salts and impaired digestion and 
waste of fat and of ingested calcium. In the ab- 
sence of normal alkali, calcium of the food com- 
bines with the fatty acids in the intestines, forming 
an insoluble calcium soap, so that both the fat and 
the calcium are lost to the body. Normally, cal- 
cium is held in combintion by the bilirubin of the 
bile. 

The patient's condition, appetite and digestion 
promptly improvved, gaseous distention promptly 
ceased, bowel movements were normal in time and 
color. Everything ran smoothly until .\pril 20th, 
eighteen days after the cholecystoduodenostomy, 
when she began to have fever — t. 99 to 102^/2. 
The urine, which had become clear, showed pus 
cells in increased numbers. On .April 24th her 
weight was 84 pounds. 

On May 2nd dull pain was felt in the left lumbar 
region which radiated into the left lower abdominal 
quadrant. The pain gradually increased with all 
the signs of toxin absorption. 

A mass appeared over the left kidney area May 
13th, which gradually grew larger and tenderer. 
.■\t this time the urine was loaded with pus, the 
white cells were 19,000, with 91 per cent, polymor- 
phonuclears. 

A diagnosis of lumbar abscess was made, and on 
May 18th, forty-five days after the gallbladder- 
duodenum anastomosis, under local procain anes- 
thesia, a transverse incision was made over the 
center of the lumbar tumor. After cutting through 
the quadratus lumborum muscle we entered a large 
abscess cavity, from which was evacuated about 
300 c.c. of thick yellowish-green pus. A hurried 
examination of the cavity failed to reveal any 
connection of it to the left kidney, but we are 
reasonably certain there was such a connection. 



Januarj', 1936 



SOUTHERN MEDICINE AND SURGERY 



2S 



Although the patient complained of no pain at any 
time during the operation, she fainted and, when 
the cavity was entered, had a convulsion. The 
pulse for a few minutes was 160 or more. The 
cavity was quickly wiped clean and packed. On 
leaving the table the pulse was 130 and the patient 
was conscious. 

Immediate improvement followed, the wound 
draining freely. During the week following several 
gravel passed by the natural route. 

About July 1st, the abscess cavity began drain- 
ing less freely. The t. and w. b. c. — with 
polymorphonuclears predominating — began again to 
rise, and signs of toxin absorption reappeared. On 
July 22nd, 110 days after the cholecystoduodenos- 
tomy, a bismuth subnitrate paste was introduced 
by means of a catheter as deeply into the abscess 
cavity as possible, and anteroposterior and lateral 
films made. These showed that the cavity extend- 
ed to and connected with the large coral stone pre- 
viously mentioned. On the following day, under 
local anesthesia supplemented by a small amount 
of ether, the previous lurnbar incision was enlarged 
and entered. From the bottom of the cavity there 
was removed a stone weighing '4 oz. A large 
quantity of pus escaped from behind the stone. 
The wound was packed and closed up to the drain. 

The patient's condition again improved prompt- 
ly. She is free of fever now, has no signs of tox- 
emia and has gained 24 pounds since the last oper- 
ation. She sits up practically all day, walks about 
one hour each day and is rapidly gaining strength. 
She now weighs 108 pounds. 

The question now is, What will be the future 
course of this case? Can it be reasonably assumed 
that no more trouble will be experienced in the 
biliary tract? Nine months have elapsed since the 
jaundice began disappearing. On April 2nd, when 
the anastomosis was done, the head of the pancreas 
was smaller and softer than when the first opera- 
tion was done. Have we sufficient grounds to as- 
sume that the lesion which obstructed the common 
bile duct is not malignant? 

I wish to emphasize the point that, at each oper- 
ation, the patient's condition was too serious to 
warrant very extensive procedure. 

What will be the ultimate outcome of the nephro- 
lithiasis? I think we feel safe in assuming that 
the left kidney has been destroyed. X-ray pictures 
show definitely the increase in the number and 
density of the stones in the left kidney area, and, 
what is more alarming, the appearance and rapid 
increase in the number and density of stones in the 
right kidney area. We have not made a cystoscopic 
examination because we did not think the informa- 
tion would justify the procedure. At a later date a 
cystoscopy will be done, and if the left kidney is 



found to be out of commission and the right kidney 
is functioning, we will remove the left kidney and 
thereby stop the drainage from this source. 

Addendum. — Since this case was reported at the 
Wadesboro meeting of the Seventh District Med- 
ical Society on November 12th, 1935, the fistulous 
opening in the left lumbar region has healed. We 
believe that the use of Beck's paste had much to 
do with this healing. The patient is now in good 
condition except for occasional attacks of right 
renal colic. Her present weight is 121 lbs. 



Xanthomatosis: Schuller-Christian's Disease 

(Jos. Dauksys, Excelsior Springs, in Jl. Mo. State Med. 
Assn., Dec.) 

Xanthomatosis (Schuller-Christian's disease) is a disturb- 
ance of lipoid metabolism with an irregularly periodic in- 
crease in blood cholesterol, followed by the deposition of 
cholesterol, and its esters in the reticulo-endothelial sys- 
tem, usually at places where either infection or trauma has 
produced with subsequent nodule formation, fibrosis, foreign 
body giant cell formation and sometimes hyalinization. 

Clinically, it manifests itself by the presence of a com- 
bination of all 3 or any 1 or 2 of the major symptoms, 
viz., bony defects of the skull, diabetes insipidus and ex- 
ophthalmos. There are frequently other symptoms present 
depending upon the localization of the deposits. 

The male sex is more susceptible in the ratio of 2:1. It 
is usually found in the first decade of life, though the oc- 
currence may be grouped in three age periods, infantile, 
juvenile and adult. Mortality estimates range from 25 to 
33%. 

A successful scheme of treatment has not yet been evolv- 
ed although roentgentherapy has shown remarkable results, 
especially in the treatment of local lesions. The evaluation 
of the results of treatment has been rendered difficult be- 
cause of spontaneous regression in some cases. In spite 
of the occurrence of remissions, the actual improvement 
noted in cases where roentgentherapy was used speaks 
strongly for its use. 

A review of the literature brings to light 123 cases which 
appear to conform to this group; the one here reported 
makes 124. 



Onion Odor Removable 
Howard W. Haggard and Leon A. Greenberg, New Ha- 
ven, Conn. {Journal A. M. A., June 15th, 1935), state that 
the odor given to the breath by onion or garlic comes from 
the essential oil contained in these vegetables. The oil does 
not, as has been suggested, reach the breath from aeration 
of the blood in the lungs, from pulmonary secretion, from 
salivary secretion, or in air passed from the stomach. It 
arises solely from particles of onion or garlic retained in 
the structure about the mouth. Brushing the teeth and 
tongue and washing the mouth with soap and water fail 
to deodorize the breath. Washing the mouth with a 30 
per cent, solution of alcohol is ineffective. The breath can 
be immediately and completely rid of the odor by washing 
the teeth and tongue and rinsing the mouth with a solution 
of chloramine. The chlorine liberated in the mouth reacts 
chemically with the essential oils and deodorizes them. It 
is probable that many cases of foul breath from other 
cau.ses would be amenable to the same method of treat- 
ment. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



D EPARTMENT S 

HUMAN BEHAVIOR 

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



Cyclic Civic Financing 
James Henley, so I read in a newspaper de- 
spatch from Petersburg, must return to the state 
penitentiary in Richmond and there spend the re- 
mainder of the days originally allotted by the Lord 
to him. Convicted of having slain a neighbor in 
1916, he was sentenced to the penitentiary for life, 
but after having served ei^teen years, he was pa- 
roled a year or two ago upon condition that he 
violate no law of the Commonwealth. He was so 
sent out amongst his fellow mortals, perhaps be- 
fore the State of Virginia had become a saloon- 
keeper. While celebrating the anniversary of th'' 
birth of his Saviour a few days ago in Danville, he 
was arrested for drunkenness, his identity was 
established by scrutinization of the palmar aspect 
of a thumb, and back to the prison for life he 
must go. 

And I fell to wondering. The whole punitive 
ritual is too much for my psyche. Did Henley 
buy his liquor in a store owned and operated by 
the State of Virginia? If so, did he not render the 
State a service and the bootlegger a disservice, and 
thereby do his best to help to support the govern- 
ment of which he is a constituent member? Should 
he be punished for such a patriotic effort? And if 
so punished, should he be punished with unusual 
severity? I think I have heard that such punish- 
ment is against the constitution. 

Is it not to be considered that in so punishing 
him the State may be discouraging some of its citi- 
zens from patronizing State liquor stores, and 
thereby lessening the accumulation of revenue in the 
State's treasury? Without money — liquor money 
and all other sorts — how can the State educate its 
children, care for its physical and mental cripples, 
and maintain its high standing amongst its sover- 
eign neighbors? If the State sells to Henley or 
another the stuff that makes him drunk does not 
the State become particeps criminis? That prob- 
lem, what becomes of the snaJke that succeeds in 
swallowing itself, and all such other abstrusities I 
shall have to leave to the legalistic and theological 
luminaries. It is too difficult to begin the year 
with. A apologize for its presentation to you. But 
v/hat do you suppose James Henley thinks of Vir- 
ginia's punitive ritual? 

On Avoidance of Ingratitude 
I invite the attention of the unsubsidized mem- 
bers of the congregation to the following para- 
graph: 



''Contrasted with these well organized hospitals 
are those built for profit. Their owners soon find 
that they are unintentional philanthropists and they 
use every possible means to curtail expense, thereby 
lowering their standards of care. The scarcity of 
patients who have been able to pay for hospital 
service during the past few years has quite forcibly 
removed thoughts of dividends on hospital invest- 
ments. With no interest in the welfare of their 
community and no prospect of profits, such hos- 
pitals are rightfully passing out of existence." 

The excerpt is from a piece in The Modern 
Hospital, May, 1934, by Dr. Lucius R. Wilson, 
Superintendent, John Sealy Hospital, Galveston, 
Texas. The title of the article is: Southern Hos- 
pitals fit Themselves to Serve more Adequately. 
The content of the contribution is a eulogium of 
the Duke Endowment and the Julius Rosenwald 
Fund. 

One should not be surprised. The hospital of 
which Dr. Wilson is Superintendent is thoroughly 
foundationized. He speaks in derogation of doctors 
working for a profit. Does any one suppose that 
his superintendency constitutes an eleemosynary 
service? 

A group of Indian braves, led by their chief, 
visited Washington City, and the Great Chief in 
the White House assigned an army officer to show 
them the sights of the Nation's Capitol. The offi- 
cer asked the Chief what he thought of the great 
mural in a gallery — in which a clash on the plains 
was portrayed betwixt a troop of cavalry and 
mounted Indians. But the arresting item in the 
scene was a private soldier holding his pistol to 
the temple of an Indian whom he had unhorsed, 
and upon whose prostate neck he pressed down one 
of his military feet. After long meditation the 
Chief remarked: "White man made that picture." 
And the white man continues to make pictures, 
many of which call for interpretation. 

Dr. Lucius R. Wilson does not propose to run 
the risk of having his Foundation say to him what 
David the Psalmist said in his bitterness about one 
of his ungrateful week-end guests: "Yea, mine 
own familiar friend, in whom I trusted, which did 
eat of my bread, hath lifted up his heel against 
me." 

On Psychiatric Mediaevalism 
Out in Saint Louis the other day, at the meeting 
of the Southern jNIedical Association, Dr. W. L. 
Treadway, Assistant Surgeon General, Division of 
Mental Hygiene, United States Public Health Ser- 
vice, Washington, read a paper before the Section 
on Neurology and Psychiatry. He discussed: The 
Significance and Content of Mental Health Admin- 
istration. The paper should be read by every phy- 



January, 1936 



SOUTHERN MEDICINE AND SURGERY 



sician in the country and by all intelligent laymen. 
I remember that Dr. Treadway remarked that 
psychiatry, as a public health problem, is being 
dealt with about as stupidly as public health folks 
dealt with physical diseases eighty years ago. And 
he added that there is no hope of the situation's 
being any better so long as the management of 
mental hospitals is controlled by politicians and 
by other laymen who know nothing about medicine. 

How can progress ever come out of ignorance? 
Most State hospitals are managed by boards of 
directors composed of laymen — politicians and so- 
called business men. The responsibility of selecting 
the medical superintendents of such hospitals is 
given to such lay boards. And not infrequently 
they elect as superintendent a physician who knows 
no more about psychiatry than the family doctor 
knows, and who knows nothing at all about hospital 
administration. Here in Virginia the five State 
hospitals and several allied institutions function in 
a general way under the auspices of the State 
Board of Public Welfare. But that is an organiza- 
tion of laymen, untrained in psychiatry and inex- 
perienced in hospital management. Per contra, the 
State Board of Health is composed largely of phy- 
sicians, and the President of the Board is a physi- 
cian. Yet no intelligent person can believe that 
the problems with which the Boards of Directors 
of the State Hospitals deal are smaller or less com- 
plex than those with which the State Board of 
Health deals. Why are those conditions relating to 
mental sickness handled by laymen, and those 
caused by disease of the body cared for by physi- 
cians? Who knows? 

Time was, of course, and not so long ago, when 
the medical colleges gave no instruction in the 
diagnosis and the treatment of mental sickness. 
But that time has passed. .All medical schools 
now give some instruction in psychiatry, and the 
younger physicians know something about the im- 
portance of mental hygiene. I am wondering how 
much longer the younger doctors are going to be 
willing for laymen to have charge of every State's 
biggest and most difficult medical problem — mental 
sickners. 



EYE, EAR, NOSE AND THROAT 

For this issue, Neilson H. Turner, M.D., Richmond, Va. 
Associate in Ophthalmology at the Med. Col. of Va. 



Some Ophthalmological Pitfalls and How to 
Avoid Them 
Pitiful cases of hopeless blindness in which the 
sight could have been saved — cases that I have 
seen in my private practice and at the Medical 
College of Virginia Dispensary — have prompted me 
to carry this message to my fellow practitioners. 



In addition to these terrible afflictions of blindness, 
think of the number of such cases throughout the 
entire country, and of the economic loss and the 
burden placed upon the taxpayers in taking care 
of them. In this paper no reflection is implied or 
intended on any one, but it is hoped that by em- 
phasizing a few simple rules, vision which in many 
cases would be lost from a lack of proper attention 
will be saved. These rules have been stressed 
over and over, they are not repeated often enough 
or as forcefully as the situation demands. 

If a patient, one past middle life in particular, 
complains of failing vision and if on throwing a 
light into the pupillary space a grey reflex results, 
do not jump to the conclusion that he is getting 
cataract, and tell him to wait until it matures to 
go to the ophthalmic surgeon to have it removed. 
The grey appearance may be due to senile changes 
(sclerosis) taking place in the lens. Or, if he 
does have cataract there is always the possibility 
of other serious intraocular or optic-nerve condi- 
tions — such as extensive choroiditis, simple glau- 
coma, optic atrophy, uveitis and optic neuritis — 
being present, all of which seriously threaten vis- 
ion. The visual defect may be due to one of these 
causes, and in these cases early proper attention 
is necessary to save vision. Even in the very early 
stages the very best attention is needed. 

On July 11th, 1934, a woman was brought to me by 
her husband to have cataracts removed. She had been 
referred by her sister-in-law, a patient of mine. On throw- 
ing a light into the pupillary spaces there was a grey 
reflex, but on examination with the ophthalmoscope each 
lens was found to be transparent. Both eyes were in a 
state of advanced glaucoma simplex — with the intra-ocular 
tension in the right at 45 mm. and that in the left at SO 
mm. — and she was hopelessly blind. As the husband 
would not agree to an operation for the relief of the 
pain, pilocarpine was ordered. At this point she said that 
nearly a year ago when she complained to her family 
doctor about her sight failing, he threw a light into her 
eyes and then told her that she had cataract, but to "wait 
until you become blind, then go to the eye doctor to have 
them removed." Now, had this patient received the indi- 
cated care early enough, her vision might have been saved, 
or at least the evil day would have been postponed for 
an indefinite period. 

A gentleman, Si years of age, came to see me on Au- 
gust 24th, 1931. His vision was 3/200 in his right eye and 
7/200 in his left eye, no improvement with lenses. There 
was extreme pallor of both optic discs with degenerative 
changes in the fundi. The lens of each eye was unaffected 
and the intra-ocular tension was normal by tactile sense. 
On throwing a light into the pupillary space a grey reflex 
resulted. This patient had also been told to wait until 
the cataracts ripened and then go and have them removed, 
but his trouble was optic atrophy, and it was so far ad- 
vanced as to make saving of vision hopeless. Had this 
patient been seen in time, a good vision might have been 
the outcome, or the process arrested if degenerative changes 
had taken place, or certainly the evil day could have been 
postponed. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



If on throwing a light into the pupillary space 
a grey picture results, especially in one past 
middle life, don't jump to the conclusion that it is 
a case of cataract — pass the responsibility to a 
competent and experienced ophthalmologist. 

Following the removal of a foreign body from 
the eye, or at any other time, if you wish to em- 
ploy a local anesthetic in an eye, do not order a 
solution of cocaine for the patient. It may cause 
an attack of acute congestive glaucoma in a person 
with that tendency, and its repeated use will result 
in exfoliation of the corneal epithelium, thus pro- 
viding a fertile field for bacterial growth. 

In August, 1926, a locomotive engineer, 57 years of age, 
consulted me because of a very uncomfortable and a 
badly inflamed right eye. Two days prior to this time 
the company's physician had removed a foreign body from 
the eye and prescribed a solution of cocaine for the dis- 
comfort. This he had used ver>' freely. The whole an- 
terior portion of the cornea was infiltrated, there was 
desquamation of practically all of the epithelium, and he 
had a suppurative keratitis. The prognosis was grave; he 
had been told by another ophthalmologist that he was 
going to lose that eye. Fortunately the eye was saved, 
with 20/40 vision in an eye that formerly had 20/15. 

The use of the cocaine solution and the infection 
came very near resulting in loss of this eye — and 
in a condition which, as a rule, causes very little 
trouble to the competent oculist and to the patient. 
So do not prescribe cocaine for the patient to use 
in his or her eyes. It should be used only by the 
physician under suitable conditions. 

Atropine, homatropine and scopolamine solutions 
or ointments should not be used in an eye until a 
proper examination by one competent to make it 
indicates that it is a safe procedure, for if there is 
glaucoma or a tendency in that direction, the in- 
stillation may cause acute congestive glaucoma, 
which, unless properly treated immediately, will 
lead quickly to hopeless blindness. So do not 
employ any drug of this type in an eye unless you 
know that no contraindication exists. 

Recently at the Medical College of Virginia Dispensary 
I saw a colored man with old well advanced case of glau- 
coma simple.x, who having had some trouble with his 
eyes called in his family doctor, who diagnosed the case 
as iritis and prescribed atropine. The next day he was 
brought to the dispensary suffering intense pain and head- 
ache, m an attack of acute congestive glaucoma, induced 
by the atropine. Fortunately no damage to vision could 
result as he was already blind, but the same thing can 
happen in a person with good vision. 

Solutions of silver nitrate should never be pre- 
scribed for a patient to use in his or her eyes. Its 
injudicious employment in the eyes may result in 
a permanently stained cornea, especially so if there 
is a break in the corneal surface. Aside from other 
considerations, a suit for damages may follow. 



The use of organic silver compounds should be 
strictly supervised by the physician, as prolonged 
use may produce permanent staining or the con- 
junctiva. In many this results from the patient 
not returning as he was instructed by the physi- 
cian, but continuing to use the drug. Cases of 
argyrosis are not uncommon. 

Only recently I saw at the dispensarv- a woman, 37 years 
of age, totally blind in the right eye and practically so in 
the left, with only light perception in the upper and tem- 
poral fields. She had been having trouble with her eyes 
for some time. Her physician gave her one intravenous 
injection and told her to go to an optician to get some 
glasses. She went to the optician several times about 
her glasses and in the meantime she was getting progres- 
sively worse. Her trouble was a luetic uveitis. The pupils 
were contracted, dense posterior synechiae prevented com- 
munication between the anterior and the posterior cham- 
bers, resulting in iris bombe and secondary glaucoma. 
From the increased tension in the structually weakened 
right eye an anterior staphyloma resulted. Degeneration 
of the retina and the optic nerve had also occurred and 
the eye was hopelessly blind. The same condition, with 
the exception of the staphyloma and the fact that she had 
bare light perception in the upper and temporal fields, ex- > 
isted in the left eye. 

No physician should refer a patient to an opti- 
cian to have an eye examination; to do so may 
plunge the patient into life-long darkness, when the 
attention for which an ophthalmologist is trained 
would have preserved good vision. I have seen 
cases of glaucoma, optic atrophy and other path- 
ological ocular and optic-nerve conditions in which 
the optician had continued to change the glasses 
until the patient had become practically blind, then, 
often too late, an ophthalmologist was consulted. 

If a patient comes with a red eye, do not jump 
to the conclusion that it is "pink eye" or con- 
junctivitis, or that it is an iritis. It may be either, 
but it may not: it may be an acute congestive 
glaucoma, and if it is and is treated as an iritis or 
as a conjunctivitis the result will be disaster to 
the eye. If it be an iritis and it is treated as a case 
of "pink eye", the outcome may be an eye with 
dense posterior synechiae and an iris bombe, with 
a secondary glaucoma, or obliteration of the pupil 
and a blind eye. So be sure that you understand 
the ocular affection before trying to treat it; better 
still, refer the case to an experienced and compe- 
tent ophthalmologist, let him have the responsibil- 
ity. 

So long as sight is being lost that C(juld be pre- 
served, it is our duty to call attention to errors in 
the diagnosis and treatment of ophthalmic condi- 
tions, to illustrate some of the serious consequences 
of these errors of omission and commission, and 
to impress upon all doctors the necessity of ob- 
serving simple rules to see that these patients re- 
ceive proper medical service early. 

—200 E. Franklin St. 



Januar>', 1936 



SOUTHERN MEDICINE AND SURGERY 



Posture and Post-operative Treatment in Eye 
Conditions 

(J. B. Hamilton, Hobart, in Australian & New Zealand Jl. 
of Surg., Oct.) 
While acting as house surgeon both in Australian and 
English ophthalmic hospitals, I was confronted by three 
facts in the post-operative treatment of eye conditions, and 
especially of patients with cataract: 

1. Patients suffered great discomfort by being nursed 
in a supine position, without any alteration for 7 to 10 
days. This discomfort manifested itself by extreme pain 
in the loins and shoulders. 

2. This pain in the back invariably led to flatulence 
and often to vomiting, with consequently disastrous results 
to the eye that had been operated on in the form of intra- 
ocular hemorrhage and prolapse of the iris. 

3. This unnatural position often resulted in congestion 
of the lungs, retention of urine, mania, and sometimes sud- 
den death from cardiac failure. This sudden death was 
due to sudden alteration of the patient's posture resulting 
in coronary thrombosis. 

I therefore suggested to my senior colleagues that Fow- 
ler's position should be tried as an alternative in post- 
operative treatment. Ultimately I was allowed to nurse in 
the erect posture a few patients whose cataracts had been 
extracted, and the results were just as I anticipated, that is, 
post-operative convalescence was free from all complica- 
tions and discomforts. 

In all conditions except detachment of the retina, when 
the patients are returned from the theatre (operating), I 
superintend their move from trolley to bed in the supine 
position. Then they are asked to sit erect very slowly, 
their heads being supported with my hand. They are 
bodily lifted towards the head of the bed about 12 inches 
and seater on an air cushion. Pillows are then piled behind 
them to keep them in this erect position and a "Fowler's 
pillow," strapped to the head of the bed, is placed under 
their knees to prevent them from slipping. At night their 
hands are lightly tied by clove hitches to the sides of the 
bed, and an electric bell is placed in one hand. Rest in 
this posture is assisted by hypnotics given before and after 
operation. 

In dealing with cases of detachment of the retina the 
patient's head is placed in such a position that the retinal 
hole is in the most dependent portion of the eye, as rec- 
ommended by Gonin. Patients who have been subjected 
to general anesthesia are not placed in Fowler's position 
until full consciousness has returned. 



A woman entered the clinic and complained to the desk 
attendant that she had "seen nothing" for 3 months. Re- 
ferred to the eye clinic, she underwent a complete exam- 
ination. "Madam," said the doctor, "there is nothing the 
matter with your eyes; they are normal. Why did you 
come to me?" "Well, Doctor, I told the girl at the desk, 
but she would not listen to me; I haven't seen anything 
for three months." 



UROLOGY 

For this issue, Ekmer Hess, M.D., F.A.C.S., Erie, Penn. 

From the Urological Department of St. Vincent's and 
Hamot Hospitals, Erie, Pennsylvania. 



Is Nephritis a Medical or a Urological 

Problem? 
It has long been a question whether or not so- 
called medical nephritis falls within the realm of 
the internist or the urologist. Before scientific 
urology made a place for itself among the medical 



specialties, many of the diseases of the kidney were 
considered medical. 

There are many classifications of renal disease. 
The pathologist recognizes the degenerative, the in- 
flammatory and the sclerotic types in all of their 
various manifestations. Clinically, it has been dif- 
ficult to fit renal disease into any definite path- 
ological classification. Any classification, to be use- 
ful, must so clarify the nomenclature that the same 
words will mean the same things to all. The Amer- 
ican Urological Association, a few years ago, des- 
ignated Montague Boyd and others to set a stand- 
ard nomenclature for our use. Confusion has always 
resulted in medical discourses because of this lack 
of uniformity in nomenclature and particularly with 
reference to renal disease and its proper classifica- 
tion. 

Volhard and Fahr's classification is, to me, the 
most acceptable. Hinman, in his new book, at- 
tempts to place all renal disease in two classes, 
medical and surgical. Neither of these classifica- 
tions has seemed to me quite as good as the one 
which I offer, not as original with me, but a com- 
bination of former classifications, practical and ap- 
plicable to all renal disease. 

I do not like to separate renal disease into med- 
ical and surgical. A patient either has renal path- 
ology or he does not. I do not see how diagnosis 
and treatment of the urinary tract can be scien- 
tifically accomplished without the use of the cys- 
toscope. True, we will always need the help and 
cooperation of the internist as well as the other 
specialists, but in the last analysis the diagnosis 
and treatment of any renal disease is essentially 
urological regardless of the pathology. 

Volhard and Fahr's classification is well known: 

A. Degeneration Diseases: Nephroses, genuine and of 
known etiology, without amyloid degeneration of 
the vessels. 

(1) Acute course 

(2) Chronic course 

(3) End stage: Nephrotic contracted kidney 
without increased blood pressure. 

B. Inflammatory Diseases: Nephritides. 

(1) Diffuse glomerulonephritis with obligatory 
increased blood pressure, course in three 
stages. 

(a) Acute stage 

(b) Chronic stage without kidney insuf- 
ficiency. 

(c) End stage, with kidney insufficiency. 

(All three stages may run a course. 

(a) Without edema 

(b) With edema, i.e., with marked 
and diffuse degeneration of the 
epithelium.) 

(2) Focal Nephritis, without increased blood 
pressure. 

(a) Focal glomerulonephritis 

(1) Acute stage 

(2) Chronic stage 

(b) Septic interstitial nephritis 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



(c) Embolic focal nephritis 
C. Arteriosclerotic Diseases: Scleroses. 

(1) Benign Hypertension — pure sclerosis of the 
kidney vessels. 

(2) Malignant Hypertension — the combination 
form, genuine contracted kidney — sclerosis 
plus nephritis. 

Volhard and Fahr's classification is incorporated 
into the one which I offer and in which any clin- 
ical or pathological renal entity can find a logical 
position regardless of the mixed pathology, and 
immediately the dominant clinical entity will be 
qualified. I submit the main heading of nephrosis 
as proper because this term means "any diseased 
condition of the kidney," and under this general 
classification come the principal subdivisions — (1) 
Nephrostasis, (2) Nephrotoxicoses, (3) Nephro- 
phlegmasias, (4) Nephrectasias, (5) Nephrosclero- 
ses, (6) Nephro-anomalies, and (7) Nephro-neo- 
plasias. 

NEPHROSIS 

1. Nephrostasis 

(a) Orthostatic Albuminuria 

(b) Congestive Albuminuria 

2. Nephrotoxicoses 

(a) Acute 

(1) Toxic 

(2) Lytic 

(b) Chronic 

(c) Terminal. Contracted kidneys without in- 
crease in blood pressure or with increase in 
blood urea and creatinin. 

3. Nephrophlegmasias 

(a) Diffuse Glomerulonephritis. (Increased blood 
pressure and bilateral.) 

(1) Acute. (With or without edema.) 

(2) Chronic. (With or without edema and 
without renal insufficiency.) 

(3) Terminal. (With or without edema but 
with renal insufficiency. A degenera- 
tion of the epithelial cells.) 

(b) Focal Nephritis. (Without increased blood 
pressure. May or may not be bilateral.) 

(1) Glomerulonephritis 

(a) Acute 

(b) Chronic 

(2) Interstitial Nephritis. (Septic) 

(3) Embolic Nephritis. (Focal) 

(c) Pyelonephritis. 

(1) Acute. (Bilateral or unilateral with or 
without stasis or obstruction.) 

(2) Chronic. (Unilateral or bilateral with or 
without stasis due to obstruction.) 

(3) Terminal. (Unilateral or bilateral with 
or without stasis due to obstruction.) 

4. Nephrectasias. 

(a) Congenital or acquired. 

(1) Hydroecstasias. (Bilateral or unilateral.) 

(a) Acute — always obstructive. 

(b) Chronic — always obstructive. 

(c) Terminal — always obstructive. 

(2) Pyoecstasias. (Bilateral or unilateral.) 

(a) Acute — always obstructive. 

(b) Chronic — always obstructive. 

(c) Terminal — always obstructive. 



5. Nephroscleroses 

(a) Benign Hypertension. (Sclerosis of the renal 
vessels and sympatheticotonias.) 

(b) MaUgnant Hypertension. (Sclerosis plus 
nephritis, cardio-vascular-renal disease.) 

6. Nephro-anomalies 

(a) Aplasia. (Unilateral or bilateral.) 

(b) Hypoplasia. (Unilateral or bilateral.) 

(c) Fetal-lobulated. (Unilateral or bilateral.) 

(d) Double kidneys. (Unilateral or bilateral.) 

(e) Horseshoe kidneys. 

(f) Cystic kidneys. (Unilateral or bilateral.) 

(1) Multilocular. 

(2) Unilocular. 

7. Nephro-neoplasias. 

Nephrostasis 
Orthostatic albuminuria is due to congestion of 
a kidney as a result of pressure on the renal vein, 
due to posture, the albumin disappearing upon the 
relief of the pressure by change of posture. Many 
of these cases are due to a lordosis and the albumin 
disappears from the urine after a night's rest in 
bed. A similar group of innocuous albuminurias 
are those caused by fatigue, common in athletes 
and soldiers after severe physical strain. Finally, 
there are those individuals whose renal threshold is 
low and albumin will spill into the urine following 
heavy ingestion of albuminous foodstuffs. These 
cases require complete urological surveys for diag- 
nosis. Obstructive uropathies, infections of the 
upper urinary tract, anomalies and ptoses of the 
kidneys must be eliminated. Barring definite uri- 
nary pathology, the patients should usually be re- 
ferred to an orthopedic surgeon: if the lordosis is 
complicated by active urinary disease, the latter 
should have urological supervision. Again, a com- 
plete urological study is necessary to rule out ab- 
normalities of and pathology in the urinary tract, 
and diet and exercise must be judiciously con- 
trolled. 

Nephrotoxicoses 

These are the degenerative diseases, or the 
nephroses of Volhard and Fahr. They fall in 
the category of medical nephrosis in other classi- 
fications. They are neither medical nor surgical 
but urological conditions. These are tubular in- 
volvements due to the toxins of inflammatory 
disease, or to direct poisons. The pathology is best 
represented by cloudy swelling, fatty and finally 
amyloid degeneration. In the acute cases are the 
toxemias of pregnancy and the renal picture often 
seen in chronic infectious disease elsewhere in the 
body, and in poisoning by the heavy metals. If 
the toxic elements being eliminated through the 
kidney are lytic, then the entire process is acute 
and shortly terminal with rapid lysis of the renal 
tubular epithelium. 

This picture is typical in the toxemia of preg- 
nancy where toxins, probably from the placenta 



January, 1936 



SOUTHERN MEDICINE AND SURGERY 



31 



and the new fetus, cause the morbid process to 
assume an acute stage. The condition must be 
differentiated from the nephritis or the pyeloneph- 
ritis of pregnancy by complete urological study. 
The same picture, much more acute in its mani- 
festations, is also the result of bichloride poisoning 
and may be produced by other poisons of extrane- 
ous origin. The course in all of these conditions 
may also be slow. This chronic type of the dis- 
ease may also be found in syphilis, tuberculosis, 
osteomyelitis, sinus and tonsillar infections, etc. In 
these cases the toxins are constantly being released 
into the blood stream in small quantities and the 
tubular epithelium is very gradually poisoned. 
Cloudy swelling and degeneration of the cells pro- 
gress much more slowly but the end result is the 
same. It is in these cases that cure of the renal 
condition means the surgical and hygienic treat- 
ment of the original focus after a thorough urologi- 
cal and general systemic survey. 

This is the work of allied medical groups, but 
the diagnosis is urological and the kidney lesion 
must be treated urologically in cooperation with 
the internist, the surgeon or other specialist. The 
quickest way to treat a toxemia of pregnancy is, 
of course, to have the obstetrician or gynecologist 
empty the uterus, when the renal condition will 
usually improve immediately unless this procedure 
has been postponed to the terminal stage. Much 
can be done by the urologist to hasten renal im- 
provement in these cases. 

In mercury poisoning, after all measures to get 
rid of the poison have been tried, the urologist 
should come into the picture. Sodium thiosulphate 
should be given intravenously, a solution of the 
same drug should be adminstered orally, vaginally 
and per rectum, cystoscopy should be done and 
the renal pelvis lavaged with a continuous flow of 
the same solution. In poisoning by the heavy 
metals there is a definite insoluble chemical com- 
pound formed with the protein of the renal cells 
and this must be changed chemically so that the 
cell may throw off the metal. The long-standing 
chronic infections eliminate toxins that likewise 
gradually destroy the epithelial cells of the tubules. 
Certain of these toxic products seem to have a 
definite selective activity upon these renal cells. 
Of course, the treatment is the treatment of the 
primary infection; but the differential renal diag- 
nosis depends upon the urologist and local treat- 
ment is often of great assistance. As a rule, all 
of these conditions are bilateral; only occasionally 
are they unilateral. .■Mso occasionally, denervation 
and decapsulation aid in the ultimate recovery of 
the individual. 

The blond pressure is usually but little influenc- 
ed unless complicated by some other type of neph- 



rosis, and in the acute stage and at times in the 
chronic, the blood chemistry findings will be of 
prognostic as well as diagnostic significance. In 
the terminal stage urea and creatinin will be high, 
the urine scanty, highly albuminous and containing 
casts of all varieties. At autopsy, the kidneys will 
be small and contracted. There will be diffuse evi- 
dence of cloudy swelling, fatty degeneration and 
terminal amyloid degeneration throughout these 
kidneys. 

Nephrophlegmasias 

Under this heading are classified all those dis- 
eases which are due directly to infections with defi- 
nite secondary infections of the kidney parenchyma 
and the pelvis. We will not discuss subdivision 
two or three because it is well recognized that the 
diagnosis and treatment of these is purely urologi- 
cal and is a medical, cystoscopic and operative com- 
bination. 

The first classification, however, I wish to dis- 
cuss. Hinman identifies this group as a part of 
his medical sub-group and claims that no organ- 
isms are found in the urine in these cases. Vol- 
hard and Fahr classify this group in their main 
classification of the inflammatory diseases, the 
nephritides. 

The first subdivision then of the nephrophleg- 
masias is that entity heretofore known as diffuse 
glomerulonephritis (the old-fashioned Bright's dis- 
ease, a name which I hope will be dropped forever 
from our nomenclature) as a classification. This 
disease is bilateral and is accompanied by increased 
blood pressure. It is further subdivided into the 
acute, chronic and terminal stages. These cases 
usually fall into the hands of the medical man and 
are often treated in their entirety by him. Many 
internists today call in the urologist first, for as- 
sistance in the differential diagnosis, and secondly, 
to assist in the supervision of therapy. This is 
particularly advantageous because often the path- 
ology is extremely complicated. When these cases 
consult me first I go ahead and make the complete 
urological survey with a thorough physical exam- 
ination in all its details and when I find I need the 
services of the internist, the otolaryngologist, the 
surgeon, or the cardiologist, I ask him to assume 
mutual responsibility with me. When this type of 
cooperation is an accomplished fact, it is surprising 
how many of these cases of diffuse glomerulone- 
phritis will improve and many of them will become 
clinically cured. 

It is hard for me to believe that organisms are not 
present from time to time in the glomeruli and 
urine, and that the disease is a combination of 
glomerulitis caused by toxins and bacteria. The 
acute type, if fulminating, may be accompanied by 
edema or not, depending entirely upon the injury 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



to the glomerular cells and incapacity of these cells 
for taking salt and water from the blood, with up- 
set of cell function in other organs, this affecting 
every cell in the body. The acute condition may 
soon become a terminal one, or resolution and re- 
pair may take place to such a degree that the con- 
dition becomes chronic. In these cases the degree 
of permanent damage can be estimated only by 
complete, thorough urological investigation — in the 
vast majority of cases sufficiently accurately to es- 
tablish rational methods of management. At times, 
even clinical cure may be accomplished. 

My beloved Professor of Medicine at the Univer- 
sity of Pennsylvania, the late James Tyson, ad- 
vised: "Never give a nephritic a wholly bad prog- 
nosis but always give a guarded one. When I was 
a young physician a man came under my care who 
had an acute parenchymatous nephritis. His urine 
was filled with blood and albumin. He had almost 
a general anasarca. He was to my mind incurable 
and I told him that he had better make his will 
and straighten out his affairs as he had but a short 
time to live at best. I told him he might possibly 
live two years when he asked for his expectancy and 
he asked' me to put my prognostication in writing. 
This I did knowing full well that instead of two 
years longevity, a year of life would be miraculous. 
Gentlemen, for forty years on the anniversary of 
my prognostication, the gentleman presented him- 
self at my office and reminded me of my ignorance 
by presenting my signed statement." 

The urologist, in my opinion, is best equipped 
to make the differential diagnosis in these cases 
and to qualify the diagnosis. The treatment of 
the case may best be managed by him or he may 
be associated with one or more men from other 
branches of medicine: but his should be the re- 
sponsibility for the treatment of the renal lesion. 
If he is fortunate to have a clever internist as his 
collaborator even better for the patient. When the 
chronic stage of the disease is reached there may or 
may not be renal insufficiency, but who is as able 
to estimate this as the well-trained urologist? Sure- 
ly here, for the sake of accuracy, anything short of 
a complete urological survey will not suffice. It is 
in these cases that the laboratory is of so much 
value. 

Focal Nephritis 
No one disputes that the conditions classified 
under focal nephritis are usually diagnosed and 
treated by urologists, nor are the cases under the 
general classification nephrectasias under particular 
discussion. 

Nephroscleroses 
In this group are two types of renal disease, 
heretofore considered more or less medical prob- 



lems, falling into the hands of the urologists only 
when they were complicated by other renal path- 
ology. Here there are two subdivisions. In one 
there is sclerosis only, or constriction, of the renal 
vessels. The process is usually limited to anything 
which causes spasm of the renal arterial tree, such 
as sympatheticotonia, or toxic products in the blood 
which may have a special affinity for the renal ar- 
teries causing a localized sclerosis. 

For the sake of classification, we consider the 
principal symptom as one of benign hypertension, 
whose differential diagnosis can be arrived at only 
by elimination. In these cases skillful urological 
diagnosis is far more efficient than any medical 
treatment. Foci of infection must be found and 
eliminated. The ingestion of drugs and other in- 
dustrial poisons must be taken into consideration. 
Sympathetic imbalance must be corrected. This 
very often can be done by separating the kidney 
from its sympathetic ner\'e supply. Certain endo- 
crine disturbances may be responsible for this con- 
dition and if found to exist must be corrected, if 
possible. Very often this condition is curable by - 
surgical attack upon the kidney plus the elimina- 
tion of the causative factor. The prognosis requires 
difficult differential diagnostic study and may re- 
quire the assistance of some other branch of medi- 
cine. 

The so-called malignant hypertension case is 
possibly the only condition which may be consid- 
ered purely medical, and many of these cases may 
be benefited by a complete urological survey supple- 
menting the medical treatment. This is not a local 
condition. It is cardio-vascular-renal disease, the 
renal disease being secondary and terminal as a re- 
sult of the vascular sclerosis. The primary disease 
is vascular, the heart and renal complications being 
secondary. Added oftentimes is nephritis or cal- 
culous disease, or some other process which further 
cripples the kidney. This condition demands dif- 
ferential diagnosis and very often appropriate local 
treatment, either cystoscopically or surgically, to 
relieve renal embarrassment, to make the patient 
more comfortable and to prolong life. 

Since the advent of insulin patients with diabetes 
no longer die from starvation or coma, but from 
vascular scleroses, usually by cardiac or renal fail- 
ure. So, even here, it is the essayist's humble opin- 
ion that many lives will be prolonged even with 
malignant hypertension if they be turned over to a 
competent urologist, first for a differential diagnosis 
and then for secondary treatment locally, even 
though the medical man may be in charge of the 
situation. 

It is inconceivable to me how any medical man 
untrained in cystoscopy can feel that he can in- 
telligently treat these cases without every bit of 



Januan-, 1936 



SOUTHERN MEDICINE AND SURGERY 



aid that may be obtained from a careful urological 
survey, the results of which must either verify his 
therapeutic logic or cause him to change his ther- 
apy in accordance with the facts found by such a 
study. 

Nephro-Anomalies 

The anomaly itself seldom requires intervention, 
but it usually comes under the supervision of the 
urologist when a secondary nephrosis of any type 
is added to the anatomic deformity. 

One of this group requires special mention and 
that is congenital bilateral cystic kidneys of the 
multilocular type. The diagnosis can usually be 
made only by pyelography; the supervision is 
urological e.xclusively and may be surgical; the 
question of surgical attack upon them can never 
be anything else but urological. Many of these 
cystic kidneys resemble very materially in their 
findings the diffuse glomerulonephritic which we 
have classified under the nephrophlegmasias. The 
differential diagnosis can be made only by urologi- 
cal survey supplemented with careful pyelographic 
study. No one, of course, disputes any of these 
nephro-anomalies as other than urological. 

The last classification, the nephro-neoplasias, or 
tumors of the kidney, pelvis and ureter, are not in 
question. These in all of their various manifesta- 
tions should be referred immediately to the urolo- 
gist for diagnosis and treatment and should be re- 
ferred for subsequent treatment usually to the 
roentgenologist and radiologist rather than to the 
internist. 

Conclusion 

1. I have offered you a new classification of 
renal disease which is a modification of and an 
addition to, and I believe an even better classifi- 
cation than, that of Volhard and Fahr. I know of 
no renal condition that cannot find a proper place 
in this classification. 

2. There is no renal condition that cannot bene- 
fit diagnostically, prognostically and therapeutically 
by a complete urological survey by a competent 
urologist. 

.3. There is no single renal pathological entity 
that should not be under the supervision of the 
urolo<iist rather than the internist; but urologist 
and internist should cooperate in the management 
of any renal disease regardless of the one directly 
in charge of the case. The internist in treating 
renal disease should never get along without urol- 
ogical opinion, and the urologist handling renal dis- 
ease cannot get along without cooperation with the 
internist and other medical specialists, if the patient 
is to be given the best of medical care. 



SURGERY 

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



Operations Upon the Anemic 
Before any major operation is undertaken ex- 
perience proves the wisdom of being sure that the 
patient's blood is of sufficient quantity and quality 
to enable him to withstand the ordeal. Until the 
blood volume has been restored by the intake of 
fluid after acute hemorrhage the hemoglobin may 
remain practically normal; ordinarily, however, the 
hemoglobin is accepted as an accurate index to the 
degree of anemia present. 

Blood transfusion ranks with asepsis and anes- 
thesia as a basic aid to modern surgery. In the 
anemic, before the days of transfusion, one was 
dependent upon the administration of organic iron 
to build up the blood before operation. If there 
was no blood loss from hemorrhage during treat- 
ment this often proved effective. However, even 
without hemorrhage, some patients did not improve 
from iron therapy and the surgeon had to take the 
chance of relief by operation or lose his patient 
from the primary disease plus progressive anemia. 
Experience showed 30 per cent, the lowest pre- 
operative hemoglobin index compatible with rea- 
sonable chance of survival from major operation. 
If the hemoglobin reading could not be raised to 
30 per cent, operation was not undertaken. With 
such severe anemia, even though the patient sur- 
vived the operation, convalescence was slow and 
uncertain. Now, when transfusion may so readily 
be done, we do not think major surgery should be 
undertaken when the hemoglobin of less than 50 
per cent., and if any operation is to be long with 
the probability of considerable bleeding and shock 
a donor should be typed and ready for transfusion 
during operation. Practical experience proves Fra- 
zier right in his assertion that shock, with or with- 
out hemorrhage, is from blood volume loss and 
can best be treated by transfusion. 

The old classification of anemia into primary 
and secondary types depending largely upon the 
ability of the physician to find some causative 
source of bleeding has been found to be inade- 
quate. Now pathologists use the modern classifi- 
cation based upon the size of the red cells and 
their hemoglobin content. Although considerable 
skill in microscopical study is necessary for proper 
grading of the cells the work is worth while, for 
effective treatment depends upon accurate diagno- 
sis. Boyd says "Differences in the mean cell vol- 
ume and the hemoglobin content of the erythro- 
cytes are associated with fundamentally different 
pathological disturbances in the formation of the 
red blood corpuscles, and these differences may be 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



used as a clue to the nature of the anemia and a 
guide to the appropriate type of treatment." 

In the modern classification there are four kinds 
of anemia: 

1. Macrocytic, in which both the average size 
and the hemoglobin content of the red cell is in- 
creased. It occurs in pernicious anemia, sprue and 
the pernicious anemias of pregnancy and is best 
treated by the administration of liver. 

2. Normocytic, in which the red cells are of 
normal size and hemoglobin content. The cell 
count is low. In this group are acute blood loss, 
malaria and the aplastic anemias. Blood trans- 
fusion is a specific for hemorrhage. 

3. Simple microcytic, in which there is a large 
reduction in the number of red cells and a moderate 
reduction in size and hemoglobin content. It is 
the commonest of all the anemias and includes 
chronic infections, bronchiectasis, chronic nephritis 
and carcinoma without bleeding. In this group 
neither iron nor liver is helpful. 

4-.- HypeebfiOTwie- microcytic, in which there is 
great reduction in the size of the red cells but a 
greater reduction in hemoglobin content. It oc- 
curs in chronic hemorrhage, hookworm infestation 
and the simple achlorhydric anemias. It is best 
treated by organic iron. 

In conclusion: the anemic patient is a poor risk 
for major surgery and every precaution should be 
taken to get him in condition before operation is 
done. 



ORTHOPEDIC SURGERY 

John Stuart Gaul, M.D., Editor, Charlotte, N. C. 



Chronic Osteomyelitis 

The solution of any particular problem of osteo- 
myelitis which has reached the chronic stage re- 
quires an understanding of the pathology present, 
and a knowledge of the progress of the pathology 
through its several stages. 

The phases, in the following order, occur in any 
given case. The infection is implanted either by 
embolus through the blood stream or directly by a 
traumatic force — such as in gunshot wounds or in 
compound fractures. Inflammation follows with its 
attendant edema and pressure, which occurring 
within unyielding walls interferes with the circula- 
tion within the bone. Necrosis of the bone follows, 
which is nothing but gangrene of the bone. Nature 
is endeavoring at this time to limit the spread of 
the condition; to build new bone to replace that 
which is being destroyed; and to break up and 
expel the destroyed bone. The osteoclasts are at 
work to break up the sequestrated bone and to 
bore a hole to the surface through which they may 
be extruded. With the rupture through the cortex, 



the infected material starts abscess formation in the 
soft tissue, with local signs of inflammation and 
abscess formation in these tissues. Eventual rup- 
ture through the skin follows and sinus formation 
with subsequent discharge of pus, serum and se- 
questrated bone. The sinus persists for years un- 
less the diseased bone is properly treated. Man, 
with misguided interference, has added to this story 
by having the condition spread from its original 
focus to involve the whole bone or adjacent bones 
and joints. This interference has consisted in un- 
timely surgery without regard to the pathology 
present. 

What then is timely surgery in this condition? 
It, rationally, must be related to the pathology; 
and a very wide experience, thus based, has con- 
vinced me of the soundness of it. 

In the early stage where the infection has just 
been implanted and the early inflammation with its 
attendant edema is being established, the clinical 
course shows fever, a rising white cell count, and 
a dull, boring, or throbbing pain in the bone which 
the patient can localize for you, and over which he 
cannot withstand sustained pressure, immediate 
surgical intervention is indicated. An adequate in- 
cision is made over that area and drill holes made 
through the cortex. This relieves the tension, and 
by so doing prevents the later cycle with destruc- 
tion and necrosis of the bone because of the blocked 
blood supply. With this done and hot fomenta- 
tions maintained for a few days many of these 
cases clear up without further damage. In those 
which do not clear up the destruction and sequestra- 
tion is minimized and may be adequately treated 
in the following weeks. 

If this valuable period of time has passed, the 
surgery indicated is merely evacuation of forming 
abscesses and practicing masterly inactivity wait- 
ing until the gangrenous bone has its definite line 
of demarcation as you would wait in gangrene of 
the foot. This requires from six to ten weeks and 
is well indicated by x-ray in which the sequestrated 
bone shows greater density than the normal bone, 
and is surrounded by a black line or gas shadow. 
At this time the dead bone should be removed with 
the least possible disturbance of Nature's protect- 
ing wall of involucrum. With the removal of the 
sequestra the operator will use his best judgment 
in the method of treating the wound. To interfere 
before the bone that is being destroyed is definitely 
limited is to invite disaster by spreading the in- 
fection through the limiting wall and involving the 
entire bone and adjacent bones and joints. 



Orthopedic sukgery means the surgery of the straight 
child, the attention that keeps the child straight, prevents 
it becoming crooked, or straightens it when it was born 
crooked or has become crooked since birth. 



Januarj', 1936 



SOUTHERN MEDICINE AND SURGERY 



OBSTETRICS 

Henry J. Lanxston, M.D., Editor, Danville, Va. 



We Seek Excuses 

Many may think it foolish to discuss a subject 
of this nature in a department that is supposed to 
be dealing exclusively with obstetrical problems. 
What is in mind is to face some of our problems 
as physicians looking after expectant mothers. 
About a year ago I started out with some ambitious 
ideas as to this department for 1935, and my rea- 
sons for not having, to a degree, realized some of 
these ideas are personal sorrow, financial difficul- 
ties, professional problems, and a court suit which 
was from the onset groundless and in which I was 
vindicated. Now, as I look back over the year's 
work and the difficulties which I have had, I am 
very sure they are more or less common in the lives 
of physicians and now the problem presented to us 
is how we are going to handle these difficulties and 
at the same time perform our function as physi- 
cians and our obligations to society at large. 

We seek excuses because our patients are not 
more considerate of us. While our patients are 
sick they are profuse orally in their appreciation, 
but after the baby, mother, son, daughter, father 
or grandparent has recovered, one excuse or another 
is offered for failure to compensate us for our ef- 
forts. Consequently, many of us are going along 
from year to year in financial straits; our wives 
suffer; our children are deprived, and in a little 
while human society places us on the shelf feeling 
that it has done its duty to us. It is expedient 
that we listen to these patients' excuses, but when 
we have served them satisfactorily and well, while 
this service is fresh in their minds, we should urge 
settlement, for experience says gratitude is short- 
lived. Particularly in the field of obstetrics, the 
mother having been brought through pregnancy, 
delivery and the lying-in period and given back to 
her family in a healthy state, immediately the hus- 
band should put forth effort to pay for this service. 
In looking over my records I find that I have not 
been able to collect for SO per cent, of such ser- 
vices. In the face of such facts there is a cry 
among certain groups in the laity that we, as doc- 
tors, are not serving human society adequately. 
This group is composed of people who are seeking 
alibis and excuses of one kind or another instead 
of using their own talents in an effort to pay for 
these services; they are busy-bodies who have failed 
in their own special fields and now they propose to 
be millstones about our necks. We should be brave 
enough and courageous enough to tell them to get 
in their places and stay there. 

There is another group that is very desirous of 
hiding behind certain excuses to pass cert.iin laws 



which aim to limit our activities and take away 
from us certain rights which are inherently ours. 
This group, as this department has emphasized be- 
fore, is exceedingly anxious to limit reproduction 
of offspring. We appreciate their sympathies, but 
the motives back of these sympathies are not whole- 
some; hence, it is imperative that we expose these 
people who are so willing to criticise the efforts 
of medical men, and tell them to get in their field 
and do their duty and leave us alone, except for 
cooperation and help we may call upon from them. 
In the field of education, in practically all of 
our institutions from the high school through the 
university, there are certain faculty members who 
are endeavoring to teach certain subjects like hy- 
giene and biology who are not fitted to properly 
teach the youth; hence, thousands of high-school 
boys and girls and college and university students 
are turned out yearly who have not been properly 
instructed in these important health matters. 
Health nurses employed by counties and cities have 
taksn over practically altogether the examination 
of eyes, ears and throats, and so on, and teachers 
are sending slips home to parents about this action. 
This service can be properly rendered, and the 
teaching of these subjects can be properly done by 
none but physicians who are adequately trained, 
and there are plenty physicians for the jobs. Of 
course I know that certain leaders in education say 
that the physician does not have time for this, but 
we have time for anything that is of value to the 
building of the proper kind of human society, so 
the excuse is only a kind of alibi because certain 
individuals in education are afraid that someone 
will get a little part of their leadership away from 
them. 

There is another group of the young and the old 
who feel that because of economic conditions the 
young people should not reproduce so early in 
their marital life. In the past few months I have 
had more young women, married and pregnant, to 
apply to me in a most appealing manner to termi- 
nate the pregnancy because the parents- felt that 
they were economically unprepared for assuming 
such responsibility at the time. This attitude rep- 
resents a form of mental and physical laziness. In 
this field we should take a positive stand and should 
seek opportunity to publicly discourage such an 
attitude and to encourage the positive attitude of a 
wholesome nature. 

As we review the history of the past twelve 
months in the field of obstetrics, there is very little 
evidence to show much improvement. Bacteria 
have taken hundreds of expectant mothers; many 
thousands of the women who have been delivered 
are crippled more or less for life because of im- 
proper care during the delivery and immediately 



SOUTHERN MEDICINE AND SURGERY 



Januar>', 1936 



following; fetal mortality has been about the same 
as in previous years; septic infection due to so 
many abortions is probably greater this year than 
the previous year, and children crippled because of 
improper management during delivery will be about 
the same as before. Some are saying that if the 
doctors had taken care of them properly these things 
would have been different. To a degree they are 
right, and also wrong, for they forget that we 
physicians who to an extent are fairly well educated 
have to deal with so many people who are ignorant, 
superstitious and have minds that do not grasp 
what we try to teach them in the way of taking 
care of themselves and going through the period 
of pregnancy, labor and the lying-in period, carry- 
ing out to the letter directions which we have given 
them. However, we cannot excuse ourselves and 
be indifferent to the situation. On the other hand, 
we must take a philosophical attitude and be ready 
to continue to give, and give, and give, until people 
will take our instructions and carry them out. 

Our main purpose in discussing these excuses is 
to stir up our own selves and get our own houses 
in order because of the various demands on our 
time in the field of economics, sociology, finance, 
raising of families, politics, science and religion, 
and a thousand other things. We frequently excuse 
ourselves from study and we get off of the main 
line of the business of practice in the field of ob- 
stetrics. There is an imperative need that we be 
more diligent in the study of the principles. At 
the same time it is urgent that we wake up to the 
fact that there is more knowledge yet to be ac- 
quired in the field of human reproduction which 
has to do with all currents of society. If we do 
not wake up to these facts, in a few decades society 
will be broken down with the burden of the care 
of irresponsible and abnormal species of humanity. 
The business of understanding more completely and 
thoroughly the internal secretory glands in the field 
of obstetrics may be more important than any other 
branch of medicine. It offers every challenge to 
the imagination to do, as Tennyson has said: "To 
strive, to seek, to find, and not to yield." 

Just this one other excuse: We physicians are 
constantly telling our creditors that we cannot pay 
because our patients have not paid. This is due 
to our own negligence, and it behooves us to be- 
come more business-like in our dealings and not to 
assume obligations and responsibilities unless we 
can see the path clearly as to how we are going to 
meet these obligations. Honesty in business deal- 
ings is essential to the success of the physician in 
serving expectant mothers, and we should so im- 
press this fact as to convince men that the respon- 
sibility for a family includes paying the bills in- 
curred thereby. 



This department extends to all physicians who 
read our Journal a word of encouragement. We 
have a real opportunity to make the field of practice 
much more attractive to competent well trained 
young men than our fathers had, and we should be 
ready and willing to impart this attitude and stim- 
ulation to young physicians. At the same time it 
is imperative that we gently impress one fact that 
seems not to have occurred to the young men com- 
ing out for practice at this time — the fact that older 
men in the profession may know a thing or two 
worth while. Too many younger ones idle their 
time away and complain, and if they do not get a 
practice in a little while they move on to another 
place. 

So we come to the end of our discussion having 
in mind many more things that we could bring to 
our readers about this excuse business. Even 
though the world is in a muddle, there is a way 
out, but that way must be guided by certain funda- 
mental principles of human life and our philosophy 
must not be cluttered up with irrelevant matters. 

This department wishes for every physician a 
better year from every angle in 1936. 



HOSPITALS 

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



A Hospital Daddy 

In every well organized and well operated hos- 
pital, whether private, community or sectarian, 
there is one personality always to be found as the 
lead horse. This person never ceases working for 
the interest of the institution. Asleep he dreams 
of the success of the hospital. His wakeful mo- 
ments not taken up with his necessary business are 
filled with planning for better service, greater suc- 
cess and the expansion of the hospital. He is ever 
ready to pour oil on troubled waters. Oftentimes 
he sacrifices his personal income in order that the 
institution may profit, and in no few instances he 
gives financial support in order that some depart- 
ment of the hospital may be developed. It is this 
personality that the writer designates A Hospital 
Daddy. 

The statement has often been made that no hos- 
pital can succeed without a daddy and it is ever- 
lastingly true. The physicians who can qualify for 
this position are rare jewels, and any institution 
and community which is so fortunate as to possess 
one of these individuals is to be envied. The editor 
of this department in recent years has known of a 
number of newly-erected hospital buildings which 
were magnificently equipped and should have ful- 
filled all of the needs and requirements of the com- 
munity in which they were located, but occupied a 
second place in prestige. The people whom these 



January, 1936 



SOUTHERN MEDICINE AND SURGERY 



were built to serve did not have the confidence that 
is so vitally necessary. Such an institution to all 
intent and purposes, although thoroughly equipped 
to do a man's job, is still a boy in knee pants. 

It is indeed unfortunate that a community does 
not obtain the services of a physician who is capa- 
ble of qualifying as daddy of an institution, before 
it decides to spend the great amount of money that 
is necessary for an up-to-date hospital. Edgar A. 
Guest says, "It takes a heap of living in a house 
to make a home.'" It can be equally as well said 
that it takes a heap of loving service to make a 
hospital a home for the sick. 

Because of some farsighted philanthropic finan- 
cier and his enthusiasm the people of a certain dis- 
trict are persuaded to add to his donation large 
sums of money for the purpose of creating a public 
institution. While these philanthropists are greatly 
to be admired and respected they are making an 
economic error by contributing to the formation of 
an institution in the community which has not 
qualified for their gifts by enlisting one who is will- 
ing to pour his life's blood into the operation of 
that institution after it is ready to render service. 

All successful private institutions are founded on 
this principle. It is seldom that a private hospital 
goes broke and has to close its doors. The finan- 
cial burden, however, has often become very great 
and this frequently produces wear and tear upon 
the physical stamina of the head of the institution. 
For that reason he has often changed the economic 
procedure of his institution which might cause 
some to think that he had failed. This is not the 
case. On the other hand he has been eminently 
successful in rendering the very best type of service 
to the sick of that community. No matter what 
economic change may take place in that institution, 
so long as the daddy lives and is able to take the 
lead in service it will continue to be successful. 
That institution will enjoy prestige and confidence. 

If a community does not possess a proper per- 
sonality to place in charge of the service to be ren- 
dered its citizens, it would be far better that such 
an individual be imported for that community even 
if it cause some temporary feeling in the local pro- 
fession. This superior character will soon iron out 
any feeling that might have been created, and once 
that has been done the hospital staff will be on a 
sound service basis, free from petty jealousies and 
selfish motives. The daddy assumes fathership, 
wisely judging, unselfishly counseling and lovingly 
serving all of those with whom it is his privilege 
to work. 



PUBLIC HEALTH 

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



Hospital is taken directly from Late Latin, and is 
closely related to hospice and hatel, each centering around 
the basic idea of entertainment of a guest — Latin, hospes. 



The Soci.al Security Act and Public Health 

Policies 

Is Organized Medicine Concerned? 

Funds having recently been made available to 
the State, through the Social Security Act for the 
extension of public health work, it seems appro- 
priate that the matter be discussed at this time. 

I will quote freely from an article entitled "The 
Social Security Act and Its Relation to Public 
Health," by C. E. Waller, M.D., Assistant Surgeon 
General, U. S. P. H. S., in the Am-erican Journal 
of Public Health for November, 1935. 

Doctor Waller states: "The general title of the 
Social Security Act approved by the President on 
August 14th, 1935, sets forth the purpose of the 
Act as follows: 

'To provide for the general welfare by establishing a 
system of federal old-age benefits, and by enabling the 
several states to make more adequate provision for aged 
persons, dependent and crippled children, maternal and 
child welfare, piMic health (italics N. T. E.), and the ad- 
ministration of their unemployment compensation laws; to 
establish a Social Security Board; to raise revenue; and 
for other purposes.' 

"The U. S. P. H. S. will administer the grants 
to States for aid in establishing and maintaining 
State and local health services." 

"It is to be assumed that every feature of the 
social Security Act will have some relation, either 
directly or indirectly, to the public health." 

"Under the Public Health Work Title of the Act 
authority is granted for: 

'1. An annual appropriation of not to exceed $8,000,000 
for the purpose of assisting states, counties, health districts 
and other political subdivisions of the states in the estab- 
lishment and maintenance of adequate health services, in- 
cluding the training of personnel for state and local health 
work. 2. An annual appropriation of not to exceed $2,000,- 
000 to the Public Health Service for research activities of 
the Service and for the expense of co-operation with the 
states in the administration of the federal funds to be 
granted for aid in the establishment and maintenance of 
state and local health services.' 

"Responsibility for allotment of the proposed ap- 
propriation of $8,000,000 for State and local health 
services is placed upon the Surgeon General of the 
Public Health Service. . . . The Surgeon General 
must take into account ... the relationship of the 
population of each State to the total population 
of the United States; ... the inability of the States 
to meet their health problems without financial as- 
sistance; and special health problems imposing un- 
usual burdens upon certain States." 

"For the first time .... the Congress has made 
a declaration of permanent policy under which it 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



assumes in part responsibility for protection of the 
health of the individual within the State, and has 
made provision for participation of the Federal 
Government in the establishment and maintenance 
of administrative health service for this purpose." 

Doctor Waller very pertinently remarks that the 
significance of the appropriation lies in the Federal 
policy enunciated. He calls attention to the fact that 
the Social Security Act substantially leaves unsolv- 
ed "the problem of medical care for the poor and 
for the low-income family that can pay something 
but not the whole cost of medical and hospital ser- 
vice which it requires.'' 

Almost the sole object of my article has been to 
call your attention to the last clause of the para- 
graph just quoted. 

It appears to me that unless organised medicine 
proposes a plan of its own for "the medical care 
of the poor and the low-income family" group, a 
plan will be proposed by some other group or 
groups less capable of solving the problem rightly, 
which plan will be put into effect by National, 
State or local legal act. 

In my opinion, the implication in the following 
paragraph from Doctor Waller's article contains, 
for organized medicine, much food for thought. 
Says Dr. Waller: 

"I am not prepared to advocate at this time 
(italics mine) that the health department shall act- 
ually undertake to render with its own personnel 
all (italics mine) medical care for the poor. I feel 
that there is and should be a place for the practic- 
ing physician in a medical relief program wherever 
economic limitations (italics mine) will permit the 
utilization of his services." 

Doctor Waller further observes: "But I do not 
believe we shall have a satisfactory solution of the 
problem until the health department takes the lead- 
ership in working out with the medical profession a 
plan that will serve the need and at the same time 
make a place for the services of the private doc- 
tor." 

It is my opinion that a better solution can be 
made if organized medicine takes the leadership in 
working out a plan with the various State health 
departments. What I here mean by the term lead- 
ership is that no plan should be adopted which does 
not have the approval of organized medicine. 

Without the sympathetic approval of organized 
medicine no plan can be a success; and so high a 
regard have I for the wisdom and unselfishness of 
organized medicine that I venture the opinion that 
a plan which does not meet its approval does not 
deserve to succeed. 



PEDIATRICS 

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



Ple.\s.\nt words are as an honeycomb, sweet to the soul 
and health to the bones. — Proverbs 16:24. 



The Georgia Pedl^tric Meeting 
The third annual scientific meeting of the Geor- 
gia Pediatric Society was held at Atlanta December 
12th. As is their custom, the speakers were invited 
guests of national reputation. Drs. Isaac Abt, J. 
Lovett Morse, John Kolmer and Chas. Bills 
(Ph.D.) read papers of unusual interest. The type 
of program and the hospitality of the Georgia pe- 
diatricans are making this annual event one of the 
important meetings of the South. 

Dr. Chas. Bills is head of the research depart- 
ment of ]Mead Johnson Co. His two papers dealt 
with various phases of vitamin D. Codliver oil 
has been used as a folk remedy and later empiri- 
cally for ISO years. 'Vitamin D was discovered in 
1922 and today we learn that there are at least 6 
chemically distinct forms of vitamin D. 

Dr. John Lovett Morse endeared himself to many 
new friends who had never before had the privilege 
of hearing him speak. His abundance of good • 
common sense plus his ever-ready Scotch wit makes 
him one of the great teachers of the day. He has 
the happy faculty of leaving out the unessentials 
and stressing the important factors. He spoke on 
one of his pet subjects. The Thymus Delusions. 
The thymus gland atrophies in inanition, with age 
and in every acute disease. "The x-ray picture of 
the thymus does not lie, but those who read the 

pictures ." The only correct interpretation 

is that of the lateral exposure. "No one knows 
what is the normal x-ray picture for any given 
child." It varies in size with respiration and with 
the amount of blood it contains at the time a pic- 
ture is taken. The thymus shadow is very wide in 
the newborn. To cause symptoms the gland must 
produce pressure on various tissues. The veins and 
arteries are too readily displaced to be constricted 
by an enlarged gland. The right recurrent laryn- 
geal nerve's position makes it impossible for it to 
be. compressed by the enlarged thymus; very un- 
usual pressure would be required to involve the left 
recurrent nerve; and even great pressure would not 
cause great change in the voice of a child. A noisy 
inspiration (only) or a noisy expiration (only) 
would not result from an enlarged gland. Such a 
gland would produce noisy inspiration and expira- 
tion. The x-ray may show an enlarged thymus, 
but such a picture does not rule out other causes 
for the symptoms presented. Pressure of the gland 
would cause cyanosis of the head, neck and upper 
extremities only, not generalized cyanosis. Noisy 
respirations are more frequently due to hypertro- 
phied adenoids and tracheitis. Inspiratory crow is 
present in laryngeal stridor. Breath holding, laryn- 



January-, 1936 



SOUTHERN MEDICINE AND SURGERY 



gismus stridulus, bronchitis and asthma have all 
been mistaken for enlarged thymus. "Convulsions 
are not due to thymic disorders." -An increase in 
the size of the thymus does not mean an increase 
in the secretion, because the gland does not possess 
an internal secretion. There is apparently a con- 
nection between the thymus and the adrenal glands. 

It is now understood that status thymico-lym- 
phaticus has no existence as a pathological entity. 
Many sudden deaths have been attributed to status 
lymphaticus, but it is not a proven cause of death. 
"Such a diagnosis is frequently the easiest way 
out." The x-ray does reduce the size of the gland 
and from a recent report we learned that we can 
"thank God that x-ray treatment for enlarged thy- 
mus does no harm." 

Dr. Morse's second paper was a gem of wisdom, 
dealing with Diagnosis and Prognosis. Dr. Morse 
again emphasized the importance of an adequate 
history in such a way that such repetition was not 
trite. The good history invariably directs you to 
the part involved by a disease process and a good 
physical examination must follow to confirm or 
deny the impressions obtained. "Every child should 
be stripped for examination or else don't try to treat 
it for any condition." In diagnosis the case falls 
under one of three headings. 1) We know what 
is wrong with the child; 2) we know there is one 
of two or three conditions present; or 3) we know 
w'e don't know. In children there is usually only 
one disease present. Most mistakes in diagnosis 
are due to lack of care in making the study rather 
than the lack of knowledge. Pure laziness and be- 
ing in too great a hurry account for many grievous 
mistakes. In prognosis most physicians are, and 
rightly so, optimists. The child tends to recover 
not only once but many times, but it dies but once. 
The physician has no right to carry the worry of 
an unfavorable prognosis alone. H,e should inform 
some member of the family as sobn as he thinks 
the outcome is unfavorable. The average parent is 
not interested in the diagnosis except out of curios- 
ity, — what they wish to know is, "Will the child 
recover and how soon." The parent wants the 
child made comfortable whether it is going to re- 
cover or not. 

Dr. Isaac Abt was introduced as the "Dean of 
Modern Pediatrics." Dr. Abt is likewise an un- 
usually capable teacher. In his lecture to the stu- 
dents of Emory University on Pneumonia, he de- 
scribed the disease under four different types, the 
pulmonary, the cardiovascular, the atonic and the 
pallid. He likened these four types to different 
colors. The colors representing the color of the 
skin in each type. The pulmonary type was de- 
scribed as pink pneumonia, the cardiovascular type 
as blue, the atonic type as gray, and the pallid type 



as white. "More can be learned about the condi- 
tion of a pneumonia patient by standing at the 
foot of the bed and observing the patient than by 
all the laboratory findings and the clinical charts 
combined." The prognosis becomes more unfavor- 
able as the colors change from pink to white. Dr. 
.•\bt's first paper W'as on the History of Pediatrics, 
dating back as far as 1600 B. C. The first pedia- 
trician was Walter Harris of England, who lived 
in the 1650's A. D. The paper was a fascinating 
record, which did not lend itself to ready abstrac- 
tion. His second paper was on Avitaminosis. In 
three vitamin-deficiency diseases — beri-beri, scurvy 
and rickets — the heart may be greatly hypertro- 
phied. 

Dr. John Kolmer, the originator of the attenu- 
ated virus vaccine against poliomyelitis, certainly 
won many friends in favor of his vaccine. It is 
unusual for a physician-speaker to have to make a 
curtain call after his speech, but that is exactly 
what occurred in Atlanta. In part he said: A 
filtrable virus has never been seen or so far culti- 
vated on a dead medium. No State in the U. S. 
is free of acute poliomyelitis. During the past SO 
years the disease has become world-wide. Every 
test for antibody content of an individual's blood 
requires a monkey at a cost of $10.00 to $15.00 
each. That is why a susceptibility test is not yet 
practical. No other susceptibility test has been 
devised. It has been shown that the newborn has 
a degree of antibody protection which lasts only a 
few months. The child between one and four years 
has little or no immunity. At least 25 per cent, 
of adults have no immunity. Therefore when adult 
serum is used as a prophylactic agent, it must be 
pooled serum. Dr. Kolmer has shown by careful 
study that in the child the antibody content pro- 
duced by the injection of three doses of his vaccine 
has lasted for 1 1 months. In the monkey the anti- 
body content is present after three years. He has 
the record of over 11,000 individuals who have been 
vaccinated, 10,250 of these records have been ana- 
lyzed. None of these individuals had a severe re- 
action following the vaccine injections. One lot of 
the vaccine was contaminated with colon bacillus 
and staph, albus with 16 abscesses developing at 
the site of injections. Today all of his vaccine 
contains 1-80,000 phenyl mercuric nitrate against 
accidental bacterial contamination. This antiseptic 
is bactericidal against ordinary organisms, but not 
against the virus. Dr. Kolmer insists that to be 
of value the vaccine must be of an attenuated and 
not a killed virus. He has been no case of de- 
myelinization encephalitis such as follows rabies 
vaccinations. Dr. Kolmer respects his critics and 
proudly names them as most eminent and well fitted 
to criticise his work. He does feel that much of 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



their criticism is premature. There have been 10 
cases of poliomyelitis reported to have developed 
following the use of his vaccine. In all of these 
cases only one or two of the prescribed three injec- 
tions were administered. Dr. Kolmer believes that 
these 10 cases received their one or two injections 
during the incubation period of the disease and 
that the vaccine had nothing to do with the indi- 
vidual's developing the disease. Dr. Kolmer be- 
lieves that his vaccine is safe for the following three 
reasons: 1) The passage of the virus through mon- 
keys has caused the virus to lose much of its infec- 
tivity for human beings; 2) the injections are made 
subcutaneously; 3) small doses are used. 



RADIOLOGY 

Wright Clarkson, M.D., and Allen B.wker, M.D., 
Editors, Petersburg, Va. 



Cervical ^Metastatic Epidermoid Carcinoma 
The curability of the great majority of carcino- 
mas about the mouth, pharyn.x and larynx by early 
and skillful irradiation is conceded by most cancer 
therapists. Yet these lesions, because treatment is 
so often improper or delayed, rank with the dead- 
liest of neoplasms. In many cases lymph drainage 
areas are neglected entirely and as a result cervi- 
cal metastases occur, and these also are neglected 
or treatment is quite inadequate. The patient 
with cervical node metastases presents a problem 
which demands that therapeutic acumen which is 
acquired only through special training and wide 
experience in the treatment of cancer. It is, then, 
obvious that one should not attempt to treat a 
carcinoma of the upper mucous membranes unless 
he is prepared to treat cervical metastases also. 
The percentage of five-year cures of carcinomas of 
the upper mucous membranes is directly propor- 
tional to the percentage of patients presenting no 
evidence of cervical metastases at the time of 
treatment of the primary lesions, and individual 
statistics improve greatly with experience and with 
the ability of the individual physician properly to 
treat metastatic nodes. 

There are so many factors involved in evaluat- 
ing the therapeutic measures in the treatment of 
cervical metastatic lesions that the literature is 
quite controversial. ^lany surgeons advise com- 
plete block dissections of the neck, but the fact 
remains that striking success has been credited this 
procedure only in those cases with no clinical evi- 
dence of metastases before operation. As irradia- 
tion technique and the physical equipment for ad- 
ministering the treatment have improved, the great 
majority of these patients fall into the group suit- 
able for radiation therapy. However, neither ra- 
diation alone nor surgery alone is adequate in 



every case, and the correct combination of surgery 
and irradiation, determined by close consultation 
between surgeon and radiologist, is the method of 
choice in a large percentage of cases. 

Biopsy of the primary lesion following prelimi- 
nary irradiation should be performed in every case, 
as the final choice of the method of treatment 
should be determined by the grade of malignancy 
and by the radiosensitiveness of the neoplasm, 
which sensitivity can be quite accurately deter- 
mined microscopically provided one has sufficient 
knowledge of tumor pathology. 

For practical purposes all cases may be divided 
into three classes, namely; those having no palpa- 
ble nodes, those with palpable nodes that are con- 
sidered operable, and those with palpable nodes 
that are inoperable. 

For the first group many surgeons advise com- 
plete block dissections of the neck, while radiolo- 
gists as a group advocate external irradiation. Sta- 
tistics show that prophylaxis is just as successful 
with irradiation as with surgery, and irradiation 
does not necessitate an operative procedure. Ex- 
ternal irradiation should consist of high-voltage, 
low-intensity radiation to both sides of the neck 
given in fractional doses over a period of four to 
six weeks for a total of 4,000 to 6,000 roentgen 
units following the principles set forth by Coutard.' 
If palpable nodes do not appear later, no further 
treatment is given. The common practice of giv- 
ing one erythema dose to the neck is worse than 
useless, for it creates a false sense of security. 

The management of the second group requires 
the most critical judgment. Operability is often 
difficult to determine, but the number of cases 
placed in the surgical group diminishes in propor- 
tion to the increased experience of the radiologist. 
Quick's- criteria for operability are as follows: 
"Surgical dissection of the neck, when done, is 
unilateral, but the most radical possible. Dissec- 
tion is limited to fully differentiated epidermoid 
carcinoma, palpable involvement unilateral, capsule 
of the node or nodes presumably intact in patients 
presenting good physical condition and in whom 
the primary growth is either controlled or gives 
promise of complete controllability." 

As stated above, the final choice of the method 
of treatment must be determined by the grade of 
malignancy, which also largely determines the prog- 
nosis. From a histologic point of view implanta- 
tion therapy is indicated in all cases except the 
grade-iv, and even in most of these it is a valuable 
precaution. Only the most radiosensitive metasta- 
ses can be trusted to external irradiation alone. 
All cases should be subjected to preliminary high- 
voltage, low-intensity irradiation. After the skin 
reaction has subsided the remaining palpable nodes 



Januar>-, 1936 



SOUTHERN MEDICINE AND SURGERY 



should be implanted, through surgical exposure, 
with platinum-filtered radium emanation for a total 
of 3,000 to 10,000 millicurie-hours, depending on 
the size of the metastatic mass. It has been 
shown^ that it requires 7 to 10 skin-erythema doses 
to all parts of a tumor mass to destroy a fully 
differentiated carcinoma, and that it requires 10,- 
000 millicurie-hours to deliver 10 skin-erythema 
doses to a mass S cm. in diameter and 6 skin-ery- 
thema doses to a mass 7 cm. in diameter. As a 
large percentage of tumors arising from the upper 
mucous membranes belong to this adult type of 
lesion, one can determine from these figures the 
amount of interstitial irradiation necessary to de- 
stroy their metastases: but the dose must be accu- 
rately calculated, and scientifically applied. 

In certain selected cases of highly differentiated 
carcinomas presenting a single accessible node, it 
is wise to remove the node by means of electro- 
surgery, and implant the node bed with radium 
emanation. Patients with recurrent, operable low- 
grade metastases following radiation therapy should 
be subjected to radical neck dissections, because 
the disease, as a result of previous treatment, has 
become radioresistant, and any additional roentgen 
or radium therapy is practically useless. 

Inoperable cervical nodes are entirely a radiol- 
ogical problem. Treatment of these cases consists 
of a combination of external and interstitial irra- 
diation, both being employed in massive doses. 
With such treatment the glands usually decrease 
in size, and the patient shows clinical improvement 
which may persist for a few months and occasion- 
ally for years. 

Coexisting diseases — especially syphilis, diabetes, 
arteriosclerosis and chronic cardiorenal disease — 
make the prognosis of any malignancy unfavorable, 
but little mention is made of this fact in the litera- 
ture. A metastatic malignancy complicated by a 
syphilitic infection is fatal in nearly 100 per cent 
of cases. Therefore, if syphilis is present, it is 
imperative that it be discovered early in the course 
of treatment and that specific therapy be instituted 
at once. Every patient should have a Wassermann 
reaction determination before the beginning of 
treatment, and a suggestive history or physical 
signs of syphilis demand repetition of a negative 
or doubtful reaction. In diabetics interstitial irra- 
diation is strictly contraindicated until the quantity 
of sugar in the blood is reduced to normal, and 
none shows in the urine by ordinary tests, and the 
disease must be completely controlled during radia- 
tion therapy. Arteriosclerotic and cardionephritic 
subjects must be placed in the hands of a compe- 
tent internist during treatment. 

Preservation of strength and appetite is as im- 
portant in the successful treatment of cancer as in 



any debilitating disease. The patient with far ad- 
vanced carcinoma is already in a state of poor 
nutrition, which becomes exaggerated after the in- 
stitution of radiation therapy. In these cases, the 
administration of insulin in daily doses of 15 to 45 
units is invaluable. In many patients, appetite in- 
creases almost immediately and it can be main- 
tained throughout the course of treatment. A 
mixed vitamin concentrate also helps raise resist- 
ance to infection and inanition and patients with 
advanced malignancy should be given one of these 
preparations as a routine. 

References 

1. CouTARD, H.: Roentgen Therapy of Epitheliomas of 
the Tonsillar Region, Hypopharynx and Larynx from 
1920 to 1926. Am. Jl. Roentgenol, and Rod. Therapy, 
1932, 28, 313-331. 

2. Quick, D.: Radium in the Treatment of Metastatic 
Epidermoid Carcinoma of the Cervical Lymph Nodes. 
Am. Jl. Roentgenol, and Rod. Therapy, 193S, 33, 677- 
681. 

3. Martin, H. E., Quimby, E. H., and Pack, G. T.: 
Calculations of Tissue Dosage in Radiation Therapy. 
Am. Jl. Roentgenol, and Rad. Therapy, 1931, 25, 490- 
506. 



CARDIOLOGY 

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



Rheumatic Fever: Early Treatment 
The degree of success in the treatment of rheu- 
matic fever can accurately be gauged only by the 
degree of cardiac damage after recovery. While 
eventual damage to the heart can not be prevented 
by any present means of treatment its degree may 
be greatly lessened by proper treatment in the early 
and active stage and by the prevention so far as 
possible of recurrent attacks. 

Treatment of the Acute Attack 
Rest — By far the most valuable therapeutic 
measure at our disposal in the management of this 
and many other acute infections is rest. This can 
be obtained only by the use of a hospital bed. 
Mental and physical rest should be complete. The 
patient should be put in an environment free from 
disturbing events and nervous strain. Competent 
nursing care is essential. Cardiac failure should 
be anticipated and avoided if possible by treating 
the case similarly to that of a far advanced decom- 
pensation from the time the diagnosis of rheumatic 
fever is definitely made until some time after the 
active infection has subsided as evidenced by the 
cessation of fever, the return to normal of the 
white count and sedimentation time, the disappear- 
ance of rheumatic nodules, and the absence of A-V 
block in the electrocardiogram. Drugs must be 
discontinued and a temperature record kept for 
some days afterward before arriving at this conclu- 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



sion. Regardless of symptoms, so long as there is 
evidence (especially fever and leukocytosis) of 
active infection the patient should be at absolute 
rest in a hospital or cardiac bed. 

Salicylate Therapy — Salicylates continue to be 
used, not so much in the hope of influencing the 
infection as for the comfort of the patient. It is 
evident that any measure that will add to the 
patient's comfort and his regimen of rest will assist 
him in overcoming the infection. The drug should 
be given in large doses during the acute stage, as 
sodium salicylate or aspirin. Over long periods of 
time our cases tolerate better the effervescent prep- 
arations combining sodium salicylate with an alkali. 
Salicylates may be given per rectum if not toler- 
ated by mouth. Occasionally codeine may be nec- 
essary for the relief of pain and sedatives should be 
used to control nervousness, preferably phenobar- 
bital or bromides, these being the least toxic. 

Treatment oj Joint Symptoms — The affected 
joints should be first kept in wet packs of magne- 
sium sulphate solution until the acute pain is re- 
lieved and then should be splinted or immobilized 
with sandbags. Methyl salicylate ointment or lin- 
ament is useful and heat from hot water bottles 
or a strong electric light bulb gives added comfort. 
It is characteristic of the joint lesions of rheumatic 
fever that they clear up with no permanent damage 
to the joint, so any therapeutic measures consid- 
ered should be only for the relief of the pain and 
radical measures such as tapping and drainage are 
usually contraindicated. 

Treatment oj Secondary Anemia — Early in the 
disease there is usually secondary anemia and this 
should be watched for and corrected quickly. A 
combination of copper and iron-ammonium citrate 
gives the quickest response in increasing hemoglobin 
and red blood cells. Liver extract may be benefi- 
cial in severe cases. In patients with extremely 
low resistance frequent small transfusions are often 
of value. It was for a time thought that transfu- 
sions might promote immunity; but, since repeated 
recurrences of rheumatic fever do not render the 
individual immune from the infection, it is logical 
to assume that no known therapeutic agent will so 
serve, other than general measures directed to the 
building up of his general condition. 

Climatic Factors — That geographical location 
has an effect on the incidence of rheumatic infec- 
tion is generally agreed. The treatment of rheu- 
matic fever by changing the patient to a subtropi- 
cal climate has been advocated and tried in the 
past few years with favorable results. There is 
usually improvement while the patient is in a warm 
dry climate, but recurrences are frequent when the 
patient is returned to his former environment. 



Diet — General diet is recommended after the 
first few days and there is some evidence to sup- 
port the theory that a diet high in vitamins in- 
creases resistance to infection. We usually insist 
on an added quantity of orange juice, milk, tomato 
juice and fresh vegetables, with the addition of 
codliver oil in some form during the winter months. 

Non-specific Protein Therapy (Shock Therapy) 
— Antistreptococcus serum therapy and vaccine 
therapy have, to date, been failures. Immediate 
and startling improvement frequently follows the 
use of protein shock therapy, the improvement 
being apparently contingent on the allergic response 
to the agent employed, whether this be milk, pro- 
tein extracts, bacterial extract or drugs such as 
formaldehyde intravenously. One author reports 
2>i cases of rheumatic fever treated by the use of 
typhoid vaccine intravenously with good results. 
While it is true that the arthritic symptoms are 
usually promptly relieved by this procedure, it 
would seem unwise to introduce such a potent 
agent into the veins of a patient with an already 
damaged heart since there is no way of controlling 
the resulting protein shock. Typhoid vaccine or 
one of the milk proteins intramuscularly would 
seem much safer, and I believe is a valuable ad- 
junct to drug therapy. 

Removal oj Focal Injection — The disease is ag- 
gravated by any focal infection and the frequency 
of maxillary sinusitis in our series has been men- 
tioned. As soon as the patient's condition will per- 
mit the condition of the teeth, sinuses, tonsils and 
pharynx should be thoroughly investigated with 
drainage or removal of infected areas. 

Convalescent Care — A part of the damage re- 
sulting from rheumatic infection consists of the 
fibrotic changes which occur in the tissues after the 
active infection has become quiescent. For the 
prevention of fibrosis potassium iodide in small 
doses over a long period of time has been used for 
years and its value apparently has been confirmed 
by recent experimental work. Secondary anemia 
should receive especial attention in this stage and 
should be controlled b\" the measures outlined 
above. 



Editor's Note — This is the second of a series of articles 
on rheumatic fever. CompHcations, recurrent attacks and 
late sequelae will be discussed in subsequent issues. 



The possibility of an aputrid PtjLMON.ytY necrosis (J. 
Greenstein, Providence, in R. I. Med. JL, Dec.) should be 
considered in those cases of pneumonia in which the x-ray 
findings suggest a lung abscess and where marked differ- 
ences exist between the clinical and the roentgenological 
findings. In such cases it is suggested that s«rial roentgen 
studies should be made and checked with the clinical 
course. The diagnosis of aputrid pulmonary necrosis as 
differentiated from lung abscess alters the treatment and 
the prognosis. 



January, 1936 



SOUTHERN MEDICINE .\ND SURGERY 



INTERNAL MEDICINE 

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



Paroxysmal Tachycaedia 
This is a condition that can easily cause much 
worry to the physician when the patient is seen 
for the first time during an attack, and it is ap- 
parently a rather common practice to use digitalis, 
when it seldom appears to have any beneficial ef- 
fect on the condition. I have seen only one case 
of the ventricular type, and this is the only one 
detected in 700 electrocardiograms that have been 
run when organic disease was suspected. The 
man was seen in 1930 and reported in this journal, 
shqwing the very interestin,g electrocardiograms 
with the ventricle contracting at a rate of 240 
each minute. The patient would get nearly un- 
conscious during the attack. He was found to 
have several abscessed teeth and no free HCl. 
Even though this type of tachycardia is associated 
with organic heart disease in most every case, a 
correction of these faults helped this man who is 
now 48 j-ears old, and when seen a month ago he 
stated that he was able to do most all of his work 
as a farmer. 

When we mention paroxysmal tachycardia, we 
usually mean the auricular type and think of some 
irritable focus in the auricle, ectopic to the sino- 
auricular node, which for the time being (during 
the attack) puts the heart under control of this 
abnormal focus. The normal vagal control is lost 
and the heart beats regularly and rapidly (rarely 
exceeding 200 per minute) . From a study of cases 
that I have seen and from reviewing reports on 
various series of cases, I do not believe we are able 
to state the cause of this condition. Foci of infec- 
tion are always mentioned, but many cases never 
reveal any foci; and, as the condition may continue 
for many years without further sign of foci, al- 
though we should naturally look for foci and re- 
move all found, we should also try to find the one 
thing that will stop the patient's attack. After 
study of the heart, if possible, reassure the patient 
and the family. Pressure over the vagus above the 
clavicle seems to stop the attack most frequently. 
It is true that these attacks may be associated with 
organic heart disease, as also may extrasystoles, 
but such attacks do not necessarily call for heart 
treatment. It seems that most of these cases are 
in women, and there is usually some emotional 
disturbance associated with the attack. When we 
remember that a hypothyroid patient may lose 
weight and become run down as well as a hyper- 
thyroid, it seems well to try and build the patient 
back to a normal general health, trying to get away 
from nervous instability. 



This subject is well covered in good medical 
books, and it is with the idea of trying to prevent 
the abuse of digitalis in simple paroxysmal tachy- 
cardia that I am mentioning it here. The detail 
men for the various drug houses, each, naturally, 
thinks his product the best and proceeds to tell 
the doctor why. They come around so often that 
digitalis is kept in the doctor's mind. It is a 
great drug as we all know, but much abused. Its 
dosage is just as simple to figure out as that of 
atropine, and its indications are just about as clear- 
cut as are the indications for the use of ergot, yet 
patients are seen who are taking three drops t. i. d. 
(the average person can eliminate IS m. daily) 
and on up to as many as thirty or more drops 
(not minims) every four hours for several weeks. 
.■\t times with the large doses fibrillation begins, 
cerebral or gastrointestinal symptoms appear, which 
complicate the original condition, and the patient 
is sent to the hospital on account of the symptoms 
from over-digitalization. An interesting point in 
this connection was recently brought out by F. A. 
Willius at a staff meeting of the Mayo Clinic, name- 
ly, that in such a case (over-digitalization) even 
in the presence of edema, the proper procedure is 
to force fluids, giving 1000 c.c. daily 10 per cent, 
glucose, in the vein, and 2000 c.c. by mouth if 
possible. 

The attacks of paroxysmal tachycardia, coming 
suddenly and stopping the same way, are interest- 
ing, but not harmful in themselves, and when we 
can tell our patients about an attack that lasted 
29 days without apparent damage it will certainly 
relieve some of the anxiety while we go quietly 
about our business of trying to stop it and then 
giving them more examination and study and less 
drugs. 

Mild Hypothyroidism 

(R. O. Russell, Birmingham, in J I. Med. Assn. State of 

Ala., Dec.) 

These patients have a vague, poorly defined condition of 
ill health, which begins insidiously and usually progressive- 
ly. They feel sluggish physically and mentally. They 
have to drive themselves to do things which they formerly 
did with zest. There is slowness of thought and movement. 
Another prominent symptom is constipation. Brown of 
Baltimore reports the case of a woman sent for a resection 
due to intestinal obstruction. She frequently went 9 days 
without a stool and had other symptoms of hypothyroid- 
ism. Brown advised postponing the operation 3 days and 
began giving thyroid extract, grs. 6, daily. This started 
normal bowel movements, reduced weight and brought 
back mental and physical activity. 

Other symptoms are loss of appetite, cold hands and feet, 
difficulty in keeping warm in cold weather. Some give a 
history of gaining weight, some of losing. The thyroid 
may be slightly enlarged or no enlargement. Nervousness 
and glandular enlargement may cause the physician to 
mistake for hyperthyroidism or toxic goiter. Another oc- 
casional symptom is a tingling or burning over the body. 
A tendency to infections of the nose and throat is present 
in some. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



Surgical Observations 

A Column Conducted by 

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



Pyloric Obstruction in Infants 

Soon after birth symptoms of pyloric obstruc- 
tion may be manifested in infants, and where per- 
sistent, it is always a condition which calls for care- 
ful study and prompt treatment. 

The most common symptom, and usually the 
first that is noticed, is vomiting. The onset fre- 
quently occurs in the second or third week; al- 
though it may begin earlier or later. The type of 
vomiting ranges from simple regurgitation of food 
to projectile expulsion. 

Two types of lesions which should be thought 
of in any vomiting in early case of infants are 
pylorosj^asm without any great hypertrophy of the 
pyloric structures, and congenital pyloric stenosis. 

One curious fact is that pyloric obstruction oc- 
curs far more frequently in boys, indeed only occa- 
sionally in girls. The causes are unknown. 

The onset may be gradual, or s3Tnptoms may 
come on suddenly, usually \vith the regurgitation 
of food which may progress to vomiting of the 
projectile type. The vomiting may be regular in 
time, or it may follow each feeding. Sometimes 
there will be no vomiting until the child has nursed 
two or three times, or has had two or three feed- 
ings, and then the entire contents of the stomach 
may be expelled. Along with the continued vomit- 
ing comes a gradual loss of weight, constipation 
and general malnutrition. With the child entirely 
undressed and lying so that the light shines in the 
proper way upon the abdomen, visible waves of 
gastric peristalsis can usually be seen. 

Careful palpation of the abdomen will often dis- 
close the presence of a tumor in the region of the 
pylorus. The exaggerated gastric peristalsis and 
the tumor are usually diagnostic of congenital py- 
loric stenosis. 

The pathology that is present varies. In the 
mild cases there may be only a spasm of the pyloric 
muscles without any appreciable hypertrophy. It 
is this type of cases that yields to medical treat- 
ment. In the hypertrophic type there is a great 
thickening of these muscular fibers, and on palpa- 
tion the pylorus presents a hard, tumor-like forma- 
tion which is usually fusiform in shape. This is 
hard and fibrous and may close the pylorus so 
tightly that nothing can pass through it. In a case 
of this kind surgical treatment offers the only pos- 
sibility of relief. 

The medical treatment of pyloric obstruction 
usually consists of giving the infant a small dose 
of phenobarbital sodium 20 to 30 minutes before 



each feeding. This may relieve the spasm or the 
pylorus and allow it to act normally, permitting 
the food to pass from the stomach into the intes- 
tines. In mild cases seen early, before there is any 
wasting or dehydration, this treatment may be tried 
before surgical reatment is resorted to. 

If medical treatment fails, surgical relief shoidd 
be afforded promptly, before the child is too weak 
to undergo an operation. 

Where there is a fibrous, hypertrophic stenosis 
with complete obstruction of the pyloric outlet of 
the stomach, naturally death can be the only ter- 
mination unless relieved by surgical treatment. As 
in most other surgical conditions, delay in institut- 
ing treatment increases the hazard, and with each 
day of delay the mortality rises. 

When surgical treatment is decided upon, the 
infant should be plentifully supplied with fluids. 
Glucose and saline solution, or saline solution alone, 
may be given subcutaneously or intraperitoneally. 
Intravenous treatment may be given under certain 
circumstances, but is difficult in infants. Whole 
blood from the mother given intramuscularly is of ■ 
help. 

Operation should never be attempted until the 
child is in the best possible condition, but the pre- 
operative treatment requires only a very short time. 

Through a small, high right-rectus incision the 
tumor mass is exposed and it is very easy to retract 
the liver upward and reach down and lift up the 
pylorus and bring it into position so that the con- 
stricting fibers can be incised. The incision is car- 
ried down to the mucosa, great care being taken not 
to injure the mucosa itself. The mass is then sep- 
arated sufficiently to insure relief from the obstruc- 
tion. The Fredet-Rammstedt operation is usually 
the one of choice. An operation devised by A. A. 
Strauss of Chicago, a variation of the Fredet- 
Rammstedt technique, is useful in some types of 
cases. 

This operation is carried out under local infiltra- 
tion anesthesia, as a rule requires only a few min- 
utes, and the results are almost uniformly good. A 
gastroenterostomy is not advisable in these cases 
for obvious reasons. 

Anyone who has examined the pylorus in a tv^ji- 
cal case of congenital hypertrophic pyloric stenosis 
will realize the futility of medical treatment in a 
case of this kind. 

The most important factor in saving infants with 
this condition is an early diagnosis and prompt 
treatment. Persisent, forcible or projectile vomit- 
ing with constipation and beginning wasting, with 
visible peristalsis of the stomach and a palpable 
tumor in the region of the pylorus demand imme- 
diate surgical treatment. Persistent vomiting with 
the presence of a palpable tumor or a visible peris- 



January, 1936 



SOUTHERN MEDICINE AND SURGERY 



45 



talsis of the stomach should within themselves be 
sufficient evidence of a surgical obstruction of the 
pylorus in infants. 

As in other surgical conditions, the condition of 
the patient has much to do with the results. Where 
the diagnosis has been early and there is very little 
wasting the outlook is good. As the dehydration, 
wasting and malnutrion increase the mortality rises. 

After operation for the relief of pyloric obstruc- 
tion improvement begins immediately, .'\fter the 
first twenty-four hours the child begins to retain 
nourishment, the bowels begin to move and recov- 
ery is usually very rapid. So far as can be told, 
there are no after-effects and the children grow up 
well, and those that have been followed up for 
years after these operations have usually shown no 
further signs of pyloric trouble. 



A SrupLE Classification op Pitlmonary Tuberculosis 
(T. L. Havlicek, Sanator, S. D., in Jl. -Lancet, Dec. 1st) 

Many do not readily recognize the cases of tuberculosis 
for which institutional treatment is indicated. 

When a patient comes into your office and you get the 
history of contact, do a skin test — if negative no infection 
present, if positive the individual has been infected with 
the bacillus. The severity of the reaction, or the size of 
the reaction, does not show the severity of the tuberculo- 
sis. 

Ne.xt an x-ray of the chest — -50% of positive reactors 
will show the pulmonary lesion, and the other 50% to be 
glandular, mesenteric, cervical or mediastinal. If the x-ray 
shows the apices clear with calcium deposits along the 
hilus, the patient has the first infection which is healed 
and is only an observational case. He should have fre- 
quent x-ray examinations, and if extension or infiltration 
begins to spread a reinfection is taking place. The patient 
may feel in exceptionally good health. This case is an 
institutional one, or the patient should be placed under 
therapy at home and placed at rest. If the lesion does 
not show signs of regression within a few months some 
form of collapse therapy is usually indicated and should 
be immediately instituted. The exudative lesion gradually 
advances and becomes caseous if treatment is not through, 
and when extension is present in the other lung with 
much destruction, collapse therapy, although still appMca- 
ble in some cases, is, as a rule, useless. 

A patient becomes an institutional case when secondary 
infiltration shows itself in the lung, or when secondary 
infection or reinfection takes place. To admit a patient 
to the institution before this stage is a detriment to the 
patient as in the first two stages mentioned above addi- 
tional contact is harmful. Nothing is audible in the chest 
with a stethoscope in the first two stages. When reinfec- 
tion takes place, as a rule, rales are not present at the 
beginning of the infection, some interrupted breath sounds 
or dim sounds are heard but not enough to make a diag- 
nosis. When the fourth stage is reached, however, symp- 
toms are present and in most cases diagnosis can be made 
with a stethoscope. 

At present, 99% of the patients suffering from tubercu- 
losis, reach the institutions in the fourth stage of the dis- 
ease, and over 75% of this group are in the late fourth 
stage. 

The large number of fourth-stage cases keeps many third- 
stage cases from being admitted OTid given a chance of 
arrest and cure. 



CoFPEE AND Turkish Coppee 
(Editorial N. E. M. A. Quarterly, Dec.) 

Coffee is invaluable in the home whether palace or hut. 
The Turk has the advantage of all others in that his coffee 
cup is very small and his proportion of coffee to liquid very 
large. He sips the coffee from the grounds. He seldom 
uses cream, though many Turks use sugar. 

The Turk's cup is white porcelain and holds two fluid 
ounces. The guest orders coffee, and after a few minutes 
the waiter brings a small tray containing the empty cup 
and saucer and a large glass of water. Then, from a small, 
cone-shaped copper vessel, with a handle, is poured coffee 
to fill the cup. If two guests be present, the copper vessel 
is of a size to fill two cups. If four or six guests, the 
vessel is of increased size and fills all the cups. 

The vessel used in making coffee is always of one shape, 
and is of such size as to exactly fiU the number of cups 
ordered. I observed that when three cups were ordered 
two vessels were employed, one for a single cup and the 
other for two cups. In all cases the tray of empty cups 
is brought the guest, and then, hot from the fire, come 
the vessels with the smoking coffee. 

In the typical native coffee-house the fire is artfully 
manipulated. It consists of a bank of hot ashes, through- 
out which glow small fragments of charcoal. No flame is 
visible, and when at rest the pile of ash seems dead. 

Into the one-cup copper vessel the native puts one tea- 
spoonful of pounded coffee and one teaspoonful of gran- 
ulated sugar, unless sugar is not wanted. Then the vessel 
is filled to the top of this cone with cold water and the 
mixture stirred. Then the projecting base of the vessel is 
thrust beneath the ash heap, and in a few seconds projected 
farther until the contents boil, when it is immediately 
drawn back. Next the ashes are gradually drawn about 
the base so as to encircle it, and soon the vessel is thrust 
into the center of the heap, the manipulator watching it 
closely. At the first sign of ebullition the vessel is with- 
drawn, quickly thrust back, where it boils at once. The 
contents are then poured into the cup, where the grounds 
quickly settle. This same macerative-extractive method is 
employed with the various-size vessels. 

The entire contents of the extractor, grounds and all, 
are poured into the cup. Turkish coffee is thus not clear, 
but quite like a dirty emulsion. A scum rises to the sur- 
face and the grounds slowly settle. The drinker, as a 
rule, first takes a few swallows of cold water (a glass of 
water is always served, if water is convenient), and then, 
very slowly and deliberately, sips the liquid from beneath 
the scum until the grounds are reached. Then he may 
again take a swallow of cold water. This completes the 
process. In all, not more than a full tablespoonful of 
liquid coffee is swallowed. Hence, considering the fact 
that the powdered coffee is but partly extracted by the 
process of manipulation, and that the sugar dissolved takes 
up some space, whilst the grounds hold much of the liquid, 
the coffee actually consumed in inconsiderable. 

The Turks do not favor grinding coffee in a mill. They 
claim that the flavor is lost. If the pestle be not heavy 
iron, a weight is affixed to the top so that the labor 
required is an upward pull instead of a downward blow. 

The flavor of Turkish coffee at first does not usually 
appeal to one accustomed to European and American cof- 
fee. The act of sipping the liquid from the grounds is an 
art to be acquired. The absence of milk or cream is dis- 
tasteful to persons accustomed to these accompaniments. 
But very soon I experienced a craving for the peculiar 
beverage, which carries no touch of bitterness, nor any 
indication of rankness. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



Southern Medicine and Surgery 

Official Organ of 

Tri-State Medical Association of the 

Carolinas and Virginia 

Medical Society of the State of 
North Carolina 



James M. Northington, M.D., Editor 



Department Editors 

Human Behavior 

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

Dentistry 

W. M. RoBEY, D.D.S - Charlotte, N. C 

Eye, Ear, Nose and Throat 

Eve, Ear and Throat Hospital Group Charlotte, N. C. 

Orthopedic Surgery 

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

John Stuart Gaul, M.D.) 

Urology 

Hamilton W. McKay, M.D I Charlotte, N. C. 

Robert W. McKay, M.D j 

Internal Medicine 

W. Bernard Kinlaw, M.D Rocky Mount, N. C. 

Surgery 

Geo. H. Bunch, M.D -^- Columbia, S. C. 

Therapeutics 

Frederick R. Taylor, M.D High Point, N.C. 

Obstetrics 

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

Gynecology 

Cjias. R. Robins, M.D Richmond, Va. 

Pediatrics 

G. W. KUTSCHER, JR., M.D... Asheville, N. C. 

General Practice 

VViNGATE M. Johnson, M.D... _.. .Winston-Salem, N. C. 

Clinical Chemistry and Microscopy 

C. C. Carpenter, M.D. Wake Forest, N. C. 

Hospitals 

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

Pharmacy 

W. L. Moose, Ph. G Albemarle, N. C. 

Cardiology 

Clyde M. Gii-MORE, A.B., M.D -.-.Greensboro, N. C. 

Public Health 

N. Thos. Ennett, M.D.. -. Greenville, N. C. 

Radiology 

Ai.LEN Barker, M.D. — . I Petersburg, Va. 

Wright Clarkson, M.D.j 



Offerings for the pages of this Journal are requested 
and given careful consideration in each case. Manu- 
.>>cr-ipts not found suitable for our use will not be returned 
unless author encloses postage. 

This Journal having no Department of Engraving, all 
costs of cuts, etc., for illustratmg an article must be 
tome by the author. 



Unlawful for Corporations to Practice 
Medicine 

Once in a while a law court makes a decision 
which might be used as evidence that Mr. Bumble 
should have made some little reservation in pro- 
nouncing "The Law is an ass." 

In its last issue for 1935, the Journal oj the A. 
AI. A. carried this information: 

The Dr. Allison, Dentist, Inc., the plaintiff in this action, 
entered into a contract with the defendant dentist wherein 
the latter agreed, according to the record, "that he would 
not practice operative dentistry for a period of three years 
at any place within two miles of the corporate location." 
Shortly thereafter the dentist opened a dental office directly 
across the street from the corporate dental parlors and the 
corporation sought to enjoin the violation of the agreement. 
The trial court, in denying the injunction, held that the 
plaintiff corporation was illegally practicing dentistry, that 
the corporation's only damage would arise out of compe- 
tion in a line of business which it could not lawfully follow, 
and that therefore the petition of the corporation for an 
injunction did not appeal to the conscience of a court of 
equity. The corporation appealed to the Supreme Court of 
lUinois, contending that Section ISa of the dental practice 
act, which prohibits corporations from practicing dentistry, 
was unconstitutional. 

The Supreme Court, however, considered it to be unnec- 
essary to pass on the constitutional question. The gist of 
the corporation's complaint, and its claim to equitable relief, 
was based on damages alleged to be feared through the 
defendant's competition in practicing dentistry. The prac- 
tice of a profession, said the court, is everywhere held to 
be subject to licensing and regulation under police power 
and not subject to commercialization or exploitation. To 
practice a profession requires something more than the 
financial ability to hire competent persons to do the actual 
work. It can be done only by a duly qualified human 
being, and something more than mere knowledge or skill 
is essential to qualify. The qualifications include personal 
characteristics, such as honesty, guided by an upright con- 
science and a sense of loyalty to chents or patients, even 
to the extent of sacrificing pecuniary profit, if necessar>'. 
These requirements are spoken of generically as that good 
moral character which is a prerequisite to the licensing of 
any professional man. No corporation can qualify. It can 
have neither honesty nor conscience, and its loyalty must, 
in the very nature of its being, be yielded to its managing 
officers, its directors and its stockholders. Its employees 
must owe their first allegiance to their corporate employer 
and cannot give the patient anything better than a second- 
ary or divided loyalty. 

The corporation, in its complaint, stated that the dentist 
had acquired secrets and confidential information in regard 
to the patrons of the corporation. It might be well in- 
quired, said the court, in whom are these personal secrets 
imposed when a corporation attempts to practice? Can it 
be in the president alone, or is he under the corporate duty 
of disclosing them to his directors? And are the directors 
under the further corporate duty of disclosing them to 
stockholders? This very allegation of the corporation 
clearly demonstrates, the court said, the inappropriateness 
of any corporate attempt to practice one of the learned 
professions, involving personal and confidential relations, 
and most clearly demonstrates that such practice is not and 
cannot be open to commercial exploitation. The corporate 
charter of the corporation, the court said, did not and could 



Januar>', 1936 



SOUTHERN MEDICINE AND SURGERY 



not authorize it to practice dentistry, and the trial court 
quite properly dismissed the complaint. 

It will be seen that Illinois has a law specifically 
prohibiting practice of medicine by a corporation. 
Whether or not North Carolina has such a law, we 
do not know: but it would seem that this is im- 
material, for the trial court in this Illinois case 
waved aside the alleged unconstitutionality of the 
law and decided that principles "everywhere held" 
made the practice of medicine by a corporation 
illegal. 

We believe a good deal of this would apply right 
here in North Carolina to contracts sold by a cor- 
poration, whether profit or so-called, non-profit, 
under which the services of doctors are promised. 

The concluding paragraph is a real joy. Nothing 
as neat in a court's decision on a medical matter 
has come to our attention since a Nebraska judge 
denied a claim of a religious healer on Scripture 
grounds, and recounted in detail how Simon got 
to be a leper and the word simony originated. 

We are glad to have the backing of the Illinois 
Supreme tribunal in a long-held opinion that a 
corporation ''can have neither honesty nor con- 
science." 



The Health Bulletin and Its Editor 

In last month there came to this desk No. 12 of 
Vol. SO of the Bulletin of the North Carolina State 
Board of Health. For half a century has this 
bulletin gone out over the State carrying health 
information and inspiration. How it was started 
and how it was made to grow through its infancy 
and childhood is told by The Editor in a leading 
article which every citizen should wish to read. 
(This Bulletin will be sent free to any citizen of 
the State upon request.) This article tells about 
the work of Dr. Thomas F. Wood and Dr. Richard 
H. Lewis. These were mighty men and deserving 
of the highest praise; but we would say something 
about the work of the present Editor of the Bulle- 
tin, Dr. George M. Cooper. 

A great number of State and National public 
health periodicals come into our hands regularly. 
Many of these are much more pretentious than the 
one that is the work of Dr. Cooper; but not one 
can be compared with his for solid worth. 

Dr. Cooper says of himself that "since March 
1st, 1923, he has been the responsible Editor of 
the Health Bulletin." Dr. Cooper is much more 
than "responsible:" he is able, energetic, resource- 
ful, faithful — and many other things that all of us 
admire in others and covet for ourselves. 

We are most amazed at the faith revealed by 
the evidences of sustained zeal through 23 years of 
striving against ignorance and indifference, in an 
endeavor to save people in spite of themselves. 



Our own faith is of the kind that believes it can 
remove mountains — but very little at a time. If 
all of us doctors in private practice will put our 
full strength into carrying out measures of disease 
prevention such as The Bulletin advocates and 
keeps fresh in our minds, then will the mountains 
of preventable disease disappear rapidly and Dr. 
Cooper's faith be justified. 

Will we not water where he plants and all share 
in the increase? 



Reconsideration as to Chapel Hill and Wake 
Forest Medical Schools 

Abstracts of Minutes of Meeting Council on Medical 

Education and Hospitals, Dec. 8th and 9th. 

(From Journal A. M. A., Dec. 28th) 

1. The meeting was called to order at 10 a. m. 
Those present included Drs. Ray Lyman Wilbur 
(chairman), Merritte W. Ireland, Frederic A. 
Washburn, J. H. Musser, Fred Moore, Reginald 
Fitz, William D. Cutter, Herman G. Weiskotten, 
Carl M. Peterson, Oswald N. Andersen and Mr. 
Homer F. Sanger. 

2. It was resolved that the minutes of the busi- 
ness meeting of Sept. 15th, 1935, be approved. 

3. It was voted to reconsider the resolution 
passed in September to the effect that after July 
1st, 1938, the Council would no longer list two- 
year schools and it was further voted that such 
schools be considered individually. 

4. It was voted that the nineteen sophomore 
students at present enrolled in the University of 
Mississippi School of Medicine may be accepted in 
approved schools without prejudice to the standing 
of the latter. 

5. It was voted that the American Board of 
Dermatology and Syphilology be approved. 

6. It was voted that the American Board of 
Radiology be approved. 

7. It was voted that the list of pathologists as 
submitted be approved. 

8. It was voted to approve the lists of hospitals 
and other institutions recommended by the staff. 

WILLIAM D. CUTTER, Secretary. 



A Heartening Incident 
.4 s far back as our memory goes and on up to 
now, church newspapers have been carrying many 
and varied advertisements of "patent" medicines. 
It has been alleged that the religious press is the 
main prop of that business; but, after glancing 
through recent issues of the big dailies of our State, 
and after trying vainly to listen to a radio pro- 
gram without hearing about our bowel movements 
and body odors, we are disposed to doubt that the 
church papers should be given chief place. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



The incident which heartens in this connection — 
unique, so far as our knowledge goes — is that of a 
church paper boldly announcing that it will no 
longer carry this kind of advertising. An editorial 
in the December 12th issue of Charity & Children, 
a Baptist weekly published at Thoniasville, goes 
like this: 

The editor of Charity and Children has been accused of 
rank inconsistency. We make public note of the charge 
because the one making it proves his case most completely. 
He is at the head of a great institution for people with 
diseased minds. His charge is that Charity and Children 
is strong against liquor and at the same time advertises 
nostrums that are much worse than liquor. All that we 
can say to that charge is that the doctor's point is well 
taken. He says that he treats (until death) persons who 
come to his institution because of taking some of the stuff 
advertised in Charity and Children. We do not bow in 
shame. We have long been shamed by the type of articles 
sent in by our advertising agency that has a contract with 
us. We thank the good doctor and all of the other physi- 
cians for their forbearance with us and promise them here 
and now that w'e are going to part company with the dis- 
pensers of nostrums. Hereafter our Orphanage physician 
will OK every medical advertisement that appears in this 
paper. We may be tied up in a 90-day contract but we 
will not accept a new medical advertisement without the 
approval of our family physician and will discontinue all 
that are objectionable to him within 90 days. Now! we 
have said what we have longed to say and we feel like we 
have had a good bath. 

This stand would be praiseworthy under any 
circumstances; when we consider the fact that it 
is costing Charity & Children a large part of its 
income, we are deeply impressed with this proof of 
religion and morality. We hope that virtue will 
net be penalized for long, and we promise to be 
on the lookout for opportunities to steer in the 
way of this honest paper the kind of advertising 
an honest paper can accept. 



COMMUNICATION 



Wilson, N. C, December 24th. 

Dear Dr. Northington: 

I have just read your editorial on reducing highway fa- 
talities, and I hasten to write you that your plan is the 
sanest and most tenable and entirely practical that I have 
seen anywhere. I hope you will continue to hold this up 
in the face of every oificer of the law, and before the 
public. I have been trying for several years to help work 
up a public sentiment and moral influence against this 
organized killing system and found it as you know very 
hard and at times discouraging. But during this time I 
have seen criticism of my efforts gradually fade and change 
into commendation. I am proud of a iew accomplishments, 
principal of which was a summer's work trying to get a 
patrolman eliminated from our local force, which finally 
succeeded, but not until after going to the Governor with 
it. I don't mind letting the officers know that we expect 
action from them and that I am willing to appear as 
witness in any case that I see. I simply tell my critics 
that when I look down upon a corpse of the road out of 



my family I shall not have to suffer the agony of knowing 
that I never did the first thing to try to prevent it. So, 
many of the critics have experienced this anguish and have 
been converted as the time and accidents piled up. 

I believe yours will be the best Christmas present given 
in North Carolina this year. 

Hoping for you a happy Christmas this year and many 
more in a long future. 

Sincerely, 

E. T. DICKINSON. 



Dr. E. a. Hines, Secretary-Editor for the South Caro- 
lina Medical .Association, writes that he brought this edi- 
torial before the next meeting of his Civic Club and a 
Committee was appointed to further the idea. We are 
proud to have the approval and grateful for this backing 
of such men as Dr. Hines and Dr. Dickinson. — Editor. 



Obituary 

Robert B. Babington 

A Layman Who Contributed to Medicine 

From time to time some layman has a vision of 
service to his fellowmen which expresses itself in 
the creation of an institution for making the bene- 
fits of medicine and surgery available to the peo- 
ple. It is evident from the history of medicine 
that much of the advance made by medicine and 
surgery has been due to the means, inspiration and 
guidance furnished by laymen. Those of us 
who work in the profession are truly grateful for 
the enlarged opportunity thereby afforded to prac- 
tice the art and render a type of service which 
might otherwise have been denied us or at least 
longer deferred. 

This brief is written to express appreciation for 
the life of Robert B. Babington — Citizen, and Foun- 
der of The North Carolina Orthopaedic Hospital 
for Crippled Children. 

Some twenty-five years ago, !Mr. Babington be- 
came interested in creating an institution for the 
care of needy crippled children. He was truly a 
pioneer in this movement which later spread so 
generally over the country, resulting in the Shrin- 
ers' chain of crippled children's hospitals, other 
State institutions for orthopedic patients and con- 
tributed largely to the progress of orthopedic sur- 
gery. 

The creation of the North Carolina Orthopaedic 
Hospital was due solely to the vision and deter- 
mination of this man. If one knew the many ob- 
stacles overcome and the discouragements ignored 
by Mr. Babington in his early years of work in 
connection with raising funds for the proposed 
State Hospital for Crippled Children his accom- 
plishments would be appreciated even more. He 
raised money at first through gifts of his own, by 
penny contributions from children, by soliciting 
small contributions at the County Fair, by enlist- 
ing friends in the cause and, finally, by interesting 



Januao'> 1936 



SOUTHERN MEDICINE AND SURGERY 



the State Legislature in a series of sizeable appro- 
priations, making possible the erection of the first 
units of the hospital. 

Under a board of trustees and with Mr. Babing- 
ton as president and prime mover the Orthopaedic 
Hospital was opened for patients in the summer of 
1921. Thirty beds were available then. These 
were promptly taken by indigent crippled children 
from Xorth Carolina and the hospital has been 
full of needy children from that day to this. 

The number of beds was soon increased to fifty. 
In 1927 a building program brought the bed ca- 
pacity to one hundred. Shortly thereafter the Ben- 
jamin X. Duke Ward for the Colored was added 
with a capacity of fifty beds and the hospital now 
operates w-ith one hundred and fifty beds — one of 
the largest hospitals of its kind in the country. 

The Xorth Carolina Orthopaedic Hospital has 
been the recipient of handsome appropriations from 
the State, apparently gladly given, and substantial 
gifts have been made by a number of individuals. 
^Ir. B. X'. Duke gave, during his lifetime and later 
through his will, some fifty thousand dollars to the 
colored division. Mr. Edwin D. Latta left in his 
will a bequest to the hospital estimated at two 
hundred and fifty thousand dollars. The sum of 
seventy-five thousand dollars has already accrued 
to the institution from this estate. Many miscel- 
laneous donations have come from other sources 
until now a plant is in operation which has invested 
in it a half-million dollars in money, the affection 
and goodwill of thousands of patients and citizens, 
and the confidence of a great State in its permanent 
usefulness. 

These things are briefly summarized (and they 
far from tell the whole story) to show the results 
of the diligence of one layman as he contributed to 
medicine. He successfully promoted a good cause 
which will bear fruit in the generations to come. 
While not on so large a scale, but in spirit propor- 
tionately, Robert B. Babington will go down in 
history along with the Rockefellers, the Dukes and 
other laymen who have substantially contributed 
to the progress of medicine. Mr. Babington in his 
active working days often termed himself Andrew 
Tackson, whom he greatly admired, and one of the 
favorite homely e.xpressions of the Founder of The 
North Carolina Orthopaedic Hospital, when he 
girded himself for action on behalf of any issue re- 
lating to this institution, was: "I ganny, they ain't 
nothing Andy Jackson can't do." And so he lived, 
labored and wrought and erected for himself a fit- 
ting monument of service to the handicapped and 
underprivileged children of his native State. 

—0. L. MILLER, M.D. 



NEWS ITEMS 



The Southe.4stern Surgical Congress will hold its sev- 
enth annual assembly in New Orleans, March 9th- 10th- 
11th, 1936, at the Roosevelt Hotel. The following doctors 
have accepted places on the program: Arthur Hertzler, 
Halstead, Kan.; Chevaher Jackson, Philadelphia; Francis 

E. Lejeune, New Orleans; .Arthur \V. Allen, Boston; John 

F. Erdmann, New York City; Jennings Litzenberg, Minne- 
apolis; Joseph E. King, New York City; Fred Rankin, 
Lexington, Ky.; C. C. Howard, Glasgow, Ky. ; George W. 
Crile, Cleveland; Garnett W. Quillian, Atlanta; Paul Flo- 
thow, Seattle; .\lan C. Woods, Baltimore; Virgil S. Coun- 
seller, Rochester, Minn.; .Alfred h.. Strauss, Chicago; W. D. 
Haggard, Nashville; Roger G. Doughty, Columbia; Thomas 
E. Cormody, Denver; Charles 0. Bates, Greenville, S. C; 
Guy Caldwell, Shreveport ; Gerry Holden, Jacksonville ; 
Emmerich von Haam, New Orleans; Roger Anderson, Se- 
attle; A. Street, Vicksburg; James S. McLester, Birming- 
ham; Edgar Fincher, jr., Atlanta. There will be others. 



American Board of Ophthalmology, Room 1417, 122 
So. Michigan .Ave., Chicago, 1936 examinations, Kansas 
City, May 11th (at time of meeting of A. M. A.), and 
New York City, in October (at time of meeting of Amer- 
ican Academy). All applications and case reports must be 
filed at least 60 days before date of examination. 

For information, syllabuses and application forms, please 
write at once to Dr. Thomas D. Allen, .Assistant Secretary, 
122 So. Michigan Ave., Chicago, 111. 



The annual meeting of the Seventh District (N. C.) 
Medical Society was held at Wadesboro, November 12th, 
with Dr. L. A. Crowell, jr., president, in the chair. Dr. 
Forest M. Houser of Cherryville, Councillor, called the 
meeting to order. Following the afternoon program a 
banquet was held at 6:30 to which an address of welcome 
was given by Dr. Chas. I. Allen with a response by Dr. 
D. A. Garrison, followed by an address by Dr. L. B. 
McBrayer. The new officers are: president, Dr. J. M. 
Davis, Wadesboro; vice president. Dr. McT. G. Anders, 
Gastonia; secretary, Dr. C. H. Pugh, Gastonia; place of 
meeting, Gastonia. 



At the last meeting of the Richmond Academy of Med- 
icine for the fiscal year ending on December 10th, the fol- 
lowing officers were elected: president. Dr. Roshier W. 
Miller; first vice president, Dr. Emory Hill; second vice 
president. Dr. L. J. Stoneburner. Dr. Charles M. Cara- 
VATi continues as secretary. The life of the Academy is in 
excellent condition. The organization has 315 members, it 
owns its own home, in which there is an excellent audito- 
rium, in which the Miller Library is attractively housed, 
and the Medical Society of Virginia has its offices in the 
Academy bulding. In the basement of the building is a 
refectory, in which the members mingle in intimate and 
informal fashion around the refreshment table after each 
meetinir. The new home of the Academy, with the price- 
less Miller Library, is doing much to unify and to inspire 
the members of the medical profession of Richmond. 



Buncombe Count\- Medical Society, .Asheville, 40th 
annual meeting. Grove Park Inn the evening of December 
16th, President L. M. Griffith in the chair, 6S members 
present, many visiting physicians from Oteen and from 
adjoining towns. 

Reports from the following com. were heard: 
1) Public Health and Legislation, Dr. P. H. Ringer, 
chr., reporting. Accepted and filed. 



50 



SOUTHERN MEDICINE AND SURGERY 



Januar.', 1936 



2) Medical Ethics, Dr. W. M. HoUyday, chr. Accepted 
and filed. 

i) Medical Economics, Dr. G. W. Murphy, chr. Ac- 
cepted and filed. 

4) Certified Milk Commission, Dr. G. W. Kutscher, sec- 
treas. Accepted and filed. 

5) Publicity Committee, Dr. C. H. Cocke, chr. Accept- 
ed and filed. 

6) Com. to Co-operate with Welcome to Asheville, Inc., 
no report submitted. 

7) Medical Relief Advisory Committee, Dr. H. G. 
Brookshire, chr. Accepted and filed. 

8) Constitution and By-Laws, Dr. G. S. Tennent, chr. 
For a change in by-laws, Chapter V, Sections 1 and 11, in 
regard to the dues for 1936. Report accepted as informa- 
tion. 

9) Obituaries, Dr. M. L. Stevens, chr. Accepted as 
presented. 

10) Asheville Cancer Clinic, Dr. C. C. Orr, chr. Ac- 
cepted and filed. 

Auditing Committee, Dr. J. W. Huston, chr., reported 
that the books of the treasurer had been examined and 
found to be correct. His committee recommended that 
the secretary-treasurer be directed to purchase and properly 
keep a ledger of income and disbursements, and that a 
record be so kept that will show each member's dues are 
paid, together with the date of payment. Motion made to 
accept the report and the recommendation as presented. 
Seconded and carried. 

Report of the Secretary-Treasurer: The Secretary read 
before the meeting his annual message, the same being a 
resume of the year's work and activities and accomplish- 
ments of the society. 

The Treasurer's report, being an exhibit of the income 
and disbursements of the society for the year. Motion 
made to accept the reports as presented and file. Seconded 
and carried. 

The chairman called on the Nominating Committee for 
the nominations. 

President: Dr. H. S. Clark, Dr. Mark A. Griffin and 
Df.G.'Farrar Parker.- Nominations from the floor asked 
for. None made. The balloting was then begun, three 
ballots were taken before a choice could be made. Dr. 
Geo. Farrar Parker won the nomination on the last ballot 
and was duly declared elected president for 1936. (Dr. 
Parker was not present in the room at the time.) 

Vice President: Dr. G. W. Kutscher and Dr. C. C. 
Swann. Nominations from the floor asked for. None 
made. The balloting was begun and two ballots were nec- 
essary for a choice (1st a tie). Dr. G. W. Kutscher was 
elected on the 2nd ballot and was declared elected. 

Secretary-Treasurer: The incumbent. Nominations from 
the floor asked for and none heard. Election by acclama- 
titon. 

Third Member of Board of Censors: Dr. L. M. Grif- 
fith. Motion made to close nominations. Sec. and carried. 
Election viva voce. 

1936 Delegates to the State Society session. The follow- 
ing five delegates and their alternates: Delegates — Drs. R. 
R. Ivey, Chas. C. Orr, Chas. A. Hensley, R. C. Scott, W. 
C. Lott; Alternates— Drs. R. A. White, A. B. Craddock, 
S. L. Whitehead, W. M. Hollyday, C. H. Cocke. Motion 
made to accept the nominations as presented and the elec- 
tion be by acclamation. Seconded and carried. 

The secretary was instructed to convey the society's 
greetings to the following physicians unable to attend the 
meeting tonight because of illness: Drs. Lynch, Craddock, 
L. L. Williams, Scott and J. E. Cocke. 

Buncombe County (N. C.) Medical Society, .\sheville, 
the evening of January 6th, at the City Hall Building, 



President Parker in the chair. 4S members present; visitor. 
Miss Margaret Thompson, a teacher of lip reading for the 
hard of hearing. 

Dr. Kutscher presented a baby, 8 months old. The 
history of case outlined, a display of the blood work and 
laboratory work done, x-ray films shown and consultant's 
report read. Case undiagnosed. Essayist's opinion was 
condition a mediastinal tumor, possibly a tumor of thy- 
mus. 

The president then asked Dr. Kutscher, the vice presi- 
dent, to take the chair, and the Presidential Address and 
Outline of Policies for the year was delivered. Dr. Ward 
moved the address be reviewed by a committee appoint- 
ed by the chairman and reported back to the society. Dr. 
Grantham, chr., and Drs. Mears and Huston appointed on 
this committee. 

Miss Thompson was then called on and spoke of the 
importance of recognizing the hard of hearing children 
early and starting immediate treatment, medical, surgical 
or lip reading. She spoke of the work of the Volta Bureau 
at Washington, D. C, and the American Society for the 
Hard of Hearing. Presentation discussed by Dr. Elias. 

Committee reports: 

Welcome to Asheville, Inc., Dr. Colby, chr., made a ver- 
bal report to the effect that several of our members were 
also members of this organization and their advise and 
counsel was always available. 

Dr. C. C. Orr submitted a written report from the N. C. 
State Nurses Assoc, District No. 1, which gives an outline 
of the work done for the year 193S. Report accepted as 
information and filed. 

Dr. G. S. Tennent, chr. of the By-Laws committee for 
1935, presented the amendment to the By-Laws up for 
adoption on Jan. 20th. 

Dr. McCall of the 1935 Banquet Committee reported 
that the banquet exhibit came out even as to income and 
expenditures. Applause. 

The Standing Committees for 1936 were announced by 
the president. 

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



GiTiLFORD County Medical Society', December 5th, King 
Cotton Hotel, Greensboro, 6:30 p. m. Dr. W. P. Knight, 
the president, presided; invocation by Dr. C. W. Banner. 

Paul H. Harrel. Greensboro manager of the Hospital 
Care Association, Inc., addressed the society briefly con- 
cerning the Association. He stated that the Association 
is operating in the larger towns of the State, including 
Greensboro. He also explained the plan, rates, etc. 

Dr. Chas. E. Moore was elected into full membership of 
the society. 

Dr. W. T. Tice of High Point was then presented to the 
society and read a very interesting paper on Syphilis in 
General Practice: discussed by Drs. F. R. Taylor, S. F. 
Ravenel, C. C. Hudson, Wesley Taylor, A. D. Ownbey 
and W. W. Harvey. 

Second paper by Dr. Russell O. Lyday on Surgical 
Treatment of Chest Conditions (illustrated) : discussed by 
Drs. M. D. Bonner, Harry Brockman, Marion Y. Keith 
and F. R. Taylor. 

Dr. W. P. Knight, retiring president of the society, ex- 
pressed his appreciation for the splendid co-operation he 
received throughout his period as president of the society. 

Adjourned until the first Thursday in January. 

January 1st the following officers (elected in October) 
take charge: president. Dr. J. W. Tankersley; vice presi- 
dent. Dr. R. 0. Lyday; secretary-. Dr. Norman A. Fox; 
treasurer, Dr. H. R. Parker; member board of censors. 
Dr. F. R. Taylor; delegates to State Society— Drs. R. O. 
Schoonover (3 years). Dr. Houston B. Hiatt (2 years). 



Januan-, 1936 SOUTHERN MEDICINE AND SURGERY 



Eli Lilly y\ND Company 

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the nasal application of ephedrine in head 
colds. Ephedrine Inhalants, Lilly, in the one- 
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prescription form. For prompt and well-sus- 
tained tissue shrinkage with improved respira- 
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Inhalant Ephedrine CPlaM, Lilly, 

containing ephedrine (in the form of ephed- 
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hydrocarbon oil . . . or 

Inhalant Ephedrine Compound, Lilly, 

containing ephedrine 1 percent, with men- 
thol, camphor, and oil of thyme in a neutral 
hydrocarbon oil. 



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



Please Mention THIS JOURNAL When Writing to Advertisers 



52 



SOUTHERN MEDICINE AND SURGERY 



January, 1Q36 



Other officers whose terms have not expired are as follows: 
board of sensors— Drs. Fred Patterson, H. L. Cooli; dele- 
gates to state society— Drs. W. F. Cole, J. T. Taylor, S. S. 
Saunders. 

(Signed) D. W. Holt, Acting Secretary. 



Regular monthly meeting of Wake County (N. C.) 
Medical Society held in the Carolina Hotel, Raleigh, the 
evening of December 12th, 1935, at 7:30. The meeting 
was called to order by the president. Dr. M. R. Gibson. 

Mr. C. A. Douglas, Raleigh attorney, was introduced 
by the president, and gave a most interesting talk to the 
society on Medical Jurisprudence. At the conclusion of 
the address. Dr. H. B. Haywood moved a rising vote of 
thanks, seconded, passed and heartily applauded. Dr. C. 
C. Carpenter moved that the society ask Mr. Douglas the 
permission to have the paper published in Southern Med- 
icine and Surgery. This was seconded and passed. Mr. 
Douglas gladly granted the request. 

The secretary and treasurer then made his annual re- 
port. 

A letter of transfer for Dr. R. H. Hackler, from the 
Buncombe County Medical Society, was read. Dr. J. B. 
Wright moved unanimous acceptance, seconded and passed. 

Dr. Gibson then gave a resume of the year's programs. 

Nominations for the election of officers for 1036 were 
then entertained. Dr. J. B. Wright nominated Dr. Ivan 
Procter for president, seconded by Dr. Carl Bell. Dr. 
J. W. McGee nominated Dr. Henry Turner, seconded by 
Dr. L. N. West. Dr. Turner then maDV lt>< request that 
his name be withdrawn. Dr. McGee acquiesced. Dr. L. 
N. West then moved that the nominations '.e closed, the 
rules be suspended, and the secretary be ins rycted to cast 
the unanimous vote of the society for Dt. Procter. This 
was seconded by Dr. McGee and the motion passed. The 
secretary so cast the vote. 

Dr. Procter took the chair and nominations for vice 
president were entertained. Dr. B. J. Lawrence nomi- 
nated Dr. R. L. McGee. Dr. Yarborough seconded and 
moved that the nominations be closed, the rules be sus- 
pended, and the secretary be instructed to cast the unani- 
mous vote of the society for Dr. McGee. 

For secretary-treasurer Dr. Hugh Thompson nominated 
Dr. N. H. McLeod. Dr, J. W. Ashby moved that the 
nominations be closed, that the rules be suspended, and 
that the president be instructed to cast the unanimous vote 
of the society for Dr. McLeod. 

Dr. J. B. Wright moved that Dr. J. M. Judd be re- 
elected to the censorship committee for two years. This 
was seconded and passed. 

(Signed) N. H. McLeod, jr., M.D., Sec.-Treas. 



At the last meeting of the Randolph County (N. C.) 
Medical Society, Dr. C. S. Tate was elected president, and 
Dr. W. L. Lambert, vice president. Dr. J. H. Soady was 
re-elected secretary-treasurer. 

Dr. C. C. Hubbard was named Councilor. 

Those attending the meeting and enjoying the turkey 
dinner served were Drs. J. H. Soady, C. C. Hubbard, L. M. 
Fox, R. L. Caveness, W. L. Lambert, J. T. Barnes, F. C. 
Craven, J. C. Rudd, E. A. Sumner, G. H. Sumner, J. T. 
Barnes, H. L. Griffin, J. V. Hunter, J. T. Burrus and R. P. 
Sykes. 



At the meeting of the Edgecombe-Nash County Medi- 
cal Society the following officers were elected for 1936: 
Dr. J. H. Cutchin, Whitakers, president; Dr. A. G. Nor- 
fieet, Tarboro, vice president ; Dr. W. O. House, second 
vice president, and Dr. A. L. Daughtridge, Rocky Mount, 



secretary-treasurer. Dr. R. S. Anderson, Rocky Mount, 
and Dr. Borden Hooks, Tarboro, were elected delegates to 
the State convention with Drs. J. G. Raby and M. W. 
DeLoach as alternates. Dr. Thomas H. Royster, Tarboro, 
joined the society at this meeting. 

The officers of the Wayne County Medical Society 
for 1936 are Dr. D. J. Rose, president; Dr. Luby War- 
rick, vice president. Dr. Jack Harrell, secretary-treasurer, 
all of Goldsboro. 



Officers of the Wilson County Medical Society for 
the ensuing year are Dr. M. P. Mullen, Wilson, president ; 
Dr. R. H. Putney, vice president; Dr. E. T. Clark, secre- 
tary-treasurer. 



RuTHEREORn CoUNTY Medical SOCIETY at its regular 
meeting elected the following officers for 1936: president, 
Dr. W. H. Knight, Bostic; vice president. Dr. R. N. Har- 
din, Rutherf ordton ; secretary-treasurer. Dr. C. F. Glenn, 
Ruthcrfordton. 



A BOND ISSUE of $80,000 which will be supplemented by 
a like amount from Duke Endowment was voted by a 
large majority in Cabarrus County on December 17th. 
This bond election was provided for by the last session of 
the General Assembly. 



The University of North Carolina School of Med- 
icine will continue its course in Public Health Adminis- 
tration in 1936. 



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

The semi-annual meeting of the First (S. C.) District 
Medical Association was held in Walterboro, S. C, Wed- 
nesday, November 20th, at 4 p. m. The program was as 
follows: The Clinical Use of the Electrocardiogram, by 
Dr. G. P. Richards, Charleston — discussion by Drs. W. C. 
O'DriscoU and P. G. Jenkins, Charleston; Treatment of 
Skin Diseases, Drs. Robert Taft, John van de Erve and 
A. E. Baker; Some Common Diseases of the Eye, Dr. P. 
G. Jenkins, Charleston, Dr. L. C. Stokes, Walterboro, Dr. 
J. T. Townsend, Charleston; Treatment of the Common 
Cold, Dr. W. P. Rhett— discussion by Drs. J. F. Town- 
send, P. G. Jenkins and A. E. Baker, .\fter this program, 
a delightful dinner was served. 

Dr. Charles C. Higgins of the Urological Department of 
the Cleveland Clinic gave an address to the Columbia Med- 
ical Society, November 11th, at the Forest Lake Club, on 
Experimental Production and Solution of Urinary Calculi 
with Clinical Application and End Results. 

Dr. I. R. Wilson was inaugurated for his second term 
as Alderman, ward 7, Charleston. He was appointed Mayor 
Pro Tem for the year of 1936. 

Dr. Josiah Smith, Charleston, was inaugurated for his 
first term as Alderman. Both doctors are members of the 
Ways and Means Committee, the most powerful committee 
on the board. 

Darlington went to the polls November 26th in a second 
municipal election for mayor between Dr. G. B. Edwards 
and J. H. Willcox in perhaps the closest election in the 
histor>' of the town, votes cast were: Dr. Edwards, 383, 
and Mr. Willcox, 379. Dr. Edwards has been a practicing 
physician in Darlington for a number of years. He has 
served on the town council and was for two years County 
Health Officer. 

Dr. James H. Hutchison, prominent Columbia physician, 
and Miss Hildegarde Schroder of Lancaster, Pa., and Char- 
leston, S. C., were united in marriage Saturday afternoon, 



Januan-, 1936 SOUTHERN MEDICINE AND SURGERY 



SERENIUM 

Aids the natural processes 
of recovery 



The use of an effective bacteriostatic agent in the treatment of genito- 
urinary infections restrains the growth of bacteria, and thus, by hmiting 
the irritation, frequently aids the natural processes of recovery. 

Serenium (diamino-ethoxy-azobenzene hydrochloride) is an orally ad- 
ministered agent which, while bacteriostatically effective, is so free from 
toxic effects as to be innocuous. Serenium imparts a reddish orange color 
to add urines, a fact which often inspires confidence in the patient that a 
cure is being effected. The relief from symptoms which it brings 
strengthens the patient's morale and enables the physician to institute 
other suitable local treatment. 

Serenium is often useful in the treatment of pyelitis and cystitis even 
when the condition has become chronic. It has given excellent results in 
children. In gonorrhea it has been shown effective in alleviating the 
symptoms and in shortening the duration of the infection as much as 
30 per cent when used in conjunction with local treatment. 

Serenium is supplied exclusively by E. R. Squibb & Sons. It is supplied 
in bottles of 25, 50 and 500 chocolate-coated tablets of 0.1 gram each. 
The usual dose is one tablet three times a day after meals. 

Por literature write the Professional Service 
Department, 745 Fifth Aienue, New York 

ERrSoinBB SiSONS^NEW^YbRK 

MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858. 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



November 30th, in St. John's Lutheran Church, Charles- 
ton. 

Dr. Edward Sinton Cardwell, Columbia, and Miss Lily 
Mikell Legare, formerly of Charleston, but now of Colum- 
bia, were married November 29th, at the First Presbyterian 
Church in Columbia. Doctor Cardwell is a graduate of 
the University of S. C. and in 1934, was graduated from 
the Medical College of S. C, where he is now assistant 
pathologist. He completed a year's interneship at the Co- 
lumbia Hospital this past summer. He is a member of 
Alpha Kappa Kappa, medical fraternity. 

Dr. J. Dougal Bissell, a South Carohnian who for many 
years was connected with the Woman's Hospital of New 
York, died in the second week of December. Com- 
mittal services were held at Magnolia Cemetery, Charles- 
ton, on December ISth. Dr. Bissell was one of the famous 
surgeons of this country. A few years ago, he was invited 
to read an essay on the life of Marion Sims, in London, 
England, at which time he was made a Fellow of the Royal 
College of Surgeons. 

Dr. William C. Austin, head of the Loyala University 
School of Medicine, chemistr>' department, in Chicago, 
died the last of November of a heart attack. Dr. Austin 
was a native of Cross Hill, S. C, the son of Dr. J. D. 
Austin. He was a graduate of the Medical College of the 
State of South Carolina and had been with Loyola for 12 
vears. 

Dr. L. Rosa Hirschmann Gantt, wife of Robert J. Gantt, 
Spartanburg attorney, and the first woman graduate of 
the Medical College of the State of South Carolina, died 
November 16th, at a Philadelphia hospital where she was 
taken for treatment. Dr. Gantt was a former president of 
the Medical Women's National .Association and was one 
of the most prominent of the women physicians of the 
section. She was also active in social work, having pro- 
moted the establishment of the Reform School for Girls at 
Columbia. Later she served on the State Welfare Board. 
Dr. Gantt was a native of Charleston. 



Annual meeting of Pirr Coitnta- Medical Society, No- 
vember ISth, Dr. S. M. Crisp elected president, Dr. W. 
M. B. Brown, vice president, and Dr. W. K. McDowell, 
secretary-treasurer, all of Greenville. Dr. Alban Papineau 
of the State Sanatorium staff presented a paper on Tuber- 
culosis and Dr. N. Thos. Ennett made his monthly report 
as County Health Officer. Drs. Winstead and Wooten of 
Pitt Memorial Hospital, Greenville, gave a report of their 
attendance at the recent meeting of the College of Sur- 
geons in the State of Washington. 



The Medical College of Virginia, Richmond, has re- 
ceived recently from a donor who does not wish to have 
his name given a princely gift of 250 mgms. of radium. 



Dr. WiLLLAii R. Hill, native of Statesville, has recently 
been given a three-year appointment as assistant resident 
physician at the University of Virginia Hospital. 

Dr. George Bachisian, director of the Rockefeller School 
of Medicine at the University of Puerto Rico, San Juan, 
has lately been the guest of Dr. W. B. Porter at his home 
in Richmond. 



Dr. B. H. M.artix, of Richmond and Westhampton, has 
been appointed by the Circuit Judge to membership on 
the Board of Supervisors of Henrico County, Virginia. 



Dr. a. D. Crec«. who served as Edgecombe County 
Health Officer from August until recently, has gone to 
Liberty where he will engage in the practice of medicine. 



Narna Darrell, a historic novel by Dr. Beverley R. 
Tucker, Richmond, will be issued from the press of the 
Stratford Company, Boston, about February- 1st. In this 
romance Dr. Tucker traces from its earliest origin the in- 
flux of Anglo-Saxon civilization into Virginia. 



Dr. Mark T. Frizzelle, Ayden, has been elected presi- 
dent of the Duke Alumni Association of Pitt County, 
N. C. 



MARRIED 

Dr. Paul D. Camp, of Richmond, and Miss Nellie Cor- 
nelia Staves, of Schenectady, New York, at the home of 
the bride on December 7th. After January 1st they will 
be established in the Tuckaho Apartments in Richmond. 



Deaths 

Dr. James J. Stewart, 59 (N. C. Med. Col. '04), at his 
home at Mt. Holly, Januar>- 1st. Dr. Stewart was a 
practicing physician at Mt. Holly for 30 years, having 
retired about three years ago. He had been in declining 
health for several years, although he was able to walk 
about town up to the time of his death. 



Dr. Charles W. Gleaves died at his home at Wytheville, 
V'irginia, on December 12th, at the age of SO. He was a 
graduate of the Medical College of Virginia in the class 
of 1S79. For several years he had been president of a bank 
in Wvtheville. 



Dr. .\rthur Ogburn Spoon, at his home in Greensboro on 
December 10th at the age of 54 of post-influenzal pneu- 
monia. He was a graduate of the Medical Department of 
the University of Maryland. 



Dr. James Carlisle Moore, McCoU, S. C, died at a 
hospital in Florence, S. C, on December 13th at the age 
of 58. He was a graduate of the Medical College of the 
State of South Carolina in the class of 1901. 



Dr. Parran Jarboe, Greensboro, surgeon of this State, 
aged SO years, died from an automobile injury at the 
Shelby Hospital, December 29th. 



Dr. Wm. R. Goley, aged 59, Southport, a prominent 
physician and mayor of Shallotte, died in the Brunswick 
Hospital November 12th. 



Dr. John Arnold Board, 44 (M. C. V. '13), Altavista, 
Va., December 18th, after a long period of ill health. 



Dr. A. R. Hodge, aged 35, Severn, died recently of pneu- 
monia. 



Our Medical Schools 



Medical College of Vieginla 



A gift of 250 milligrams of radium with the most ap- 
proved type of filters, applicators, et cetera, has been an- 
nounced. 

Work on the foundation of the new clinic and laborator>' 
building is well under way. This building will house out- 
patient clinics on the first four floors; one floor each will 
be given to bacteriology, biochemistry and pathology; one- 
half floor each to physical therapy and preventive medicine, 
and perhaps the top floor to offices. 



Januar>-, 1936 



SOUTHERN MEDICINE AND SURGERY 




INHALANT 

No. 77 



An Ephedrine Compound used as an inhalant and 
spray, in infections, congested and irritated condi- 
tions' of tlie nose and throat. Relieves pain and con- 
U'estion, preventing infection, and promotes sinus 
ventilation and drainage without irritation. 

Description 
Inhalant No. 77 contains Ephedrine, Menthol, and 
essential oils in a Paraffin oil. 

Application 

Can be sprayed or dropped into the nose as directed 
by the Physician. 

Supplied 

In 1 ounce, 4 ounce and 16 ounce bottles. 



Burwell & Dunn Company 

Manufacturing Pharmacists 
CHARLOTTE, N. C. 

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



When the clinic and laboratory building is ready the 
department of anatomy will be given the full third floor 
of McGuire Hall. 

Contracts have been let for the new laundry to be con- 
structed on Thirteenth street back of the Ruffner School. 
This is a PW.'\ project. 

Miss Frances H. Zeigler, a member of the National Red 
Cross Committee, attended the annual meeting of this 
committee on December 10th, in Washington. 

Dr. Roshier W. Miller was inducted into the Rho Chi 
Honor Pharmacy Society on December 3rd. 



BOOK REVIEWS 



THE PRACTICAL MEDICINE SERIES OF YEAR 
BOOKS: Series 1935. The Year Book Publishers, Inc., 
Chicago, 111. 

DERMATOLOGY AND SYPHILOLOGY, edited by 
Fred Wise, M.D., Professor of Clinical Dermatology and 
Syphilology, New York Post-Graduate Medical School and 
Hospital of Columbia University ; Members of the Ameri- 
can Dermatological Association, Inc., and Marion B. Sulz- 
berger, M.D., Assistant Professor of Clinical Dermatology 
and Syphilology, New York Post-Graduate Medical School 
and Hospital of Columbia University ; Member of the 
American Dermatological Association, Inc. $3.00. 

Included in the introduction is a 12-page article 
on "Modern Treatment of Eczema: A Guide for 
the General Practitioner." This evidence of the 
practical nature of the work is substantiated by 
the contents as a whole. 



FOR 



PAIN 



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



tablets 



^AMDS 



751 



Analgesic and Sedative ' parts 5 parts I part 
Aspirin Phenacetin Caffein 



JFe will mail professional samples regularly 
with nur compliments if you desire them. 
Carolina Pharmaceutiral Co., Clinton, S. C. 



MEDICAL TREATMENT OF GALLBL.ADDER DIS- 
E.ASE, by M.^RTiN E. Rehfuss, M.D., Clinical Professor of 
Medicine at Jefferson Medical College, Philadelphia; and 
Guy M. Nelson, M.D., Instructor in Medicine at Jefferson 
Medical College, Philadelphia. 465 pages with 113 illustra- 
tions. Philadelphia and London. W. B. Saunders Com- 
pany, 1935. Cloth, !?5.S0 net. 

The subject of gallbladder disease is presented 
from a medical viewpoint. In the great majority 
of instances medical management is the proper 



SOUTHERN MEDICINE AND SURGERY 



January, 1936 



FERRICIT 



Each tablet contains ten grains 
Iron and Ammonium Citrate, of 
the highest medicinal quality. 

ISSUED IN BOTTLES OF 100 TABLETS 

INDICATIONS 

Secondary (hypochromic) Anemia 

Chlorosis 

Also in Pernicious Anemia in 

conjunction with liver therapy. 

mples sent to any Physician in the United Stales on Request 



Van Pelt & Brown, Inc. 

Richmond, Va. 



management, and the authors of this book are 
admirably equipped by long experience of the right 
sort for giving this instruction on recognition and 
management of these commonly encountered condi- 
tions. 



LAW AND CONTEMPORARY PROBLEMS (Vol, II, 
No. 4). Published Quarterly by the Duke University School 
of Law, Durham, N. C. 

This volume's interest for doctors lies in its be- 
ing taken up with the subject, Expert Testimony. 
The Development of Expert Testimony is recounted 
first, then follow: An Alternative to the Battle of 
the Experts, The Briggs Law of Massachusetts, 
The Qualification of Psychiatrists as Experts in 
Legal Proceedings, ^Medical Testimony in Personal 
Injury Cases, and a number of other articles, some 
dealing with the testimony of medical experts in 
foreign countries. 

This volume is full of information of interest and 
profit to any doctor liable to have to appear in 
court as a witness — and who is not? 



Impotence in Man 
(O. S. Lowsley, New York, in Sou. Med. Jl,, Dec.) 
In man, plication of the bulbocavernosus and ischio- 
cavernosus muscles with ribbon gut has been followed by 
ability to have erections and satisfactory intercourse, even 
in cases in which erections had been impossible over a 
period of years. The operation has been performed upon 



14 men whose ages were 22 to 66 years. The results were 
perfect in 9 cases, all of whom had had no erections, or 
entirely unsatisfactory ones for 2 years or over. The 57- 
year-old man had had no erections for S years. Since the 
operation he has had both erections and intercourse and 
is improving all the time. A man 5S years old has had 
erections, contemplates matrimony. The 6S-year-old pa- 
tient is still in the hospital. The 63-year-old patient had 
syphilis 20 years ago and has not had an erection since. 
He has received no benefit from the operation. The 66- 
year-old man had the operation following a prostatectomy, 
with very little benefit. 

The operation must be skilfully performed: if the mus- 
cles are too tight, a constant painful erection will result; 
if not tight enough, satisfactory erections will not be pro- 
duced. The success of the operation apparently depends 
upon the use of ribbon gut, which does not tear through 
the delicate muscles as does ordinary twisted catgut. 

Sufficient time has not elapsed since performance of 
these operations for us to say how permanent the results 
will be. 



Congenital Malaria 

(Bela Schick and Martin Stein, New York, in Jl, Mt, Sinai 
Hosp,, Nov, -Dec.) 

A consideration of the literature establishes fairly well 
the occurrence of malaria transmitted from the mother to 
the fetus either before or at the moment of birth. 

A case of malaria is presented which appears to be in' 
this group, though wholly on circumstantial evidence. 

Despite some evidence to the contrary, it appears that 
transplacental migration of the parasites is made possible, 
or at least facilitated, by pathological changes in the pla- 
centa induced by a severe type of malaria, by syphilis, and 
possibly by other factors. 



The hardest part in the diagnosis of calcium defi- 
ciency (J. W, Boggess, jr,, in Jl. Med. Assn. Ala., Dec.) 
is to suspect it ; once it is suspected and determinations 
made, it is my opinion that fewer diagnoses of neurosis 
will be made. 



CHUCKLES 



The Mote and the Beati 



Disgusted Lady — Does your mother know you smoke? 
Small Boy — Does your husband know you speak to 
strange men in the street? — Ghost. 



Patient — "The size of your bill makes my blood boil." 
Doctor — "That will be $20.00 more for sterilizing your 
svstem." 



Bishop — "Ethel, you are a bright little girl, can you re- 
peat a verse from the Scripture?" 
Ethel — "I'll say so." 
B. — "Well, my dear, do so for me," 
E. — "The Lord is my shepherd; I should worry," 



Old Lady — "Where did those large rocks come from?" 
Tired Guide — "The glaciers brought them down, ma'am,' 
0. L. — "But where are the glaciers?" 
T. G. — "Gone back for more rocks, ma'am." 



"What did father say when you told him you were 
going to take me away from him?" 

"He seemed to feel his loss keenly at first, but I squared 
things with a good cigar." — Lincoln County News. 



January, 1936 



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January, 1936 



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INTERNAL MEDICINE 
DISEASES OF THE CHEST 

Pine Crest Manor, Southern Pines, N. C. 



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Diagnosis and Treatment 

in 
INTERNAL MEDICINE 

Professional Building Charlotte 



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ACCIDENT SURGERY and ORTHOPEDICS 



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DOCTORS GRIFFIN and GRIFFIN 

NERVOUS and MENTAL DISEASES, 
and ADDICTIONS 



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UROLOGY, DERMATOLOGY and PROCTOLOGY 



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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 



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DOCTORS McKAY and McKAY 

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Journal 

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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 





3 


2-8 weeks 


9 


2 


6 


3-6 months 


7 


3 


7 


6-12 months 


S 


2 


5 


1-2 years 


4 


1 


4 



Our series includes 32 children from birth to 
eleven years of age. Sixteen patients had inade- 
quate treatment, i. e., less than eight weeks. Table 
1 shows the varying amounts of treatment and 
periods of observation in these children. Acetarsone 
seems to be more efficacious in infants under one 
year of age (Table 2). Of 15 infants in this 
group, only eight received adequate treatment. Of 
this number, six had reversal of the Wasserman 
reaction. They were treated from 2 to 18 months. 

The clinical improvement obtained was remark- 
able, especially in gain in weight and in the dis- 
appearance of such lesions as: skin manifestations, 
rhinitis, periostitis, condylomata and other mucous 
membrane lesions, epiphysitis, interstitial keratitis 
and Glutton's joint (syphilitic synovitis). The 
skin lesions unless secondarily infected were well 



healed or markedly improved within two weeks. 
Rhinitis responded more slowly though some im- 
provement was noticeable after two weeks of 
therapy. Three children with condylomata showed 
complete healing of the lesion within three weeks. 
Four children with epiphysitis and pseudoparalysis 
responded rapidly, and in two to three weeks' time 
there was normal function of the involved extremi- 
ties. Bone x-rays were not taken routinely, but 
in those who were followed roentgenologically the 
healing of the pathological lesion was rapid. Two 
children with interstitial keratitis showed marked 
improvement with a nine-weeks' course of acetar- 
sone, but complete healing was not obtained until 
treatment had been carried out for six months. An- 
other child with interstitial keratitis was prac- 
tically blind when treatment was instituted and, 
although vision improved after three weeks, it did 
not become normal with continued therapy. Two 
of the three children with interstitial keratitis also 
had syphilitic synovitis involving the knees, a fre- 
quent combination as recently demonstrated by 
Klauder and Robertson *. The synovitis was 
promptly ameliorated in both of these patients, but 
another child with syphilitic synovitis required 
three weeks of therapy. 

Table 2. — Relation of Age to Efficacy of Acetarsone 

Therapy 

Wassermann Clinical 

No. of Reversed Improvement 

Age Patients No. % No. % 

Under 1 year *15 6 40 12 80 

1-5 years 8 2 25 7 88 

6-12 years 9 6 66 



♦Only 8 of these patients were treated longer than 3 
weeks; 6 or 75% had reversal of the Wassermann reac- 
tion. 

Following ingestion, acetarsone is rapidly ex- 
creted in the urine ''. Although individuals vary in 
their susceptibility to the drug, we have had very 
few reactions; one eleven-year-old boy was given 
0.8 gm. daily for approximately six months and 
showed no ill effects. Practically all of the toxic 
reactions were seen in the group of infants under 
one year of age. Vomiting and diarrhea occurred 
four times, but subsided within a few days after 
cessation of treatment and did not recur when 
therapy, using the minimal dose, was again started 
shortly afterwards, .•\rsenical dermatitis occurred 
twice, but the lesions disappeared seven to twelve 
days after the drug was discontinued and did not 
reappear when treatment was again instituted. One 
child developed a mild hemorrhagic nephritis with- 



AC ET ARSON E IN CONGENITL SYPHILIS— Arem and Gay 



Februar>', 1936 



out edema. The urine cleared within two weeks 
and remained clear with further treatment. Al- 
though very few severe reactions to the drug were 
seen, it should be strongly emphasized that pa- 
tients undergoing treatment with acetarsone should 
be kept under close and careful observation. Parents 
should be warned that at the first sign of fever, vom- 
iting, diarrhea or appearance of a rash, the medi- 
cation should be immediately discontinued. When 
therapy is again instituted, the course should start 
at the beginning with the minimal dosage regard- 
less of the dose at which the drug was discontinued. 

Conclusions 

Acetarsone is an effective and convenient drug 
for the oral treatment of congenital syphilis in the 
infant and of great value in the older child. The 
clinical response is excellent and the influence of 
the drug on the serologic condition of the ade- 
quately treated patients is satisfactory. 

The medication is easily administered and con- 
trolled and has many advantages over the previous 
therapy of congenital syphilis, which required 
weekly intravenous or intramuscular injections over 
a period of tv/o years. 



The acetarsone (Stovarsol) used was provided through 
the Courtesy of Merck & Company. 

References 

1. Maxwell, C. H., jr., and Glaser, J.: Treatment of 
Congenital Syphilis with acetarsone (stovarsol) given 
by mouth. Am. Jl. Dis. Child., 43:1461, June, 1932. 

2. Bratxjsch-Marr.un, a.; Wert and Durchfuhrung der 
Spirocidbehandlung der Syphilis im Kindersalter. Arch, 
j. Kinderh., 92:26, Nov. 2Sth, 1Q30. 

3. Tr/USMAN, a. S.: Further Observations on the use of 
Acetarsone in the Treatment of Congenital Syphilis. 
Jl. Pediat., 7:495, Oct., 1935. 

4. Klauder, J. v., and Robertson, H. F.: Symmetrical 
Serous Synovitis. /. A. M. A., 103:236, July 28th, 
1934. 

5. Chen, M. Y., Anderson, H. H., and Leake, C. D.: 
Rate of Urinary Arsenic Excretion after Giving Acetar- 
sone and "Carbarsone" by Mouth. Proc. Soc. Exper. 
Biol. & Med., 28:145, Nov., 1930. 



The Age of Choice for Non-Emergency Operations in 

Infancy and Childhood 
(J. W. Duckett, Dallas, in Texas State Jl. of Med., Jan.) 

Some deformities, such as imperforate anus, must be 
operated upon within a short time after discovery. Cor- 
rection of other defects is not an immediately urgent mat- 
ter and the best interests of the patient may be served by 
postponement. 

Clejt Lip and Palate. — In the pre-alveolar cleft group 
repair may be done preferably before 3 months of age. In 
the post-alveolar cleft group, the palate alone is involved, 
and operation should be delayed to allow the soft tissues 
on either side of the cleft to develop a maximum strength 
for use as sliding flaps; most prefer the age of 16 to 22 
months. 

Spina Bifida. — No operation for correction when there is 
more than the mildest paralysis of the lower extremities 
or of the sphincters, or when a definitely developing hydro- 
cephalus is present; in the absence of these conditions. 



early operations — even in the first few days of life — may 
be necessary when the covering membrane is torn or so 
thin that spinal fluid is leaking or rupture seems inevitable. 
Early operation is indicated only to prevent meningitis, 
in a child which has a good chance to live and develop 
normally without paralysis or hydrocephalus. Careful 
protection of the sac is imperative. 

Birth Palsies. — Mechanical treatment must be begun 
early and persisted in. If at the end of 3 months no 
recovery of function, approximation of severed nerve ends 
can be done, and sometimes all that is necessary is a 
removal of excessive scar tissue surrounding the damaged 
nerve trunks. 

Exstrophy of the Bladder, Epispadias and Hypospadias. — 
Correction of these anomalies should be deferred until the 
child is several years old, but completed before school age. 

Webbed Fingers and Supernumerary Digits. — Sterile pre- 
cautions, thin webs, loosely connecting fingers or toes may 
be clipped; with more solid webbing digits have bony con- 
nections operations are best deferred until the age of 2 
years. 

Strabismus. — In young infants this may be usually more 
apparent than real. If definite and persistent a competent 
ophthalmologist should give corrective exercise for the 
weak eye muscles very early, with lenses later, may effect 
a complete cure. Operation, if necessan,-, may be done 
after 5 years of age. 

Clubbed-Feet and Poliomyelitis Deformities. — Each an . 
individual problem. 

Hernia. — Small umbilical often cure with no treatment 
whatsoever. Better — wide strip of adhesive almost encir- 
cling the abdomen, and tight enough to invert the umbilicus 
between two longitudinal folds of skin for a few weeks: 
may require months or a year. When operation is neces- 
sary, it should be delayed until the age of 2 years. 

Inguinal hernia in the infant is often corrected spon- 
taneously, with control of constipation and phimosis. A 
very effective truss of ordinary skein of woolen yarn. 
The hernia reduced, the skein is applied about the infant's 
waist one end looped through the other in front and 
drawn snugly tight, so that the point of crossing of the 
loops lies directly over the external inguinal ring. The 
free end of the skein is then carried back between the 
child's legs, and tied behind. This type of truss will 
usually hold the hernia, and it can be changed when soiled, 
with little more trouble than the diaper is changed. In 
some cases, an adult type of spring truss, carefully padded, 
may be more satisfactory. If trussing is unsuccessful after 
the age of 18 months, operation will be necessary. When 
a hernia does not occur, or is not recognized, until after 
the age of 2 years, a truss may be tried for 3 to 6 months. 
If no improvement results, operation should be advised. 

Hydrocele. — Even a large hydrocele in a child is likely 
to disappear permanently after 1 or more aspirations. 

Undescended Testicle. — Many cases are wrongly diag- 
nosed, and repeated observation will show the testes both 
in the scrotum at one time, though drawn up into the 
inguinal canal or higher at other times. In some instances, 
one or both testicles never enter the scrotum until the 
child is several years old, but will descend finally into 
normal position. Recent reports indicate that descent of 
the testis may be brought about in some cases by the 
injection of the anterior pituitary hormone. Operation 
should not be done before the age of 5 years. Many prefer 
to wait 10 years, or just before puberty. The objections 
to long postponement of operation are the questionable 
susceptibility of such testicle to occurrence of malignant 
disease, and atrophy of the abdominal testis. Atrophy 
probably does not occur until after puberty. 



Februarj-, 1936 



SOUTHERN MEDICINE AND SURGERY 



Institutional Treatment of the Negro With Special Reference 
to Collapse Therapy* 



J- 



Donnelly, M.D., Huntersville, North Carolina 
Mecklenburg Sanatorium 



TUBERCULOSIS in the Negro still remains 
a matter of great importance, not only 
from a humanitarian viewpoint, but also 
because of the increased demands for public funds 
to care for those handicapped by the disease. Since 
the greater proportion of the unskilled laborers and 
practically all of the house-servants throughout the 
Southern States are recruited from the Negro pop- 
ulation, the effort to save the lives and increase the 
working capacity of the members of this race re- 
solves itself largely into an economic problem. 
Consequently, the mortality caused by tuberculosis 
among Negroes is a matter of gravest import be- 
cause of the great loss of productive power in this 
very necessary class of laborers. 

To illustrate, I quote some figures from the rec- 
ords of my own institution, which was opened in 
1926. Of the Negro patients admitted since that 
date 14.5^ have been cooks, 21.55% common 
laborers, and 7.439r farmers. A total of 43.48% 
of any number of individuals prevented for a con- 
siderable period of time from working at their var- 
ious occupations indicates a very considerable eco- 
nom'c loss to a community. The high percentage 
of cooks in this series also is an item of extreme 
importance. From the nature of their occupation 
they must necessarily have been a menace to the 
various households in which they have worked, 
and particularly so to the children in these house- 
hold i. Consequently, it is evident that a reduc- 
tion of the incidence of tuberculosis among Negroes 
and the institutional care of the open cases among 
them is of vital importance to the health of both 
races. Laborers and farmers are a most necessary 
part of the physical equipment of a community, 
and any procedure which will tend to reduce the 
death rate and prolong the working time of these 
two classes of workers will certainly add greatly 
to the public wealth. 

.Although the Negro death rate from tuberculosis 
is still three to four times as high as the white race, 
it has been considerably reduced in the last few 
years, e.xcept probably in the large centers of pop- 
ulation. During the period of slavery their death 
rate from this disease was approximately equal to 
that of the whites, but, after attaining their free- 
dom, the rate rose rapidly reaching more than 600 
per 100,000 in 1885. This was unquestionably 



•Read liefnrp the Medical Section at the 
Sept. 16th, 1935. 



largely due to poor environmental conditions and 
lack of lucrative employment, with the consequent 
lack of the food necessary to preserve their physical 
resistance to disease. 

The cause of the prevalence and high mortality 
of tuberculosis among Negroes is probably a combi- 
nation of several factors. The greater proportion 
of adult Negroes, in addition to being practically 
uneducated, have no particular desire to better 
their economic situation. Furthermore, their re- 
action to the effects of a disease of any type is rad- 
ically different from that which obtains in the white 
race. As a rule the Negro pays no attention to the 
initial symptoms of disease, making no effort to 
seek medical advice until the disease is well ad- 
vanced. For that reason tuberculosis is frequently 
far advanced in the Negro before he is willing to 
admit that he feels ill, because in this disease pros- 
tration is not often extreme. Also it seems a diffi- 
cult matter to impress on many members of the 
race that each individual case of adult disease is a 
serious menace to all contacts. A very difficult 
and discouraging procedure is an attempt to teach 
the basic principles of sanitation and health to the 
average uneducated adult Negro. 

Environmental facto)rs enter largely into the 
maintenance of the high death rate from the disease 
among Negroes. The greater number of them are 
fitted only for occupations in which the wages, 
as a rule, are low. Because of this, the food supply 
of the family is invariably limited; and cheap, 
more-or-less insanitary living quarters are the rule. 
However, in the Southern States the living quarters 
of Negroes are usually not so congested as is the 
case in the larger Northern centers of population, 
which may account for the much lower death rate. 
The Negro has a much better chance to escape 
death from tuberculosis if he remains in his South- 
ern home. Just a few months ago I was told by 
a physician interested in tuberculosis work in one 
of the largest cities in the LTnited States that he had 
never seen a Negro obtain an arrest of his tuber- 
culous process. Several other factors have their 
effect in increasing the incidence of the disease, viz: 
the prevalence of venereal disease, disregard of 
fatigue whatever the cause, addiction to alcohol and 
drugs, and carelessness about exposure to the dis- 
comfort and rigors of severely cold and damp 

annual meeting of the Southern Tuljerculo.sis Conference, Hou.ston, Tex., 



COLLAPSE THERAPY— Donnelly 



February, 1936 



weather. Sensitiveness to discomfort of any type 
is far less acute in the Negro race than in the white. 
All of the elements mentioned have an effect, nec- 
essarily, on the incidence of tuberculosis in the 
Negro. 

It has been the opinion of many authors more 
or less familiar with disease conditions among 
Negroes that they are lacking in physical resist- 
ance to infection by the tubercle bacillus. This 
opinion has no doubt been based on the fact that, 
in previous years, the greater proportion of cases 
of the disease have been far advanced when first 
seen by the physician. It is very difficult in many 
cases to obtain an authentic history as to the length 
of time the individual has been ill from the disease, 
since seldom is medical attention sought until the 
patient is unable to work. It is susceptible to proof 
that even repeated infections in the Negro child are 
handled quite as successfully as in the white child. 
Many cases of childhood type tuberculosis in the 
Negro become completely healed without removal 
of the child from its old environment. Furthermore, 
many of the far-advanced cases when under ob- 
servation in an institution show a remarkable re- 
sistance to extreme toxemia over long periods of 
time. Frequently one observes maximum tempera- 
tures of 103 to 105^ with daily variations of 6 to 
7° continuing over periods of weeks, or even 
months. Evidence of such severe toxemia over 
such long periods is not usually seen in tuberculosis 
in the white race. With the proper care and effort, 
in even the far-advanced cases, life may be pro- 
longed considerably. 

In- spite of numerous difficulties which interfere 
with the institutional treatment of the tuberculous 
Negro, many excellent results therefrom indicate 
that it is well worth while. However, many more 
sanatorium beds are necessary. There are, I be- 
lieve, approximately 700 beds for the care of 
Negroes in the institutions of the South. There 
should be 7,000. Statistics indicate that although 
Negroes comprise only li'yc of the population of 
the South, among them occur 53% of the deaths 
from tuberculosis. Many times Negroes afflicted 
with the disease refuse to remain in a sanatorium 
where their activities are limited, and where they 
might at least receive sufficient benefit to prolong 
their lives. In my own experience, however, cases 
leaving the institution against medical advice are 
not nearly so numerous as they were even three 
years ago. It is also my experience that benefits 
derived from institutional treatment are far more 
appreciated among Negro patients, as a rule, than 
among some classes of whites with whom we have 
to deal. 

The oft-repeated statement that institutional 
treatment of the adult tuberculous Negro is a hope- 



less effort to my mind is a statement which is not 
supported by the facts. Although many cases are 
discouraging, excellent results are sufficiently num- 
erous to offset such disappointments. The addi- 
tion of collapse therapy to the treatment by bed- 
rest frequently eventuates in surprisingly good re- 
sults. Since many cases of tuberculosis among 
Negroes are well advanced when first seen, it is 
frequently impossible to obtain results by means 
of pneumothorax because of adherent pleurae, but 
this difficulty is probably found no more frequently 
among Negroes than among the whites who are 
afflicted by the same degree of disease. Collapse 
therapy is certainly of inestimable value in the re- 
duction of infection by rendering the sputum 
negative. 

To illustrate results which may be obtained in 
institutional treatment I wish to offer the short 
case histories and x-ray reports of several cases. The 
first two cases have shown remarkable improvement 
on bed-rest alone, without the addition of any 
form of collapse therapy. The others have had 
collapse therapy in addition. 

Case I. — Negro man, 29, entered sanatorium for treat- 
ment Nov. 29th, 1926. History indicated that he had been 
ill for about two years. He had worked in an automobile 
tire manufacturing plant before becoming ill. He had had 
several pulmonary hemorrhages, had lost weight and had 
considerable cough. He weighed 154 pounds, and his 
sputum was positive for tubercle bacilli. His temperature 
did not exceed 100.5° for several days before entering the 
sanatorium. There was no family history of tuberculosis. 
The physical e.xamination and x-ray indicated a bilateral 
tuberculous involvement considerably more extensive in 
the right lung. 

On continuous bed-rest the patient began to show grad- 
ual improvement. During the first year he had several 
small hemoptyses, but apparently was not damaged by 
them. On discharge as a quiescent case on Aug. 10th, 
1029, 32 months after entering the sanatorium, he weighed 
184 lbs., having gained 30 lbs. He has remained in ex- 
cellent physical condition since discharge and is still work- 
ing every day. Bed-rest alone, and no form of collapse 
therapy, was used in this case. 

Case II. — Negro man, 28, common laborer, entered the 
sanatorium for treatment June 20th, 1934, complaining of 
feeling ill since the fall of 1933, loss of weight, weakness 
and a hacking cough. He said he had lost about 20 
pounds in weight, his weight on admission being 132 lbs. 
His sputum was positive for tubercle baciUi. There was 
no family histop.' of tuberculosis. The physical examina- 
tipn and x-ray films indicated an extensive bilateral 
tuberculosis, which was apparently of a more or less 
acute type. The prognosis did not appear at all good, 
although the patient appeared to be willing to co-operate 
in any way possible. 

He was put on continuous bed-rest immediately. Within 
three months he began to show marked improvement, not 
only in his general physical condition, but also in the 
clearing up of the chest condition. His cough became 
considerably reduced, his appetite remained good, and he 
continued to gain in weight. He is still under treatment 
in the sanatorium. He rarely coughs and his expectoration 
is slight, his sputum is continuously negative, his tempera- 



Februan-, 1936 



COLLAPSE THERAPY— Donnelly 



77 



ture and pulse rate remain normal, and he weighs 1795^2 
lbs., a gain of 47}2 lbs. in weight in fourteen months. The 
x-ray film taken May 1st, 1935, compared to the ones 
taken June 15th and July 20th, 1934, indicates that this 
Negro man has made remarkable improvement on bed- 
rest alone. 

C.«E III. — Xe.sro woman. 2Q, entered the sanatorium 
for treatment July 24th, 1033. Her occupation was given 
as "cook." She stated she had been ill about seven 
months, her complaints being fever, productive cough, 
gradual loss of weight, poor appetite and slight dyspnea. 
She said she had recently had an attack of "influenza." She 
had lost 2S pounds in seven months, and her symptoms, 
she stated, had gradually become more marked. The 
maximum daily temperature at the time of entering the 
sanatorium was from 100.5 to 101°. Her mother had died 
from pulmonary tuberculosis. 

The physical examination and x-ray films indicated an 
extensive bilateral tuberculous involvement, apparently of 
a more or less acute type, with a cavity in the right upper 
lobe. 

Patient was put on continuous bed-rest, and began to 
show gradual improvement, gain in weight, reduction in 
temperature and some reduction in cough. When she had 
been in the sanatorium for one year her general condition 
had become surprisingly good. She had gained 39 lbs. 
in weight, her temperature remained practically normal, 
and her cough was considerably better. The activity in 
the left lung had cleared considerably, and we decided 
to do a phrenic interruption on the right. This was done, 
resulting in a considerable reduction in the size of the right 
upper lobe cavity and a further improvement sympto- 
matically. Several months later this patient left the sana- 
torium against medical advice. Her sputum had been 
much reduced in quantity, but was occasionally positive for 
tubercle bacilli. Although I have not seen her lately, I 
understand her general condition still remains good. The 
x-ray films show a marked improvement in the lung con- 
dition, in spite of the well advanced bilateral involvement. 

Case IV. — Negro man, 37. This patient entered the 
sanatorium Oct. 31st, 1933. His occupation was common 
laborer. His complaints were loss of weight, cough and 
general malaise. He had been feeling ill since April, 1933, 
but continued to work until .\ugust, 1933. He had a 
moderate pulmonar,- hemorrhage on Oct. 15th, 1933, and 
had lost 24 pounds in weight in about 8 months. His sputum 
was positive for tubercle bacilli. His weight on admission 
was 1395/2 lbs., and the daily temperature range was 98° 
to 102°. The family history was negative for tuberculosis. 

The physical examination and x-ray films indicated a bi- 
lateral tuberculous involvement, which was considerably 
more extensive on the right. The x-ray film showed a fair- 
.=izcd cavity in the right lower just above the diaphragm. 

A phrenic evulsion was decided upon and this was done 
Nov 9th, 1933. After this time the improvement was con- 
tinuous. There was a steady gain in weight and the cough 
L'radually entirely disappeared. Later x-ray films showed 
the right basal cavity completely closed, and the sputum 
became continuously negative. This patient was discharged 
-■Vpril Sth, 1935, in excellent condition, weight 202 lbs., a 
gain of 6254 lbs. since admission, no cough or expectora- 
tion, and pulse rate and temperature within normal limits. 
This man still remains in fine physical condition. 

Case V. — Negro man, 27, entered sanatorium for treat- 
ment Jan. 3rd, 1933. He said he had been ill about two 
months, his complaints being loss of weight, lassitude, 
dyspnea and cough. He had had no hemoptysis, but had 
suffered from night sweats, and had afternoon rise of 



temperature. He had lost about fifteen pounds in weight 
in two months, his weight at this time being 135 pounds. 
He was a hotel bellboy by occupation. The family history 
was negative for tuberculosis. The sputum was positive 
for tubercle bacilli. 

The physical examination and x-ray films showed ex- 
tensive bilateral tuberculous involvement with, apparently, 
cavitation in the right apex. The afternoon temperature 
record approximated 101°. 

This patient was immediately put on complete bed-rest, 
which was continued for about 20 months. At the end of 
this time he had improved considerably. His temperature 
and pulse rate had remained practically normal for some 
time, weight had increased to 217 lbs., a gain of 82 lbs. 
since admission, and the chest condition had cleared, par- 
ticularly on the left side. The cough had decreased con- 
siderably. 

.At this time it was considered advisable to do a phrenic 
interruption on the right to attempt if possible to close 
the cavity in the right apex which still remained open. A 
phrenicectomy was done in September, 1934, with fairly 
satisfactory results. The cavity at this time is not com- 
pletely closed, but is much smaller. The last few sputum 
examinations have been negative for tubercle bacilli. The 
man's temperature continues practically normal, and the 
cough is slight. His general condition is quite good, and 
he weighs 214 lbs. He is still under sanatorium treatment. 

C.«E VI. — Negro man, 24, entered sanatorium for treat- 
ment May 26th, 1933, with a history of having been 
ill about two months. His complaints were loss of about 
ten pounds in weight, and a productive cough. His gen- 
era! health previous to his present illness had been good. 
His afternoon temperature had been for several days from 
100 to 101°, and his symptoms were gradually becoming 
more marked. He had worked as a janitor, and had con- 
tinued to work until Feb. 1933, when he was forced to 
quit because of physical weakness. Two brothers had 
died from tuberculosis. His sputum was positive for 
tubercle bacilh. 

His physical examination and x-ray films indicated an 
extensive involvement in the right lung, with the prob- 
ability of a slight amount of activity in the left apex. After 
slightly less than thirty days bed-rest, artificial pneumotho- 
rax was instituted. Eventually a fairly satisfactory col- 
lapse was obtained, as indicated by the film taken April 6th, 
1934. This patient was discharged from the sanatorium 
Dec. 9th, 1934, as a quiescent case. He was symptom-free 
having had a negative sputum for some time, and had 
gained 19i/^ lbs. in weight. The collapse was maintained 
until June, 1935, at which time the patient left the 
county, and I have not seen him since. I hear, however, 
that he still remains in excellent physical condition. 

Although the institutional treatment of the adult 
tuberculous Kegro is at times discouraging, it seems 
to me that these few cases indicate that such treat- 
ment is far from a hopeless effort. To those who 
adhere to the idea that the Negro is racially sus- 
ceptible to tuberculous disease, I should like to add 
that, with one e.xception, all of these patients are 
pure blacks. Consequently, it cannot be argued 
that their strong resistance to the disease is due to 
an admixture of white blood. To my mind collapse 
therapy in its different forms is most valuable in 
the treatment of adult tvpe tuberculosis in the 
Negro. The results obtained are very frequently 



COLLAPSE THERAPY— Donnelly 



February, 1936 



most gratifying, and the procedure offers great 
hope not only in returning many of these patients 
to some form of productive work, but also in mate- 
rially reducing the sources of infection to contacts. 



The Practicai, Management of Cardiovascular 

Emergencies 

(E. F. Horine, Louisville. Ky., in Jl. Indiana State Med. 
Assn., Dec.) 

In a person who has fainted if the cardiac sounds are 
clear, or with a murmur, if the rhythm is alternate slowing 
and quickening with apparent relationship to respiration, 
the condition is harmless vasovagal syncope. If it occurred 
upon the assumption of an upright position and if the 
heart is slow and regular with low and variable b. p. the 
cause is a postural hypotension. Profuse sweating is an 
almost constant accompaniment of the former whereas 
anhidrosis is the rule in the latter. 

The history of illness with anemia or of hemorrhage 
will clarify fainting from these causes. With vestibular 
involvement there is a typical sense of rotation. Fainting 
due to intracranial lesions will require study and laboratory 
and instrumental aid. First-aid treatment of syncope due 
to extracardiac factors consists in supine position, seeing 
that the rela.xed tongue does not obstruct breathing and 
losening about the neck and waist, lifting the lower jaw, 
turning the head to one side and inserting some type of 
airway. Atropine 1/50 gr. subcutaneously to reUeve sweat- 
ing and increase the heart rate. The intramuscular injec- 
tions of 10 m. of a 1-1000 epinephrm is of value. 

In heart block differentiation requires electrocardiographic 
observations which are seldom possible. Ventricular fibril- 
lation may be suspected when rapid heart action precedes 
the syncope. Slowing of the already slow ventricular rate 
in complete block possibly precedes a syncopal attack due 
to ventricular standstill. Epinephrin solution into the 
heart might be of value in ventricular standstill but it 
would probably maintain a ventricular fibrillation and 
cause death. Hence a patient with an Adams-Stokes seizure 
must not be given epinephrin unless one is reasonably 
certain of the exact mechanism present. In the prevention 
of Adams-Stokes seizures barium chloride, 1/3 gr. three 
times daily, will often abolish the attacks. Ephedrine, 
gr. 1,3, has been reported to be effective. 

Paroxysmal tachycardia, multiple premature contractions 
and a bigeminal rhythm only occasionally produce faint- 
ing. Very firm pressure for 20 seconds over either carotid 
artery below the angle of the jaw will frequently terminate 
an attack of paroxysmal tachycardia. 

In the loss of consciousness of ventricular fibrillation, 
death is inevitable if the ventricles fail to contract within 
6 or 7 min. There is no known preventive nor has any 
type of treatment proved of any value. Epinephrin is apt 
to kill and quinidin is contraindicated. Some patients have 
hundreds of attacks while for others a single attack may 
prove fatal. 

Syncope and even sudden death may occasionally occur 
in patients with aortic stenosis. 

The common basis for paroxysmal dyspnea in its varied 
forms is acute left ventricular failure ("defeat") of greater 
or lesser degree. Morphine sulphate in full dosage in 
consideration of the weight, strength, age, sex and severity 
of the attack should be given intramuscularly. In the 
more severe attacks, when marked relief has not been 
obtained within 45 minutes, half the primary dose should 
be given intravenously. Should pulmonary edema be man- 
ifest, at least 1/50 gr. atropine sulphate should be admin- 
istered with the first dose of morphine. Venesection may 
prove a life-saving measure. If the patient is plethoric 



and has hypertension, from 300 to 600 c.c. of blood should 
be withdrawn. Patients of this type are usually receiving 
digitalis and it should be continued in a maintenance dos- 
age. When attacks of parox>-smal dyspnea recur frequently, 
the daily administration intravenously of 100 c.c. of a 50% 
glucose solution may prove beneficial, also a mercury 
compound and theophylline, even though congestive failure 
is not manifest. A high-protein diet, no added sodium 
chloride. The attacks may be, at times, prevented by ab- 
solutely prohibiting the ingestion of liquid from noon until 
the following morning. Epinephrin is contraindicated. 

Patients with moderate to severe grades of heart failure 
occasionally manifest delirium and become difficult to 
manage. Hypnotics in large doses will not entirely con- 
trol the condition. Ammonium chloride, daily oral dosage 
60 to 90 grs., and 2 c.c. of mercupurin given intravenously 
each day will often control the psychotic state. 

An excellent rule to follow is that any type of discom- 
fort, whether oppressive, burning, tingling, severely painful 
or only enough to barely register itself, radiating or not, 
anywhere above the umbilicus up to the upper jaw, in 
the arms or hands, and which is uniformly provoked by 
exercise but relieved by rest or the administration of the 
nitrites is angina pectoris. Instruct upon the onset of the 
symptoms to cease any exercise, sit or lie down, dissolve 
under the tongue a hypodermic tablet of nitroglycerine, 
gr. 1/100. A 2nd tablet is to be taken in 10 minutes and 
if relief is not secured after this one, a physician is to be 
called, inasmuch as there is now to be considered the ■• 
possibility of a coronary thrombosis. Amyl nitrite may be 
used instead of nitroglycerine, though the latter is more 
easily and satisfactorily employed. 

In preventing attacks sedatives, the xanthine derivatives, 
alcohol and bromides may be of value. Frequent attacks 
with slight effort or at rest and despite the medication 
indicate a coronary thrombosis is imminent. Placed at 
absolute rest in bed for 4 weeks, often not only is the 
threatened coronary thrombosis averted but the anginal 
syndrome is temporarily abolished. Patients with diabetes 
mellitus who are receiving insulin experience an anginal 
syndrome when the blood sugar is lowered below or even, 
at times, to a normal level. 

Of pains suffered by human beings that of coronary 
thrombosis is the most excruciating. Yet cases of coronary 
thrombosis occur without pain. Embolic phenomena in- 
volving arteries of the systemic circulation in a person 
who does not have rheumatic heart disease or an active 
endocarditis strongly suggests a coronarj' thrombosis. More 
or less shock, a fall in b. p., fever, leukocytosis, a pericar- 
dial friction rub, hematuria and certain electrocardio- 
graphic signs round out the perfect picture. Morphine 
sulphate in adequate dosage intravenously, if necessary, is 
the emergency remedy for the painful type. Shock or 
embarrassment of respiration will be benefited by an oxy- 
gen tent or chamber. The presence of coronary thrombosis 
necessitates the 9 to 15 grs. daily of quinidine sulphate 
to prevent frequent premature contractions or auricular 
fibrillation. Digitalis is not used unless congestive heart 
failure is present and then only a maintenance dose. Co- 
deine, a carbamides or paraldehyde, but barbiturics are 
contraindicated. If vomiting occurs the intravenous use of 
50 to 100 c.c. of a 50% glucose solution once or twice daily 
is quite effective. Patients with coronary thrombosis should 
be kept absolutely at rest in bed for a minimum period of 
4 weeks, dating from the last attack of pain. A relatively 
low-calorie diet is indicated. 



I believe that in influenza the combination of codein and 
pyramidon is almost specific. — T. E. Zerfoss, in Jl.-Lancet, 
Dec. ISth. 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



79 



Surgical Observations 

A Column Conducted by 

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



The Treatment of Laryngeal Obstruction in 
Diphtheria 

In the treatment of diphtheria with or without 
complications, a large initial dose of the antitoxin 
and general supportive and symptomatic measures 
are necessary. Proper means for protection of oth- 
ers and prevention of the spread of the disease are 
also very important. 

In the air passages of the child who is develop- 
ing obstruction due to the disease, we usually have 
a highly inflamed condition, especially of the larynx 
and upper trachea. In addition to the inflamma- 
tion and swelling there may be a membranous for- 
mation which in itself is often sufficient to cause 
partial or complete obstruction. Much obstruc- 
tion, however, is caused by thick, tenacious mucus, 
the removal of which will give relief, at least for 
the time being. 

In the treatment of obstruction, the first measure 
should be an examination of the larynx with a 
laryngoscojje and aspiration of this area and the 
upper trachea to remove this mucus and any mem- 
brane which may be loose. Repeated aspirations 
may keep the air passages clear and prevent the 
necessity of intubation or tracheotomy. 

Where aspiration does not relieve the obstruc- 
tion, intubation should be done promptly. In in- 
tubation one of the most important points is to 
select a tube of the proper size and to intubate 
without trauma. 

Usually after intubation the patient will cough 
and expel a considerable amount of mucus. By 
holding the child with the head downward and 
getting the aid of gravity, the escape of mucus 
from the upper air passages will be facilitated, the 
child made much more comfortable; the necessity 
for removing the tube for cleaning it may be ob- 
viated by this simple procedure. 

During the period of intubation the child should 
be fed very carefully. Those children who can not 
swallow well when held with the head inclined 
downward, should be given their food by means of a 
small nasal tube. This is probably the most satis- 
factory means of giving liquid food, laxatives and 
other medicines, as it involves no risk of any 
aspiration of these things into the air passages. 

The removal of the intubation tube may be done 
on the fourth or fifth day; in some cases it is pos- 
sible to remove the tube earlier and in others it is 
necessary to leave in position for a longer period. 

Whenever a tube is removed, the child should 
be under observation for some time, and if any 



symptoms of serious obstruction develop, the tube 
can be replaced and left in for a day or two more. 

Rarely tracheotomy is necessary. It is indicated 
more often in cases where there is an extensive 
membrane formation in the upper trachea and 
where pieces of membrane come loose and obstruct 
the tube, or where the mucus forms so rapidly 
and is so thick and tenacious that intubation is 
unsatisfactory. 

Tracheotomy should never be done except where 
absolutely necessary, as it greatly increases the 
liability to bronchopneumonia, which is perhaps 
the most frequent serious complication of diphthe- 
ria unless it be the degeneration of the heart muscle 
due to the action of the diphtheria toxin. 

The medical treatment of the patient should be 
constantly kept in mind and every precaution used 
to protect the patient's heart from unusual strain. 

Feeding is extremely important and aids greatly 
in enabling the child to overcome the infection and 
to combat the toxemia. Considerable quantities of 
liquid food may be given through a nasal catheter 
and without any great difficulty. A careful check 
should be kept upon the amount of food given. 
The child should receive the proper nourishment, 
especially during the period of obstruction when 
swallowing is difficult or almost impossible. 

The importance of suction in treatment in laryn- 
geal obstruction is not generally properly appreci- 
ated. It will remove much of the obstructing ma- 
terial and, in many instances, prove an entirely 
satisfactory substitute for the more heroic meas- 
ure of intubation or tracheotomy. 

An early diagnosis of diphtheria with the prompt 
administration of a sufficient amount of antitoxin 
usually controls the disease, but sometimes patients 
are not seen by a doctor until obstruction has de- 
veloped. When a child is found to have obstruc- 
tion with difficult respiration, retraction of the 
suprasternal space and cyanosis, only prompt ac- 
tion will save its life, and there should be no delay 
in instituting proper treatment. With the aid of 
the laryngoscope, view the obstructed portion of 
the air passage and insert a suction tube removing 
all loose material from this air passage, protecting 
yourself with a Negus face shield to prevent the 
child coughing infectious material into your face. 
A large, circular sheet of plate glass held in front 
of the face by a head band and rotated as 
certain areas become covered with moisture enables 
the operator to work close to the child's face with- 
out any particular danger to himself. Everyone 
who treats diphtheria should use this little device, 
besides it is a great protection to the doctor in 
examining the throats of patients who are inclined 
to cough unexpectedly. 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



Bronchopneumonia and otitis media are com- 
mon serious complications following diphthe- 
ria, and I believe frequent aspirations have done 
much and will do more to lessen the frequency of 
pneumonia and, consequently, the mortality. In 
large hospitals for contagious diseases the mortality 
from diphtheria is gradually being reduced and 
intubations are less frequently done. Repeated 
aspiration, where there is any obstruction at all, is a 
routine treatment and is most satisfactory. 



The Tongue 
(J. Milner Fothergill, Va. Med. Monthly, Mar., (1SS2) 
Tell the patient to put out his tongue fully, so that the 
circumvallate papillae can be clearly seen; it is no use to 
study the tip. If the patient is an infant. Sir William 
Jenner's plan of placing a drop of syrup upon the chin is 
well worth following. 

Tremulousness of the tongue indicates alcoholism, or, 
less frequently, lead or mercurial poisoning, muscular weak- 
ness. When seen in the early stages of typhus, or typhoid 
fever, it indicates a grave condition of bad prognostic 
omen. In advanced stages, the tongue is protruded slowly 
and with difficulty. In hemiplegia, the protruded tongue 
turns its apex to the paralyzed side, from loss of power 
in the genio-hyoglossus muscles of the affected side. In 
glossolabial paralysis the capacity to protrude the tongue 
is impaired or lost. In facial paralysis, without hemiplegia, 
the loss of power to protrude the tongue tells that the 
mischief is within the skull. 

Dryness of the tongue is found in pyrexia, in diabetes 
and other conditions of polyuria, and in some of the 
functional disorders of digestion. It is marked by the 
teeth in conditions of debility, from menorrhagia, chronic 
diarrhea or acute prostration, however mduced. The 
tongue is furred constantly with some individuals who are 
well and strong; and especially in the morning, is common 
with heavy smokers. Usually, a furred tongue denotes dis- 
turbance of the digestive organs, or the oncome of acute 
disease. When found with shivering fits, this condition of 
the tongue tells of coming trouble. When the coating has 
a distinctly yellow or brownish hue, there is usually a bad 
taste in the mouth in the morning. Repeated free purga- 
tion without a mercurial, often leaves the tongue as thickly 
coated as before, and a few grains of calomel produce a 
clean tongue in a few hours. Clearing up of the tongue 
tells of uninterrupted convalescence. In scarlet fever, the 
tongue assumes a strawberry appearance — sometimes the 
red papillae stand out on a red surface, like a ripe straw- 
berry; at other times, the red papillae stand out upon a 
coat of fur like the seeds of an unripe strawberry. In 
almost every case of indigestion with furred tongue, con- 
stipation is present, and a continuous course of laxatives 
must be considered in therapeutic plan. Mechanical 
means of cleaning the tongue, as scraping it or rubbing it 
with lemon-juice or vinegar, are well enough for the local 
sense of cleanliness or comfort. 

The tongue may be furred along one sive only, or may 
be raw and irritated, or even ulcerated by a jagged tooth. 
At other times the epithelium of the tongue is stained, as 
by drinking elder wine, sucking a piece of licorice, or 
chewing tobacco; or it may be discolored by some prepara- 
tion of iron. 

The raw tongue has not received a tithe of the attention 
it deserves. So long as this condition remains, tonics are 
useless and are not digested. Give bland food, with seda- 



tives to the gastro-intestinal tract. In phthisis it is of all 
semeia the one I personally dislike most. It is not usually 
complete over the whole tongue, but lies as a large patch 
in the middle, the irregular edge usually extending further 
on one side of the mesial line than on the other. We have 
even.- reason for supposing that this condition of the tongue 
is significant of the state of the unseen portion of the 
gastro-intestinal canal; and the absence of epithelium 
interferes with assimilation. This it is which excites one's 
apprehension in all wasting diseases. 

It is easy to get rid of the layer of dead epithelium cells 
of the coated tongue; but it often taxes all our resources 
to restore the epithelial coat where the tongue is raw. 
Here our best efforts are futile and unproductive of good 
result ! 

There is a peculiar silvery sheen of the epithelial cover- 
ing of the tongue in many cases of menorrhagia ; especially 
when the tongue looks swollen and shows the indentation 
of the teeth. 

In relapsing fevers, there is often a small triangle on 
the tip of the tongue, much cleaner or rawer than the 
rest of it. 

Deep rugour fissures are very suggestive of syphilis. 
Chancre must be discriminated from cancer by the history, 
the age, and the condition of the glands of the neck. When 
inspecting the tongue, other evidences of syphilis may be 
furnished by the state of the phar\-nx or soft palate. Cica- 
trices are observed in persons subject to epilepsy, as the 
result of wounds inflicted by the teeth during the parox- 
ysms. These may be useful in determining that paroxysms 
which a patient has experienced were epileptic. Coldness 
of the tongue belongs to the moribund condition. 



iTEur From Report on Advances in Surgery to Medicax 

Society of Virginia 1881 
(M. C. Kemper, Goshen, in Va. Med. Monthly, Jan.. 1SS2) 

Girdner, of New York, says, in Medical Record, July 
30th, ISSl: A patient comatose for several hours from 
lightning stroke. Skin came off his left arm and scapula, 
leaving a large, raw surface; treated by different means for 
some weeks, until a healthy granulating surface was ob- 
tained. .\bout this time, a healthy young German, who 
had attempted suicide by cutting his throat, was brought 
to the hospital, and died within a few hours. Six hours 
after his death, I removed a portion of skin from the 
inner side of the thigh, cut this piece of skin into a great 
many small pieces and applied them, and dressed the sur- 
face. 

After 4 days the dressings were removed. One-fourth of 
the grafts had failed to take, and were washed off when 
the wound was cleansed. The remainder have attached 
themselves to the ulcer, and the lower and central portions 
of the ulcer on the arm are already covered with a thin, 
delicate skin, as a result of fusing together of the islands 
of skin. 

{Dr. Kemper concluded his report with this admirable 
statement. — J. M. N.) 

It has become a custom for the chairman of the various 
committees of this Society to apologize for the length of 
their reports, and to plead as excuses, for whatever de- 
fects they may contain, want of leisure and facilities for 
familiarizing themselves with the literature of their sub- 
jects. While no one can be more keenly alive to the 
defects of this report than myself, and while it has been 
spun out far beyond the usual length of such reports, I 
propose to honor this custom by deliberately breaking it. 
This is the result of an honest effort to comply with the 
duties imposed by my position, and as such I respectfully 
submit this report, 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



•I***'*******J»*'I**I*'5**I*'5«»J«*5«»J»»J»^»«J»^^J» "j 



President's Page 

Tri-State Medical Association of the Carolinas and Virginia 






"In lazy apathy let stoics boast. Their virtue fixed; 
'Tis fixed as in a frost: contracted all, retiring to the 
breast; But strength of mind is exercise, not rest." 

It is said that the passions are the springs of 
most of our actions, and that apathy has come to 
signify a sort of moral, mental or physical inertia, 
the absence of all activity or energy. 

If we are not alert we may find ourselves in that 
state of apathy where every glow of enthusiasm is 
paralyzed. Apathy means indifference, an absence 
of any special interest toward anything, due to 
lack of the proper moral, physical or mental exer- 
cise. In every man's career there are certain im- 
portant things about which he dare not be indiffer- 
ent and this applies especially to the members of 
the medical profession — a profession ever laboring 
to prevent diseases among his fellowmen and to 
bring amelioration and cure to the suffering and 
siclc. 

General Robert E. Lee is quoted as saying that 
duty is the noblest word in the English language. 
It is our duty to keep physically fit, morally right 
and mentally alert. Every physician should look 
to his own physical welfare. Yet how often are 
physicians in their busy lives indifferent to their 
own physical needs. They are forgetful of the 
much-needed vacation, regular hours and the cul- 
tivation of a hobby outside of their routine duties, 
all which would add much to their wellbeing, until 
finally they find themselves gradually and uncon- 
sciously slipping into that category of ills so com- 
mon to our profession, namely, cardiorenal disturb- 
ance, hypertension, or nervous breakdown. Give 
some thought to your own physical fitness; culti- 
vate a hobby; take a vacation and thus prove 
yourself better able to serve your practice longer 
and better. 

As to moral indifference perhaps few are guilty, 
for the success of any physician in his community 
and among his fellow practitioners depends much 
on his conduct as to distinction between right and 
wrong, and in his ethical attitude in all things per- 
taining to the practice of medicine. Let us look 
at ourselves through our fellow-practitioners, for 
by knowing each other better we receive a stimulus 
to right conduct. There is some of good in the 
worst of us, much of bad in the best. 

.\s to mental apathy perhaps most of us are 
culpable to a certain degree. We need our books 
and our journals. So many changes are taking 
place and there is so much about which we know 



so little. However, there is no better way to ex- 
ercise the mind and to familiarize ourselves with 
a subject than to write a paper. It is said that 
a nationally known physician of enviable reputation 
and a member of a widely known clinic once made 
the remark that when he came across a subject of 
which he knew little or nothing, he wrote a paper 
on that subject and so informed himself about it. 
If we all used this means of selecting a subject 
there would be little difficulty in finding a title for 
a paper. I am certain I would be writing papers 
the rest of my days. However, it is a plan well 
worth consideration and adoption. On the other 
hand, the physician who has learned well, observed 
and gathered much knowledge from that great 
teacher, experience, may also present papers worthy 
of the careful attention of any audience. There 
is no one who acquires more from experience than 
the general practitioner who is usually the family 
physician, and the doctor from the smaller com- 
munities who does not have at his beck and call 
the expert laboratory technician or the specialist. 

As a stimulus to physical, moral and mental ex- 
ercise there is nothing better than regular attend- 
ance on the meetings of a good medical society. 
Osier was a regular attendant on medical meetings 
and he emphasized to his fellow practitioners the 
importance of this habit; he insisted that thereby 
harmony and goodfellowship were promoted. He 
emphasized that physicians are inclined to live 
apart too much. They need friction. The daily 
round of the busy doctor tends to develop an 
egotism to which there is no antidote. The few 
setbacks he gets are soon forgotten. Mistakes are 
buried and then after a few years of successful 
practice he tends to become touchy, dogmatic and 
self-centered. To this mental attitude the medical 
meeting is the best corrective. 

This brings me to the very important point in 
my message to you, fellow members and friends 
of the Tri-State Medical Association — the urgent 
request that you now make your preparation to 
attend the Thirty-eighth Annual Meeting to be 
held February 17th and 18th, at Columbia, S. C. 
There are invited guests from well known clinics, 
which to hear will be well worth the trip. It will 
be a two-day program full of interesting papers and 
discussions. We know a cordial welcome from 
the physicians of Columbia awaits us. Let us go 
early and stay late. 

CHARLES C. ORH 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



DEPARTMENTS 

HUMAN BEHAVIOR 

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



.•\bout Mr. Polydoron 

I shall call my friend Mr. Polydoron, a man of 
many gifts, although he is experiencing difficulty 
in making helpful use of them. Even though he 
appears before us only through the medium of his 
own words and mine, you can easily see that his 
physical appearance does not suggest that he lacks 
four years only of being sixty. There is no graying 
even about his temples; he is somewhat overweight; 
his color is good; and you feel that his physical 
structure may be sound. He is large of body and 
his mental capacity is spacious. Before he had 
reached the age of twenty he had obtained a college 
degree. Innately studious, he has continued to 
add to his store of knowledge. His memory is 
tenacious, and what he learns he retains. He is a 
member of one of the learned professions, and in 
that profession he lives in the upper stratum. 
Throughout the years his acquisitions have steadily 
increased. But his losses have been heavy and 
continuous. Let him speak to you as he spoke to 
me, for only he knows that immaterial structure 
which constitutes himself. His vocabulary is large; 
he uses words with careful discrimination; he 
knows himself. He will present that invisible, that 
impalpable, that real self known only to himself: 

"Doctor, I proffer my apology to you for calling 
you back to your office at night. But I thought it 
best to speak to you, for you have known me long 
and intimately, and you may know me more inti- 
mately than even I know myself. 

"Several years ago I came to you a wreck — 
physical, emotional, spiritual, and perhaps mental. 
For no man could drink as much whiskey as I 
had then been consuming for a long time and re- 
main normal. You will recall that I had a persist- 
ent bronchitis, attended by an annoying cough that 
kept sleep from me at night and wracked me 
throughout the days. My kidneys were in poor 
condition, and I had to guard my diet to prevent 
the development of diabetes. For a long time I 
had relied upon alcohol to propel me during the 
day, and I had depended upon hypnotics to soothe 
me during the night. Before it had been possible 
for you to finish the treatment you had prescribed 
for me I was unavoidably called back to my home. 
But, for a while, I restrained myself and my health 
continued to improve. Eventually, however, my 
former mode of life reasserted itself, and I lived 
as imprudently as I had formerly done. 

* Presented to the Neuropsychiatric Society of Virginia 
at its first meeting, Richmond, January 24th. 



"I speak not in defense of myself, but there were 
distressing factors. Many years ago my wife died. 
I devoted my life to my two children. The older, 
a splendid, brilliant boy, became my professional 
associate. A short attack of pneumonia took him 
from me. The other son measured up to me, un- 
fortunately, rather than to my expectations of him, 
and now he is in a remote corner of the world. A 
little more than a year ago, when I had been with 
you, for the second time, only a little while, I was 
unexpectedly called to the grave of my brother 
who had come to a tragic death. I know and you 
know that the man who sits in your office tonight 
is many times more than a year older than that 
same man who talked to you twelve months ago, 
for many things are more ageing than the mere 
passing of the years. 

"I am bowed down by grief and by deprivations 
and by my own self-reproaches. Disease and dissi- 
pation have left their permanent imprints upon 
my structures — material and immaterial. I have 
eaten immoderately: I have imbibed alcohol long 
and excessively; I have sought surcease in sedative 
and hypnotic drugs. At last morphine has em-" 
braced me, and I cannot free myself from its ten- 
tacles. I doubt not that I have made use of pain, 
physical pain, real and imaginary; and mental and 
emotional pain, to justify this morbid indulgence. 
My sinuses have been infected; some of them have 
been operated upon, and they have had much sub- 
sequent attention. 

"But I know myself well enough to know that 
I am not always and, perhaps, not ever, wholly 
honest with myself. I know that I am unwilling, 
perhaps I am unable, to face the world of reality; 
to stand up and be the man I once was. In spite 
of the self-depreciation and the self-reproaches that 
I bring upon myself by my morbid self-indulgences, 
I live more comfortably in that world of unreality 
and phantasy, created by the physiological and the 
psychological effects of opium, than in that world 
of reality made possible only by self-discipline, 
self-denial, and rigid self-control. I know that 
only to him that hath shall be given. Now I am 
giving myself morphine daily no less than five or 
six grains, and at night I induce sleep by heavy 
phenobarbital medication. I know that this mode 
of life cannot continue. I shall be obliged to give 
up these indulgences, to face life as it is, or to give 
up life itself. 

"And before my life reaches its termination I 
may become a mental wreck. I am already hallu- 
cinated. I hear voices speaking to me almost con- 
stantly. Yes, I know what hallucinations are. I 
read much. I think even more. I know that those 
around me do not hear the voices that I hear. I 
know the voices are unreal, but they are terribly 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



real and vivid to me. But so far the voices have 
not begotten delusions. They remain pure hallu- 
cinations. I do not believe, except most momen- 
tarily, what the voices say. Occasionally I step to 
the window to see the man who is talking about 
me, but I stop myself, for I know that the experi- 
ence is altogether internal. I think I understand 
that the voices merely project into the outer world 
and into those around me those things that I am 
thinking about myself. The voices serve the pur- 
pose of making my subjective self objective to my- 
self. They reveal my inner self to me, but in 
defense of myself I try to attribute the voices to 
others. For no one has the inclination nor the 
courage, perhaps, to speak even in corrective con- 
demnation of himself. I am a professional man, 
well educated, and competent in my profession. I 
know that I should occupy a pedestal in my com- 
munity. Every professional man should live an 
ideal life. Every professional man must respect 
his own character if he is to expect others to have 
respect for him. I have come to feel inferior; to 
be without adequate respect for myself. When I 
see two or three men talking together it is easy 
for me to imagine that they may be talking about 
me — and in derogation of me. Eventually, 1 
imagine I actually hear them talking about me. 
Generally, but not always, they speak in adverse 
criticism of me. Sometimes, rarely, to be sure, a 
voice speaks a word in approval and in commenda- 
tion of me. Perhaps that merely represents the 
dialogue that I often have with myself about my- 
self. Well, here I am, doctor. Take me, and see 
what you and the other doctors and I can do with 
and for myself. But I fear there is no balm in 
Gilead. I fear that my state is that of despair — 
and that word means without hope. I know that 
I am running away from life, and that alcohol and 
drugs merely serve as avenues of escape for me. 
And I know that the denouncing voices represent 
such conscience as I still have left and that it is 
speaking in reproof of my waywardness in an effort 
to save me from myself." 

A mere generation or so ago the examination of 
the physical body was made mostly by observation 
limited to its surface. But that day is gone. Even 
so recently as when I was a medical student psych- 
iatric investigation reached scarcely beyond a de- 
scription of the individual's behavior. The de- 
pressed were inert; the excited were overactive. 
But we have come to know that the immaterial 
domain — the instincts, the emotions, the world of 
ideas and of thoughts — is inconceivably larger and 
infinitely more complex than the interior of the 
physical body; and that the content of this world 
of the unconscious may be explored and analyzed 
and understood and, if in disorder, may sometimes 



be corrected. And we know, too, that out of this 
buried world come all hallucinations and delusions. 
Every individual represents an energy system. En- 
ergy insists upon being liberated. It resents and 
resists restraint and incarceration. Toxic sub- 
stances, whether they be drugs or disease products, 
may liberate repressed emotions and ideas, but they 
cannot create them. But within us at all times at 
least two antagonistic forces are at work. We are 
instinctively inclined to express ourselves freely — • 
our feelings, our thoughts, our yearnings, our fears, 
our hopes, our hates, and our loves. Such behavior 
is nistinctive, natural — in such manner, perhaps, 
the lower animals live. But, for many reasons, 
chiefly because of the demands of religion and 
law and order and respect for public opinion and 
devotion to that fabrication we miscall civilization 
we cannot live in that simple, natural and whole- 
some manner. We dare not allow many of our 
impulses to express themselves — we must repress 
them — push them clear out of daily consciousness 
down into the unconscious and hold them down 
there. And that unceasing effort calls for the 
constant use of energy. And sometimes we be- 
come tired holding things down. This repressive 
mechanism we speak of as inhibition. When we 
are made perhaps our more complete, natural 
selves by a toxic disease, by alcoholic ingestion, by 
drug addiction, by an attack of mental sickness, 
or by any other factor which releases the hand 
from the inhibitory lever, then our real, natural, 
repressed selves are liberated. And then our neigh- 
bors may talk in whispers about us, because they 
have made a discovery that was shocking to them. 
And the individual, whether he be sick or well, 
insists upon and succeeds ultimately in dsclaring 
himself. We are all many-faceted. When in one 
state we exhibit one facet; when in another state, 
another facet. But the individual is always him- 
self, and not another. Perhaps we cannot reveal 
ourselves in our entirety until we have been well, 
and also unwell — from disease, from drugs, and 
from what we may call mental abnormality. 



The Role of Psychotherapy in General Medicine 



Psychotherapy is the attempt to find the psychic origin 
of functional symptoms and either to remove their causes 
or enable the patient to overcome or tolerate his symptoms. 
This paper is to give scientific facts devoid of humbug 
concerning psychotherapy. 

In analyzing the histories of psychoneurotic individuals I 
have found that the majority have received illogical, un- 
necessary examinations and treatments which have fre- 
quently further discouraged the patient and increased his 
neuroticism. About 20% of my patients have been sub- 
jected to needless surgical procedures. 

All neuroses are over-reactions in suggestible, sensitive 
types; faulty responses to difficulties or problems not met 
frankly by the individual. A running away from the hard 



84 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



realities of life produces a neurosis to compensate or pro- 
tect the individual. 

Psychoneuroses are: 1. Hysterical reactions. 2. Anxiety 
states. 3. Neurastiienic reactions. 4. Obsessive compulsive 
states. 

Anxiety states include the largest number of psychoneu- 
rotic patients. Here morbid fear motivates the conduct: 
dread produces physical symptoms through the vegetative 
nervous system. 

Neurasthenic reactions are rare and limited to irritable 
exhaustive states with hypotensive phenomena. 

The obsessive compulsive states are also rare types; they 
fear disease and contamination, are guilt conscious, and set 
up defensive symbolic rituals to escape from their un- 
conscious conflicts. 

Establishment of emotional rapport usually obtained by 
the physician's warm personal interest in the patient, is 
the first objective. Care in the taking of the history con- 
vinces of the physician's thoroughness. Encourage the pa- 
tient to talk out everything. After the physical study to 
exclude organic disease, the examination consists in getting 
a detailed record of the patient's previous life: the study 
of his background, of factors leading up to the current con- 
flicts. 

The constant question in the physician's mind being, 
"What is the genesis?", if the problem is psychogenic one 
must determine whether simple suggestive therapy, super- 
ficial re-educative therapy or detailed psychoanalysis is 
indicated. 

For the majority of mildly neurotic individuals of average 
intelligence, re-educative therapy is the best method. The 
goal is to get the patient to stand upon his own judgments, 
and is reached through a mutual understanding relation- 
ship, sometimes reinforced by persuasion or suggestion. 
The next step is desensitization, wherein, by intimate dis- 
cussion of the conflict material as elicited, the patient is re- 
quired repeatedly to face the situation or to make con- 
tinued adjustments until the symptoms in that situation 
no longer occur or can be tolerated or ignored. Encourage- 
ment, patience with setbacks, and positive reassurances are 
essential. Gradually one will be rewarded by a rebirth of 
emotional control and a grateful patient. 

Suggestive therapeutics must first develop in the patient 
the belief that he can get well, since he is cured on the 
day he believes himself cured. Stick to scientific sugges- 
tive measures. After one is certain of the patient's power 
to get well, he should reiterate the positive statement 
pointing out all improvements, however slight. Asking the 
patient to measure his own improvement is an indirect sug- 
gestion. At times patients benefit from reading such books 
as "Outwitting Our Nerves," "Re-educating Ourselves," and 
certain books on sex. Avoid setting time limits for re- 
covery, teach the patient endurance and tolerance — the 
doctor practicing the same perseverence and never display- 
ing by word or deed any lack of confidence in the patient's 
recovery. 

Some patients need a temporary change of environment, 
hospitalization or even psychiatric treatment if there are 
harmful eounter influences from family or friends. Rela- 
tives often have to be taught insight into the patient's 
neurotic mechanisms. By suggestion the patient is also 
taught sensible ideas about digestive functions, constipa- 
tion, anorexia, cardiac action, etc. He is taught to ignore 
cr overcome many distressing sensations. He must learn 
to use whatever normal recreation and social assets he may 
have; at times the therapist must supply him with new 
ones. 

All these measures may or may not be reinforced by 
drug therapy. Some patients are helped by sedative drugs, 
but these should be dropped gradually and the importance 



of self-control and independence should be stressed. With 
certain resistant symptoms, hypnotic therapy is valuable in 
overcoming insomnia, aphonia, amnesias, impotency, and 
vaginismus or in probing for unconscious material in an- 
alysis; but it is of temporary value only. The lasting cure 
must be a change in the total personality reaction with the 
development of a new objective stronger than the old 
neurotic desire to yield to inferiorities. 

In certain cases where ordinary superficial psychotherapy 
fails, psychoanalysis is successful. It is superior to other 
psychotherapy in only a very small group of patients. 



UROLOGY 

For this issue, P. A. Yoder, M.D., Winston-Salem, N. C. 



Medical Treatment of Genito-Urinary 
Tuberculosis * 

Until comparatively recent years a paper on 
this subject would have been almost as important as 
a drink of water to a drowning man. The little 
attention that was directed to the subject was very 
aptly designated either palliative or expectant 
treatment — palliative in that it was reserved for 
use in trying to palliate suffering in the hopeless 
case, expectant in that some measures were though! 
to be of slight value in preparing the patient for 
the expected operation. Today we all agree that 
in certain cases medical treatment has an import- 
ant place in tuberculosis of the urogenital tract. In 
fact, some genito-urinary surgeons, as well as many 
internists, have begun to insist on a clinical trial 
of general rest and sanatorium care in practically 
all of these cases before resorting to surgery. 

There is surely no question as to the importance 
of genito-urinary tuberculosis itself, as available 
statistics show that from 3 to 8 per cent, of all 
pulmonary tuberculosis cases have associated uro- 
genital lesions, and that 50 to 60 per cent, of all 
extra-pulmonary tuberculous lesions are genito- 
urinary. It therefore behooves the general prac- 
titioner who is treating tuberculous patients, as well 
as tuberculosis workers, to be ever on the alert 
for indications of these frequent complications. As 
is true of uncomplicated pulmonary cases, this 
watchfulness is all that is needed for diagnosis; 
for with present modern technique of examinations, 
and with so many excellently trained and compe- 
tent specialists, the suspected case is essentially a 
diagnosed case. 

It is the duty of the genito-urinary man, also, 
to be on the lookout for pulmonary complications 
in his cases, since 60 to 70 per cent, of all genito- 
urinary tuberculosis is accompanied by pulmonary 
tuberculosis. Of course, many of these present 
pulmonary involvement of little consequence, many 
being a primary focus (or Ghon tubercle) with its 
associated regional lymph mode; but many of 



'Presented to the North Carolina Urologieal Society, 
eeting at Salisbury, October, 1935. 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



them have a lung involvement of clinical import- 
ance requiring careful weighing before surgical 
procedures are undertaken. Here, probably, is the 
most important place for medical treatment of 
these cases. Many lives have been lost that could 
have been saved by preliminary efforts directed 
toward building up the patient's general condition. 

As in tuberculosis of other organs, the most im- 
portant single element in medical treatment of 
genito-urinary tuberculosis is rest — physical rest 
in bed, on an open porch if possible, but in any 
event where there is an abundant supply of fresh 
air and as much sunlight as it is possible to obtain; 
mental rest so far as possible, preferably in a good 
sanatorium — with a full diet of simple, easily di- 
gested foods of high caloric value; and plenty of 
water. 

Under such a regimen a certain percentage of 
these cases will go on to recovery, as is proved by 
calcified areas shown in x-ray films and in speci- 
mens removed at operation. A still larger per- 
centage will be so generally improved that later 
surgery can be performed with a greatly increased 
chance of ultimate cure. 

In addition to rest and diet, attention must be 
directed toward control of symptoms. A majority 
of these cases are of kidney involvement, with 
secondary cystitis, and in practically all of these 
there is dysuria. One teaspoonful every three hours 
of a mixture of one part potassium citrate, one 
part tincture hyoscyamus, and three parts water, 
in a full glass of water, will help to relieve the dis- 
comfort and tenesmus nearly always complained of. 

In certain cases heliotherapy is of value. Natural 
sunlight is best, but artificial light containing the 
whole solar spectrum is an acceptable substitute. 
Caution must be exercised here, however, as un- 
favorable reactions occur. For highly toxic and 
febrile patients, with acutely active pulmonary 
complications, sun baths are definitely contraindi- 
cated. 

As in pulmonary tuberculosis, climate and alti- 
tude are generally accepted now to have little or 
no direct effect on any tuberculous process, but 
indirectly, as they affect the patient's comfort and 
thereby contribute to relaxation and rest. 

While of great value in diagnosis, after years of 
thorough trial in various forms of tuberculosis, 
tuberculin has been abandoned as a therapeutic 
agent, it having failed to show any demonstrable 
beneficial results, except, possibly, in some indolent 
eye conditions, such as tuberculous keratitis. It 
surely has no place in genito-urinary tuberculous 
conditions and is mentioned here only to be con- 
demned. 

An important and often little considered field 
for medical treatment, in these cases, is the postop- 



erative care of the surgically treated patient. Very 
often the final outcome will be found to depend as 
much on after-care as on the surgical manipulations. 
Several months of postoperative routine sanatorium 
treatment is surely little enough to advise for all 
patients in this group. 

In conclusion let me say a word for teamwork. 
The word has been used so frequently by our pro- 
fession lately that it is becoming very trite; but I 
know of no place where genuine teamwork is more 
vitally necessary to efficient medical practice than 
in the handling of these cases. The urologist, the 
internist, the radiologist and the clinical patholo- 
gist must work hand in hand in arriving at a cor- 
rect estimate of the situation; in deciding what 
procedures to adopt and when to apply each; in 
preparing the patient for operation, in giving him 
the best chance to get the best results possible from 
his surgery, and last, but not least, in correctly 
evaluating the results that have been obtained. 



Routine Treatment of Gonorrhea in Females 
(Bernard Notes, in Amer. Jl. Obs. & Gyn., July, via 
International Med. Dig., Nov.) 
Positive diagnosis was based on smears with gram- 
negative intracellular diplococci having the morphology of 
the gonococcus, plus objective clinical signs. While not 
taken as diagnostic, e.xtracellular gram-negative diplococci 
were considered as suspicious. In order to discharge a 
patient as cured, 4 consecutive smears negative for both 
intracellular and e.xtracellular gram-negative diplococci ob- 
tained at intervals of 2 weeks absence of objective clinical 
signs were required. Thus each patient was observed 2 
months for recurrences. 

The basis of treatment in the beginning was drainage 
and antisepsis. Results in 1931: discharged as cured, 1%; 
in 1932, 3.4%; in 1933, S.7%. In August, 1933, treatment 
on the bases of creation of local reaction and drainage 
with the omission of antiseptics was begun as follows; 

(a) all crevices with glands functioning were cauterized 
one or more times with the electrocautery at intervals 
of 2 or more months in order to cause local reaction and 
to give better drainage; (b) urethral meatus and cervix 
were treated weekly with applicators saturated with 25% 
silver nitrate (considered a local irritant in this strength), 
in order to cause local reaction and to favor better 
drainage; (c) 5% sodium-bicarbonate douches were taken 
by the patient at home twice daily, by fountain syringe 
until the cervix healed and by pressure syringe (bulb type) 
after the cervix healed; (d) nightly instillations of 1 dram 
of 1% lactic acid jelly were made by nozzle to the vaginal 
vault in order to promote the normal bacterial flora and 
to get rid of secondary invaders which cause desquamative 
vaginitis. During the first 6 months of this period but 12 
patients were discharged; however, improvment and in- 
crease in negative smears were marked. Beginning with 
February, 1934, sustained results began to be obtained, 
and of 677 cases admitted during the followmg 12-month 
period, 131 were discharged, 19.3%. 

Ages of patients ranged from a few weeks to 60 years, 
the average being 19 years. Approximately one-half had 
syphilis which was under active treatment. The largest 
number of cauterizations upon a single patient was 5, the 
smallest 1, the average 2. Some cases which had resisted 
treatment by antiseptics for as long as 4 years were cured 



S6 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



within 1 year by creation of local reaction and drainage. 
No patient who co-operated failed of cure. 

Complications such as pelvic peritonitis and hemorrhage 
were at times severe but at no time dangerous, and these 
did not develop often. Patients were prepared for these 
reactions by a thorough explanation of what was being 
done, why, and what was to be expected. Occasional in- 
complete stenosis of the cervLx developed as was expected 
but no cases of hematometra. 

It is concluded that antiseptics should be abandoned in 
the treatment of gonorrhea in females. 



CARDIOLOGY 

For this issue, Samuel F. Ravenel, M.D., Greensboro, N. C, 



Rheumatic Fever: Complications 
Generalizations. — (1) Chorea, involvement of 
the pericardium, myocardium or endocardium, 
rheumatic pneumonia, etc., are sometimes spoken 
of as complications of rheumatism. As a matter 
of fact they are part and parcel of that disease just 
as chancre, gumma, aortitis, paresis all are syph- 
ilis, the specific infectious agent remaining con- 
stantly present within the body, its attack upon 
various organs being conditioned by such factors 
as time, functional strain, intercurrent infection. 

(2) There is a unanimity of authoritative opin- 
ion in regard to rheumatism in a few respects only, 
such as (a) involvement of all the body tissues, 
(b) duration of infection, (c) predilection for 
youth, cold damp climates and the mitral valve, 
(d) specific nature of the pathologic lesion, (e) 
the necessity for prolonged rest in its treatment. 
Almost all else is controversial. 

(3) It is necessary constantly to remember with 
reference to involvement of the heart that the en- 
tire organ is affected in rheumatic carditis; that 
no matter whether pericardial effusion, myocardial 
failure or valvulitis give rise to the principal 
symptoms, all three structures invariably are in- 
vaded. 

Chorea is regarded by many as a rheumatic en- 
cephalitis, the immediate precipitating factors be- 
ing upper respiratory infection, emotional and 
physical strain. The diagnosis ordinarily is so 
obvious are not to be missed. It is necessary, 
however to recall that one may encounter forms 
so mild they may be confused with tics or "nerv- 
ousness," so severe as to simulate grave disease of 
the central nervous system or so limited as to 
effect only half the body (hemichorea). Import- 
ant features in treatment are mental and physical 
lest until the mind and body are normal, as evi- 
denced by (a) loss of nervousness, (b) cessation 
cf abnormal muscular movements, (c) return of 
pulse, temperature and leucocyte count to their 
customary levels. Isolation, bed rest, bromides 
and phenobarbital usually suffice. Recent studies 
suggest that intravenous tj-phoid vaccine fever ther- 



apy shortens the course of the disease dramatically 
and safely. 

Pericarditis and pericardial effusion are often 
missed or confused with other diseases — the former 
with appendicitis or pleurisy, the latter with car- 
diac dilatation or left-sided pneumonia. These 
mistakes may be obviated by thinking of it in 
any unexplained acute fever (pericarditis is rare 
but probably not more so than typhoid in most 
cities) and by loking for it in children who pre- 
sent a history or any manifestation of rheumatism. 
It may be helpful to remember that: (1) the fric- 
tion rub may be audible only over the sternum, 
(2) the pulse usually is very rapid, (3) in the 
case of large effusions orthopnea is often present, 
the neck veins are engorged, the apex impulse is 
diffuse, signs of solidification of the lung may ap- 
pear in the left interscapular space, the respirations 
are rapid but not sharply limited on one side as 
in the case of pneumonia. .Accepted therapeutic 
measures are bed, back rest, ice bag or dry heat and 
opiates for pain, sedatives. In case severe dyspnea, 
cyanosis, falling systolic pressure herald fatal tam- 
ponade of the heart, decompression by aspiration 
of the effusion may be life saving. After care in- 
cludes bed rest until all signs of rheumatic activity 
have disappeared — whether that requires weeks, 
months or years. 

The classical signs of rheumatic heart disease 
are those referable to the mitral valve. It is nec- 
essary to recall that weeks or months may elapse 
after the initial febrile attack before signs of mitral 
disease are manifest. Prior to that tachycardia 
may be the only suggestion that the heart is in- 
volved. An accelerated pulse following acute up- 
per respiratory infections should act as a fire alarm 
to the physician. If practitioners insisted upon 
bed rest for all children suft'ering acute infections 
until pulse and rectal temperature returned to nor- 
mal and then examined these patients carefully in 
the office 2 weeks later, an incalculable amount of 
cardiac damage would be prevented. JNIitral sten- 
osis is inherently a lesion implying chronicity — it 
requires j'ears to develop. One may hear a mitral 
diastolic murmur early in the course of rheumatic 
fever but this is due to mitral "roughening." Le- 
sions of the aortic valves are usually found in severe 
cases only: almost always mitral disease is also 
present: very rarely a pure rheumatic aortic valv- 
ulitis may be encountered. In rheumatic heart dis- 
ease the activity of infection and the efficiency of 
the muscle are vastly more important than the 
character and location of the murmurs. Digitalis 
is of value only in children with congestive failure 
and then must be prescribed in adequate dosage. 
One practical method of administration in such 
cases is to give 3 grains of the powdered leaf by 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



87 



mouth each 6 hours until nausea or marked slowing 
of the pulse supervenes, and thereafter V/, grains 
twice daily as a maintenance dose. The subjects 
of rheumatic valvular disease obviously must be 
kept in bed until rectal temperature, pulse rate, 
leucocyte count, heart size are restored to normal 
levels. 

Finally it is necessary to realize that every tissue 
in the body may be invaded by the virus (?) of 
this disease to such an extent that clinical symp- 
toms may be produced. .Accordingly we may en- 
counter in its course pleurisy, pneumonia, periton- 
itis, erythema nodosum, subcutaneous nodules, etc. 
— all due to rheumatic fever. 

—371 N. Elm Street. 



Editor's Note: This is the 3rd in a series of articles on 
Rheumatic Fever. The Early Diagnosis and Early Treat- 
ment have been discussed in previous articles. Next month 
Late Sequelae will be discussed by Dr. Elias Faison, of 
Charlotte. 



Poisonous ANiMAts and Their Poisons, With Speclax 

Reference to Snakes, Spiders and Insects 
(H. E. Essex, Rochester, Minn., in Jl. -Lancet, Xng- 1st) 

In spite of the fact that investigators have repeatedly re- 
ported the finding that potassium permanganate is of less 
value than no treatment at all in cases of snake bite, text- 
books still recommend it. 

The best method of treating a person who has been bit- 
ten by a rattlesnake or moccasin: If of one of the ex- 
tremities, a tourniquet should be tied between the wound 
and the body, this released 1 min. in every 10. If antivenin 
can be obtained, the contents of 1 ampule, 10 c.c, every 
1 or 2 hrs. until symptoms are relieved. In severe cases 
intramuscularly or intravenously. If antivenin is not avail- 
able, only one method of treatment has been found of 
value: an incision J-2 in. long, J4 in- deep over each fang 
mark, and another cut should be made at right angles 
to the first. Suction should be applied either by mouth 
or by mechanical means for 20 min. out of each hr., for 
15 hrs. The victim should not consume alcoholic bever- 
ages or apply kerosene, gunpowder, bile, or potassium 
permanganate. 

Centipedes are commonly held in much dread. The 
venom of these animals has not been found to be danger- 
ous to man. The appUcation of antiseptics should follow 
the bite. 

The scorpions are close relatives of the spiders. The 
sting of the larger species is capable of causing severe 
symptoms even in an adult; in a child alarming symptoms 
have been known to follow the sting of even the smaller 
species. Treatment is principally symptomatic. According 
to some relief has followed spinal puncture. Antiseptics 
aid in the prevention of local infection. As a rule the 
sting of a scorpion causes only a temporary inconvenience. 

The bite of the tarantula has been found to be incapable 
of causing serious danger to human hfe. I injected intra- 
venously into a small dog all the venom obtained from 
both poison glands of one tarantula. A very slight de- 
pression in blood pressure resulted. 

The female honeybee, bumblebee, wasp and hornest pos- 
sess a sting which is in reality a slightly modified ovipositor, 
consists of a sheath that encloses a pair of barbed stylets, 
which move backward and forward, penetrate the skin, 
and the venom is so carried into the puncture. It is not 



generally known that the action of the venom of the 
honeybee resembles ver\- closely that of the rattlesnake. 
The venom from 6 bees when given intravenously to a 
dog weighing 4.5 Kg. was sufficient to cause the death of 
the animal. The best method of treatment is cold appli- 
cations. Should alarming symptoms result, they should 
be treated symptomatically. Epinephrine has been shown 
to be of benefit in restoring the blood pressure. 



GENERAL PRACTICE 

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



An Open Letter to the American Foundation 
Doubtless many readers of this Journal re- 
ceived letters from Miss Esther Lape, member in 
charge of The American Foundation Studies in 
Government. Apparently this letter was sent to 
private practitioners of medicine, with the object 
of finding the prevailing sentiment of these men as 
to the future of medicine. For the benefit of 
readers of this department, I am publishing my 
own reply for what it is worth. 

Dear Miss Lape: 

Your letter of December sixth impresses me most 
favorably, for a number of reasons. It is pleasing 
to know that The American Foundation has noth- 
ing to advocate, that it has no preconceived ob- 
jective, and is not yet convinced that any essential 
change in the present system is indicated. So far 
as I know — and I have done my best to keep in- 
formed on all matters concerning the medical pro- 
fession — it is the first "foundation" that has done 
the private practitioner of medicine the courtesy 
of asking his opinion about the future of his own 
profession. Perhaps we private practitioners de- 
serve to be thus snubbed, since, as H. L. Mecken 
has said, "The men of no other profession are so 
facilely operated on by specialists in other peoples' 
duties." It is true that the traditions of our profes- 
sion have made us ready to give our services too 
freely, perhaps, for our own good. Certainly our 
idealistic tendencies have caused the social service 
workers and professional propagandists who favor 
socialized medicine to discount our ability to man- 
age our own affairs. 

In 1883 W. G, Sumner wrote: "The type and 
formula of most schemes of philanthropy of hu- 
manitarianism is this: .\ and B put their heads 
together to decide what C shall be made to do for 
D. The radical vice of all these schemes is that 
C is not allowed a voice in the matter. ... I call 
C the forgotten man." In all the schemes yet ad- 
vanced for revolutionizing medical practice, the 
most important factor — the doctor himself — is cer- 
tainly playing the role of C. .As one of that group, 
I thank you for at least remembering our existence. 

With this rather lengthy preface, I will try to 
answer your questions, as far as possible, in order. 



SOUTHERN MEDICINE AND SURGERY 



Februar>-, 1936 



At the risk of deserving my friend T. Swann 
Harding's characterization of me as "an outspoken 
reactionary," I feel that we do not need any 
essential change in the present organization of med- 
ical service, except the apparently backward step 
of restoring the family doctor to the central place 
in medicine; of debunking much of the current 
literature dealing with the exhaustive medical re- 
search needed to diagnose a case of measles or of 
the itch; and of discouraging the hospitalization of 
the simplest maladies. These views I set forth at 
some length in an article published in the Atlantic 
Monthly in 1931, a copy of which I am enclosing. 

As to voluntary health insurance I can not see 
any reasonable objection, provided there is no re- 
striction in the choice of doctor. Insurance com- 
panies have been selling such insurance for years, 
but my observation is that in too many instances it 
is a question of whether the company or the patient 
profiteers the most. The best insurance against 
sickness I know of is a savings account, and if the 
average citizen would put into the bank the sums 
he pays for health insurance, and use it only for 
sickness, he would be far better off at the end of 
ten years — if the bank did not fail. 

Hospital care can be provided for in many states 
by comparatively small insurance payments. If 
this be kept strictly separate from the medical bill, 
and not allowed to be the entering wedge for social- 
izing medical service, it may prove a good thing. 
It should help to make the emergency operation 
or serious illness less terrifying to the family wage 
earner. 

I certainly do not think either the public or the 
medical profession would be benefitted by any form 
of socialized medicine, call it what you will — state 
medicine, compulsory health insurance, or a com- 
munity health center. On the other hand, both 
the public and the profession would have much 
to lose; the profession, in losing the incentive of 
competition and in the deadening effect of bureau- 
cratic control; the public, in giving up the time- 
honored sacred relationship between patient and 
doctor, in exchange for the indifferent attitude of 
a public employee. I am well aware that some 
lay advocates of socialized medicine claim that this 
relationship between patient and doctor would be 
preserved; but doctors know better. In the 
American Mercury for September, 1934, "an emi- 
nent New York physician," under the pen name 
of George W. Aspinwall, offers "A Plea for Social- 
ized Medicine." Although strongly in its favor, 
he admits that "Except for those desirous of pay- 
ing the doctor directly, free choice of doctor will 
be lost. . . . Calls for attendants upon the sick at 
home are to be received at these centers, such calls 



to be assigned to physicians assigned to cover spe- 
cific local territories." 

I can not refrain from another direct quotation 
from Dr. Aspinwall's article: "Politics will no 
doubt play a considerable role in the organization 
of state medicine. ... It is common knowledge that 
our law-makers will not encourage the enactment of 
a project for which large sums of money will be ex- 
pended unless they can control the disbursements." 
Comment is unnecessary. 

I hope you will not think me immodest if I re- 
fer you to "The Case Against State Medicine" in 
the Forum for November, 1933, for my further 
views on this subject. In addition I would like to 
call your attention to a few other facts. First, that 
it would cost from two to three billions a year to 
insure the workers of the United States, and to in- 
clude the unemployed would increase the cost to 
four billions. Second, that in Germany there are 
2,000 more lay workers than there are physicians 
in the Krankenkassen. Third, that in Great Bri- 
tain the time lost on account of sickness (real or 
alleged) has doubled in twenty years of compulsory 
insurance; in Germany it has increased threefold" 
in fifty years. And, finally, that the latest avail- 
able statistics of the League of Nations (for 1933) 
show that the United States has a lower general 
death rate, a lower infant mortality, and a lower 
mortality and morbidity from diphtheria and tuber- 
culosis than has any other first-class power for 
which data are available. 

In view of these facts, Miss Lape, I can not see 
where we have anything to gain by any experiment 
in socialized medicine. Your final question, "If 
you consider it desirable or imperative that the 
medical profession through the medical societies 
should control standards, public health appoint- 
ments, etc., how do you think that this end could be 
best achieved?", is not a hard one. Let local ap- 
pointments and problems that concern the local 
profession be referred to the local society or ap- 
propriate committee, such as the executive or pub- 
lic relations committee. Let state appointments and 
problems be referred to the state societies and na- 
tional ones to the American Medical .^Association. 
Certainly the members of these respective medical 
organizations are at least as intellectual, as public 
spirited, and as capable of dealing with medical 
problems, as are our aldermen, our legislators, and 
our representatives in Congress. 

I appreciate your assurance that my views will 
he kept in confidence, but this letter expresses my 
sincere convictions, and you are at liberty to make 
any use of it you see fit. I shall await with in- 
terest the result of your investigation. 
Sincerely, 

—WING ATE JOHNSON. 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



89 



The Doctor May Do Much For Man's Happiness 
{G. C. Robinson, Peiping, in Chinese Med. Jl., Sept.) 
Many people who have no disease are yet far from well. 
Here lie the problems of the future. An improvement 
in human happiness should be the next great objective to 
which the best minds of medicine may be applied. The 
human mind must be better understood, and must be the 
subject of more serious study and research from the medi- 
cal view point. It is known vaguely how largely the 
mental state may be responsible not only for generat- 
ing discomfort and suffering, but also for the actual pro- 
duction of organic disease. The time has come to convert 
these beliefs or surmises into scientific facts. Some progress 
has already been made in America and elsewhere. 

Such problems as the relation of population to the 
number of people a district or province can adequately 
support is a field of co-operation for doctor and sociolo- 
gist. Birth control must come to be recognized as a 
scientific approach to human happiness, and it must be 
recognized that over-population leads to want and disease, 
to social unrest and to war. 

The doctor may do much to improve the happiness of 
man not only by taking part in carrying out broad projects 
of social adjustment but also by developing a deeper know- 
ledge and understanding of the human emotions, mental 
problems and social difficulties of each individual to whom 
he renders service. Let the medicine of the future carry 
along all that is essential and valuable that has been 
learned by those who have lived in past generations, let 
medicine do all it can to prevent disease and improve the 
state of hygiene, but let it not stop here. The doctors of 
the future should have at their disposal more knowledge 
for the increase of human happiness, and may the gen- 
eration now coming on and those to follow give to this 
problem their best minds in the same spirit of unselfish 
toil that distinguishes the leaders of medical progress in 
the past. 



The Treattmcent of Tuberctjeosis in the Home 
(R. B. Homan, El Pasu, in Texas State Jl. of Med., Oct.) 

The vast majority of these cases must be treated in the 
home. At the beginning of the treatment, even in the 
incipient case, bed rest with bathroom privileges only 
should be instituted ; this may necessarily be prolonged 
over a period of months. As the symptoms and physical 
signs improve concessions are made slowly. The patient is 
allowed to sit up in a comfortable chair for IS minutes 
once or twice daily, the time to be gradually increased to 1 
hour before the patient is allowed to walk about the house 
or venture off the porch. 

Walking is the most strenuous e.xercise allowed for many 
months, and it must be very gradually increased, the pa- 
tient being very careful not to tire himself at any time. 
The p., t. and general reactions must be closely watched 
during these periods of graduated exercise, and any un- 
toward symptom should be the signal to go backward 
rather than forward. 



The Major Lmforta.nxe of Minor Infections 
(P. A. Caulfield, Washington, in Med. Annals D. C, Oct.) 
Every accidental wound should be considered as a po- 
tential reservoir of infection. The greatest danger of in- 
fection in wounds is from the hands and instruments of 
the doctor treating them, since these are more likely to 
be contaminated with virulent organisms. The mechanical 
force producing the wound enters it but once, whereas 
the hands and instruments enter it many times. This 
entrance usually takes place after the f\ow of blood has 
stopped, and infection is harbored better in clotted, than 



in freely flowing, blood. Before an attempt is made to 
repair any wound, all instruments to be used should be 
carefully sterilized and the hands carefully washed, the 
same as in any major surgical procedure. All bleeding 
should be stopped, the wound flushed with soapy water 
and its edges washed and shaved, all loose and devitalized 
tissue and foreign bodies removed, all cavities and recesses 
opened and obliterated and the wound flushed with 95% 
alcohol; and if badly contaminated, it should be first 
cauterized with pure phenol. AW accidental wounds should 
be drained, the drain to remain in place no longer than 
is necessary to remove serum or liquefied fat. If infection 
occurs drain until all pus has been removed. 

All sutures should be interrupted. It is best to let the 
wound remain open without a dressing unless such a pro- 
cedure is impractical. Dressings do not prevent infection. 
.\ wound uncovered can be washed and bathed with soap 
and water, and the possibility of infection being rubbed 
into the wound by a contaminated dressing is removed. 



GYNECOLOGY 

For this issue, William Francis Martin, M.D. 

Charlotte, N. C. 

The Charlotte Tumor Clinic 



A Summary of the Diagnosis and Treatment 
OF Cancer of the Cervix 

Twenty-five years ago when pelvic examina- 
tions were less common than they are today the 
diagnosis of cancer of the cervix was usually made 
at a very late stage in the disease. Even in many 
new textbooks the most frequent symptoms given 
are cachexia and loss of weight. These, of course, 
are terminal symptoms of cancer and when a pa- 
tient has reached this stage little is to be offered. 
In late years, however, pelvic examination is a 
routine procedure with most doctors in doing a 
physical examination; and, so many cancers are 
being discovered in their incipiency, when the 
prospect of cure by proper measures is good. 

The signs of cancer of the cervix should be 
more emphasized, as any symptom the patient is 
capable of discovering usually occurs late in the 
disease. In the probable sequence of development, 
they are: (1) slight odorless leucorrhea, (2) an 
odoriferous purulent discharge with hemorrhagic 
spotting, (3) bleeding. Usually the first bleeding 
that is noted is a slight spotting after intercourse. 
Frequently there is a prolongation of the menses; 
this may go unnoticed and attention first be at- 
tracted by bleeding between the periods, which 
may be an acute hemorrhage or a slow bleeding 
over a period of days. This is nearly always due 
to rupture of a blood vessel in the ulcerating le- 
sions. 

Early in its course, carcinoma of the cervix is 
usually symptomless. There may or may not be 
pain during intercourse, or pains in the back and 
resultant weakness. Late symptoms are a foul 
serosanguinous discharge, loss of weight, cachexia 
and edema of the vulva: a palpable mass is nearly 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



always diagnostic of a so-called frozen pelvis, in 
which case the tumor has invaded the parametria 
and become iixed to the pelvic walls. 

Although a number of tests have been designed 
to facilitate the making of a diagnosis of carci- 
noma of the cervix by the general practitioner, 
the most valuable point in all of these tests is the 
fact that before the test is made the examiner 
must look at the cervix. 

It is our opinion that the trained observer can 
discover a malignant lesion more accurately by 
vision than by any chemical test. It is also our 
opinion that any erosion or ulceration of the cervix 
demands a biopsy and histological examination by 
a trained pathologist. There are, however, cases 
of cancer which originate in the cervical mucosa 
and extend upward or downward and spread under 
the mucosa lining the portio vaginalis and hence 
produce no ulceration. 

Many of these lesions are pedunculated cauli- 
flower-like growths and then, to obtain a biopsy, it 
is only necessary to snip off a piece of the tissue 
with scissors or biopsy forceps. While in the re- 
gressive type of lesions an ample F-shaped section 
the entire thickness of the wall should be removed 
from the cervix. In some cases it may be neces- 
sary to dilate the cervix and obtain currettings 
from the cervical canal. The specimen should be 
preserved in a 5-per cent, formalin solution — not 
in alcohol which cooks the tissue, nor in water 
which causes it to become edematous. This pro- 
cedure can be performed easily in any well equip- 
ped office. 

The degree of advancement of any cancer of the 
cervix may for the sake of easy classification be 
divided into three grades. In grade I the cancer 
is limited to the portio vaginalis of the cervix. In 
grade II one or both parametria are involved. In 
grade III the cancer has invaded the pelvic wall 
with or without distant metastasis. This grading 
is less complicated than that which was promul- 
gated by the International Cancer Congress. 

In view of the excellent results obtained by 
competent x-ray and radium therapists it takes a 
brave surgeon indeed to institute any radical sur- 
gical procedure. Certainly, in even the earliest 
cases in which any hope for a cure can be offered, 
the radical abdominal operation of Wertheim, or 
the radical vaginal Schauta operation — each, in 
the hands of the best surgeons, has a primary 
operative mortality of 20 per cent. This, it seems, 
would argue for placing cancer of the cervix in 
the hands of the radiologist. 

The treatment pursued in this clinic may be di- 
vided into three periods. First is the period of 
deep x-ray therapy, adminstered through six ports 
over a period of three weeks for a total of 8,000 



to 10,000 roentgens, using a 200-KV machine. 
After a two-weeks rest period the patient is either 
clinically free of disease or the tumor has regressed 
to that size which will give free access to the va- 
ginal vault and the external os so that radium may 
easily be applied. The second period is that of 
the application of radium. A modification of the 
Regaud technique is used, the length of applica- 
tion being over a period of six days with a dose of 
approximately 60 millicuries destroyed. The filtra- 
tion used is 2 mm. of brass. The third period is 
the remainder of the patient's life, throughout which 
she could be closely followed. An examination 
should be made every two months in the first 
year, and at least every six months for the first five 
years. 

Summary. — Investigate all vaginal discharge and 
bleeding. Take specimens for biopsy from all ul- 
cerations of the cervix and if positive for cancer 
have it treated by a competent radiologist. Ob- 
serve the patient frequently for carcinoma recur- 
rence for at least five years. 



Claude Tardi, Early Advocate of Direct Transfusion 
OF Human Blood 



This kind of transfusion should be done promptly and 
by two able surgeons in this manner: 

Cut lengthwise on the same side, right or left, the skin 
of the arm of the two people on whom you are going 
to operate; cut it over the vena basilica or median with- 
out wounding it. Expose and tie with a noose each of 
the veins in two places, separate the nooses one from the 
other a good inch. Open the veins between the ligatures, 
then introduce a bend-pipe in the end of the vein nearer 
the heart, which is to receive the blood, and tie it with a 
noose. The other end of this same vein ought to remain 
tied as before, if bleeding is not expedient. If bleeding is 
necessary one can unty it, in due time and place, and 
draw the patient's blood, as much as he has received, 
more or less. Let the blood flow over the arm, without 
making him undergo the pain of a new ligature or of a 
pipe. 

The cut end of the vein of the healthy man which is 
nearer the heart does not need so tight a ligature, as it 
happens always to exhaust itself by its own attraction; 
but it is very necessary on the cut end of the vein nearer 
the hand. One ought to introduce there a bend-pipe simi- 
lar to that used on the patient and tie it strongly above, 
for it is through the other end of it that all the blood 
passes. One ought also to tie the arm above the elbow, 
as one does in bleeding. There are then only two liga- 
tures and two pipes which are absolutely necessary; one 
of the pipes fits into the hollow of the vein which is 
nearer the hand of the healthy man; the other fits into 
that which is nearer the heart of the patient. 

Make both men sit down opposite each other, so that 
their left legs touch. Lift their hands and apply them 
reciprocally on their shoulders. Introduce then the pipe 
of the healthy man into that of the sick, without pulling 
it, because the vein shrinks and is weakened by lengthening 
it. Join exactly the two pipes, as well as you can; warm 
them, and put over them a small cloth, dampened with 
warm mucilage or dipped m spirits of wine. 



Februan', 1936 



SOUTHERN MEDICINE AND SURGERY 



Tie gently the two arms of the two men together, in 
two places, four fingers above and four fingers below the 
openings. Loosen then the ligature of the end of the vein 
which is nearer the hand of the healthy man; apply the 
cloth without ceasing, as much on the outside as on the 
inside up to the pipes. 

Bathe also the arm of the patient, up to the arm-pit 
and the shoulder . . , continually with aponges and with 
clothes dampened and moistened with hot water, or with 
an emollient decoction; and .... the blood will flow 
from one to the other in abundance. Make the blood of 
the healthy man flow as much as the force will permit: 
let him eat and rest, he will be able to furnish blood a 
second time on the same day, by the same opening, tying 
and loosening the ligature of the vein. If the superfluous 
blood of one man does not suffice, one can receive that 
of two, of three and even of more, choosing always the 
most suitable. 

Lacking a capable [assisting] surgeon, I can myself per- 
form the transfusion alone, having practiced all my life, 
not only at operations on the dead, but also on living 
bodies. 



SURGERY 

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



The Care of the Surgeon's Hands 
No apology need be made for an editorial on 
this commonplace subject. Although the head and 
the heart should at all times control the surgeon's 
work the work itself must be done by the hand. 
The skilled hand is more important than any elab- 
orate armamentarium. Without it, expensive in- 
struments are useless. By palpation, by the sense 
of feel, by the educated finger the surgeon often 
gets information that he can get in no other way. 
It is an inspiration to watch a skilled surgeon 
explore the abdomen with the gloved hand for an 
obscure lesion. Each organ has a normal size and 
a normal resistance with which he is familiar. Any 
abncrmality in size, contour or consistency is de- 
tected. In an orderly way he explores the unseen 
viscera with an accuracy of finding that is some- 
times uncanny. When a tumor is found he learns 
its location, its size and extent, its consistency, its 
fixation, its operability. He examines for seconda- 
ries — for metastases in the liver, and for involve- 
ment of the lymph glands. From this information 
the surgical procedure best suited for the patient 
is determined. Whether this be simple closure for 
inoperable cancer or extensive resection, the tissues 
in trained hands are handled gently with mini- 
mum trauma which reduces postoperative reaction 
to the minimum. 

Modern surgery is based upon aseptic technique. 
Neither diagnostic ability nor operative dexterity 
avails if infection follows an operation and the pa- 
tient dies of peritonitis. An absolute essential in 
insuring aseptic technique is the cleanliness of the 
surgeon's hands. We are indebted to Halstead 
for the introduction of rubber gloves that may be 



sterilized by boiling before being worn by the 
surgeon at operation. Although the surgeon is 
often called upon to operate upon infected cases, 
by the use of gloves he should keep his hands un- 
contaminated. 

-Although it is impossible to sterilize the deeper 
layers of the human skin, if the skin is healthy 
and smooth most organisms may be removed from 
it mechanically by scrubbing with soap and run- 
ning water. If the hands are smooth, scrubbing 
with soap and water followed by rinsing in a mild 
non-irritating antiseptic solution, preferably 70 per 
cent, alcohol, is ideal preparation before operation. 
The inability to mechanically cleanse rough fissured 
hands, to make them aseptic, by any method, is 
known to every one. 

The surgeon's hands have to be scrubbed many 
times a day. Any method of preparation which 
irritates will in time destroy the smooth texture of 
the skin and make the hands unsafe for operative 
work. There is no place for strong antiseptics in 
the preparation of the hands. No antiseptic can 
do more than cleanse the skin surface. Organisms 
in the hair follicles and sweat glands are not reach- 
ed by any antiseptic. In preparing the hands for 
surgical or obstetrical work more stress should be 
put on thorough mechanical cleansing, scrubbing 
with soap and water, and less on antiseptics. This 
fundamental fact is recognized by most of the 
younger men of the profession. The writer has 
seen one of the most noted surgeons in America 
immerse his hands for five minutes day after day, 
operation after operation in one to one thousand 
bichloride of mercury solution. As a result they 
were fissured almost to the quick. They were 
unclean and uncleanable, an unsightly menace to 
his patients that showed their illustrious owner to 
be ignorant of a fundamental principle of asepsis. 

Now that winter is here, when every skin tends 
to chap if exposed to the weather, it behooves the 
surgeon to take good care of his hands, to keep 
them out of irritating solutions, to grease them at 
night before retiring, to cherish and to keep them 
for the wonderful asset they really are to him. 



BorLs AND Carbxincxes 
(J. R. Chappeir, Orlando, in Jl. Fla. Med. Assn., Dec.) 
The carbuncle occurs where the skin is closely attached 
to the fascia, particularly on the back of the neck; thus 
infection, instead of producing the conical swelling cus- 
tomary in boils, makes the connective tisiiue taut, and 
forces the infection laterally, producing widespread necrosis 
under a plateau-like elevation. 

The chief danger oj jur uncles of the upper face is cav- 
ernous sinus thrombosis, an infection by way of the facial 
vein. Trying to open and squeezing the infection should 
be warned against, and a plan of treatment outlined which 
places the part as nearly as possible at physiologic rest, by 
prohibiting speaking and mastication of solid foods. ' In 
cases in which the infection travels through the 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



ophthalmic vein which can be recognized by a red round 
swelling up to the grooves of the nose, ligation of the vein 
just below the inner canthus should be done. Should the 
infection follow the anterior facial vein on its way to the 
internal jugular, which may also be recognized, then this 
vein should be ligated at the angle of the jaw. 

DeKeyser recommends the oxygen treatment for boils 
and carbuncles. He introduces a needle into the opening 
of a furuncle. When the opening is delayed, he hastens 
it by hot compresses which have been wrung out in oxy- 
genated water or solution of hydrogen peroxide. He 
states that the furuncle is cured in from 3 to 4 days; that 
a carbuncle is slower to cure, but easily in about IS days. 
Many approve vaccine therapy; others foreign-protein 
therapy. Many recommend x-ray. 

Pfahler found that his series of boils usually followed 
a heavy carbohydrate meal, and he reduces carbohydrate 
food to a minimum, as long as there is any tendency to 
boils; removing all source of focal infection; local appli- 
cations of tincture of iodine to the initial lesion, allowing 
iodine to dry between applications, and massaging the 
area around the lesion thoroughly from 5 to 10 minutes, 
3 to 4 times a day. He does not recommend incision. 

Bieber states that 2 units of insulin, daily, for 2 days 
will cause the furuncle to disappear. 

Winckler advocates the use of a Paquelin cautery, the 
pcH!*b-bT«3fb4Tto.a..wi«te- beat, introduced easily and rap- 
idly, perpendicularly exactly in the center, in order to de- 
stroy the necrotic core. To do this, he recommends using 
a metal disk, perforated in the center by a small hole, 
placed on the furuncle with slight pressure so that the apex 
bulges into the opening. 

Bruce withdraws 5 c.c. blood from the median basilic 
vein, and immediately injects it into the gluteal muscles. 
He states that this causes boils to dry up within 24 hours 
and prevents further formation of boils. In only one case 
was a second inoculation found necessary. 

prophylaxis: Shaving w-ith a dull razor should be 
avoided. In diabetics, careful dietary precautions. Strict 
body cleanliness aids in the prevention of boils, particu- 
larly, in. those., people, who perform manual labor. Athletes 
are peculiarly susceptible to boils and carbuncles which, 
I think, is due largely to body massage before taking a 
shower. A good sun tan aids in the prevention of skin 
infection. 



.fiDIATRICS 

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



I Believe 

Tomorrow may be another day. but today, / 
believe that, — 

Codliver oil is not needed by the average child 
after the third birthday. 

The common cold is not prevented by the ad- 
ministration of vitamins. The best treatment for 
a head cold is absolute bed rest. It shortens the 
duration and tends to reduce complications. When 
mothers agree with you on this point, you have 
received your reward for patient and persistent 
inculcation of sense. 

Nose drops never cured a cold I They open the 
nasal airways, tend to protect the ears and give the 
mother something to do. I prefer aqueous to oily 
preparations. Too long continued, the nose drops 



themselves create a discharge. We must not forget 
that argyria results from persistent use of the silver 
salts in nasal instillations. 

I had heard of it, but now I have seen it — acute 
suppurative otitis media without pain at any time. 
This is a fairly common experience in practice on 
babies, but uncommon in 7-year-old children. 

October, January and February are the peak 
months for respiratory infections. 

Constipation developing during the first six 
months of life is usually man-made. If mothers 
and doctors would leave the baby to its own de- 
vices, constipation would correct itself. Instead 
we meddle and the result is bigger and better con- 
stipation. 

A slight nasal discharge in young babies is not 
necessarily a head cold or snuffles. It is best treat- 
ed by watchful neglect. 

The obstetrician who advised the young primi- 
para not to buy a clinical thermometer as part of 
the nursery equipment deserves a big hurrah. In 
many instances baby scales are about as bad. 

If cold hands and feet caused the colic, there 
wouldn't be enough paregoric available to keep ba'- 
bies quiet. 

There ought to be a law against a doctor giving 
advice for a baby over the telephone. My most re- 
cent dereliction was treating the baby for indiges- 
tion that turned out to be earache when I saw it 
the next day. If mother can diagnose so well why 
does she request us to treat? To her, diagnosis 
carries no responsibility, but treatment is all im- 
portant. The physician says, Any fool can look 
up the treatment, but it requires a wise man to 
make the diagnosis. 

In most instances, making a charge for swabbing 
tonsils is receiving money under false pretenses. 
Even if it did some good the fear element that 
enters the pictures far outweighs any possible bene- 
fit. Gargling probably is about as useless. Yet 
both supply the patient, the mother or the doctor 
with something to do while the patient recovers. 
Irrigations of the throat are beneficial but must be 
done by someone who has been trained to adminis- 
ter them. 

Smallpox, whooping cough, typhoid fever and 
diphtheria are diseases we should never see. They 
can all be prevented. We can convey this idea to 
every parent (with rare exceptions), but we must 
let them know the facts. If we don't protect 
against these diseases someone else will. 

What do you believe? 



H.A.BiTr.Ai CoxSTrp.^TioN As a Sign of Infaktiie 

Pre-beriberi 

(Soji Takai. Tohoku, Japan, in Tohoku Jl. of Exp. Med.. 

Dec.) 

The pharmacological action of orypan (extract of rice 

polishings) upon intestinal movements is similar to that 



Februan', 1936 



SOUTHERN MEDICINE AND SURGERY 



of pilocarpine. Various vitamin-B preparations adminis- 
tered in small amounts cause moderate peristalsis of the 
intestines; large amounts, after a momentarj- stoppage, 
cause a very marked peristalsis, and still larger amounts 
cause a complete stoppage of the peristalsis, though this 
effect is still observed after the destruction of the vitamin 
(Bj and Bo) in the preparations by exposure to a high 
temperature (1/5° C.) under a high pressure (100 lbs.) for 
4 hours. In consideration of these views and our cases, 
we can with good reason conclude that in the case of 
infantile pre-beriberi, which is an early state of infantile 
B-avitaminosis, constipation is a natural symptom which 
may occur frequently. This should prompt us to think of 
infantile pre-beriberi in the case of an apparently healthy 
infant who complains of constipation. 



HOSPITALS 

R. B. Davis, M.D., M.S., F.A.C.S., fdf/or, Greensboro,N. C. 



Hospital Waste 

XoT infrequently hospital owners and operators 
seek advice from many sources on how to prevent 
waste. If the author had only one word to use in 
ansv.'er to an inquiry concerning this matter it 
would be, Watch. 

It seems almost as natural for some people to 
v.'sate as it is for them to breathe. It is not always 
true that this type of person is an unprofitable em- 
ploye in general. This type of individual may be 
found in any position from cook to chief-of-staff. 
This being true there must be economical supervis- 
ion directly over every department. 

If one tries to analyze as to wastefulness, he will 
usually find that the surgical department is the 
chief offender. This accusation will be resented by 
a good many surgeons, but I dare say those who 
have actually operated hospitals will agree readily 
with the writer. 

Let us take for instance the matter of linen used 
in a simple appendectomy. The surgeon and his 
assistant put on clean, two-piece suits, caps and 
masks — eight pieces of clean, fresh linen — and pro- 
ceed to scrub up. Many surgeons require in every 
major operation two sterile nurses. In the case of 
a clean appendectomy where the surgeon has an as- 
sistant only one is necessary. The four pieces of 
linen necessary to properly prepare one for her duty 
at the operating table can be saved, also her time. 
In draping a patient almost every surgeon is waste- 
ful. Four towels and a regular operating cover 
sheet should be enough for any simple appendec- 
tomy. Instead most surgeons use six or eight 
towels. 

When a surgeon scrubs up he usually wastes as 
much tincture of green soap as he uses by dipping 
the brush down in the green soap dish and imme- 
diately taking it out, allowing much soap to run 
off in the basin before the brush gets to his hand. 
A pause of one or two seconds and a slight shake 
of the brush over the dish will save enormouslv 



in the soap bill. With gauze the average assistant 
is very free and after mopping a few drops of blood 
he discards the sponge. Six small sponges should 
be ample for this type of operation. No large tapes 
are needed. 

The antiseptic material used to paint the field 
of operation is usually more than is necessary be- 
cause the sponges are nearly always too large and 
soak up twice as much solution as is needed. 

Sutures are perhaps at the top of the list for 
waste. Many clever surgeons are as clumsy in ty- 
ing sutures as a farm laborer would be in tying up 
a sack of feed. The length of the average, com- 
plete suture is seldom more than three-fourths of 
an inch. Many surgeons cut and throw away off 
the ends from two to four inches. If a hemostat 
were used to tie these sutures the waste would be 
cut at least two-thirds. 

The dressing applied to the wound is invariably 
more than is needed, and usually subsequent dress- 
ings are equally as wasteful. Two small pieces of 
gauze are all that are necessary to put over a clean, 
two-inch incision. There is no need of a large pad. 
Wide, instead of narrow, strips of adhesive are 
often used. The only time large amounts of ad- 
hesive are needed is at the time of the first dress- 
ing. This is necessary because the abdomen needs 
splinting in case of postoperative vomiting. After 
this period only enough adhesive is necessary to 
hold the dressing in place. 

In a similar manner each department's activities 
could be analyzed, step-by-step, noting a number 
of wasteful habits which in no way contribute to 
efficient service. The only way to prevent hospital 
waste is for the head of each department to watch 
closely the use of all equipment and material com- 
ing under his or her supervision. Every one con- 
nected with the hospital's operation should gladly 
accept suggestions of economy from whatever 
source, and no department should feel that it is so 
efficient that advice would not be helpful at all 
times. 



Enemas ajto Colon Irrigations 
<H. W Soper. St. Loui.«. in Clin. Med. & Surg., Jan.) 
Ihe chiel current crimes against the colon are: (1) The 
cathartic habit; (2) the habitual employment of water 
enemas; and (3) colon irrigations. 

Purgative drugs should never be given in cases of spas- 
tic constipation. The atonic colon often needs a gentle 
stimulus, such as small graduated doses of cascara, the 
lapactic pill, or any similar; avoid to.xic drugs, of which 
phenolphthalein is the most popular. It is a dangerous 
drug and is never indicated therapeutically. 

The habitual use of the enema for chronic constipation 
is not to be recommended. Injury to the mucosa will occur, 
infectious material is likely to be introduced and the 
water or saline solutions are readily absorbed by the colo- 
nic mucous membrane. A toxic solution of fecal matter 
is thus produced. The patient is deprived of the use of 
any rational method for the restoration of colonic function. 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



In cases of severe atony and dilation of the lower colon, 
the daily use of an evacuant enema may be imperative. 
Then the solution should not consist of absorbable ma- 
terial. The colonic mucosa is impermeable to the passage 
of sulphates, while chlorides and some other salts quickly 
pass through the wall of the colon into the blood stream. 
Use a 3-5% solution of sodium sulphate to incite con- 
traction of the gut; solutions of magnesium sulphate to 
produce dilation. In emergencies and in post-operative 
conditions, when we know that a spasmodic tendency is 
present in the lower colon, the magnesium sulphate enema 
(107b solution) is useful. 

In cases of strong contraction or spasm of the recto- 
sigmoid region, with the patient in the knee-chest posture, 
the sigmoidoscope is introduced and direct applications of 
a 50% solution of magnesium sulphate are made by means 
of a long cotton applicator. Relaxation can be demon- 
strated in a few minutes. 

Spasmodic contractures of the iliac colon can be diag- 
nosed by palpation of the abdomen, with the patient re- 
laxed. The normal colon can be induced to contract by 
manipulation of the palpating hand, but it will agam relax. 
In cases of extreme atony, no such contraction can be 
elicited. In spasmodic contractures of the iUac colon, it 
can be felt as a firm, hard cord, which never relaxes. Pal- 
pation usually elicits painful sensations. Treatment by 
means of magnesium sulphate solutions is ver>' efficacious. 
The technic is essentially the same as described except that 
a soft-rubber, 24-F. catheter is introduced through the 
sigmoidoscope and the solution injected by means of a 
piston syringe. The patient lies on his back immediately 
after the injection and retains the solution as long as 
possible. Usually a series of 8 or 10 such treatments, 
every second day, suffices to overcome the spasm. At the 
same time a smooth diet is employed and all laxative drugs 
avoided. 

The majority of physicians have ceased to use the so- 
called colonic irrigations, but the "mtemal bath" is still 
employed by the commercial irrigation specialist. My 
experience is: the more one irrigates, the more mucus 
one gets. 

Abdominal or colonic massage is absurd and dangerous. 

The colon is readily lavaged. All the apparatus that is 
necessary is a large glass funnel, to which it attached a 
large-caliber stomach tube. 

The oil retention enema 6-8 ozs., introduced through a 
2S-F. catheter, to which is attached a large rubber valve 
bulb— a simple apparatus which the patient can easily use 
at bedtime, with instructions to retain it all night. The 
oil quickly reaches the cecum. We employ mmeral oil 
as it is not absorbed and it inhibits the growth of bacteria. 
It is of great value m recurring attacks of subacute ulcer- 
ative colitis, spastic contractures of the lower colon, mucous 
colitis and colonic diverticulosis. A series of oil retention 
enemas is the best preparation for the patient who is to be 
ooerated upon for carcinoma and other lesions of the colon. 

The use of chemical solutions, formerly much in vogue 
in the treatment of dysentery, ulcerative colitis, etc, should 
be abandoned. 

The insufflation of dry powder is a very useful pro- 
cedure i'l inflammatory and ulcerative conditions in the 
rectum and lower colon. When the pathologic process is 
limited to the ampulla recti, the patient is placed in^ the 
knee-chest posture and the sigmoidoscope (small caliber, 
Ys\.\\ to ^ in) is introduced, the obturator withdrawn and 
the powder blown directly into the bowel by means of a 
special powder-blower equipped with a long tube. My 
final choice in such conditions is a powder consisting of 
equal parts of bismuth subcarbonate and calomel. This 
powder has the advantage of adhering tenaciously to the 



mucosa; and it is strongly antiseptic and non-irritating. It 
is best to avoid the sigmoidoscope after the diagnosis has 
been made in such cases, and employ the 24-F soft-rubber 
catheter, introduced directly into the rectum, insufflating 
the powder through the catheter. This is also the method 
of choice in the treatment of lesions higher up in the 
colon, where daily insufflations are necessary. One thus 
avoids the trauma occasioned by the daily passage of the 
instrument. 

Bismuth subgallate is the best powder for higher in- 
sufflations, because of its lightness and more astringent 
qualities. I have demonstrated deposits of this powder 
as high as the splenic flexure. Care must be taken not 
to overdistend the gut: the powder-blower is detached 
from the catheter from time to time and the excess 
air allowed to escape. 

In old, chronic, ulcerative lesions in the rectume, direct 
application of 25% solution of silver nitrate, under guid- 
ance of the eye, are often very useful. Dry the tube well 
before withdrawing it to prevent any of the solution 
touching the anal canal. Polypoid growths are best de- 
stroyed by diathermy. 

A 10% aqueous solution of mercurochrome is of great 
value in the treatment of proctitis involving the anal 
canal. A f^-in. caliber scope is introduced and the 
cotton applicator wet with the solution is passed through 
the scope, which is withdrawn. Now the wet applicator 
is withdrawn through the contracted anal canal, Uterally 
squeezing its contents into the crypts and folds of mem- 
brane. 

The introduction of the ordinary foodstuffs per rectum 
has been practically abandoned, because of the failure of 
the colon to absorb and utilize them. Water, weak solu- 
tions of alcohol, physiologic saline solution, and a 3% 
solution of dextrose are readily absorbed and utilized. The 
Murphy drip method is to be preferred, but in some pa- 
tients with sensitive anal canal reflexes it is better to intro- 
duce slowly about 4 ozs. of the fluid every 2 or 3 hours. 



ORTHOPEDIC SURGERY 

0, L. Miller, MD., Editor, Charlotte, N. C. 



CoLLEs' Fracture 

CoLLEs' fracture is of comparatively common 
occurrence in the routine practice of medicine. 
The principles apph'ing to treatment of this injury 
are well recorded in the periodicals and textbooks 
on surgery, yet it is not amiss to reemphasize them 
from time to time in the interest of improving our 
end-results. There is some tendency to treat this 
fracture lightly, at times with dire consequence to 
the future use of a hand. 

The incidence of Colles' fracture is somewhat 
greater in elderly people than in younger adults 
and this fracture in elderly patients should be 
treated somewhat differently as compared with 
similar fractures in younger patients. There is 
greater hazard to obtaining a good anatmoical and 
functional result in the elderly patient. 

Haggart, of Boston, told the Bone and Joint 
Section of the A .iNI. A. at Atlantic City that, 
owing to the relative brittleness and avascularity 
of the bones of elderly individuals, comminution 
of fragments is more frequently observed at the 



Februan-, 1936 



SOUTHERN MEDICINE AND SURGERY 



time of reduction. Such comminution may not be 
evident in a preoperative x-ray picture. 

Bony union in these patients is delayed as com- 
pared with the same fracture in younger adults. 
In some elderly patients complete bone repair may 
not occur even though the fracture is perfectly re- 
duced. This is due, apparently, to disintegration 
of bone cells at the end of each fragment with 
consequent loss of bone substance. Delay in heal- 
ing is particularly prone to occur at the dorsal 
fracture line in the radius, where the distal dorsal 
end of the proximal radial fragment tends to ab- 
sorb. Hence, bone repair is often so far from 
complete that, following the usual two- to three- 
weeks splintage, a partial to complete recurrence 
of the deformity takes place on resumption of the 
use of the hand, notably the act of dorsiffexion. 

It is often necessary to hold the hand in palmar 
flexion and ulnar deviation in order to prevent dis- 
placement of the comminuted radial fragments. 
Fluoroscopic vision or x-ray photographing of the 
fracture will determine whether this position is 
indicated. 

These fractures are most satisfactorily reduced 
under a general anesthetic. Impaction of the radial 
fragments is first broken up by manipulation and 
then, with traction maintained, the fragments are 
molded into alignment by firm pressure of the oper- 
ator's thumb passing distally over the dorsum of 
the patient's wrist. This maneuver brings the pa- 
tient's hand into volar flexion, thus fixing the re- 
duced radial fragments in position. If necessary, 
the fragments are aligned by ulnar deviation of the 
hard. 

The plaster splint or cast is one of the simplest, 
yet most efficient, appliances that can be utilized 
in fractures of the forearm. The length of the 
splint is determined by the distance from the 
knuckles up the dorsum of the forearm, around the 
elbow and down the volar surface of the forearm 
to the base of the fingers. It is particularly im- 
portant to note that the respective ends of the 
plaster terminate at the knuckles on the dorsum 
and just proximal to the base of the fingers on 
the volar surface of the hand. When properly 
applied, this splint permits the patient complete 
normal range of flexion-extension in all the inter- 
phalangeal and metacarpophalangeal joints. In 
addition to antero-posterior immobilization of the 
radius and ulna, by passing around the elbow the 
splint or cast should also prevent pronation and 
supination — an especially important stabilization 
when dealing with a comminuted Colles' fracture. 
Care must be exercised to prevent circulatory dis- 
turbance and ischemia. 

After x-ray examination confirms a satisfactory 
position of the fragments and shows the restoration 



of normal radiocarpal and distal radioulnar joint 
relationship, the patient is instructed, first, to use 
the fingers constantly: not only to move the joints 
actively through their maximum range fifty times 
daily but at all times to employ the fingers as 
nearly as possible as in normal daily use: secondly, 
to abduct the entire arm over the head a minimum 
of six to eight times a day. The latter exercise 
prevents loss of shoulder joint function, which is 
so prone to occur if the arm is held constantly at 
the side of the body. Impairment of shoulder joint 
motion is particularly apt to follow Colles' frac- 
ture, since falls on the outstretched hand frequently 
injure the tendon of the supraspinatus muscle and 
the subacromial bursa. 

Because of the tendency to recurrence of the 
deformity of the distal end of the radius in these 
elderly patients owing to delayed bone repair, it is 
believed that the extremity should be continuously 
immobilized for a minimum of from five to seven 
weeks. 

Free finger-joint motion is necessary, a range of 
motion allowed by careful application of the splint. 
Daily complete arm abduction is of advantage in 
preventing limitation of shoulder joint motion. With 
this procedure, followed by intensive massage, heat 
and active exercise, a good anatomic and a good 
functional result should be obtained. 



Leucocytosis Following Inhalation Anesthesia. 

(I. B. Taylor & R. M. Waters, Madison, Wise, in Anes 

& Analg., Nov. -Dec.) 

A review of the literature indicates that administration 
of all the commoner anesthetic agents by inhalation is fol- 
lowed by a marked leucocytosis. Observations on 8S clin- 
ical cases and 5 dogs support a similar conclusion. 

Increases in the total leucocyte count amounting to 2J^ 
times the normal in long serious cases and V/z times the 
normal in minor cases are the rule. Three to S days are 
required for a complete return to normal white blood count 
following inhalation anesthesia. 



Sudden Death 

(J. H. Dible, Liverpool, in Liveroool Medico-Chiruraical 
Jl., Pt. 3. 1035) 
The form of cerebral hemorrhage which produces the 
most rapid extinction of life, and which usually occurs 
in young subjects, is that due to aneur>-sm of the large basal 
vessels. The aneurysms are of unknown etiology. They are 
neither syphilitic nor atheromatous. The rupture of such 
aneurysms produces the sudden onset of coma which, if it 
occurs prior to the degenerative period of life and is ac- 
companied by the presence of recent blood in the cere- 
brospinal fluid, is almost pathognomonic of this condition. 



Dr. /oynes'* contributions to medical literature (I'a 
Med. Monthly, Jan., 1882) were numerous and valuable. 
No article of his ever went to press without thorough 
preparation in study of the subject of which he was treat- 
ing and exactness in manuscript. 

^^'':i'^• ^'^y'". •'^- -Isynes, long Professor of Physiology and 
Medical Jurisprudence in the Medical College of Virgina. 



SOUTHERN MEDICINE AND SURGERY 



Februarj', 1936 



RADIOLOGY 

Wright Clarkson, M.D., and Allen Barker, M.D., 
Editors, Petersburg, Va. 



Roentgen Diagnosis of Heart Disease 
Holmes,! Kohler,- Assmann^ and Levene have 
contributed much to our present knowledge of 
roentgen cardiology, and the heart measurements 
established by Vaquez and Bordef* have proven of 
great assistance to radiologists in the differential 
diagnosis of heart diseases. The size of each of 
the four chambers of the heart and the thickness 
of the left ventricular myocardium can now be 
quite accurately determined. 

Von Zwaluwenburg and Warren^ have shown 
the value of studying the relationship between the 
size of the auricles and the size of the ventricles. 
If the length of the auricles is divided by the length 
of the ventricles, the auriculoventricular ratio is 
established. This ratio is definitely increased, or 
that is to say, the auricles are proportionally larger, 
in cases of mitral stenosis, and in mitral stenosis 
complicated by mitral insufficiency. The ventricles 
show relatively more enlargement, causing a de- 
crease in the auriculoventricular ratio, in cases of 
functional mitral insufficiency, in aortic stenosis, 
and in aortic insufficiency. 

Levene and his co-workers have shown that 
roentgenoscopic examination of the heart is equally 
as valuable as examination of the cardiac roent- 
genograms. Levene and Reid" say: "With in- 
creasing experience we learn to obtain from roent- 
genoscopic examination important information re- 
garding the functional status of the heart; the film 
was more useful in portraying gross, structural 
changes of the various chambers." 

By combining the roentgenoscopic and film ex- 
aminations, the roentgenologist is able to differen- 
tiate the various organic diseases of the heart with 
accuracy and in some cases the diagnosis can be 
recognized by roentgen examination before symp- 
toms appear, and before the diagnosis can be estab- 
lished clinically. For instance, mitral stenosis may 
be recognized roentgenographically at a very early 
stage, because in this condition the left auricle be- 
gins to dilate before there are clinical signs of 
impaired cardiac function. 

In mitral insufficiency the radiologist can dif- 
ferentiate between the functional and the organic 
forms. A functional insufficiency of the mitral 
valve may be caused by any condition requiring 
the left ventricle to do more work, and, following 
the hypertrophy and gradual enlargement of the 
ventricle, the valve flaps fail to completely close 
the mitral opening. The transverse diameter of the 
heart is increased and the apex becomes rounded 
from myocardial hypertrophy. 



Levene believes that mitral stenosis always pre- 
cedes the organic form of mitral insufficiency and 
therefore in this condition the cardiac changes are 
superimposed upon those produced by mitral steno- 
sis. In the latter, the left ventricle is small and 
the apex is pointed and therefore when the mitral 
valve begins to leak, we get a combination of roent- 
gen signs. The left ventricle dilates, but the apex 
remains pointed and the auricles of the heart con- 
tinue to show relatively more enlargement than 
the ventricles. These changes can be clearly dem- 
onstrated roentgenographically and this fact makes 
repeated roentgen examinations of the heart of 
great value in following the course of organic mitral 
disease. 

Aortic stenosis under the roentgenoscope reveals 
a hypertrophied left ventricle with practically no 
enlargement of the right heart, and the slow force- 
ful contractions so typical of the condition can be 
readily recognized. In like manner, all the other 
valvular lesions produce distinctive changes which 
can be readily recognized by a careful roentgen 
examination. 

A very instructive scientific exhibit on the roent- 
genoscopic appearance of the heart was given by 
Levene at the last annual meeting of the American 
Roentgen Ray Society, and again before the an- 
nual meeting of the Radiological Society of North 
America meeting in Detroit. The characteristic 
roentgenoscopic appearance of sinus arrhythmia, 
extrasystoles, auricular fibrillation, thyrotoxicosis, 
coronary disease and heart block were particularly 
striking. 

It is really hard to explain why radiologists in 
the past have paid relatively little attention to 
cardiac examinations, since by the proper use of 
the roentgenoscope it is comparatively easy to 
watch the action of each chamber of the heart. 
For instance, in heart block, due to interference 
with the conduction of impulses from the auricle 
to the ventricle, the auricle beats faster than the 
ventricle, and counting the number of beats made 
by each chamber per minute by means of a stop 
watch is a simple procedure. For example, if the 
ratio in a case happens to be two to one and the 
ventricular rate is slow (about forty per minute), 
the diagnosis of heart block is established. 

Myocardial impairment may be accurately de- 
termined by roentgen examination. The dimin- 
ished amplitude of the cardiac contractions varies 
in direct proportion to the amount of myocardial 
damage. In cases of coronary thrombosis the con- 
tractions are often barely perceptible upon the flu- 
oroscopic screen. The left border of the heart is 
straight or concave instead of being well rounded 
as seen in hearts with thick healthy myocardium. 
Care must be taken in these cases to exclude thy- 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



97 



rotoxicosis, which also produces a straight or con- 
cave left cardiac border, but in the latter condition 
the amplitude of the contractions is forceful and 
not at all like the feeble impulses of myocardial 
impairment. 

Sosman and Wosika" have succeeded in demon- 
strating calcified coronary arteries and calcified 
deposits in the valves of the heart. The fact that 
the three patients reported by them suffered with 
angina pectoris is quite significant. 

From the foregoing facts, it can be seen that the 
value of roentgen examinations of the heart is well 
established. Everyone attempting this work, how- 
ever, should realize that the successful roentgen 
diagnosis of cardiac conditions is dependent upon 
the possession of a broad knowledge of cardiology, 
and unless the roentgenologist is well acquainted 
with all the various cardiopathies his attempts will 
be unsuccessful. It is likewise true that roentgen 
examinations of the heart should always be corre- 
lated with the various clinical and laboratory ex- 
aminations now in general use. In this w^ay roent- 
genology will add materially to our knowledge of 
cardiac conditions and it will be particularly help- 
ful in permitting clinicians to follow the course of 
their heart cases under treatment. 

Bibliography 

1. Holmes, G. W.: The Use of the X-ray in the Exam- 
ination of the Heart and .\orta. Boston M. and S. 
Jl., 191S, 179, 478. 

2. KoHixR, Alban: Roentgenology. Wm. Wood and 
Co., New York, 1929. 

3. AssMANX, H.: Die klinische Roentgendiagnostik der 
inneren Erkrankungen. F. C. W. Vogel, Leipzig, 1924. 

4. V'AQtJEz, H., and Bordet, E.: The Heart and the Aorta, 
Translated by James A. Honeij and J. Macy. Yale 
University Press, New Haven, 1920. 

5. Vox ZwALU\VENBURC, J. G., and Warren, L. F.: The 
Diagnostic Value of the Orthodiagram in Heart Dis- 
ease. Arch. Int. Med., 7:137-152, Feb., 1911. 

6. Levexe, George, and Reid, William: The Differential 
Diagnosis of Organic Heart Disease by the Roentgen- 
ray. Am. Jl. of Roenl. and Rad. Th., 1932, Vol. 28, 
No. 4. 

7. Sosman, M. C, and Wosika, P. H.: The Roentgen 
Demonstration of Calcified Coronary Arteries in Liv- 
ing Subjects. /. A. M. A., Feb. 24th, 1934, 102, 591. 



Complete axd Uxiversal .Alopecia Following Fright 

(E. Wigglesworth. Boston Med. & Surg. Jl., Ort. 21, 
ISMi. \ia Va. Med. Monthly, .Jan., l.Ssl) 

.\ healthy Italian blonde, 17, lymphatic, with exception- 
ally profuse hair, was sewing at a window. Suddenly the 
floor fell in, leaving her only time to catch hold of the 
window frame, where she hung until taken down by means 
of a ladder. No subsequent loss of consciousness nor nerv- 
ousness excitement ensued through the day. At night, she 
had headache, chills and bad dreams; in the morning, 
nervous excitement, weakness at the knees, spasms in the 
fingers and itching of the scalp. The following day she 
felt better, only the itching of the scalp remaining; but 
on arranging her hair, whole tufts came out by the roots. 
In 3 days, not a hair was left on the scalp. The eyebrows 



and eyelids were lost, and in 5 days the axillae and gen- 
itals were devoid of hair. General health good; no func- 
tional disturbance of any kind. K month after the fall of 
hair began, Fredet was consulted. The fallen hair, which 
had been made into a wig, was fine, silky, very rich and 
long. Not a hair could be found on the body, though a 
lens was used in the search. Two years later, after con- 
stant treatment, no return of hair. 



Hyperpyrexia Produced by the Hot Bath in the 

Treatment of Syphilis 

(C. C. Dennle, Morris Polsky & A. N. Lemoine, Kansas 

Cit.v, Mo., in Jl. Mo. State Med. Assn., Jan.) 

Efficient temperatures can be produced in syphilitic pa- 
tients by the use of the hot bath in the ordinary tub. 
The best time is just before retiring, 2 or 3 hours after 
eating. 

We believe that in some way the defense mechanism of 
the body is raised and the virility of the organism lowered 
simultaneously by the use of hyperpyrexia. It seems that 
temperatures of 104 F. and above set the defense mechan- 
ism in motion. With the exception of early seronegative 
syphilis, inadequately treated syphilis with recurrent mani- 
festations and eariy malignant syphilis, heat should not be 
used in the early types of syphilis. By the application of 
heat alone it has been shown that syphilitic manifestations 
disappear temporarily; if subsequent treatment with heavy 
metals is employed they disappear permanently. Heat is 
an efficient therapeutic agent in recurrent neurosyphilis 
where malaria has already been used. 

Malaria still remains supreme as the treatment of neuro- 
syphilis. 

Heat as a therapeutic agent is probably the equal of 
malaria when used in other than neurosyphilis. 

The work presented here is experimental, and is not pre- 
sented with the idea that all the statements herein made 
are absolutely proved. 



Report on Advances in Hygiene and Public Health 
(S. K. Jackson, Norfolk, in Va. Med. Monthly, Jan.. 1880) 

Among the parasites recently discovered, the trichina 
spiralis is of great importance. It exists in the hog in the 
developed stage as well as in the encysted form, but it is 
introduced into the human system, generally, if not always, 
in the latter stage, as in this stage it is more likely to 
escape destruction by the process of cooking. The worms' 
favorite habitat is the voluntary muscles which they reach 
by piercing the mucous membrane soon after being hatched. 

Body-Snatching in Richmond 
(Edi. in Va. Med. Monthly, Jan.. 18S0) 

Body-snatching in Richmond has been the subject, for 
the past few weeks, of much ventilation through the daily 
papers of this city and other places. 

The acts of incorporation of the two medical colleges in 
Virginia which are State institutions and under State con- 
trol provide that there shall be in each a practical anat- 
omical course. .Anatomical and dissecting rooms have been 
built and fitted up at State e.xpense and under State law; 
but, unfortunately, there is no "dissection act" as yet 
adopted by the State. In regard to the subjects selected 
for resurrection, so far as we have any occasion to believe, 
the utmost circumspection has been used in selecting those 
bodies whose dissection cannot give grief to the living. 



Scorpion Deadlier Than Black Widow Spider 

(Col. Med., Jan.) 

.\r'uon3. State Board of Health records disclose 35 deaths 

from poisonous insects and reptiles in the past 6J/2 wears, 

of which 25 were caused by the sting of the scorpion. 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



Southern Medicine and Surgery 

Official Organ of 

Tri-State Medical Association of the 

Carolinas and Virginia 

Medical Society of the State of 
North Carolina 



James M. Northington, M.D., Editor 



Department Editors 

Human Behavior 

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

Dentistry 

W. M. RoBEY, D.D.S.- - - Charlotte, N.C 

Eye, Ear, Note and Throat 

Eye, Ear and Throat Hospital Group Charlotte, N. C. 

Orthopedic Surgery 

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

John Stuart Gaul, M.D.) 

Urology 

Hamilton W. McKay, M.D i Charlotte, N. C. 

Robert W. McKay, M.D j 

Internal Medicine 

W. Bernard Kinlaw, M.D --- Rocky Mount, N. C. 

Surgery 

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

Therapeutic* 

Frederick R. Taylor, M.D. High Point, N. C. 

Obitetrlct 

Henry J. Langston, M.D. - ^..Danville, Va. 

Gynecology 
Chas. R. Robins, M.D Richmond, Va. 



Pediatrics 
G. W. Kutscher, jr., M.D 



.Asheville, N. C. 



General Practice 

WiNGATE M. Johnson, M.D Winaton-Salem, N. C. 

Clinical Chemistry and Microscopy 

C. C. Carpenter, M.D. ...Wake Forest, N. C. 

Hospitals 

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

Pharmacy 

W. L. Moose, Ph. G .....Albemarle, N. C. 

Cardiology 

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

Public Health 

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

Radiology 

Allen Bahker, M.D I Petersburg, Va. 

Wright Clarkson, M.D.J 



Offerings for the pages of this Journal are requested 
and given careful consideration in each case. Manu- 
scripts not found suitable for our use will not be returned 
unless author encloses postage. 

This Journal having no Department of Engraving, all 
costs of cuts, etc., for illustrating an article must be 
borne by the author. 



The Columbia Tri-State Meeting 

In a few days the Fellows of the Tri-State Med- 
ical Association of the Carolinas and Virginia wil' 
gather at Columbia for the annual meeting. 

For this meeting a program has been arranged 
with a view to broad usefulness. Whether you b: 
a doctor whose day's work may include everything 
contemplated by those who made your diploma 
declare you to be "very noble and most learned, ' 
or a doctor in "practice limited," — and no matter 
how limited — much of daily helpfulness is offered, 
and in an attractive way. 

Study your program. See the subjects which 
will be presented and the names of the essayists 
and those who open the free discussions; and accept 
our assurance that the main idea will be to put out 
things of solid worth in diagnosis, in cure and in 
comfort. 

Come prepared to stay through, till v/e have 
done the work of the session and said a word in 
commendation of those whose seats will be vacant. 
Bring along your medical neighbor. Write friendi 
inside and outside the Association to meet you^ 
there. Readers of this journal who are not in the 
Association are extended a cordial invitation to 
meet and mingle with us. Don't wait for som? 
one to ask you in person. 

No doctor leaves a Tri-State meeting but he 
feels it was well that he had been there. 

Write this journal for a program if you do not 
have one. 



The Public's Obligation to Doctors 

Anyone not stone deaf hears a deal about the 
obligations of doctors to the public: who has ears 
keen enough to hear anything said about the obli- 
gation of the public to doctors? Albeit many 
who sit in seats once occupied by educators set 
little store by the classics and have only a tolerant 
smile for those who speak up for the Latin and 
the Greek, these studies — if studied — have their 
uses. 

Ligo means bind; obligo, bind about: and it is 
plain that one can not be bound to another, with- 
out the other being bound to the one. 

It has always been held that, by adopting a 
profession, one assumes a special obligation to his 
fellows; and for just as long has it been held that 
society at large has a reciprocal obligation to the 
professions. It would seem that, of late, thos? 
who profess to speak for the public have neglected 
half the postulate. 

This journal has, many times, challenged thos2 
who demand radical changes in medical practice 
to point out a specific instance in which a man, 
woman or child has, because of poverty, been 
denied the services of a physician; and all of the 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



99 



meager evidence offered has been as little convinc- 
ing as tales of "seein' hants" and of having conver- 
sations with the dead. 

The obligations of the public to doctors are 
many and important, much more important to the 
public than to the doctors. 

A good many otherwise sensible grown persons 
appear to think the practice of medicine consists 
of the laying on of hands, incantations and giving 
the command ''Take up thy bed and walk." They 
ignore the fact that, in the great majority of cases 
of illness among those who can not pay for doc- 
tor's services, the indispensables for recovery are 
proper food, clothing and shelter right now, and 
the mental relief which only assurance of the con- 
tinuation of these supplies would afford. Could 
anything be more ironically stupid than to assume 
that a doctor's visit would accomplish any good in 
a case of pellagra, when there is no money to buy 
proper food for the patient or other members of 
the family? 

For my part — and doctors generally will back 
up the offer — I would gladly contract to supply 
medical services gratis to every person unable to 
pay, the blatant philanthropists to supply at their 
expense the needed food, clothing, coal, shelter, 
medicines, furniture, school-books and other neces- 
sities. 

Food, clothing and shelter are every-day essen- 
tials. Medical care is rarely needed for more than 
a few days in the year. Why not have first things 
first, and provide "through taxation or insurance'' 
for properly feeding, clothing and sheltering every- 
body? Prevention is better than cure. The plan 
suggested would keep folks from starving or freez- 
ing, suddenly or by slow degrees; it would prevent 
more than half the cases of tuberculosis and pel- 
lagra; it would greatly reduce the incidence, the 
time in bed and the death-rate in most acute dis- 
eases; it would prevent or delay heart and kidney 
disease; it would keep a whole lot of persons from 
having peptic ulcers, and a lot of others from losing 
their minds. 

Other obligations to doctors that come to mind 
right now is the obligation which should, but does 
not, bind newspapers to refuse to lend or hire their 
pages for the dissemination of plainly fraudulent 
claims as to the value of wonderful medicines and 
methods; the obligation which should put a heavy 
hand on fortune-telling, mental telepathy and 
every other form of superstition; the obligation to 
accept and support the teachings and the leadership 
of the regular medical profession as to inoculations, 
autopsies, worthless and dangerous drugs, and in 
all health matters. Medicine has done its work well 
and still is doing it far better than any other group 
is doing its job. But for the hindrances from poli- 



ticians and other lawyers, newspapers and maga- 
zines and radios, and certain brands of so-called 
religion, it would do a whole lot more. 

What a pity it is that everyone does not realize 
the deep significance of, — Lord protect us from our 
friends; against our enemies we can defend our- 
selves. 



What's a Plain Doctor of Medicine For? 
This question must come into the mind of every 
individual at some time and, as time goes on, it 
seems to press more and more for answer. 

The only conclusion in the report of the late and 
unlamented Committee on the Costs of Medical 
Care with which this journal agreed was the one 
which said 80 to 85 per cent, of medical care 
should be rendered by family doctors. One could 
wish the Committee had gone into particulars. 

Learned and dignified Faculties accept certain 
young men and women as promising, and, after 
many years of arduous application, the few surviv- 
ors are certified to be Doctors of Medicine, worthy 
to be recommended to the general public as capa- 
ble physicians and surgeons, but, strangly contra- 
dictory, a good many of the members of those 
Faculties immediately join in with others who 
have limited their practice to a special field in 
saying, in effect, You are capable physicians and 
surgeons in every field but mine. 

All this is confusing. How is the confused young 
doctor to know what he should attempt? How is 
a head of a family to know the proper procedure 
for providing proper health care for those depend- 
ent on him and for himself? 

Should practice be divided according to organs, 
according to regions, according to special diseases, 
according to sex, according to age, according to 
station in life, according to therapeutic methods, or 
according to means of making a livelihood? 

If according to organs should one man do the 
medicine and the surgery of, say, the stomach?; or 
should there be two or more? 

When there is something wrong with an eyelid 
should the patient be in the hands of a skin spe- 
cialist or an eye specialist?, or maybe a cosmetic 
surgeon, or a radiologist or a cancer specialist? 
If the person with the diseased eyelid happen to 
be a child under seven, or a pregnant woman, 
would either of these factors have a determining 
influence? 

Up to a few weeks ago we had blandly assumed 
that one disease condition had been properly as- 
signed — and that there was no dissent to this as- 
signment. Now it seems that even that is contro- 
versial. 

In our issue for January is published an article' 
from which we quote: 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



"There is no single renal pathological entity that 
should not be under the supervision of the urologist 
rather than the internist." Who would have an- 
ticipated that organ specialism would have attempt- 
ed to go that far? 

All of us are appreciative of the manipulative 
dexterity and of the great usefulness of the urolo- 
gists. Every doctor looks upon urology as among 
the most valuable of the specialties. However, 
whenever urologists attempt to label Bright's dis- 
ease as theirs, or to supersede the medical men as 
the proper ministers to those suffering this chronic 
constitutional condition, with manifestations in the 
heart, the blood, the brain, the eyes, the lungs, the 
bloodvessels, the liver — indeed in all the tissues of 
the body — it is time to call a halt. 

It is not our belief that the opinion of this one 
urologist is generally held by urologists. We do 
not believe that there was ever a time when Dr. 
Hugh Young would have said that a patient with 
chronic Bright's disease would be better off under 
his care than under the care of Dr. Barker or Dr. 
Thayer. 

If the medical man is not the one to be in su- 
preme command in the management of what are 
commonly called the medical diseases of the kid- 
neys, then he should undertake no more in his 
profession than to act as a traffic director, advising 
which specialist should be consulted, until that 
early day when all patients would choose their own 
specialist, and the species plain doctor perish from 
the earth. 



1. Nephritis a Medical or a Urological Problem, Elmer 
Hess, M.D., Erie, Penn. 



bill. Some doctors enter in a casual way, apparently un- 
conscious of the patient's presence, and talk about the 
weather or the fire, while the patient longs for succor. The 
egotistic kind first must tell how busy they are and how 
little sleep they snatch between the rings of the telephone, 
how fast they have to drive to reach the outposts of dis- 
ease, and how extraordinary are the cures they make; these 
give comfort to some, but mostly to themselves. There is 
the stumbling lout, whose bag upsets the vase of flowers, 
and who sets his bulky hulk upon the bed; the patient 
forgives much in the hope that the doctor is mighty also 
in healing power. The business-man phj'sician whose man- 
ners smack of the marts of trade, smart, abrupt and dap- 
per, impresses the patient that he is attending a board 
meeting and wants the minutes read at once; the patient 
wishes he were more sympathetic. And then comes the 
doctor of mystery, all quiet and sedate, with soft voice, 
and furtive words, and sanctimonious manner; the patient, 
if of the susceptible type, thinks of wonders and of mira- 
cles. 

When the patients do well under their administrations, 
which in nine cases out of ten they do, each of these 
peculiarities becomes glorified into a healing virtue, and 
the doctor goes on cultivating his idiosyncrasy. 

The vast number of highly qualified physicians come 
under none of these classifications. Most physicians are 
just plain doctors. They may be tinctured with some of 
these traits, but not enough to matter. They exemplify 
good bedside manners. They possess urbanity; it is ob- 
vious that they are gentlemen; they do and say the thing 
that is fitting ; they do about their business with dignity, 
directness, and dispatch; it is clear that they have the 
matter in hand ; and then, when they have finished, they 
say the few words that indicate sympathy and understand- 
ing, and quietly take their leave. 



Doctors, Doctors and Doctors 
(Editorial Bui. St. Louis Med. Soc, Nov.) 
Some doctors come plunging into the chamber of the 
sick like a fireman about to extinguish a conflagration; 
they alarm the patient. Some come Like a detective looking 
for a criminal, and give the patient cold creeps. Others 
enter stealthily like a cat stalking a bird, and are beside 
the patient and pounce upon the pulse before any one is 
aware; they fill the patient with a weird sense of the 
chase. There is a class that come like purring doves, as 
though they would make love; they are thought nice by 
sentimental ladies. There are the doctors with the doleful 
faces, Hke the hired mourners who follow the catafalque: 
if the patient is bad they make him worse; if he is not 
they cause him to smile. A common lot enter like the 
monologue artist on the vaudeville stage and start a bar- 
rage of wise-cracks that entertain the nurse and amuse 
themselves, while the patient waits for business to begin. 
Then there is the radiant doctor who has studied how to 
impress himself upon others and fill the room with the 
effulgent aura of his personality ; he impresses only the 
weak-minded. There is the pompous doctor of the school 
of hope, who comes with a strong expression and eyes 
beaming with glad tidings; he scares the demon of disease, 
and makes the patient fearful of the size of the doctor's 



The Practical Bearing of Recent Advances in Cerebral 
Localization and General Thermometry 



We have, I think, in cerebral thermometry a means of 
determining the situation of lesions of the greatest value. 
In a letter recently received a friend mentions a recent 
case of middle ear trouble, followed by coma and death, 
in which the rise of temperature above the diseased ear 
was very marked. 

You will observe in the diagram that the left side of 
the head at all points shows a rather higher temperature 
than the right. 

There can scarcely be a reasonable doubt, I think, that 
over a localized collection of pus or an inflamed spot there 
would be a very marked rise of temperature, and, indeed, 
the cases to which we have already referred place this fact 
beyond all question. 



Hydrobromate of Quinine Hypodermically 

(G. Wm. Semple, Hampton, in Va. IVIed. Monthly, Jan., 
1SS2) 

.•\ continued experience of the effects of a solution of 
the hydrobromate of quinine increases my confidence in 
the remedy for hypodermic injection. Twenty minims of 
the solution, containing grs. iv of the salt, administered 
by hypodermic injection 2 hrs. before the expected chill, 
is much more certain to prevent the paroxysm than 20 
grs. of the sulphate administered in the course of 8 pre- 
ceding hours. It does not produce cinchonism or any of 
the other unpleasant effects so often the result of the sul- 
phate. Those subject to urticaria from the sulphate can 
take it with impunity. 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



Eli Lilly 4ND Company 

FOUNDED 18 76 

!Makers of ^Medicinal Products 




Widespread clinical application has demon- 
strated the effectiveness of Merthiolate as 
a first-aid antiseptic. It is admirably suited 
for use in many surgical fields, f Merthiolate 
(sodium ethyl mercuri thiosalicylate, Lilly) 
is an organic mercurial compound. For 
special application in medicine and surgery, 
Merthiolate is incorporated in a colored 
alcohol - acetone - aqueous tincture, in an 
ointment base, in a water-soluble jelly, and in 
a modified greaseless cream. Salient points: 
i High germicidal activity 2 Rapidity of disin- 
fection 3. Sustained action. 4 Jissue comjHilibilily 



Prompt Attention Qiven to Professional Jncfuiries 

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



Please Mention THIS JOURNAL When Writing to Advertisers 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



NEWS ITEMS 



The Southeastern Surgical Conrgess New Orleans 
Assembly 

The following doctors to appear on the program with 
papers and clinics; 

Arthur W. Allen, Boston; Roger Anderson, Seattle; 
W. T. Black, Memphis; 0. P. Board, Birmingham; Charles 
O. Bates, Greenville, S. C; Guy Caldwell, Shreveport; 
Thomas E. Carmody, Denver; Virgil S. Counseller, Roch- 
ester, Minn.; George W. Crile, Cleveland; Roger G. 
Doughty, Columbia; John F. Erdman, New York; Edgar 
Fincher, jr., Atlanta; Paul G. Flothow, Seattle; Emmerich 
von Haam, New Orleans; W. D. Haggard, Nashville; 
Arthur Hertzler, Halstead, Kan.; Gerry Holden, Jackson- 
ville; C. C. Howard, Glasgow, Ky.; Chevalier Jackson, 
Philadelphia; Kerry H. Kerr, Washington; Joseph E. King, 
New York; Francis E. Lejeune, New Orleans; Jennings 
Litzenberg, Minneapolis; James S. McLester, Birmingham; 
Julian A. Moore, Asheville; Fred Rankin, Lexington, Ky.; 
J. U. Reaves, Mobile; Curtice Rosser, Dallas; Alfred A. 
Strauss, Chicago; A. Street, Vicksburg, Miss.; J. W. Tank- 
ersley, Greensboro, N. C; Alan C. Woods, Baltimore. 

// you do not receive a program by the first oj March 
write for one to Dr. B. T. Beasley, Atlanta, Ga. 



The first meeting of the Neuropsychiatric Society of 
Virginia was held at the Memorial Hospital in Richmond 
on January 24th. The officers of the organization are: 
Dr. David C. Wilson, University, president; Dr. R. Finley 
Gayle, Richmond, vice president ; Dr. Frank H. Redwood, 
Norfolk, secretary-treasurer. 



Dr. Henry G. Turner was elected president. Dr. 
Ch.^vrles p. Eldridge, secretary. Dr. E. C. Judd, treasurer; 
and Drs. J. W. McGee, Hubert B. Haywood and Z. M. 
CANfENESS were placed on the board of censors, at the 66th 
annual meeting of the Raleigh Aa'U>EMY of Medicine 
Feb. 1st. 

The Academy elected Dr. Carl V. Reynolds, State 
Health Officer, as a member. Dr. Reynolds came to Ralei^^h 
from Asheville more than a year ago to succeed the late 
Dr. James M. Parrot as State Health Officer. 

Dr. Hubert Royster discussed briefly the histor\- of the 
.Academy, founded in February, 1870, and the oldest medi- 
cal organization in the State in point of continuous and 
active existence. 



At the annual meeting of the board of trustees of Baker 
Sanatorium, Luraberton, held there January 16th, K. M. 
Biggs was elected president of the board and R. H. Liver- 
more vice president. 

Dr. H. M. Baker, who has been at the head of the in- 
stitution since it was founded 14 years ago, was re-elected 
v.'ith the title of administrator, secretary and treasurer. 
His report showed the hospital to be in excellent condition, 
with a nice profit for the year, exclusive of an addition 
costing about $14,000 which increases the capacity from 65 
to 81 beds. 



The scientific meeting of the staff of the McGuire Clinic 
en evening of January 21st, in the Library of the Clinic 
Building. Program: My Most Humorous Case, Dr. John 
B. Williams; My Most Mortifying Case, Dr. Stuart Mc- 
Guire; Addison's Disease with Report of Case, Dr. CHfford 
Beach; Treatment Fibromyoma Uterus with X-ray, Dr. J. 
L. Tabb. 



Mecklenburg County Medical Society, first regular 
meeting for the year, evening of January 7th, Medical 



Librar>', Charlotte, President McKay in the chair. 

Dr. H. C. Neblett gave an instructive case report of an 
infection of Tenon's capsule; discussed by Dr. H. L. Sloan. 
Dr. H. L. Sloan gave a paper, Ocular Tendon Transplan- 
tations for Paralytic Squint, with lantern slides; discussed 
by Dr. H. C. Neblett. 

The meeting then was given over to business. 

Dr. Andrew Blair, Chm. Com. on Hospital Savings As- 
sociation, reported: 

" This committee feels that the Hospital 

Savings Association plan contains many desirable features 
and we are desirous to co-operate in every way consistent 
with the high ideals of the medical profession. When the 
plan was first presented to the Medical Society, the mem- 
bers of the committee understood that it was to cover 
hospital board, room and care, and not medical services. 
We firmly believe that the practice of medicine is indi- 
vidual, personal ser\-ice and should not be contracted for 
or sold by any organization, except one organized and 
operated by the doctors involved. We also understood 
that the privileges of the Hospital Savings Plan were to 
have been extended only to those whose incomes came 
within the lower brackets. We believe that this principle 
should be adhered to as closely as possible. 

"A. X-ray: The roentgenologist is and should be a 
highly specialized doctor of medicine and as such he should 
be recognized and his ser\'ices may not be sold to anyone 
except by the doctor himself. 

"B. Anesthesia: In Charlotte the doctors give nearly' 
all anesthetics and wc see no reason why their services 
should be drafted. 

"C. Pathology: .... Pathologists should be and are 
(as it is in this city) specialists in a certain branch of 
medicine and have the responsibility of the selection of 
all laboratory methods, standardizations, interpretations, 
clinical applications and pathological diagnoses. Their pro- 
fessional services may not be sold to anyone except by 
themselves 

"In a joint meeting of representatives of the staffs of all 
the hospitals in Charlotte and this committee .... it was 
the unanimous opinion that: 

"1. No contract should be entered into by any of these 
hospitals without a reasonable assurance that the contract 
was workable and could be maintained for more than 30 
days. 

"2. The hospitals will not assume the responsibility ol 
carrying out the contract of the Hospital Savings Associa- 
tion with their members unless all hospital charges are 
paid for by their association. 

"3. Professional medical services should not be con- 
tracted for or sold by any organization except one organ- 
ized and operated by the doctors involved. 

"4. The hospitals will not give any reduction on the 
bill for time spent in the hospital beyond the 21 -day limit 
of the contract. 

"It was agreed by both committees that the hospitals 
of Charlotte would and could furnish for $4.00 a day 
the following: bed in ward, board, floor nursing, use of 
delivery and operating room, dressings, simple and routine 
medication, routine urinalyses and blood counts and one 
blood chemistry determination. 

".\nyone wishing to occupy another room at any time 
other than the one in the ward, will be given a credit of 
S4.00 per day for the number of days specified in his 
contract, this period of time being paid for by the Hospital 
Savings Association. 

"The committee sees in no way how the contract fur- 
nished to the patient helps lift the load from the hospital. 
The committee feels that the individual whose income falls 
within the lower level is the one who should be helped. 



February, 1936 



SOUTHERN MEDICINE AND SURGERY 



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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 



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SOUTHERN MEDICINE AND SURGERY 



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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 
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751 



Analg«sle and Sedative 7 parts 5 parts I part 
Aspirin Phenacetin Caffein 



We will mail projessional samples regularly 
with our compliments if you desire them. 
Carolina Pharmaceutical Co., Clinton, S. C. 



Orangeburg High School. She is a daughter of Mrs. Ger- 
trude Strom Thurmond and the late J. William Turmond. 
Doctor Bishop is a son of Mr. and Mrs. W. W. Bishop, 
Inman, and is one of the most successful young physicians 
of the State. He received his medical training from the 
South Carolina Medical College in Charleston and was 
afterwards on the staff of Roper Hospital before going 
to Greenwood. 

F'uncral services for Dr. Joseph Walker Eargle, 88, of 
Chapin, who died January 4th, were conducted in the 



108 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



afternoon of the 5th from Mount Olivet Lutheran Church 
at Spring Hill. Doctor Eargle was a pioneer physician in 
the Dutch Fork section, where he practiced for 61 years. 
He was born in the Dutch Fork, July 14th, 1847, and 
attended school in Lexington County. He received a lit- 
erary degree from Mount Pleasant Collegiate Institute in 
North Carolina and was graduated from the South Caro- 
lina Medical College in Charleston. He took post-graduate 
work at Columbia University and served his intemeship 
at Bellevue Hospital in New York and at Roper Hospital 
in Charleston. 



BOOK REVIEWS 



Dr. J. F. Foster, prominent physician and a leading 
physician and a leading citizen of Sanford, N. C, has been 
selected as Lee County's Man of the Year for 1933, in the 
recent contest sponsored by the Sanford Herald, and has 
been awarded a silver loving cup. 



Dr. T. Stanley Meade announces the opening of offices 
at 913 Floyd Avenue, Richmond, Virginia. Practice lim- 
ited to Care of Infants and Children. 



Dr. Tom Sasser, Charlotte, announces the removal of 
his office to the First National Bank Building. 



Miss Edna Elizabeth Keily of Bristol, Tenn., and Dr. 
Bernard Showalter of Kenbridge, Va., on Dec. 19th. 



Dr. Hubert A. Royster, jr., of Philadelphia and Miss 
Elizabeth Rutan of Bryn Mawr were married at the home 
of the bridge on January 17th, 1936. 



Dr. Charles Walton Purcell of Charlottesville and Miss 
Cleo Virginia Ashby of Raleigh. 



Deaths 

Dri-Ghades-P.-Smithj 7S, prominent physician and well 
known in political circles, died Jan. 17th at his home at 
Martinsville, Va. 



Dr. Frank Vaughan Fowlkes, retired, of Richmond, Jan- 
uary 20th, following a paralytic stroke suffered the day 
before. 



Dr. Thomas W. Edmunds, 50, Danville, Va., for many 
years an eye, ear, nose and throat specialist, died Feb. 1st 
of puneumonia in a hospital at Clearwater, Fla., where he 
went two weeks ago because of a cold. 



Dr. Clarence Linden Lewis, 65, retired, January 17th, at 
Bilo.xi, Miss. 

Dr. Lewis established his residence in Richmond about 
ten years ago, moving to this city from Nashville, after 
retiring from the active practice of his profession. 



Dr. .-Mfred Alfred W. Howell, 7S, died at his home at 
Cherryville, N. C, Jan. 18th, after months of failing 
health. Dr. Howell was born in Cherokee County, Ga., 
and had been engaged in the general practice of medicine 
in Cherryville for 52 years. He was active and kept up his 
practice until about two months ago. Among the surviv- 
ors are two doctor sons: Dr. John H. Howell, Anderson, 
S. C, and Dr. Wayne Howell, Gaffney, S. C. 



I had an ambition for surgery — general surgery — and 
performed all sorts of beautiful and brilliant operations. — 
From The Story of My Life, by J. Marion Sims. 



SOCIAL SECURITY, by Edward H. Ochsner, M.D., 
Chicago. Social Security Press, 538 S. Wells St., Chicago, 
Cloth bound, 231 pages, 50c, postpage prepaid in U. S. 

Woodrow Wilson is quoted: "It will be a bad 
day for society when sentimentalists are encouraged 
to suggest all the measures that shall be taken for 
the betterment of the race." 

Dr. Ochsner has had experience with German 
Medicine institutions. He was for four years presi- 
dent of the Illinois State Charity Commission. His 
experience with the practical operation of the va- 
rious forms of social security insurance and large 
charities both in Europe and in this country qualify 
him to speak. 

The book discusses old age pensions, unemploy- 
ment insurance, compulsory health insurance, and 
widows' and orphans' pensions. He would arouse 
the professions and the general public to an impend- 
ing danger and dispel a number of quite generally 
held false opinions. 

Under social insurance in other countries the 
number of days lost by the German worker from 
sickness has more than doubled, and the mortality 
rate is higher in Germany today than in this coun- 
try. The quality of medical services has deteriorat- 
ed under compulsory health insurance and the costs 
of hospital and medical care are increasing year 
by year. 

Dr. Ochsner's book is not burdened with vol- 
uminous statistics. Many first hand experiences 
are recited and the facts are forcibly stated. The 
work attracts by what it says and by the method 
of saying. 



THE 1935 YE.\R BOOK OF GENERAL SURGERY, 
edited by Ev.\rts A. Grah.«i, A.B., M.D., Professor of 
Medicine, Washington niversity school of Medicine, St. 
Louis. The Year Book Publishers, Inc., 304 S. Dearborn 
St., Chicago. 3.00 postpaid. 

Peripheral vascular disease has much said about 
it, likewise thoracic surgery and acute pancreatic 
diseases. New features in preparing patients for 
operation are brought forward. Certain of the 
newer anesthetics have much said for them. Im- 
provements in operative technique are described. 
Wound healing and improved bone surgery are fea- 
tured, Dr. A. G. Brenizer on Cancer of the Thyroid 
is given a long abstract, Ulcer of the Stomach is 
given much space. Splenectomy seems to be re- 
gaining its popularity, but to be used with great 
discrimination. The editor's comments are pithy 
and pertinent. 



"As the calorimeter tells the activity of the patient's met- 
abolism, so may you determine the plus or minus activity 
of the local profession in any district by the condition of 
its library." — Harvey Cushing. 



February. 1036 



SOUTHERN MEDICINE AND SURGERY 




AS AC 

ELIXIR ASPIRIN COMPOUND 

ANTI-RIIEl'M Vnc MItJUAIMi: 



Indications 

All conditions in which any of the Salicylates 
liave proven of value for the relief of Rheumatism. 
Neuralgia, Tonsillitis, Headache; also pre and post 
minor operative cases, especially removal of the 
tonsils. 

Description 

ASAC contains five grains of Aspirin, two and 
line-half g'rains Sodium Bromide, and one-half grain 
( 'afFeine Hydrobromide to the teaspoonf ul in stable 
Elixir. 

Dosage 

The usual dose, subject to modification by the phy- 
sician, ranges from two to four teaspoonfuls in one 
to three ounces of water. 

How Supplied 

In Pints, Five-Pints and Gallons to Physicians and 
Druggists only; thus eliminating the self medication 
now so prevalent with Aspirin in tablet form. 



Burwell & Dunn Company 

Manujactiiring Plianiiaciils 

CHARLOTTE, N. C. 

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



The Doctor Looks at the Cults 
(C. L. Farrell, Pawtucket. in R. I. Med. Jl., Jan.) 

The medical profession's attitude has been more or less 
indifference toward them. When any group begins to leg- 
islate itself into the same standing as the medical pro- 
fession, it is time that something was done. 

/ believe that it is the solemn duty of the medical pro- 
Jession to protect the people from charlatans and quack- 
ery and that the education of the people in the matters 
of heahh must be undertaken by us. 

A few years ago many neurotic persons had "adjust- 
ments" apparently without any harm resulting and the 
medical doctor recognized that the cult was supplying a 
mental peace to the inferior minds that needed a placebo. 

I questioned their committee at the State House last Jan- 
uar>- as to why they wanted to administer drugs when 
the osteopathic principles were against it. To my amaze- 
ment, they refused to be bound by this principle. They 
had no answer when I informed them it was the word 
of their founder, A. T. Still. Further conversation with 
these osteopaths, elicited the belief that osteopathy was 
but one therapeutic measure in their armamentarium and 
it was no longer regarded as a separate theory of disease. 

Because of the indifference of organized medicine regard- 
ing osteopathy they have gathered unto themselves dignity 
and privileges to which they are not entitled; there is a 
determined attempt on the part of the osteopaths to legis- 
late themselves into the same standing as regular prac- 
titioners. They desire to be school physicians and health 
officers. They desire to write prescriptions — and this in 
spite of the fact that the most recent pronouncements of 
their authorized schools reiterate their belief in osteopathy 
as originally defined, the frank substitution of osteopathic 
therapeutics and osteopathic medicine in place of materia 
medica and practice of medicine. The basic science law 



will check these individuals in a fair and impartial manner. 
It is the practitioner's privilege to treat the patient any 
way he so desires especially so if it satisfies the patient, but 
we want to be sure that he first recognizes the condition 
he is treating and has been exposed to at least a safe min- 
imum of general training. We in the medical society hope 
to put through a basic science law. So far we have not 
succeeded, but we have made definite progress. You have 
no realization of the outrageous and extravagant claims 
made before legislative bodies by the irregular practitioners, 
and we are always put in the position of being afraid 
of the irregulars and jealous of our hold on the people 
"as a medical trust." 

The fault hes wholly at the door of the medical pro- 
fession because each and every individual in these other 
cuUs strives together for the good of the cults, while the 
doctors are too prone to concern themselves with scien- 
tific assemblies and neglect their professional responsibility 
in public health. 

I hope in the future, as each medical student takes 
his internship, he will begin to pick up that spirit of re- 
sponsibility, shouldering his part of the burdens and re- 
sponsibilities that go with being a doctor. The old policy 
to ignore the irregulars and let the poor fools who will 
patronize them, must be discarded, and a sense of civic 
duty and responsibility recognized wherein we assume the 
role, guardians of the public health in all its phases. 



In December, 1802, Lettsom sent to the College of Phy- 
sicians of Philadelphia a supply of vaccine virus. He was 
elected an .'\ssociate Fellow. But Jenner, proposed by 
Plunket Glentworth, failed of election. 

In 1787 the College of Physicians of Philadelphia ap- 
pointed a committee to submit plans for establishing cold 
and hot baths and a botanical garden for the city. 



SOUTHERN MEDICINE AND SURGERY 



February, 1936 



The Safest Anesthesia vs. Safest Anesthetic 

(Jos. Galasso, New York City, in Anes. & Anal.. 
Jan. -Feb.) 

The odor of cyclopropane is not unpleasant, it is rapidly 
absorbed, very rapidly eliminated, and is non-toxic, and 
non-irritating to the respiratory tract. As far as we know, 
it does not chemically combine with any fluid or tissue in 
the body, is not detoxified in any organ or tissue, does not 
affect metabolism or blood pressure, and does not cause 
any structural or functional change in any organ or tissue. 

There is absolutely no contraindication to its use. Dia- 
betes, tuberculosis, heart disease, nephritis, hypertension, or 
any of the other usual contraindications to the use of the 
ordinary inhalation anesthetic agents present no barrier. 

Not one death or aggravation of existing functional or 
structural disease has been encountered. For intra-abdom- 
inal surgery it shows its superiority over ether in the 
quiet relaxed belly simulating that of spinal anesthesia. 
Vomiting is almost an unheard-of complication when cyclo- 
propane is administered properly — and this is certainly a 
blessing for patients who have had intra-abdominal sur- 
gery and especially of the stomach. Recovery is shortened. 
Fluid and food intake can be instituted much sooner than 
after ether. \ patient who has undergone previous opera- 
tion under ether anesthesia will not only notice the great 
change but will invariably mention the fact that this one 
has been the best anesthetic he has ever taken. 

All anesthetic agents are poisons. The safest avenue of 
administration is that which is most controllable — the in- 
halation route. The best technique of administration is 
the one which insures an atmosphere of at least 20% o.xy- 
gen and carbon dioxide reduced to a minimum. The safest 
anesthetic agent — the one which presents all the good quali- 
ties and none of the objectionable side effects of the agents 
we have on hand is cyclopropane. 



Hiccough 

(E. L. Kellog & Wm. Meyer, New York, in Med. Rec, 
Nov. 20th) 

Dr. Gibson quotes the following passage from Plato's 
Dialogues: "when Pausanias came to a pause Aristodemus 
said that the turn of Aristophanes was next, but that he 
had the hiccough, and was obliged to change with Eryxi- 
machus, the physician, who was reclining on the couch be- 
low him. ■En.'ximachus' he said, 'you ought either to stop 
my hiccough or to speak in my turn until I am better.' 

" 'I will do both,' said Eryximachus, 'I will speak in 
your turn and do you speak in mine ; and while I am 
speaking, let me recommend that you hold your breath, 
and if this fails, gargle with a little water; and, if the 
hiccough still continues, tickle your nose with something 
and sneeze, and if you sneeze once or twice, even the 
most violent hiccough is sure to go. In the meantime I will 
take your turn and you shall take mine'." 

Among unusual measures are intubating the esophagus 
leaving the tube in situ, digital compression of the phrenic 
nerve, lifting up the hyoid bone and compressing it with- 
out checking respiration, grasping the left carotid sheath 
with the thumb and forefinger at the anterior border of 
the middle portion of the sternomastoid muscle and com- 
pressing it tightly for one minute, hypodermic injections 
of apomorphine (J^th gr.), hypnotism, an emetic dose of 
ipecac, hypodermic injections of ether and inhalations of 
carbon dio.xide and oxygen. Lumbar puncture has relieved 
a case of 15 months' duration. 



Thyroid extr.^ct accelerates the transition of salt and 
water from the tissue. It is best used in chronic nephrosis, 
3 to 15 gr. daily, with a high-protein diet. — Harold W. 
Jones. 



Should you be disappointed in quinine by mouth 
(0. F. Manson, Richmond, in Va. Med. Monthly, Jan., 
1882), you may give it by the rectum, and should this 
be expelled, we have, thanks to a recent discovery, an 
invaluable resource in the hypodermic method. Dissolve 
the dose in a half drachm of distilled water, by the addi- 
tion of 1 drop of dilute sulphuric acid to the grain of the 
sulphate, and inject it. There are objections to its use, 
in this way — the principal one being the excitement of 
local inflammation, and the production of troublesome 
abscesses. Usually, by persistence in its use, enough quinine 
will be absorbed by the buccal and gastric mucous mem- 
brane to bring the patient under its influence. 



The Electrocardiogram (L. H. Signer, in Med. Times 
&■ L. I. Med. JL, Jan.) must be correlated with chnical 
findings if significance is to be attached to it. As a lab- 
oratory method, a full understanding of possible techni- 
cal errors and a proper interpretation of the findings are 
imperative in order that we be not misled rather than 
aided in our diagnosis. 



The sexton had been laying the new carpet on the pulpit 
platform, and had left a number of tacks scattered on the 
floor. « 

"See here, James," said the parson, "what do you suppose 
would happen if I stepped on one of those tacks right in 
the middle of my sermon?" 

"Well, sir," replied the sexton, "I reckon there'd be one 
point you wouldn't linger on." — Waichii'Drd. 



Couldn't Remember One Off-hand 

Ed — "I guess you've been out with worse looking fellows 
than I am, haven't you?" 

Ed — "I say, I guess you've been out with worse looking 
fellows than I am, haven't you?" 

Cod-ed — "I heard you the first time. I was just tr>'ing 
to think." 

No answer. 



Somebody pulled the bell rope. The engineer put on the 
brakes too quickly, and one of the cars went off the rails. 
"We'll be tied up about four hours," announced the con- 
ductor. 

"Four hours!" exclaimed a passenger. "But I'm to be 
married today!" 

"See here," the conductor demanded, "you aren't the guy 
who pulled the bell rope, are you?" 



.^n old lady who could not see eye to eye with the taxi- 
driver on the question of fare, finally remarked: "Don't 
you try to tell me anything, my good man. I haven't 
been riding in taxis for five years for nothing." 

"No," replied the driver, "but I know you made a 
faithful try!" 



I 



"Your Honor," said the prisoner, "will I be tried by a 
jury of women?" 

"Be quiet," whispered his counsel. 

"I can't be quiet ! Your Honor, I can't even deceive my 
own wife, let alone 12 women." 



"This tonic is no good." 
"What's the matter?" 

".\11 the directions it gives are for adults, and I never 
had them." 



February. 1Q36 



PROFESSIONAL CARDS 



GENERAL 



Nalle Clinic Building 



THE NALLE 

Telephone— i-2\-i\ (If no 
General Surgery 

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

EDWARD R. HIPP, M.D. 

Traumatic Surgery 

PRESTON NOWLIN, M.D. 
Proctology & Urology 



CLINIC 

answer, call 3-2621) 

General Medicine 



412 North Church Street 



Consulting Staff 

DOCTORS LAFFERTY & PHILLIPS 
Radiology 

HARVEY P. BARRET, M.D. 
Pathology 



LUCIUS G. GAGE, M.D. 
Diagnosis 



G. D. McGregor, m.d. 

Neurology 



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



J. R. AD.'\MS, M.D. 

Diseases of Infants & Children 



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



BURRUS MEMORIAL HOSPITAL, INC. 

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



High Point, N. C. 



Diagnosis, Vro 
Pediatrics, X-Ray and Radium, Physiotherapy, Clinical Laboratories 
STAFF 
John T. Burrus, M.D., F.A.C.S., Chief Everett F. Long, M.D. 

Harry L. Brockmann, M.D., F.A.C.S. 
Phillip W. Flagge, M.D., F.A.C.P. 



O. B. Bonner, M.D., F.A.C.S. 
S. S. Saunders, B.S., M.D. 
E. A. Sumner, B.S., M.D. 



WILSON CLINIC, INC. 

AND 

WOODARD-HERRING HOSPITAL, INC. 

SUCCESSORS TO 
The Moore-Herring Hospital 

WILSON, N. C. 



Surgery 

C. A. WOODARD, A.B., M.D., F.A.C.S. 

Pediatrics and Obstetrics 

G. E. BELL, B.S., M.D. 



X-Ray and Traumatic Surgery 

M. A. PITTMAN, B.S., M.D. 

General Medicine 

R. L. FIKE, A.B., M.D. 



Miss Leona D. Boswell, R. N. 

SUPERINTENDENT OP 

The Training School For Nurses 



L. C. TODD, M.D. 

Clinical Pathology and Allergy 

Office Hours: 

9:00 A. M. to 1:00 P. M. 

2:00 P. M. to 5:00 P. M. 

and 

by appointments, except Thursday afternoon 

724 to 729 Seventh Floor Professional Bldg. 

Charlotte, N. C. 

Phone 4392 



WADE CLINIC 

Wade Building 
Hot Springs National Park, Arkansas 

H. King Wade, M.D. Urologist 

Charles S. Moss, M.D. Surgeon 

J. 0. Boydstone, M.D. Internal Medicine 

Jack Ellis, M.D. Internal Medicine 

N. B. BuRcn, M.D. 

Eye, Ear, Nose & Throat 
Raymond C. Turk, D.D.S. Dentist 

A. W. ScHEER X-ray Technician 

Miss Etta Wade Clinical Pathologist 



Please Mention THIS JOURNAL When Writing to Advertisers 



PROFESSIONAL CARDS 



February, 1936 



INTERNAL MEDICINE 



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

INTERNAL MEDICINE 
DISEASES OF THE CHEST 

Pine Crest Manor, Southern Pines, N. C. 



STEPHEN W. DAVIS, M.D. 

Diagnosis 

Internal Medicine 

Passive Vascular Exercises 

Oxygen Therapy Service 

Medical Arts Bldg. Charlotte, N. C. 



JAMES M. NORTHINGTON, M.D. 

Diagnosis and Treatment 

in 
INTERNAL MEDICINE 

Professional Building Charlotte 



ORTHOPEDICS 



J. S. GAUL, M.D. 


ALONZO MYERS, M.D. 


ORTHOPEDIC SURGERY and 


ORTHOPEDIC SURGERY and 


FRACTURES 


FRACTURES 


Professional Buildinff Charlotte 


Professional Building Charlotte 



HERBERT F. MUNT. M.D. 



FRACTURES 
ACCIDENT SURGERY and ORTHOPEDICS 



Nissen Building 



Winston-Salem, M. C. 



EYE, EAR, NOSE AND THROAT 



AMZI J. ELLINGTON, M.D. 



Diseases of the 
EYE, EAR, NOSE AND THROAT 



PHONES: 
Burlington 



Office 992— Residence 761 

North Carolina 



J. SIDNEY HOOD, M.D. 

Diseases of the 
EYE, EAR, NOSE AND THROAT 

PHONES: Office 1060— Residence 1230-J 
3rd National Bank Bldg., Gastonia, N. C. 



H. C. NEBLETT, M.D. 

OCULIST 

Phone 3-5852 

Professional Building Charlotte 



Please Mention THIS JOURNAL When Writing to Advertisers 



Februan', 1036 



PROFESSIONAL CARDS 



OBSTETRICS and GYNECOLOGY 



C. H. C. MILLS, M.D. 

OBSTETRICS 

Consultation by Appoint 

1st Nat'L Bank Building Charlotte 



NEUROLOGY and PSYCHIATRY 



W. C. ASHWORTH, M.D. 

W. CARDWELL, M.D. 

yERVOUS AND MILD MENTAL 

DISEASES 

ALCOHOL AND DRUG ADDICTIONS 

Glenwood Park Sanitarium. Greensboro 



\Vm. Ray Griffin, M.D. 



Appalachian Hall 



M. A. Griffin, M.D. 



DOCTORS GRIFFIN and GRIFFIN 

NERVOUS and MENTAL DISEASES, 
and ADDICTIONS 



UROLOGY, DERMATOLOGY and PROCTOLOGY 



THE CROWELL CLINIC OF UROLOGY, DERMATOLOGY AND PROCTOLOGY 

Suite 700-717 Professional Building Charlotte, N. C. 

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

STAFF 

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

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

Dr. Hamilton McKay Dr. Robert McKay 

DOCTORS McKAY and McKAY 

Practice Limited to UROLOGY and GENITO-URINARY SURGERY 

Hours by Appointment 

Occupying 2nd Floor Medical Arts Bldg. Charlotte 



WYETT F. SIMPSON, M.D. 

GEXITO-URJNARY DISEASES 

Phone 1234 

Hot Springs National Park Arkansas 



C. C. MASSEY, M.D. 

Diseases of the Rectum &■ Coloh 

Professional Bldg. Charlotte 



Please Mention THIb JOURNAL When Writing to Advertisers 



PROFESSIONAL CARDS 



February, 1936 



SURGERY 



G. CARLYLE COOKE, M.D. 
GEO. W. HOLMES, M.D. 



Diagnosis, General Surgery and X-Ray 
Nissen Bldg. Winston-Salem, N. C. 



R. B. Mcknight, m.d. 

General Surgery 
Professional Bldg. Charlotte 



SPECIAL NOTICES 



THE EDITING OF MEDICAL PAPERS 

This journal has arranged to meet the demand for the service of editing and revis- 
ing papers on medicine, surgery and related subjects, for publication or presentation 
to societies. This service will be rendered on terms comparing favorably with those 
charged generally in other Sections of the Country — taking into consideration the 
prices paid for cotton and tobacco. 

SOUTHERN MEDICINE & SURGERY. 



Please Mention THIS JOURNAL When Writing to Advertisers 



Journal 

of 

SOUTHERN MEDICINE ^ SURGERY 



Vol. XCVIII 



Charlotte, N. C, March, 1936 



No. 3 



Art of Practice and Healing 

C. C. Orr, jNI.D., Asheville, North Carolina 



IX choosing a subject for the address which 
it is my privilege to make at this time, I was 
mindful of the fact that my audience is com- 
posed of general practitioners and sf>ecialists in all 
the different branches of healing and that many sub- 
jects that would interest one class would be wholly 
uninteresting to others. After careful considera- 
tion I have decided to speak to you on the Art of 
Practice and Healing, a subject which if carefully 
studied and understood will add much to the suc- 
cess of general practitioners and specialists alike. 

By art of practice and healing we mean skill or 
proficiency in doing it. Art, in general, is but 
the employment of the powers of nature for an end. 
It uses system and traditional methods for facilitat- 
ing the performance of certain actions. The art 
of practice and healing is closely allied with the 
science of medicine and the one is more or less de- 
pendent upon the other. Yet, the object of science 
is knowledge and truth — the object of art is work. 
Both may be said to be investigations of truth; but 
science inquires for the sake of knowledge, art for 
the sake of production; hence they differ some- 
what in that with which they are concerned. 
Science is analytical and critical while art is syn- 
thetical and constructive. Art involves skill in the 
use of knowledge which may have been furnished 
by the corresponding science. It may be viewed 
as arranging or systematizing knowledge and form- 
ing rules which are the lessons of experience and 
which are designed to facilitate work and give it 
superior e.xcellence. The more complete the scien- 
tific basis the more perfect the art. Healing as an 
art is the work of the skilled physician: healing as 
a science is the work of the informed and analytical 
brain seeking truth. The relationship of the two 
has been paraphrased thus: ".Art consists in doing, 
science consists in knowing." 



It is difficult to say just when medicine assumed 
a definite status in human affairs, but its origin may 
be traced to the primal sympathy of man with 
man. Sympathy is one of the most effectual of the 
emotions and like all emotions it is the antecedent 
of desire. The emotion of sympathy and pity in- 
spired man with a desire to relieve human suffering 
and pain. In primitive man these emotions were 
concerned more or less with self-preservation and, 
having little or no knowledge of the phenomena of 
nature with which he was surrounded, man sought 
an e.xplanation in the supernatural. This led to 
the setting aside of men who had access to the 
invisible spirits and these men became priests and 
priest and physician were often one. Deification 
became popular. Later medicine and religion sep- 
arated. Those who followed medicine devoted 
themselves to the relief of human suffering with 
no knowledge of the fundamental sciences and the 
resources of the physician were practically limited 
to the art of magic, sorcery and incantations. Fear 
and superstition predominated in the minds of the 
physicians, priests and people. For a period there 
was a belief in astrology. Then came the Greek 
philosophers who often were physicians as well. 
Medicine became still further separated from re- 
ligion and closely associated with philosophy. The 
great impression that Greece made on medicine 
was due to the philosopher-physician. There was 
developed a philosophical reasoning and vivid 
imagination that led to constructive thinking. The 
physician, Empedocles, introduced the theory of 
the four elements — fire, air, earth and water — 
composing all bodies. The disturbance of any one, 
or all, would produce disease. .Although erroneous 
it was a step forward. The Greeks were the first 
to transcend mysticism, superstition and ritualism 
and grasp the conception of medicine as an art. 
Greek medicine as expounded by Hippocrates and 



•Presented to the Tri-State Medical Associatinn of the Carolinas and Virginia, meeting at Columbia, South Caro- 
lina, February 17th and 18th. 



PRESIDENT'S ADDRESS— Orr 



March, 1936 



later by Galen ruled the art of practice and healing 
for hundreds of years; but during this time, for 
lack of knowledge of the fundamental sciences on 
which the art must rest, little progress was made. 

After the fall of Rome there was the period of 
the Dark Ages lasting 1,000 years during which 
little progress was made in medicine either as an 
art or science. The land was overrun by quacks 
and charlatans who played upon the credulity and 
ignorance of the people. 

In the 13th and 14th centuries the little know- 
ledge of medicine had survived the Dark Ages began 
to take form in Southern Italy and soon there 
arose a medical school that became famous. There 
was an increase in the knowledge of anatomy, phy- 
siology and chemistry, but medicine made slow 
progress. The real cause of disease remained a 
mystery until the great scientific discoveries of Pas- 
teur, Lister, Koch and others were given to the 
world. From this time on medicine assumed th; 
dignity of a science and made rapid strides. 

Previous to this the art of practice and healing 
may ha.ve made certain attainments, but more 
often resulted in failure than success for it had no 
scientific knowledge of truth as a basis. With the 
knowledge of anatomy, physiology, chemistry, 
pathology and bacteriology there was constructed 
a solid scientific base for the development of the 
art of practice and healing. Every physician should 
be familiar with the fundamental and allied sciences 
to attain success in the practice of medicine, yet 
with this foundation he may be a failure if he has 
not that intuition, personality, individualism or, 
using a more comprehensive clause, if he has not 
the art of bringing relief, hope and healing into 
the life of suffering humanity. 

There are few in this audience who do not re- 
member some classmates who were good students 
and who could turn in excellent examination papers 
or answer most any scientific or technical question, 
but who when they assumed a practice somehow or 
other failed to achieve that success which was ex- 
pected of them. Perhaps, also, you remember some 
who did not do so well, barely passed the State 
Board and yet who are successful practitioners. It 
is true that some of these did not wake up or find 
themselves until brought in actual contact with 
the patient, and while they knew somethin'; o.' 
the science of medicine and surgery they were quick 
to adapt themselves to the needs and environment 
of their patients and to learn much in that greates 
of all schools, experience. They may not have been 
specialists, but they were experts in the art of prac- 
tice and healing. 

A clear definition of the art of healing is d ffi- 
cult. Some call it a knack to deal with the pa- 
tient in such a way as to gain his confidence, his re- 



spect and his liking; to remove all emotional diffi- 
culties; to adjust the prescribed treatment to his 
peculiar idiosyncracies of mind and body and to 
get his coop)eration in carrying out treatment. 

How is this art to be learned? Can it be taught? 
Our medical schools are of the highest standard. 
They are well equipped for study in all of the 
scientific branches. The requirements for entrance 
to these schools are very strict and are becoming 
more so. Most students in working for their col- 
lege degree direct their studies along scientific lines 
as a preparation for entrance into a medical school. 
The scientific preparation of our students and grad- 
uates from medical school is perhaps better than 
it has ever been. Graduates have a thorough 
knowledge of disease and its treatment, they are 
familiar with the fundamental sciences; and yet 
we wonder if they are more proficient in the art of 
practice and healing than the older practitioners 
who have had fewer advantages. This art depends 
much on the student's original endowment of brain 
and heart, on his ability to like people, to get along 
with them, to understand them, to sympathize with 
them and to make people like him and to have coit- 
fidence in him. Perhaps in no other profession is 
there such need for good judgment, for good sense, 
for the poise, culture and charity of a philosopher. 

Is it possible for the student to learn something 
of this art while pursuing his scientific studies? 
Some of the heads of the leading schools in the 
country are now beginning to see the need of 
giving this subject more attention and, wisely, they 
are turning to the successful practitioners for help; 
asking them to give lectures or act as preceptors so 
that the student may know something about the art 
of healing as it is carried on outside of the hos- 
pital and college. One of our large universities 
(Wisconsin) has had all fourth-year students work 
under the supervision of competent practicing phy- 
sicians and are sent for part of that year into 
adjacent large cities and smaller cities under the 
supervision of competent clinicians. In this way 
they are brought in direct contact with the prob- 
lems of medicine. 

No one is or should be better trained in the art 
of practice and healing than the general practitioner 
who usually is called upon to assume the position 
of family adviser. It is claimed he is rapidly dis- 
appearing. He is still a necessity with us and ever 
will be. He has discarded his high silk hat, his 
long frock coat and gold-headed cane and comes 
forth with new modern equipment, a diploma show- 
ing he is familiar with the basic sciences, equipped! 
v»fith laboratory, technicians, hospital and every! 
means for making a diagnosis and with competent! 
specialists at his service, he is better qualified than 1 
ever before to assume the envied position of family 



March, 1936 



PRESIDENT'S ADDRESS— On 



physician or medical adviser. The importance of 
the family physician is recognized and will be more 
so in the future. The public should be taught that 
the family physician is essential to its welfare no 
matter what the problem is or may be, and that 
no one is better versed in the art of practice and 
healing than he. 

Perhaps the time when the art of healing was 
at its height was the period of the Revolutionary 
War and the years following. Men's minds were 
turned to serious matters. Devotion to a principle 
was taken seriously. There were such men as 
Shippen, INIorgan and Rush, later came our beloved 
Osier. These men made an art of practice and 
healing. They were great physicians. Rush loved 
medicine. He believed in it with a patriotic fervor. 
He was a product of his time, a time when medical 
men were called upon to face adversity and when 
adversity was a stimulus to thought and action. 

Osier, himself, was a wellnigh perfect example 
of the union of science and the humanities. He was 
imbued with the art of medicine as well as the 
sciences and he advanced and enriched both. He 
was the friend of all he met. He know the work- 
ing of the human heart, metaphorically as well as 
physically. He achieved many honors but none 
greater than his power to bring hope and courage 
as he stood by the bedside of the sick. To him 
no mercenary thought or cold scientific fact ever 
overshadowed that warmth of sympathy that makes 
for trust and confidence between patient and phy- 
sician. He was a great physician and equally as 
great in the art of practice and healing. 

It is not my purpose to speak disparagingly of 
scientific training; it is essential. We are un- 
justly accused sometimes of becoming ultra- 
scientific. The urine, the blood, the spinal fluid or 
bit of tissue can be taken to the laboratory and 
should be, but we should not be forgetful of the 
personality of the patient, a dual personality, a 
physical and spiritual, each reacting on the other — 
to a personality which cannot be carried to the lab- 
oratory. To be able to correlate all symptoms, 
physical and spiritual along with laboratory find- 
ings and to give them their true evaluation, and 
to tune the eye and ear and the touch to the dis- 



cords of nature — this is an art developed by the 
true clinician only. 

Our medical education has changed and scien- 
tific study has become paramount. Specialists are 
being developed more rapidly than ever before. 
Preventive medicine has grown and is being empha- 
sized by State and Federal government. Group 
practice, large and small clinics, and various guilds 
have sprung up over the country. The probability 
or possibility of state medicine or socialistic medi- 
cine stares us in the face. These changes are prob- 
lems for organized medicine. Whether these 
changes come or not they should not cause the phy- 
sician to lose that personal touch with the patient. 
They should not make his practice become one of 
routine duty and a mechanical procedure with fixed 
compensations and rewards, destroying all enthusi- 
asm for the development of the art of healing and 
all stimulation and initiative for investigation and 
research. Under whatever scheme or change that 
may come, may the art of practice and healing be 
not forgotten. The art may sometimes be glorified 
unduly, and there is such a thing as emphasizing 
overmuch the science; the true physician is the one 
who combines both. 

It has been a very great and pleasant privilege 
for me to serve as your president during the 
past year. Conscious of the responsibilities of the 
office, I have felt my inability fully to measure up 
to the high standard set by the distinguished men 
who from year to year have preceded me. They 
were the leaders who with the faithful and untiring 
help of capable secretaries and other officers, and 
the cooperation of members, have developed our 
Association into what it is today — an Association 
of doctors of which we all feel justly proud. 

May I close with the words of Robert Louis 
Stevenson who knew the physician so well: "Gen- 
erosity he has such as is possible to those who prac- 
tice an art, never to those who drive a trade; dis- 
cretion tested by a hundred secrets, tact tried in a 
thousand embarrassments, and what are more im- 
portant Herculean cheerfulness and coura'^e. So 
it is that he brings art and cheer into the sick room 
and often enough, though not as often as he 
wishes, brings healing." 



vi^-^m"^;::::/ 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



The Upper Respiratory Infections* 

Improved Management through the Family Doctor 
Page Northington, M.D., New York City 



IT is believed that the public would not con- 
sider the common upper respiratory infections 
as trivial disorders if it were generally known 
that often they are the beginning of an infectious 
process that causes disabling illnesses of long dura- 
tion and that sometimes results in death. The lay- 
man believes that he is competent to diagnose and 
treat the usual infections of the upper respiratory 
tract, and he is encouraged in his belief by the pat- 
ent medicine vendors who are permitted to assure 
the public that self medication with their own par- 
ticular nose drop, gargle or rub is efficacious. It 
is true that the mild types of infections cause only 
slight impairment of general wellbeing and the 
sufferer recovers his health in a short time regard- 
less of the treatment. It is impossible, however, to 
foretell whether or not a patient with upper respira- 
tory infection will develop a sinus or ear disease 
that in turn may cause an orbital cellulitis, mas- 
toiditis, septicemia, meningitis, or brain abscess; 
or will develop a disease of the lungs, heart, kidneys 
or joints. To those patients who consult us, even 
those with a slight complaint, our duties are to 
make a systematic examination of the ear, nose, 
throat and larynx in order that a precise diag- 
nosis may be made, as otherwise treatment is spec- 
ulative. There is nothing new of proven value in 
the prevention, diagnosis or treatment of these in- 
fections or their complications; but there is much 
of the old, that, generally applied, would be for 
many comforting and curative, for some life saving. 
Progress in medical practice here, as in many other 
fields, is more likely to come through a greater 
use of the accepted clinical principles and formulae 
than it is from new discoveries. The hopeful phase 
of our problem is that, although at present a satis- 
factory examination of the ear, nose, throat and 
lar5mx is not commonly made, a systematic ex- 
amination is so simple and may reveal so much 
that it is gradually being adopted as a part of the 
general examination procedure by all doctors who 
treat these diseases. When such examinations are 
regularly made the diagnosis, upper respiratory 
injection, in a patient with a running nose becomes 
as unacceptable as the diagnosis, lower respiratory 
injection, is now in a patient with a cough. Ap- 
proximately, twenty-five per cent, of the patients 
referred to the otolarynologist have no disease of 
the ear, nose, throat or larynx, or have disorders 

•Presented by Invitation to the Tri-tSate Medical Assoc 
South Carolina, February 17th and ISth. 



SO mild as not to require a specialist's care. An- 
other twenty-five per cent, have such severe diseases 
that frequently treatment is not life-saving. The 
family doctor represents the main line of defense 
here, as everywhere in medicine. He has the privi- 
lege as well as the responsibility of seeing most of 
the sick as the first consultant. The specialist has 
only to know more and more about less and less; 
the family doctor must know more and more 
about more and more. 

The following outline for the examination of 
the ear, nose, throat and larynx is recommended 
to those who do not already carry out some such 
satisfactory procedure. It can be used at the bed- 
side as well as in the office and requires only about 
ten minutes of time. 

1. As complete a view as possible is obtained of 
the nares by using a nasal speculum and light re"- 
flected by a head mirror. Then, the nose is sprayed 
with a 2 % cocaine solution. After a few moments 
a 10% cocaine solution on a cotton-tipped appli- 
cator is applied to the mucous membrane along 
the floor of the nose carrying it to the nasopharynx 
and then upward to include the surfaces of the 
middle meatus. 

2. The frontal and maxillary sinuses are transil- 
luminated. The frontal sinuses are not fully de- 
veloped until about the thirteenth year and are 
equal in size in no more than half of the adults. 
Patients wearing upper dental plates should re- 
move them for this part of the examination. 

3. The ears are examined with a speculum and 
reflected light or an electric otoscope. Cerumen that 
prevents a satisfactory view of the drum membrane 
should be removed, by irrigation with a sodium bi- 
carbonate solution. It may be necessary to use a 
syringe that ejects with considerable force. The 
area of the mastoid is examined by inspection and 
also by digital pressure. 

4. The mouth and throat are examined with a 
reflected light. The tongue is depressed when the 
throat is examined. Palpation is used when any 
circumscribed swelling is present. The lower part 
of the pharynx and the larynx are examined indi- 
rectly using a mirror while the tongue is drawn 
forward. It may be necessary to spray the throat 
with a 2% cocaine solution to diminish gagging. 

5. The mucous membrane of the nose by this 
time is sufficiently anesthetized to use the naso- 
pharyngoscope. This is passed along the floor of 

:iation of the Carolinas and Virginia, meeting at Columbia, 



UPPER RESPIRATORY INFECTIONS— Northington 



the nose to its posterior limits where a view of the 
nasopharnyx, the orifices of the eustachian tubes, 
and the posterior ethmoid and sphenoid regions is 
obtained. By slightly elevating the distal end of 
this instrument and bringing it forward, the middle 
turbinate and middle meatus are inspected. 

(Through the interest of Dr. ]\Iikell patients 
are available for carrying out this examination 
procedure by all who care to do so.) 

Notes on Diagnosis and Treatment 
At the onset of the common infection, the find- 
ings are usually a red, congested mucous membrane 
of the entire upper respiratory tract and a variable 
amount of thin mucoid secretion. The diagnosis 
of rhinitis, pharyngitis, tonsillitis or laryngitis sig- 
nifies the part of the greatest involvement. In 
some patients the sinuses will transilluminate un- 
equally, secretion will be seen coming from the 
orifice of one or more sinuses, or an ear drum 
membrane will be seen to be reddened; but an in- 
fection of either the sinuses or the ears is some- 
what rare in the early stage of an infection. 

Pain, contrary to the popular belief, is not always 
present even in acute sinus infections, although it 
is an early symptom in otitis. When a sinus 
disease causes considerable pain usually it is either 
just above the eyes from a frontal sinusitis, or in 
the occipital region from a sphenoid infection. In 
ethmoiditis and maxillary sinusitis pain is seldom 
present, and the most acute infection rarely causes 
more than slight discomfort in the region of the 
sinus or about the eye. Pain in a maxillary sinus 
region is more frequently due to an infection in a 
tooth than to a sinus disease. Pain occurs almost 
invariably very early in a middle-ear infection, when 
an examination may show only slight inflammatory 
changes in the drum membrane. 

It should be kept in mind that the very young 
cannot voice their complaints. Although the sinuses 
are rudimentary at birth, the middle ear is of al- 
most adult size, and the antrum leading into the 
mastoid is larger than later in life. The ossicles and 
drum membrane are likewise well developed at 
birth. Experience indicates that these are factors 
worth reckoning in the diagnosis of middle-ear 
disease in the young. The appearance of the drum 
membrane as a sign of middle-ear infection is not 
so dependable in a child as it is in an adult. It 
is not uncommon for mastoiditis in the young to 
be diagnosed by a subperiosteal abscess over the 
mastoid or by roentgenray evidences, there being 
neither discharge from the ear, nor inflammatory 
changes in the drum membrane. The youngest in 
whom I have seen such an infection was three 
months of age. When the general condition of a 
young patient warrants the assumption of some in- 



fective focus and the location is obscure, the middle 
ear should not be excluded without making a roent- 
genray examination of the mastoids or incising the 
drum membrane, even when the membrane shows 
only slight pathological changes, as a pasty appear- 
ance with some loss in the details of its landmarks. 

The early stage of an ear infection frequently 
gives considerable constitutional symptoms which 
alarm the patient, as he thinks that his symptoms 
are due to a mastoiditis. In most cases these gen- 
eral symptoms abate within a few days and within 
ten days to two weeks the infection in the ears and 
nasopharynx is subsiding. When the fever, the 
mastoid tenderness or only an ear drainage con- 
tinues for two weeks, a roentgenray examination 
of the mastoids is indicated. Distressing pain in 
the ear is frequently due to an infection of the 
external ear canal wall, a comparatively innocent 
condition, to be looked for when movement of the 
auricle increases the discomfort. Also, at times 
pain in the ear is due to some focus of infection in 
the sinuses, throat or teeth. In an uncomplicated 
chronic infection of a sinus or ear, pain is not so 
usual as one or more of the following complaints: 
frequent head colds, expectoration due to dropping 
of secretion into the throat, irritation in the throat, 
recurrent hoarseness, coughing, or, in an ear in- 
fection, a recurrent discharge without discomfort. 

It is unfortunate that infections in the air spaces 
of the skull which are potential dangers to life so 
frequently exist without causing local or consti- 
tutional symptoms severe enough to prompt the 
sufferer to consult a doctor. Infection of the men- 
inges, brain or blood stream may come from a sinus 
or ear focus which has caused the patient no more 
previous trouble than a chronic head catarrh or 
recurrent, painless ear discharge over many years. 
Such grave complications usually occur in chronic 
sinus infections and about equally in acute and 
chronic ear infections. 

Although a diagnosis can usually be made by a 
painstaking examination of the sinuses and ears, 
roentgenray examination is indispensable in dis- 
closing obscure diseases of the sinuses and the 
mastoid. It is frequently of inestimable value in 
disclosing the extent of the disease in the mastoid 
during an ear infection of ten days to two weeks 
duration in which the patient has slight general 
symptoms of an infection and locally only a dis- 
charging ear. .'\ poor roentgenray picture may bs 
misleading and cause grave errors in diagnosis. To 
cite a personal observation: A woman became to- 
tally blind in one eye over a period of three weeks. 
There was no demonstrable disease of the eye. The 
roentgenray examination was reported as showing 
erosion of the corresponding greater wing of the 
sphenoid. The diagnosis of tumor of the orbit was 



UPPER RESPIRATORY INFECTIONS— Northington 



March, 1936 



made. The blindness was due to retrobulbar neuritis 
resulting from chronic purulent sinusitis, as indi- 
cated by recovery of vision and good health for 
the past five years under treatment directed to this 
condition. Less than one-half of one per cent, of 
cases of retrobulbar neuritis are due to sinus 
disease. 

Hoarseness is frequently an early sign either of 
a new growth or tuberculosis of the larynx, or of 
paralysis of a vocal cord due to some serious disease. 
Many lives could be saved if an inspection of the 
larynx were made of all patients with hoarseness on 
their first visit to the doctor. 

The subjective symptoms of recurrent head colds 
are frequently allergic manifestations or evidences 
of an exacerbation of a chronic sinusitis. 

An inflammatory swelling about an eye may be 
the first evidence of a sinusitis that causes the 
sufferer to consult a doctor. 

Lesions of one side of the throat are not the 
ordinary tonsillitis or pharyngitis. Peritonsillar 
abscess is the most frequent cause of unilateral 
swellings. It is not always easy to differentiate be- 
tween a peritonsillar or pharyngeal abscess and a 
new growth as shown by occasionally seeing a new 
growth that has been lanced to open a supposed 
abscess. 

Palpation is useful in determining the nature of 
swellings in the floor of the mouth, the tongue and 
the pharynx. 

A thorough examination of the sinuses should 
be made in every case of lung infection. 

Bacteriological studies are helpful mainly in 
identifying membranous and ulcerative lesions as 
the diagnosis by inspection is not dependable. A 
culture should be made at the time of incising a 
drum membrane to determine the nature of the 
organism, particularly, whether or not the middle 
ear infection is caused by the pneumococcus 
type 3. 

Biopsy of new growths is essential for a correct 
diagnosis. 

Blood studies show the general reaction to the 
ordinary infections, and also disclose evidence of 
blood dyscrasias, agranulocytosis, infective mon- 
onucleosis and trichinosis. 

Urinalyses are especially indicated in the course 
of upi>er respiratory infections because nephritis so 
frequently results from a streptococcus infection. 

Treatment does not permit of rigid standardiza- 
tion because of the variable course and of the lack 
of a specific therapeutic agent. My remarks there- 
fore, will be on the local therapeutic measures of 
greatest usefulness in the ordinary infections of 
the upper respiratory tract, and some comments 
on the care of sinusitis and otitis. Whether the 
patient has acute rhinitis, pharyngitis, tonsillitis or 



laryngitis, treatment is usually necessary for the 
entire upper respiratory tract with special attention 
to the part of greatest involvement. The treat- 
ment should be of a soothing and comforting sort 
and that which will help maintain the normal aera- 
tion of the sinuses and ears. After spraying the 
nose with a 2% cocaine solution to relieve the con- 
gestion and give a slight anesthetic effect, irri- 
gate with a warm salt and soda solution, — one 
dram of table salt and one-half a dram of sodium 
bicarbonate in a pint of water. A syringe is used 
for the irrigating, while the patient's head is straight 
forward and the face slightly tilted downward and 
he is breathing only through his mouth. This pre- 
vents the solution from entering the pharynx and 
exciting a fit of gagging or coughing that may ex- 
tend the infection to the ears. Patients can be 
taught to take this treatment at home, using a foun- 
tain syringe for the solution suspended two feet 
above the head. Blowing of the nose should be 
done with both nostrils open. During an acute 
nasal infection, it is preferable to snuff the secretion 
into the throat and expectorate it than to clear the 
nose by blowing it. Irrigation of the throat with 
a 2% warm soda solution is useful when the 
throat is acutely inflamed. One-per cent, ephedrine 
in oil for the nose and silver protein solutions for 
the nose and throat are useful between irrigations. 
In acute follicular tonsillitis 3% silver nitrate solu- 
tion applied in the crypts frequently is followed 
within a few hours by a considerable drop in tem- 
perature. In simple laryngitis voice rest is usually 
the only care needed. Use of the inflamed vocal 
cords may result in a permanent change of voice. 

Examination will show that many patients have 
a sinusitis from the early stage of the acute upper 
respiratory infection, although there are no sub- 
jective symptoms to suggest it other than a thick 
mucopurulent nasal discharge. Many such infec- 
tions will not require any additional treatment, 
the infection of the sinus subsiding along with that 
of the mucous membrane of the nose and throat. 
However, in some patients, the sinus infection will 
persist with no more discomfort than nasal drain- 
age and perhaps a cough. Such patients cannot 
be discharged from medical care if the cases of 
chronic sinusitis and their complications are going 
to be lessened. Treatment by irrigations of the in- 
fected sinus with the salt and soda solution is us- 
ually curative. 

In a small percentage of the cases of acute upper 
respiratory infections, the course is not so benign. 
From the onset the symptoms may be of a fulmin- 
ating nature or there may be slowly developing local 
and constitutional symptoms of a virulent infection 
of the sinuses or ears. A sinus infection requires 
satisfactory drainage. This can be accomplished in 



March, 1936 



UPPER RESPIRATORY INFECTIONS— Nortliinglon 



some cases by shrinking the mucosa about the ori- 
fice of the sinus with cocaine and adrenahn solu- 
tion. If relief is not obtained by this treatment the 
safest and most effective measure is irrigation of 
the sinus. In some patients the maxillary, sphenoid 
and frontal sinuses can be flushed out by entering 
their normal openings with a small cannula, whereas 
in others it is necessary to puncture the maxillary 
sinus or remove the obstruction to the normal 
opening of the frontal or sphenoid sinus in order 
to do this. 

I am aware of the sentiment among the laymen 
and a few doctors against sinus irrigations. It is 
not infrequent to have a patient, before an exam- 
ination is made, say in effect: I don't want my 
sinuses irrigated because someone has told me that 
if once a sinus is irrigated this treatment will have 
to be continued throughout life. It is not reason- 
able to believe that irrigating a mucous membrane 
cavity, infected or not, with a sterile bland solu- 
tion is going to have any harmful effect. The irri- 
gations are purposeful in that they are done to re- 
move from the cavity infection products that na- 
ture has failed to remove and, most likely, can- 
not remove. 

The late Doctor C. G. Coakley, to whom I was 
an assistant for several years, was a firm believer 
in employing conservative measures in the care of 
sinus diseases. In his latter days he depended more 
and more on simple irrigations of the sinuses, and 
resorted less and less to operations, in the care of 
sinus infections that needed special treatment. Oper- 
ations on the sinuses cannot be entirely avoided; 
however, they may be lessened by the cooperation 
of all concerned in encouraging a general accept- 
ance of the fundamentally sound principle that 
evacuation of pus retained in an air space in the 
skull is helpful to the patient. 

The use of suction in the treatment of sinus in- 
fections by placing a tip firmly in the anterior part 
of one naris and applying negative pressure while 
the patient alternately closes and opens the naso- 
pharynx by saying K-K-K is mentioned, only in 
order that it may be condemned. The fluid ma- 
terial in the sinus, having no air beneath it, can- 
not be aspirated by this method, also the suction 
causes congestion of the mucosa about the orifices 
of the sinuses and thus interferes with the drainage. 
1 am of the opinion that the sinusitis was made 
worse by suction in this patient. A woman who 
had a doctor sister and a doctor brother was found 
to have an acute suppurative sinusitis of both 
frontal and both maxillary sinuses. She had been 
ill for going on four weeks, having severe head 
pains, vomiting and a daily rise of temperature to 
103. Suction had been used since the onset of her 
illness. The nasal mucosa was so congested that 



there was scarcely any drainage from the infected 
sinuses. Irrigations of the frontal and maxillary 
sinuses were begun at once as it was thought that 
there was imminent danger of a bloodstream or 
intracranial infection. Considerable relief was ob- 
tained in spite of the irrigations being infrequently 
done on account of opposition in the family. At 
the end of three months this patient developed an 
osteomyelitis of the frontal bone that required an 
extensive operation. 

I have never seen a patient with sinusitis have 
grave complications when the infection was treated 
early with irrigations. I don't want to leave the 
impression that it is my opinion that all infected 
sinuses should be irrigated, but with more reason 
that it is the most conservative and effective treat- 
ment to use when the infection does not subside 
under simpler care. 

In middle-ear infections a red, bulging drum 
membrane should be opened. In a few cases, local 
or constitutional symptoms will require incision of 
the membrane without such considerable inflam- 
matory signs. In those cases in which the infection 
does not seem to warrant a membrane incision, a 
treatment, honored by time only, is that of phenol 
and glycerine drops. This produces very slight 
analgesia; also, it is destructive to the epithelium, 
which is harmful in itself, and it obscures the true 
picture of the drum membrane. Pain may be re- 
lieved by acetyl salicylic acid, codeine, or morphine. 
The use of barbituric acid preparations is to be dis- 
couraged. They are not dependable analgesics and 
also may cause a giddiness that may not be dis- 
tinguishable from a vertigo caused by the infection. 
Vertigo is a very important symptom if arising in 
the course of an ear infection, therefore nothing 
should be taken that might make it confusing. 
This local infection is not comparable to an 
abscess in which time is allowed for a walling-off 
process. The objective in the treatment of early 
middle-ear infections is to drain the infected cavity 
before extension takes place to the mastoid, to the 
petrous pyramid or to intracranial structures. The 
membrane should be incised, therefore, without 
waiting for the infection to extend through and 
cause its spontaneous rupture. If culture shows the 
pneumococcus type 3, a special watch should be 
maintained to detect the first signs of complications 
that are so frequent and so insidious. When the 
middle ear is discharging, drainage is improved bj' 
keeping the external canal free of the accumula- 
tions. This may require frequent treatments. Irri- 
gations with boric acid solution are resorted to be- 
cause no one but a doctor will satisfactorily clean 
the canal with a dry cotton-tipped applicator. Anti- 
septics that stain the tissues are to be condemned 
as ear drops because they fail to reach the middle 



UPPER RESPIRATORY INFECTIONS— Northington 



ear, the seat of the infection, and make it im- 
possible to see the changes in the membrane from 
day to day. It is advisable to keep it in mind that 
a middle-ear infection comes about by extension 
through a eustachian tube from the nasopharynx. 
Treatment therefore of the nasopharynx is of great 
importance. If the nasopharyngitis is dependent 
upon a sinusitis the best treatment for the ear in- 
fection is that directed to the cure of the sinusitis. 
In spite of pain, fever, mastoid tenderness, pro- 
fusely discharging ear and the roentgenray examin- 
ation showing cloudy mastoid cells being frequent 
in the early stage of an ear infection, a simple mas- 
toidectomy is very rarely indicated in less time 
than ten days to two weeks. On the other hand, if 
all of these symptoms subside except a discharging 
ear and there is roentgenray evidence of the break- 
ing down of the mastoid septa, a simple mastoidec- 
tomy is indicated. This is a common experience: A 
patient is referred by the family doctor with the 
opinion that he has a mastoiditis. The patient 
has fever, pain in the ear, mastoid tenderness, 
cloudiness of the mastoid cells on roentgenray ex- 
amination and a discharging ear for three or four 
days. The diagnosis, mastoiditis, as commonly used 
means that there is sufficient disease present to re- 
quire a mastoidectomy. A cloudy mastoid always 
may be seen in an acute middle-ear infection. The 
patient and the family doctor are relieved to know 
that an operation is not immediately indicated. The 
symptoms in a little while subside excepting a dis- 
charging ear and roentgenray evidence of pus in 
the mastoid. Then, neither the patient nor the 
family doctor is convinced of the necessity of a 
mastoidectomy. This treatment is indicated in 
such cases because of the grave complications that 
may arise from the infection, either during the acute 
stage or later from the resulting chronic middle-ear 
and mastoid infection. 

Chronic suppurative middle-ear disease is always 
a manifestation of either chronic mastoiditis or 
petrositis and is a menace to life. Cleaning of 
the canal with dry cotton swabs and using alcohol 
and boric acid drops are helpful in some cases. 
Granulations should be removed so as to improve 
the drainage. Aqueous solutions should not be 
used for irrigating the ear. Also, patients who have 
recurrent ear discharge should be advised to avoid 
getting water in the ear. When pain which is 
usually diffuse on one side of the head, or vertigo, 
appears as a result of a chronic middle-ear infec- 
tion, a radical mastoidectomy is indicated, because 
these signs frequently appear just before extension 
of the infection to the intracranial structures. Also, 
a mastoidectomy and clearing the lateral sinus of an 
infected thrombus is a curative procedure in many 
that develop a blood-stream infection from the 



ear and mastoid disease. A sinus thrombosis should 
be considered the diagnosis in the presence of chills 
and fever and a running ear, even when the ear 
infection appears innocent, unless there is some 
other obvious cause. No one dies of a mastoiditis 
or a sinusitis: many die of their complications. 

Opinion 
A thorough examination of the ear, nose, throat 
and larynx is within the capacity of all competent 
medical practitioners. Vast improvement in the 
care of upper respiratory infections and their com- 
plications can be easily brought about by the gen- 
eral use of a systematic examination, because such 
examination leads to an accurate diagnosis that 
makes possible the most beneficial treatment. 



Trichinosis No Rare Occtjrkence 
(H. T. Brooks, New York, in Med. Rec, Feb. 19th) 
Februan- 7th, a woman, 22, ate of pork tenderloin. On 
February 9th, pain in the eyes, conjunctival congestion 
and puffing of the lids ; muscular pain, swelling of the lip:- 
and face, pruritus, exhaustion and depression; no diarrhei 
or vomiting. On February 13th the fever was 103° F., at 
which time she entered Bellevue. On February 20th she ^ 
left the hospital, but continued to visit the clinic. On 
February 26th, 12 bluish maculae, each 4 inches in diameter 
and painful on pressure, upon the inner surfaces of the 
thighs. Recurrent sharp pains and conjunctival congestion 
persisted until March 1st. Wasserman reaction was nega- 
tive. February 15th, 53% eosinophilia. A second exam- 
ination, 40% eosinophilia. The portion of the lateral 
aspect of the biceps near the tendinous insertion revealed 
encysted trichinae. 

In muscle trichinae retain their viability in the encysted 
state even in calcified capsules up to 31 years. Heat of 
proper cooking kills them. 

Trichinous invasion in man and animals attacks especially 
the vigorously active and richly vascular diaphragm, laryn- 
geal musculature (particularly the glottis dilators), ocular, 
lingual, intercostal, abdominal, lumbar and other muscles, 
particularly in the neighborhood of the osseous and ten- 
dinous attachments; usually in lesser degree the muscles 
of the extremities. That the parasites do not settle in the 
heart muscle is said by Hertwig to be due to the extreme 
delicacy of the sarcolemma of the cardiac muscle fibers. 

The duration of the disease in severe cases is from 4 
to 6 weeks. The mortality is sometimes very high. (Don't 
eat, or allow your patients to eat, any hog meat that is not 
thoroughly cooked. — Ed.) 



I AM OF THAT MIND (C. O. Stallybrass, in Pres. Address 
99th Session Liverpool Med. Ins., Liverpool Med. Chir. Jl., 
Pt. 3, 1935.) that I believe that learning to think aright 
will be of as great service to mankind as all the preven- 
tion of physical ills that the Medical Profession has be- 
stowed upon a not very grateful world. We have a long 
way to go before we attain the ideal of me}is sana in cor- 
pore Sana, but I believe that the medical profession has 
yet a large part to play in teaching mankind — and doctor 
means teacher — how to think aright. 



P.ATIENTS SENSITIVE TO HORSE SERUM (F. A. SimOn, Louis- 

ville, in Ky. Med. Jl., Jan.) are sometimes sensitive to the 
sera of other animals also. If serum other than that of 
the horse is to be given, skin tests must be made with 
the serum of that particular species. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



The Diagnosis and Treatment of Acute Appendicitis* 

Hugh H. Trout, M.D., Roanoke, Virginia 



IHA\'E personally operated on patients for acute 
appendicitis when they had one of the fol- 
lowing conditions, and the appendix was the 
innocent victim of an unnecessary attack. 

1 . Pneumonia 

2. Pleurisy 

3. Pneumococcus peritonitis 

4. Acute spontaneous pneumothorax with 
tuberculosis 

5. Acute hemorrhagic pancreatitis 

6. Strangulated hernia through foramen of 
Winslow 

7. Gallstones — acute cholecystitis 

8. Perforated "peptic" ulcers 

9. Ureteral calculi 

10. Ureteral stricture 

11. Renal calculi 

12. Tuberculosis of kidney 

13. Infected cyst of kidney 

14. P\'elitis 

15. Bladder calculi 

16. Bladder diverticuli 

17. Intussusception 

18. Intestinal polypi 

19. ^Mesenteric thrombosis 

20. Intestinal parasites of various kinds 

21. Seminal vesiculitis 

22. Acute epididymitis 

23. Tuberculosis peritonitis 

24. Typhoid perforation 

25. Regional ileitis 

20. Acute ^leckel's diverticulitis 

27. Tabes mesentericus in children 

28. Acute enteritis in children 

29. Strangulated hernia, reduced 

30. Postoperative inguinal hernia case which 
developed acute appendicitis while in 
bed 

31. Rupture of graafian follicle 

32. Twisted pedicle with small ovarian cysts 

33. Necrotic fibroids following irradiation 
treatment 

34. Ectopic pregnancy 

35. Acute pelvic inflammatory disease. 

Having had this experience in making the in- 
correct diagnosis of appendicitis so many times is 
perhaps the reason for my having been invited 
to discuss this subject with you. While this list 
looks long and is long, still the correct diagnosis 
of acute appendicitis was made in over ninety- 



five per cent, of the cases operated on, and this 
is a far higher percentage of accuracy than we 
have been able to obtain in any other disease. In 
fact, in the vast majority of cases the diagnosis 
has been made by the family physician before any- 
one connected with the hospital staff saw the pa- 
tients, and for this reason, we certainly cannot claim 
any of the credit. The ease with which such a 
high percentage of correct diagnoses is obtained 
indicates that there must be some sort of standard 
attack of acute appendicitis. 

The truth of the situation is that such a large 
proportion of the attacks are almost identical with 
the symptoms and signs given in our textbooks 
that perhaps we become careless and jump to the 
conclusion that every right-sided pain is due to 
appendicitis. Such attitude is possibly the ex- 
planation of numerous mistakes in diagnosis. In 
other words, we are often afraid of consuming time 
that is valuable to the patient in taking a more 
careful history and in making helpful laboratory 
examinations. 

If one will consult any textbook one will find 
that the standard attack of acute appendicitis is 
about as follows: The patient is taken, or as the 
Negroes express it in our part of the world, "hit", 
with a rather sudden pain all over the abdomen. 
This pain usually localizes in the right lower quad- 
rant of the abdomen. The time required for the 
pain to localize varies greatly, but, in my exper- 
ience, the younger the patient the more rapid is 
this localization. We have operated in three cases 
of acute appendicitis with the pain localizing in 
the left lower quadrant, but in these cases there 
was a transposition of viscera with the ascending 
colon on the left. We have seen acute appendi- 
citis more frequently in boys than in girls, and in 
young people than in those over fifty • years of 
age. However, age does not give immunity for we 
have operated on a fairly large number of persons 
over seventy-five with very acutely inflamed 
appendices. 

I presume we all have had families in which, 
apparently, acute appendicitis was either hereditary 
or like an epidemic. These instances might be due 
to an inherited development anomaly of the an- 
atomy of the appendix. One experience was with 
an educational institution from which we received 
an unusual number of cases of acute appendicitis 
one fall. An exhaustive study by an epidemiologist 

•Presented before the Postgraduate Meeting Duke University, Durham. North Carohna, October 31st-November 
1st and 2nd, 1935. 



ACUTE APPENDICITIS— Trout 



did not disclose any definite etiological factor, but 
such a study did produce many interesting theories 
from various members of the faculty — one, a new 
type of enamel pan for the baking of rolls — and 
in spite of the fact that no enamel was found in 
any of the appendices removed. A new commandant 
was blamed, this officer being held responsible for 
an earlier drill period, which, in the opinion of one 
of the faculty did not give the students sufficient 
time to attend to their daily duty, and the conse- 
quent constipation, in this instructor's opinion, was 
the real cause of the series of cases. 

The vast majority of our patients are not only 
nauseated but vomit. One should be very careful 
to inquire concerning the taking of purgatives. Oc- 
casionally one finds that the vomiting is due to 
the misapplied medication, but much more fre- 
quently a careful history will reveal that the pa- 
tient vomited before the taking of the purgative. 

Fever is usually present, but this is not a true 
index of the trouble. Fever apparently has a close 
relationship to the degree of resistance of the pa- 
tient — the more resistance the patient possesses 
the higher the fever is apt to be. The type of 
causative organism has a large influence on the 
degree of fever. In our experience, those cases in 
which there is sudden rise of temperature which 
goes very high but is sustained for a few hours 
only, at operation, smears of the peritoneum will 
show a streptococcus more often than the colon 
bacillus. The cases in which the peritoneum show 
the colon bacillus on smears and cultures usually 
have a more gradual elevation of temperature, 
which is maintained at a relatively high degree for 
a much longer period. In other words, apparently, 
the streptococcus permeates the walls of the ap- 
pendix more quickly. In our experience if clinical 
peritonitis has existed longer than twelve hours 
a mixed bacterial invasion of the peritoneum is 
disclosed at operation. 

The pulse usually rises commensurate with the 
fever. However, in some of the worst cases of 
appendicitis I have seen temperature and pulse 
normal. 

Gentle examination of the entire abdomen with 
the finger-tips usually reveals the right rectus 
muscle to be firmer than the left, especially in the 
lower abdomen. A deeper pressure elicits more 
firmness of the right rectus and frequently a sharp 
sudden pressure will be met with a muscle spasm 
almost as definite as a knee reflex. Frequently sud- 
den release of pressure which has been made in 
(.he lower left fossa will produce marked pain in 
the appendix region. 

We have not found rectal examination of much 
aid unless there was a palpable appendix abscess 
or a swollen appendix lying in the pelvis. 



The leucocyte count is usually of definite aid 
in confirming an already established diagnosis, but 
I think we should be careful not to place too much 
dependence on laboratory tests. Sometimes I feel 
that those of us who have been "raised"' in hos- 
pitals are failing to use fully our special senses and 
taking the easier course of attaching too much 
importance to laboratory methods. Sondern's 
curves and Schilling's modification of the Arneth 
method of shifts of the immature cells are interest- 
ing, and usually more helpful concerning the prog- 
nosis and assisting in the direction of postoperative 
care than they are of diagnostic aid before oper- 
ation. 

It might be interesting to you, and it certainly 
has been helpful to us, to make a hasty review of 
the mistakes in diagnosis which we have made. 

1. Pneumonia and 2. Pleurisy. — I recall four 
of these mistakes. In three cases the lung involve- 
ment was in the lower right base, but in one case 
the disease was limited to the left base. In none 
of these cases was any condition found in the re- 
moved appendix to explain the preoperative paia 
in the region of McBurney's point. Of course, a 
more careful examination of the chest before op- 
eration would probably have revealed the true 
condition. 

3. Pneumococciis peritonitis. — Here the appen- 
dix is involved and injected along with the rest of 
the peritoneal cavity. Even if the history of a fairly 
recent attack of pneumonia is elicited from the 
patient I doubt if a surgeon would be justified in 
not opening an abdomen presenting signs and symp- 
toms of such marked peritoneal involvement. 

4. Acute spontaneous pneumothorax associated 
with pulmonary tuberculosis, but with nausea and 
vomiting and patient having pain tenderness and 
spasms localizing in right lower iliac region. This 
patient also had an increase in both the total leu- 
cocyte and polymorphonuclear counts. We had 
an accurate preoperative estimate of the true pul- 
monary condition, but the abdominal signs and 
symptoms were so suggestive of an associated acute 
appendicitis, that we deemed it a safer policy to 
explore the abdomen with the use of a local 
anesthetic. This exploration revealed a normal 
postcecal appendix, which was removed and, for 
some unexplained reason, this apparently relieved 
the pain. I believe the pain in this case would 
have disappeared in several days without the ap- 
pendectomy, for I have since seen two other such 
cases in which the abdominal symptoms did sub- 
side in a very short time, and without surgical inter- 
ference. However, in all fairness to phthisiologists 
who were associated with us in these cases, in the 
case on which we operated the abdominal symp- 
toms were very much more marked than in those 



March, 1936 



ACUTE APPENDICITIS— Trout 



two cases not subjected to appendectomy. Of 
course, there is the possibiHty that having had this 
experience with the first case made us more con- 
servative in estimating the symptoms and signs in 
the other two patients. Anyhow, this experience 
of ours might at some time be of assistance to 
some one of you. Permit me to add that the ap- 
pendectomy apparently did not interfere with the 
progress of the patient, and she actually thought 
the operation relieved her abdominal pain. Such 
is within the realms of possibilities and if I could 
bring myself to share her conviction it would be 
of a lot of comfort in mitigating the pangs of an 
unpleasant memory. 

5. Acute hemorrhagic pancreatitis. — As a rule, 
in these cases the extreme signs of shock with the 
usual cold clammy skin should give a hint that 
the abdominal pain might not be due to acute ap- 
pendicitis with peritonitis. However, as surgical 
assistance is indicated with either diagnosis the 
practical indication s a right rectus diagnostic in- 
cision. Incidentally, it is worthy of note that the 
operative mortality in acute hemorrhagic pan- 
creatitis has been greatly improved since the ap- 
plication of the rule to drain the gallbladder as 
well as the site of the pancreatic explosion in 
such cases. 

6. Strangulated hernia through the foramen oj 
Winslow. — In our series of mistaken diagnoses was 
the only case we have had of this condition. In 
this case a resection of about three feet of gan- 
grenous small intestine was necessary. In spite 
of the intestine being strangulated in the lesser 
peritoneal cavity the whole mass had gravitated 
to the lower right flank and our preoperative 
diagnosis was appendiceal abscess. 

7. Acute cholecystitis. — ^We all, I feel quite 
certain, have mistaken acute gallbladder disease 
for acute appendicitis, and acute appendicitis for 
acute gallbladder disease. I am sure it is important 
to realize that both conditions may exist at the 
same time. I recall quite a number of cases in 
which an acutely diseased gallbladder has been 
exposed through a right rectus incision, and then 
an examination of the right iliac region disclosed 
an acutely inflamed appendix, which required re- 
moval before giving further attention to the condi- 
tion of the gallbladder. And of course, we have all 
had the experience of having seen an acutely in- 
flamed appendix removed through a McBurney in- 
cision, and the pain continue until the removal of an 
acutely inflamed gallbladder. In other words, we 
should remember that the appendix and the gall- 
bladder can be acutely inflamed at the same time, 
and that in cases presenting such a possibility a 
right rectus incision should be employed in spite of 



all the many advantages and comforts of a Mc- 
Burney incision in acute appendicitis. 

In one of our cases we removed an acutely in- 
flamed gallbladder with calculi but failed to ex- 
amine the appendix region. The patient's tem- 
perature continued elevated and we drained a sub- 
phrenic abscess through a lumbar incision without 
relieving the condition. Before the patient finally 
recovered we removed a post-cecal gangrenous ap- 
pendix. It is more than probable that, had we 
examined the appendix region at the time of the 
first operation, the patient might not have de- 
veloped the subphrenic abscess. 

In spite of all the differential diagnostic symp- 
toms and signs described in journals and textbooks, 
I believe it to be impossible to be certain of a 
preoperative diagnosis in those cases in which a 
post-cecal appendix and a low gallbladder are close 
together. 

8. Perjorated "peptic" ulcers. — A carefully 
taken and logically considered history of previous 
ulcer symptoms will usually give the clue to the 
peritoneal involvement associated with perforations 
of these ulcers. Then, too, the patients having 
such perforations do not have a fever for a few 
hours after the pain begins, while with appendi- 
citis the pain and fever usually run concurrently. 
However, fever is dependent on so many different 
factors that too great reliance should not be placed 
on this reaction to bodily insult. 

Also, as a general rule, an increase in the leu- 
cocyte count does not always appear early with 
"peptic" ulcer perforations. The generally ac- 
cepted reason for this is that at first the peri- 
toneal reaction is a response to a chemical invasion 
by gastric and duodenal contents which contain 
few (if any) bacteria that have not been killed or 
made dormant by the hydrochloric acid, etc. 

9, 10, 11, 12, 13, 14, 15 and 16. Urinary diseases. 
— As a rule, involvement of the urinary tract does 
not produce symptoms as quickly as does acute ap- 
pendicitis, and a surgeon therefore feels he can 
take the time for examinations necessary in mak- 
ing a differential diagnosis. A flat x-ray plate 
takes only a very few minutes, and will often pre- 
vent an unnecessary appendectomy. It is also 
helpful not to forget that the intravenous injection 
of the dye, followed by x-ray examination of the 
urinary tract, gives considerable information with- 
out subjecting the patient to the pain of a cysto- 
scopic examination. 

In the case of renal tuberculosis in which we 
operated for acute appendicitis the ureter was 
acutely inflamed, and I think this explained the 
similarity of symptoms. 

Pyelitis, especially in children, is very difficult 
if not impossible to differentiate from acute appen- 



ACUTE APPENDICITIS— Trout 



March, 1936 



dicitis. Pus and bacteria are often found in ca- 
theter specimens of urine in patients with acute 
appendicitis, and who probably have pyelitis sec- 
ondary to the primary infection of the appendLx. 
Whether this is an accurate surmise I do not know, 
but I do know we have had a number of cases in 
which the pus (or white blood) cells and bacteria 
never reappeared in the urine after the removal 
of an acutely inflamed appendix. 

As a general rule, in patients with uncomplicated 
pyelitis both the temperature and the blood findings 
are more quickly and more markedly elevated. The 
pain associated with pyelitis is more apt to be 
more localized toward the back and nausea is very 
much less frequent than with acute appendicitis. 

17 and 18. Intussusception and intestinal polpyi. 
— In intussusception and in obstruction of the 
small intestine due to a polypus, usually an ab- 
dominal mass can be palpated, the temperature and 
blood counts are not elevated until very late if 
ever, and the pain is rhythmical. A rectal exam- 
ination will often be of great assistance. If the 
symptoms of intestinal obstruction have persisted 
for as long as forty-eight hours, the blood will be 
altered chemically— increase of the non-protein 
nitrogen, diminution of the plasma chlorides and 
an increase of the combining power of the blood 
for carbon dioxide. 

19. Mesenteric thrombosis. — There is no ab- 
dominal condition with which I am familiar that 
gives such profound shock and complete collapse 
of the patient as that produced by mesenteric 
thrombosis. The pain is more agonizing and really 
"hits" the patient so quickly that someone has 
described the suddeness of the pain to that of a 
bullet wound of the abdomen. In my experience 
the pain "hits" very much harder and very much 
more quickly than any bullet wound I have ever 
seen. 

20. Intestinal parasites. — In spite of the fact 
that I live in a State, and am now talking in a 
State, in which intestinal parasites flourish, I have 
been caught off guard and removed appendices 
which should not have been removed, but the pa- 
tients should have had their parasites removed by 
proper treatment. As a rule, an increase in the 
eosinophiles of the blood with a careful history 
will indicate the necessity for a stool examination. 
However, it is wise to recall that acute appendi- 
citis can exist with (if not actually be caused by) 
intestinal parasites. A patient was sent to us with 
the diagnosis of acute appendicitis by one of the 
most competent doctors I know. We found hook- 
worm in his stools and returned him to his family 
physician for treatment; but, fortunately for the 
patient, his doctor sent him to another hospital 
where an acutely inflamed appendix was removed 



the next day and the patient's life probably saved. 
Had his doctor followed our instructions, the pa- 
tient would have had some purgative, which would 
not have added to his chances of recovery from the 
involvement of the appendix. 

On one occasion we operated on a little patient 
with a preoperative diagnosis of appendiceal ab- 
scess, and found the terminal ileum completely 
blocked with dead round worms. The boy had 
taken treatment for the parasites three days before 
I saw him. 

21. Seminal vesiculitis. — Had we made a rectal 
examination and found a swollen, hard and pain- 
ful right seminal vesicle, we might not have re- 
moved an unoffending appendix in one case. In 
such instances a history of gonorrhea can frequent- 
ly be obtained 

22. Acute epididymitis. — It should not be for- 
gotten that acute epididymitis will sometimes pro- 
duce pain in the right iliac region, w'ith fever, usual- 
ly a very high leucocyte count and sometimes nausea 
and vomiting. Frequently in the examination of 
the inflamed epididymis the pain will be either in-* 
creased or reproduced in the appendix region, and 
such palpation will not infrequently produce nausea 
and vomiting. Our failure to evaluate this obser- 
vation properly caused us to remove a normal ap- 
pendix in one case. 

23. Tuberculosis peritonitis. — As a general rule 
with tuberculosis peritonitis there is to be found 
pulmonary involvement. However, frequently the 
tuberculous invasion of the intestine is somewhat 
localized and permits a resection with increased 
chances of an arrest of the tuberculosis. 

24. Typhoid perforation. — In the vast majority 
of cases a history of typhoid, a positive Widal, etc., 
will prevent confusion in the diagnosis between ty- 
phoid perforation and acute appendicitis. In one 
case our medical associate made the diagnosis of 
typhoid perforation based on a pxjsitive Widal, low 
leucocyte count, and a somewhat indefinite history 
of typhoid fever about six months previously from 
which the patiently apparently had not fully re- 
covered. I was equally as certain of my diagnosis 
of acute appendicitis, based on the evident peri- 
tonitis, generalized abdominal pain, localizing some- 
what to the right iliac fossa, nausea and some vom- 
iting. After some hours of discussion, an incision 
was made, and a generalized tuberculosis peritonitis 
found. 

25. Regional ileitis. — About four years ago the 
attention of the medical profession was called to 
what is apparently a new and unexplained patho- 
logical entity, namely regional ileitis, the lesion be- 
ing most frequently found in the terminal ileum. 
Had we taken the time to have made an x-ray 



ACUTE APPENDICITIS— Trout 



Study of the intestinal tract we would have found 
the string-like occlusion these cases present, and 
such as we have found in all such cases admitted to 
the hospital. As a rule, the symptoms of this con- 
dition are not acute, but progressive over a period 
of weeks or months, but, with the case in which 
we made the wrong diagnosis of acute appendicitis, 
the patient, a non-complaining type of individual, 
did not complain of his symptoms until the con- 
dition had produced an almost complete intestinal 
obstruction. 

26. Acute Meckel's diverticulitis. — In each of 
seven cases, after removal of a normal appendix, 
we were able to bring into the field of operation, 
through a McBurney incision, an acutely inflamed 
^Meckel's diverticulum which had given the picture 
of a case of acute appendicitis. I know of no ac- 
curate method to differentiate these two conditions. 
We make it a practice to always examine the last 
several feet of the ileum in every case unless the 
appendix is too acutely inflamed. If such an ex- 
amination is made routinely one will be surprised 
to find the frequency with which a Meckel's diverti- 
culum is found, and many of them inflamed almost 
as badly as the appendix. In one of our cases both 
the appendix and the diverticulum were gangrenous. 

2 7 and 28. Tabes mesentericus and acute en- 
teritis in children. — These conditions will, in my 
opinion, always present unsurmountable difficulty 
in some cases; but the history of chronicity in the 
former and of dietary indiscretions in the latter 
should give a clue in the vast majority of cases. 
However, in these cases there will always be found 
children that have cried "wolf" so frequently that 
unless we are careful we will be fooled into disre- 
garding the chronic symptoms of tabes mesentericus. 
.■\bount dietary indiscretions, otherwise truthful 
children often lie most earnestly, in many instances 
from fear of parental punishment. 

29. Strangulated hernia, reduced. — You can 
imagine my surprise when one day I was operating 
on what I took to be an appendix abscess when I 
discovered a strangulated hernia, which the pa- 
tient had reduced with the sac and all into the 
abdomen. Xaturally, examination of the inguinal 
I ring before operation showed a closed but tender 
I opening. The patient manfully kept the history 
I of hernia from the intern who took his history, 
I for fear of the wrath of his family physician who 
I for years had told him to have this hernial open- 
I ing repaired, and to stop reducing it. 

! 30. Postoperative hernia case which developed 

i acute appendicitis while in bed. — Very occasionally 

some intern will become rather critical of doctors 

who send patients to the hospital with ruptured 

appendices and which cases they had watched for 



a few days before admission. Whenever an intern 
is so inclined these days, I take great pleasure in 
reminding him of a former intern (who is now a 
well, and favorably, known surgeon) who gave the 
usual purgatives to an uncomplicated postoperative 
hernia patient complaining of pain, etc., in his right 
side, and after watching this patient for a few 
days, we removed a ruptured appendix. 

31. Rupture oj graafian jollicle. — This will oc- 
casionally produce pain nausea so simulating acute 
appendicitis that a differential diagnosis is almost 
impossible. 

?>2. Twisted pedicle with small ovarian cysts. — 
If a pelvic or a rectal examination is made before 
every operation a small ovarian cyst with a twisted 
pedicle will sometimes be found and the ad- 
vantage of a right-rectus incision gained. 

ii. Necrotic fibroids following irradiation treat- 
ment. — In one case we removed a necrotic peduncu- 
lated fibroid with the preoperative diagnosis of 
appendix abscess. We failed to obtain before 
operation the history that several months before 
admission, the patient had been given radium to 
cause her fibroids to disappear. It is interesting to 
note that the hemorrhage, which was due to the 
also-present intramural fibroids, had ceased — 
probably the result of the radium. 

34. Ectopic pregnancy. — As a rule, a ruptured 
tubal pregnancy does not present much difficulty 
in differentiation from acute appendicitis. The 
history of missed periods, pallor associated with 
pain, and pallor continuing and increasing after 
the rupture (and therefore relief of pain), lower 
than normal leucocyte count, no fever and often 
subnormal temperature, presents a very definite 
suggestion of the true condition. In only one case 
do I recall having seen the so-called Cullen's 
sign of blueness in the umbilicus — and this in spite 
of the fact that I have been looking for it many 
years. 

35. Acute pelvic inflammatory disease — Acute 
pelvic inflammation of the right tube can and often 
does present many difficulties in diagnosis, but in 
the vast majority of cases it can be differentiated 
by a pjelvic examination. Often the appendix is in- 
volved in this pelvic inflammatory invasion, and 
it is in such cases that careful surgical judgment is 
necessary. 

An unusually high leucocyte count, with a posi- 
tive blood sedimentation test, high fever, compara- 
tively little nausea, often burning and frequency of 
urination and sometimes a history of exposure, cer- 
tainly demand a pelvic examination even in an un- 
married patient. 

If one comes to the conclusion that the appendix 
is involved in the infection, I believe it should be 



ACUTE APPENDICITIS— Trout 



removed through a McBurney incision, and the 
cure of the acute pelvic condition carried out by 
complete rest in bed, injections of foreign protein, 
hot douches, etc. Immediate removal of acutely 
inflamed pus tubes carries with it a far higher mor- 
tality than delay until the infection is somewhat 
quieter and in many cases the tubes apparently 
return to normal. The temptation to remove 
acutely inflamed tubes is greater if they are ex- 
posed through a right rectus incision than if seen 
through the opening afforded by a INIcBurney 
incision. 

Having made the diagnosis of acute appendicitis 
the immediate removal of the appendix is indicated 
in the vast majority of cases. In my opinion, it is 
not as much a question of time since the beginning 
of the attack as it is of a proper estimation of 
the condition of the patient when first seen. If we 
operate or do not operate according to some time 
schedule, we are certainly doing an injustice to 
ourselves and to our patients. It is our rule to 
operate on every case just as soon as the diagnosis 
is made, provided there is not found some very 
definite contraindication. 

Perhaps it would be wise for us to consider some 
of these contraindications which delay or prevent 
immediate operation. 

Chest conditions: If the patient has definite 
pneumonia, which is not secondary to peritonitis, 
we usually delay surgical interference. If the pa- 
tient has a secondary pulmonary infection following 
a history of appendicitis with peritonitis, we try 
to determine if the abdominal symptoms and signs 
indicate definite localization; if so we delay oper- 
ation. On the other hand, if the patient is pro- 
gressively becoming worse with no indication of 
localization of the peritoneal invasion, we make 
a McBurney incision with either local or spinal 
anesthesia and remove the appendix if it can be 
located without disturbing any protective adhesions 
that might be forming. If the appendix is not 
readily located, several drains — one to the pelvis, 
and one to the flank — are very gently inserted. It 
should be recalled that the blood pressure in these 
desperately ill patients is very low, and, for that 
reason, spinal anesthesia can be safely employed 
only in a limited number of cases. If the surgeon 
feels that he must hurry through with such a pro- 
cedure, then I feel that the patient stands a better 
chance of recovery by pursuing the policy of 
watchful waiting. I do not believe that anyone can 
be dogmatic about if or when an operation should 
be done in this type of case; there are so many 
factors to be considered, and these factors differ 
so markedly in different cases that each individual 
case should be separately considered at the time 



and no attempt be made to follow any preconceived 
fixed general rule. 

With the use of insulin a diabetic patient can be 
and should be rapidly conditioned for an early 
operation. 

If the case is complicated by active pulmonary 
tuberculosis the chances are that the patient's blood 
pressure is too low to safely employ spinal anes- 
thesia. However, ethylene can be given safely to 
such patients without the cyanosis that so frequent- 
ly accompanies the administration of nitrous oxide. 
Ethylene does not produce the pulmonary irrita- 
tion which usually follows the employment of ether 
in tuberculosis cases. 

The postoperative care of the peritonitis cases 
will be considered by the other men on the pro- 
gram. However, we have found continuous 
suction through a nasal tube of so much comfort 
to these patients that I cannot refrain from men- 
tioning it. As each year goes by we find we are 
more frequently employing the continuous in- 
travenous drip with increasing satisfaction to both 
the patient and to us. With these two aids or\e 
can be more liberal in the employment of morphine 
to make postoperative convalescence more com- 
fortable. 

The above is my confession of my shortcomings, 
and I hope it has been as helpful to you as it has 
been a relief to me to unburden my guilty con- 
science. 



The Complementary Sex and Its Important FtmcTioN 
(A. L. Soresi, New York, in Med. Rec, Jan. 15th) 

It is common knowledge that primarily the organism is 
bisexual and that, in the great majority, later on one of the 
sexes becomes predominant, while the other atrophies. No 
man or woman is 100% male or female, respectively; both 
are a blending of the 2 sexes, with a varied predominance 
of one sex over the other. 

Rejuvenation of an old, worn-out organism even if it 
could be accomplished, would do more harm than good. 
If any one function, like the sexual, should be predominant 
the comparatively weaker organs presiding over the func- 
tions would be unable to stand the strain put on them by 
the more powerful, more exacting sexual organs. Thus the 
whole organism, instead of being improved, would go 
rapidly to pieces. 

I firmly believe that in the complementary sex hor- 
mones we have a means by which all the parts of the 
organism can be co-ordinately and proportionally re- 
activated. 

The complementary sex hormones are a general stimu- 
lant, not a sexual rejuvenator. 

When dealing with males we are able to administer a 
good preparation of their complementary sex hormones 
and the results are most satisfactory. When dealing with 
females we have not been able to administer a good prep- 
aration of their complementary sex hormones and the 
results were greatly inferior to the results obtained in the 
males. 



The commonest cause of intraperitoneal hemorrhage, 
other than traumatic, is ectopic pregnancy. 



1 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



Chemical Antisepsis* 

SouTHGATE Leigh, M.D., Norfolk, Virginia 



IT \i OS at the request of our very active secre- 
tary that I am imposing on you with this 
paper. I was also emboldened by the very 
cordial reception accorded my simple effort at the 
last meeting in discussing the Family Physician. 

Xo one is more heartily in favor than I of the 
adoption of every advance in medicine and sur- 
gery of proven helpfulness, but I believe that 
many of our younger men, in their anxiety to be 
up-to-date, are rather inclined to undervalue some 
of the older, tried and true remed,i€S and 
methods. 

Take, for instance, Sims' splendid teachings and 
instruments. The practical discarding of them 
both by the profession and by the medical schools 
has been a grievous hurt to the practice of gyne- 
cology, and is probably one of the causes of our 
failure to control the prevalence of dancer in 
women. 

In a way, this same unfortunate tendency has 
affected surgical cleanliness. In the early days it 
required a tremendous fight on the part of the 
doctors and nurses to get clean results. It was 
at that time rightly considered the most vital mat- 
ter in operative surgery. Vigorous and continued 
effort was necessary to put it over, but with such 
effort clean results were obtained, notwithstanding 
the almost insurmountable obstacles in the way, 
and the results were even better than those reported 
from many sections today. Of course no one has 
ever thought of giving up antiseptic methods: they 
are fundamental; but many are underestimating 
their vital necessity, are taking surgical cleanliness 
for granted, and often are leaving it to others, 
with frequent disastrous results. 

As I have often said, the vital necessity of strict 
attention to details is as pressing today as it was 
in Lister's time. Hospitals are still hotbeds of 
infection. Serious and dangerous infection can 
come upon us at any time if we are careless. We 
must all admit that in these modern times, with 
modern arrangements and facilities, it is nothing 
short of a crime to infect a clean operative case. 
.And yet it is frequently done. 

In the first two years of the World War, the mor- 
tality from infection was frightful, and the pro- 
fession seemed helpless to combat it. The situa- 
tion appeared so hopeless that it brought from 
the great English surgeon, Godlee, an article in 
the public press, entitled "Back to Listerism," 

•Pre.sented by Title to the Tri-State Medical Association 
faouth Carjima, February 17th and 18th. 



showing that the profession had gradually gotten 
away from the use of chemical antiseptics and was 
depending almost entirely on sK-called apepsis. 
Heat, the main agent for asepsis, could not, of 
course, be used on deeply infected tissues with- 
out injury to the patient. At that stage, Carrell and 
Dakin, recognizing the urgency of the situation, 
developed the splendid Dakin's solution, through 
which with its e.xact method of preparation and use, 
and with its general employment, the mortality 
was immediately and largely reduced. 

The wounds caused by deeply penetrating frag- 
ments, bursting shells, many of these neglected 
of necessity for hours and even days, could 
not be successfully handled by bathing with salt 
solution! Dakin's solution saved many a valuable 
life in the latter half of the war and is still doing 
fine work in accident surgery. Unfortunately, 
many surgeons fail to observe the strict rules of 
preparation and use laid down by Carrell in his 
excellent little book. It is also of great aid in 
other suppurating wounds, and especially in ap- 
pendiceal sinuses. 

Chemical antiseptics, especially bichloride and 
carbolic, still have a useful and vital place in sur- 
gery, notwithstanding the frequent warning from 
theoretical writers to the effect that their use will 
interfere with healing. 

Those of us who, in the early days of antisepsis, 
washed all wounds with chemical antiseptics, can 
testify that such fears are unfounded in fact. We 
know that such wounds healed just as promptly as 
the wounds of today and that the average result 
was even better than those in many sections now. 
Has anyone ever seen any interference with healing 
caused by the surgeon using bichloride solution for 
bathing his gloved hands during the operation? Yet 
we know that such a practice is a safeguard for 
cleanliness. 

Practically everyone sterilizes the stump of the 
amputated appendix before inverting it, and yet 
many fail to use bichloride solution in bathing off 
a gastroenterostomy. Many a brilliant operation 
about the intestinal tract is spoiled by infection 
simply because chemical antisepsis has not been 
judiciously used. 

All accident wounds are infected, many of them 
badly infected. Killing the infection by chemical 
means will convert a dirty wound into a clean one. 
In small wounds it insures quick healing. In a 
compound fracture it means success as against 

or the Carolinas and Virginia, meeting at Columbia, 



CHEMICAL ANTISEPSIS— Leigh 



March, 1936 



failure. Here a constrictor is applied (where feas- 
ible) and the wound not only cleaned out by de- 
bridement but scrubbed out vigorously with a 
strong antiseptic, such as 1-500 bichloride followed 
by salt solution, bones brought together, fastened 
if' necessary, blood vessels carefully ligated, wound 
sutured very loosely without drains, large com- 
pressing dressings applied with splints and then 
the constrictor removed. 

If operated on early, primary healing is obtained, 
the dressing not being changed even for a month. 
Without chemical antisepsis the situation is de- 
plorable and the job an endless one. 

Chemical antiseptics are also essential in the 
dressing of both clean and dirty wounds— for the 
former to keep them clean, and the latter to lessen 
the severity of the infection. 

Of late there have been several new preparations 
reported and used to some extent. It is a good 
sign and I hope means that the profession is be- 
coming interested. They, all of them, no doubt, 
will be of use. However, we can hardly get away 
from carbolic and bichloride which were used by 
Lister, and have continued to be of great aid in 
surgery ever since that time. 

It is not in the province of this brief paper to 
discuss more than the principles involved. 

I say then that it is a serious mistake to get 
away from the use of chemical antiseptics, which 
were the foundation stone of Lister's revolutionary 
work, and which today have their place in careful 
and safe conservative surgery. 

Judiciously used, I have never seen any mtev- 
ferenee witli-'prmnpt' healing, and even if such 
interference existed, it would not be as harmful as 
that from sepsis. 

For the Comtort of the Cancer Patient 

(T G. Miller, Philadelphia, in Jl. Okla. State Med. Asso., 

Jan.) 

Every patient with cancer should be actively treated, 
given attention for minor ailments and treatment directed 
toward an improvement of their general physical condition. 
Few, if any, cancer patients are not suffering from some 
secondary or associated disturbance: weight loss, anemia, 
general weakness, cough, dyspnea, anorexia, intestinal 
indigestion. It is almost invariably helpful to prescribe a 
specific hygenic program, including periods of rest, of mild 
exercises and of entertainment, and carefully to supervise 
the diet. On such a regimen alone many patients promptly 
will improve and cooperate more completely in the spe- 
cific therapeutic procedures. 

When specific measures cannot be considered or have 
been employed to the limit, it is all the more necessary 
to outline a routine of life conducive to physical and 
mental wellbemg. This may involve an entire change of 
environment, a return to noutine work or even the de- 
velopment of new hobbies and life activities. 

Anemia deserves special mention, for it is frequently 
looked upon as an essential part of the malignant process 
and given insufficient attention. It should be treated 
actively: by iron, liver extract, sometimes by transfusion. 



as well as by hygienic measures and an adequate and varied 
diet. The restoration of a normal blood picture often 
brings about decided improvement in the general physical 
condition of the patient and in his morale. Thus it con- 
tributes, even if not to a prolongation of his life, to hb 
comfort and peace of mind. 

Particularly important is it that the patient secure regular 
periods of sleep: this may necessitate use of the bromides, 
the barbiturates or even the opiates; sometimes it may be 
secured in a warm bath or a hot drink at bedtime. Under 
all circumstances, however, it is as important as the relief 
of pain, and it justifies the use of any effective remedy. 

When tlie prognosis is hopeless, nothing is to be gaiyied 
by sparing such drugs a^ are required to give the patient 
comfort and to relieve his fears: habit formation doesf 
not have to be considered. When the case is not far ad- 
vanced, severe pain is unusual or of brief duration, and, 
ordinarily, can be controlled by some of the specific forms 
of therapy or by the temporary exhibition of sedatives. 
Under no circumstances, however, should the patient be 
allowed to suffer needlessly. Often this can be prevented 
by the use of the bromides, chloral or the salicylates, but 
when such drugs are not effective, codeine, mor- 
phine or pantopon should not be withheld. If the opiates 
are used discriminatingly, only when needed and in the 
smallest doses that will be effective, the total amount is 
usually small. Dilaudid, of the newer opium preparations, 
seems very promising in that it less frequently than mor- 
phine has untoward side actions, acts quickly when given 
subcutaneously or by mouth, and for slower and more 
prolonged action can be administered per rectum. In 
the inoperable cases it seems that small doses of morphine, 
pantopon or dilaudid frequently repeated, are more effec- 
tive than larger doses less frequently administered. For 
terminal cases in which partial narcosis is desirable, I have 
found sodium amytal, and especially dial, most helpful. 

Whether a trained nurse, a practical nurse or some mem- 
ber of the family is immediately in charge of the patient, 
she should be acquainted with the nature of the case 
in order to thoroughly cooperate with the physician. Only 
too often the medical attendant relies upon the nurse's 
judgment to handle such situations, without carefully in- 
structing her as to his viewpoint about the case and the 
methods by which she can assist him. Many patients 
have been carried through the most difficult of their 
problems by a cheerful, intelligent, tactful nurse, who 
perhaps never gives any real information but satisfies the 
patient's enquiries by clever evasion, reference to the 
doctor, or prompt attention to some minor ailment. 



Large Doses op Iron Required 
<Edi. in Col. Med., Feb.) 
Most of the ordinary doses of iron which we prescribe 
are wholly inadequate. Reduced iron, containing 90% 
iron, has a daily optimum dose of 1^ grams; iron and 
ammonium citrate not more than 17% iron, daily dose 6 
grams; ferrous carbonate, in the form of Blaud's pills, re- 
quires 17 pills as an optimum dose. Hydrochloric acid 
favors iron absorption, and is indicated where hypochlo- 
hydria exists. A physician who has decided that iron is 
indicated in any given case must direct the use of enough 
of it to equal approximately 1 to 1^ grams daily of me- 
tallic iron — if results are to be consistent with our war- 
ranted anticipations. 



Early and careful examination of all patients who are 
hoarse (M. a. Lischkoff, in //. Fla. Med. Asso., Dec.) 
will reveal many unsuspected cases of incipient laryngeal 
carcinoma that will respond to proper care. 



SOUTHERN MEDICINE AND SURGERY 



Rupture of Ovarian Cysts With Hemorrhage 
Report of Cases 

A. DE T. Valk, M.D., F.A.C.S., Winston-Salem, North Carolina 



THE occurrence of rupture of ovarian cysts 
necessitating operation, is relatively rare, 
as compared with the frequency of their 
existence, though, unquestionably, many such cysts 
rupture without serious results. This is particularly 
true in rupture of graffian-follicle or small corpus- 
luteum cysts. In such cases the fluid or slight 
bleeding associated therewith is readily absorbed. 
Such evidence is frequently found at a subsequent 
operation where an ovary is found rather adherent 
to the posterior aspect of the broad ligament or 
pelvic floor, without any suggestion of tubal in- 
fection. On the whole it is rather surprising that 
more trouble does not arise from rupture of ovar- 
ian cysts, when the thinness of the cyst wall is 
considered as well as the sudden variations of intra- 
abdominal pressure that take place especially in 
young girls who are athletically inclined. 

Trauma is to be considered at all times as a 
causative factor in producing rupture of ovarian 
cysts and it is here that may be noted the danger 
of being too vigorous in making pelvic examina- 
tions, especially when the existence of an ovarian 
cyst is suspected. 

The clinical picture of ruptured cysts with hem- 
orrhage sufficient to produce symptoms is quite con- 
stant, it varying in degree with the acuteness and 
amount of bleeding. The picture is very similar 
to that of rupture of ectopic pregnancy with no 
real means of differentiation, except, possibly, the 
menstrual history. As a rule there is no previous 
history of pelvic or menstrual disturbances, the 
patient having been quite well until the onset of the 
immediate illness. We have the initial sudden, 
severe unilateral pain in the lower abdomen, soon 
becoming more or less general. Nausea and vom- 
iting is variable and may not appear until later in 
the course of the disturbance. With severe hem- 
orrhage there may be initial shock with moderate 
collapse. 

The temperature is usually subnormal during the 
first few hours with a gradual subsequent rise, while 
the pulse varies with the amount of hemorrhage. 

There may be only moderate rigidity, but tender- 
ness over the lower abdomen is quite definite and, 
with the exception of tenderness in the region of 
the broad ligaments, there is little to be made out 
on vaginal examinations that is helpful. As a 
rule, no mass is found, as in ectopic pregnancy. 

The leucocyte count is high with a marked in- 
crease in neutrophiles. This varies somewhat with 



the amount of blood in the peritoneal cavity. A 
red blood count and hemoglobin determination 
should be made in all suspected cases when first 
seen and repeated from time to time, as this may 
give very definite and valuable evidence as to the 
extent and progress of the hemorrhage. 

In most all cases in which there is much free 
blood in the peritoneal cavity, the patient will 
complain of pain under the costal margin on deep 
inspiration and at times pain in the region of the 
left shoulder is mentioned. This has been re- 
peatedly described in bleeding from ectopic preg- 
nancy and is of course present in ruptured ovarian 
cysts with hemorrhage when the blood reaches the 
diaghragm. 

If the hemorrhage is copious, the patient's condi- 
tion may become immediately so grave as to call 
for a transfusion before operative intervention can 
be considered. 

The diagnosis of rupture of ovarian cysts is more 
often made at operation than before, and not in- 
frequently the condition is confused with acute 
appendicitis or mild pelvic inflammatory disease. 
As a rule, however, the pain is more acute and 
severe than in appendicitis. The differentiation 
from ruptured ectopic pregnancy is quite difficult 
though the menstrual history may be helpful. 

In all cases where there is a possibility of the ex- 
istence of a pelvic lesion a midline incision is de- 
sirable. Whether the ovary is removed or resected 
is a matter of judgment, though conservation of 
ovarian tissue in such cases is desirable and can 
usually be accomplished. 

In two of our cases no particular causative factor 
could be ascribed ; in the other two there was a dis- 
tinct history of trauma. 

Case Reports 

(1) A white woman, a^cd .J.i yrs., niarrifd 15 months, 
referred by Dr. W. M, J., was first seen Jan. I4th, 1916. 
The chief complaints were painful menstruation and in- 
digestion. There was nothing of importance in the family 
or past history. The present illness consists of painful 
scant menses lasting four to five days for past three years. 
Last period was three vvcel<s ago. Bearing-down pain is 
felt when on feet. There is gastric disturbance with 
some epigastric pain and eructations and the patient is 
very constipated. There have been no pregnancy, no Icu- 
corrhea, nor urinary disturbances. 

Examination revealed a fair development and good color; 
eyes, ears and throat clear; heart and lungs normal; ab- 
domen natural-lookinc, no masses seen or felt, i^igmoid 
palpable, slight lendcrness in right lower quaflrant, no 
rigidity; vaginal outlet marital, cervix conical and well 
up in the vault, fundus in anterior position and freely 



132 



RUPTURE OF OVARIAN CYSTS—Valk 



March, 1936 



movable, adnexa not felt as patient held abdomen rather 
rigid. Gastric analysis showed slight hyperacidity. 

A diagnosis was made of chronic appendicitis with dys- 
menorrhea, and on January 17th (3 days later), vaginal 
examination under ether anesthesia a small cyst of the 
left ovary was felt which seemed to immediately disap- 
pear. Dilatation and curettage was done, very little en- 
dometrium being recovered. At this time the anesthetist 
noted that the patient had become slightly pale and her 
pulse had suddenly gone to 120 and lost in volume. 

A midline incision was made and on opening the peri- 
toneum much bright red blood was found. Further exam- 
ination revealed a ruptured ovarian cyst with active bleed- 
ing: apparently this occurred on bimanual examination, 
though very little force was exerted. The left ovary was 
removed, also the appendix, this organ showing definite 
chronic inflammatory changes. 

The postoperative course was uneventful and the patient 
was discharged on 18th day. 

(2) A white married woman, aged 38 yrs., was ad- 
mitted to the hospital July 31st, 1932, referred by Dr. 
W. M. J., complaining of severe pain in lower abdomen. 
The family and past history were rather unimportant. 
No disturbance of menstrual periods, the last one about 
two weeks ago. The present illness began 14 hours be- 
fore admission, with a rather acute and quite severe pain 
during sexual intercourse. This pain was low down in 
pelvis and gradually became more severe. Dr. J. saw 
this patient two hours after onset and pain was sufficient 
to require a quarter-grain of morphine. She slept very 
little during the night and in the mornmg, on attempting 
to get out of bed, she fainted. At this time the pain and 
soreness in the lower abdomen were very marked. 

On admission, temperature was 97°, p. 120, r. 20, w. b. c. 
15,200— pmn. 86%; r. b. c. 3,100,000; hgbn. 55%. The 
patient was quite well nourished though somewhat pale, 
heart and lungs negative, urine clear; the abdomen natural- 
looking with rather marked tenderness over lower half 
with slight rigidity in this region. Vaginal examination 
revealed nothing other than cul-de-sac tenderness; no 
bleeding. Complaint was made of definite pain under cos- 
tal margin on deep inspiration. 

The preoperative diagnosis was ectopic pregnancy or 
ruptured ovarian cyst. 

On July 31st, under ether anesthesia, a midline incision 
was made and the abdomen found to be filled with red 
blood, and a right ovarian cyst ruptured with active bleed- 
ing. The ovary was hastily resected as the patient's condi- 
tion was not at all good. The free blood was aspirated 
from the abdominal cavity and hasty closure made. An 
uneventful recovery ensued with discharge 15 days after 
operation. 

The next two cases are rather interesting as they 
spontaneously ruptured apparently without trauma. 

(3) White single woman, aged 20 yrs., referred by Dr. 
W. M. J., and admitted to the hospital June 1st, 1933, 
complaining of severe pain in lower abdomen, on right 
side. 

Family and past history unimportant. Patient has never 
been robust but apparently well. No menstrual disturb- 
ances with last period 15 years ago. 

The present illness began 12 hours ago when patient 
turned in bed and had a sudden severe pain in right low 
abdominal quadrant. This gradually became more severe 
with coHcky pains up under costal margin on deep inspira- 
tion. There was slight nausea but no vomiting. Some feehng 
of bladder pressure with painful urination was experienced. 



On admission, t. was 99.4°; p. 100; r. 20, w. b. c. 12,600 — 
pmn. 80% ; urine and stool negative. 

A slender girl, shghtly anemic, throat injected (recently 
had tonsillitis), thyroid palpable, no general glandular en- 
largement, heart and lungs clear; abdomen somewhat sca- 
phoid, no masses palpable, tenderness in lower half, more 
on right with some rigidity; inguinal region negative. Va- 
ginal examination not made as hymen would not admit 
tip of index finger. A rectal examination revealed some 
pelvic tenderness. 

The preoperative diagnosis was acute appendicitis. 

On June 1st, vaginal examination under ethylene anesthe- 
sia was negative other than a suggestive small mass in right 
side of pelvis. A midline incision was made and the ab- 
domen found to be filled with bright red blood from a 
ruptured right ovarian cyst, which was still bleeding ac- 
tively. Resection was done and a chronically diseased 
appendix removed. The postoperative course was un- 
eventful and patient was discharged on 18th day. 

(4) A white single girl, aged 19 yrs., was referred by 
Dr. C. H., was admitted to hospital July 15th, 1934, com- 
plaining of abdominal pain of 24 hours duration. Family 
and past history were essentially negative. Last period 14 
days ago. 

This illness began 24 hours ago with sharp pain more 
or less general over lower half of the abdomen; gradually 
the whole abdomen became sore and the patient remained 
in bed. On attempting to get up she became faint an(J 
blind. 

This pain and sense of fullness in lower abdomen soon 
became aggravated with a sense of pulling on attempting 
to stand. Nausea and vomiting ensued. When admitted 
the patient was in rather severe shock, very pale and 
restless. 

The urine was negative, r. b. c. less than 1,000,000, 
hgbn. 35%, w. b. c. 18,000— pmn. 8S%, p. 130, t. 99.4°, 
r. 28, heart and lungs clear. The abdomen was distended, 
very tender generally with dullness in flanks, and some- 
what rigid over the lower half. The characteristic pain 
under costal margin was present. No vaginal examination 
was made as the hymen was virginal. 

It was quite evident that the patient was suffering from 
an acute intra-abdominal hemorrhage and a tentative diag- 
nosis of rupture of ovarian cyst was made. 

On the day of admission, the patient was given 500 
c.c. of blood and, under ethylene anesthesia, a mid- 
line incision was made and the abdomen found to be full of 
blood, which was removed by aspiration. A large ruptured 
cyst of the left ovary was found, still in active bleeding, 
and the greater portion of the ovary resected. A hasty 
closure of incision was made. The patient reacted quite 
well, and the postoperative course was uneventful, being 
discharged 17 days after operation. 

While of infrequent occurance, rupture of ovar- 
ian cysts should be borne in mind at all times in 
dealing with all acute pelvic lesions. 



How frequently patients are told to take "a little soda 
with the aspirin." One is alkali and the other an acid. 
The incompatibilty is worse than one of ordinary neutrali- 
zation, for the acetylsalicylic acid is decomposed by the 
alkali into acetic and salicylic acids. — Edi. in Mol. Med., 
Jan. 



C.4LLF0RXIA has a tick (Ornithodorus coriaceits, com 
monly called pajaroello) which is greatly dreaded because 
its bite is very painful, slow to heal and leaves an ugly, 
permanent scar. 



i 



SOUTHERN MEDICINE AND SURGERY 



Management of Kidney Tuberculosis* 

A. J. Ceowell, M.D., Charlotte, North Carolina 



TO discuss intelligently the management of 
tuberculosis of the kidney, it is first neces- 
sary to know the type of infection, whether 
human or bovine, the extent of kidney destruction, 
whether the infection is primary, or secondary to 
extranephritic lesions; if secondary, the location 
and extent of the primary infection, whether pul- 
monary, glandular or osseous. 

It is generally recognized that tuberculosis of the 
kidney is hematogenous in origin and that primary 
unilateral tuberculosis is rare. The infection is 
carried through the blood stream in equal quan- 
tities to the two kidneys. The healthy kidney does 
not excrete tubercle bacilli. According to David 
Band, J. M. Alston and E. F. Griffith, W. P. 
Munro, Leiberthal and Von Huth, Medlar, Helm- 
holz, Allen and Montgomery (Mayos), R. I. Harris, 
and other investigators, infection of the kidney 
must occure before the bacilli can pass through and 
appear in the urine. Why one kidney should be- 
come infected through the blood stream and the 
other escape can be explained only by one kidney 
having less resistance than the other to such in- 
fection. Chronic interference with the elimination 
of its secretion may act as a predisposing cause to 
such infection. Trauma by blow over such a kid- 
ney, in cases of extrarenal tuberculosis, would be an 
exciting cause to renal infection. 

There is a tendency for the disease to spread 
to certain adjacent organs; for instance, the seminal 
vesicles and prostate are likely to become involved 
from a tuberculous epdidymitis, and tuberculous 
meningitis is occasionally seen following nephrec- 
tomy for tuberculosis of the kidney. We have had 
one such case within the last eighteen months. 

Painful and frequent urination, with blood and 
pus in the urine, are the most frequent symptoms 
and signs of renal tuberculosis: and when these per- 
sist, despite the use of measures suitable for cases 
of simple cystitis, the condition should be consid- 
ered tuberculous until proven of other nature. I 
will go further and say that every case of pyuria, 
without residual urine, with more or less blood in 
the urine should be investigated repeatedly for tu- 
berculosis of the kidney, even though there be no 
clinical symptoms of the disease. 

In the terminal stages of pulmonary tuberculosis, 
tubercles are frequently found in the liver, spleen 
and kidneys. In these cases there are no bladder 
lesions, no destruction of the calyces, no lesions in 

•Presented to the Tri -State Medical Association of tlic 
lina. February 17th and 18th. 



the parenchyma adjacent to the calyces or pelvis. 
This type of renal infection is rarely manifested by 
urinary symptoms, and it cannot be demonstrated 
radiographically. 

We believe it has been definitely established by 
various investigators, clinically and at autopsy, that 
some small tuberculous lesions in the parenchyma, 
which produce no symptoms, do heal spontaneously, 
but more go on to kidney destruction and the death 
of the patient, certainly when there is active infec- 
tion elsewhere in the body. In such cases, with no 
indication of the disease other than the constant 
presence of tubercle bacilli in the urine, nephrec- 
tomy is not justified, even if the bacilli are demon- 
strated to come from one kidney only. 

Renal tuberculosis usually develops slowly, 
making it unnecessary to rush into surgery. It is 
better to have two tuberculous kidneys than only 
one and it tuberculous. Such patients should be 
hospitalized and cared for as you would a victim 
of pulmonary tuberculosis. Tuberculous lesions 
heal in other tissues of the body, and I see no reason 
why the bacilli should behave differently in the 
kidney. In fact, it is more reasonable to believe 
that spontaneous healing would take place in an 
organ so richly supplied with blood, certainly but 
for the fact that the kidney cannot be put at rest. 
We think we are justified in saying that clinically 
established renal tuberculosis does not heal. 

Renal tuberculosis is quite prevalent in patients 
who have tuberculous lesions elsewhere in the body. 
Harris found it in 37% in a series of 143 cases in 
adults and in 13.8% of 67 cases in children exam- 
ined. Other investigators find it in about the same 
proportion. 

Ureteral stricture is a fairly common occurrence 
in renal tuberculosis, and complete occlusion results 
in autonephrectomy. It is easily diagnosed by 
means of the ureteral catheter, intravenous indigo- 
carmine and intravenous pyelography. 

About two-thirds of the cases of renal tubercu- 
losis have bladder symptoms only. If ureteral oc- 
clusion has persisted long enough for the bladder 
lesions to heal, autonephrectomy can easily be over- 
looked, and in some cases this is a fortunate event. 
Two types of autonephrectomy occur: in one the 
kidney atrophies and the other it enlarges and be- 
comes caseous or cystic; the former occurs if ure- 
teral occlusion is of long standing, and the latter 
when it is of recent occurrence. 

Carolina.s and Virginia, meeting at Columbia, South Caro- 



KIDNEY TUBERCULOSIS— Crowell 



March, 1936 



Here careful study and good judgment are very 
necessary to ascertain whether surgical nephrectomy 
is advisable. Generally speaking, it is advisable 
in the acute occlusion and especially in the presence 
of definite bladder symptoms with a mixed in- 
fection. In cases of occulsion of long standing, in 
the absence of bladder ulceration and bladder 
symptoms, the patient can be left undisturbed but 
kept under close observation. In such cases the 
infection is walled off and frequently sterile. Gibson 
is of the opinion that surgical nephrectomy is un- 
necessary in such cases, or at least the risk of 
leaving the kidney in situ is no greater than sur- 
gical nephrectomy. In some of these cases the kid- 
ney becomes calcified and this process goes on to 
the point that the pathologic process is rendered 
innocuous. Crenshaw found, in a study of 1817 
cases of renal tuberculosis at the INIayo Clinic, 
that 131 (7.17f ) showed calcification. In Caulk's 
series 20% showed calcification. Braasch found 
that more or less calcification had occurred in 30% 
of these cases. This condition seems to be much 
more prevalent in cases of renal tuberculosis with 
occlusion than in renal tuberculosis without occlu- 
sion. It seems from the reports of various urolo- 
gists of large experience that calcification in renal 
tuberculosis is neither a favorable nor unfavorable 
prognostic sign. 

Before deciding upon a definite plan of treatment, 
an accurate diagnosis should be made of the nature 
and extent of the lesion, whether unilateral or bi- 
lateral, type of infection, functional capacity of 
each kidney, and whether there be active extrarenal 
lesions, as well as the general physical condition of 
the patient. In other words, a decision must be 
made as to whether the case is to be handled medi- 
cally only, or medically and surgically. Of course 
all cases must have careful medical supervision. 

David Band finds that in extrarenal lesions in- 
fection with the bovine type of bacillus is much 
more deadly than infection with the human tv-pe; 
but when the lesion is limited to the kidney, the 
reverse is true. He found the bovine type prevalent 
in 33.3% of the cases. W. T. Munro finds it in 
about 30% of renal tuberculosis in Scotland. He 
agrees with Band that the mortality is much higher 
in the bovine type of infection, with extrarenal 
lesions. This makes it quite important that we 
know the type of infection as well as its limita- 
tion, whether intrarenal only or both intra- and 
extrarenal. This knowledge is necessary to treat 
properly renal tuberculosis. We acknowledge we 
have not stressed these diagnostic points sufficiently 
and I suspect this is true of most of us. 

It is difficult to determine, in many cases, just 
where surgical interference should succeed medical 
care. All agree that surgery is contraindicated in 



acute miliary tuberculosis and acute toxic nephritis. 
Best surgical results are obtained in the preclinical 
cases of unilateral renal tuberculosis, if definitely 
known to be unilateral. Nephrectomy before the 
disease spreads to the ureter, bladder or genital 
tract is advisable. The lesions which can be 
demonstrated pyelographically produce definite 
clinical symptoms and do not heal. In such cases 
ulcers can be found usually in the ureter and blad- 
der and abscesses in the kidney. Nephrectomy is 
here indicated. Chronic bilateral renal tuberculosis 
is not a condition for surgery. 

Great gentleness should be exercised in removing 
a tuberculous kidney to avoid infecting the 
wound with tubercle bacilli or forcing them into the 
circulation and so to the meninges or other tissues 
of the body. The pedicle should be freed by gent- 
lest manipulation possible and the blood vessels 
ligated first. The ureter should be freed as low 
down as possible, the wound carefully protected by 
means of gauze, the ureter severed between two 
ligatures by means of the electric cautery and the 
distal end of the ureter further cauterized with car- 
bolic acid or the electric cautery. Cigarette 
drainage should be established and the wound 
closed in the usual way. 

Discussion 

Dr. M.^ion H. Wym.an, Columbia: 

Gentlemen, Dr. Crowell has been very fair about this 
subject. We do not have so much tuberculosis in South 
Carolina. Dr. Ballenger, of .Atlanta, has only occasionally 
a case of tuberculosis of the bladder or kidney. I was em- 
barrassed for a while; I thought I could not find it. I was 
in Bordeaux for four months after the war and worked 
with an eminent specialist for several months. We found 
a great deal of urinary-tract tuberculosis over there. He 
was kind enough to let me work out a good many of 
them. We took out several tuberculous kidneys a week. 
But in my twenty-two years in Columbia I have seen 
very few. Up to a few years ago, when a diagnosis was 
made of unilateral renal tuberculosis, the accepted treat- 
ment, I think, was to remove any such kidney. 

We have had a few tuberculous cases in the Veterans' 
Hospital. We have veterans in this State From Florida, 
a few from North Carolina, and a few from Georgia. 
Most of them are from South Carolina. A great many 
Northern boys stayed in Columbia after the war; they 
were here in camp and stayed here. 

My conclusion is that we do not have so much tuber- 
culosis of the kidney. Of course, you want to make the 
diagnosis, but you want to be conservative. The condi- 
tion, the pathology in the kidney, whether it is functioning 
or not, and the condition of the other kidney, must be 
considered. 

I enjoyed the paper very much. Dr. Crowell. 

Dr. Hugh Wymax, Columbia: 

I believe we are indebted to Dr. Crowell for bringing 
this subject before us. It is very important, to my mind. 
In my somewhat limited experience, it is the most trying 
urological diagnosis I have ever made. I get discouraged 
in trying to make the diagnosis of renal tuberculosis, par- 
ticularly in the early stages. Now, if you have constantly 



March, 1936 



KIDNEY TUBERCULOSIS— Crowell 



135 



blood cells and a few pus cells in the urine that are un- 
explained by any other infection, if you will persist in 
looking for tubercle bacilli and make a guinea-pig inocu- 
lation you will get a positive result, if you are persistent. 
It is my experience that the bacilli come down in showers. 
You will get a number of negatives, then finally one 
positive. So persistence is ver>' important. 

As Dr. Crowell mentioned, and in my experience, stric- 
tures of the ureter are very, very common. In any stric- 
ture, tuberculosis of the kidney should be ruled out very 
definitely. I want to emphasize that where you have ad- 
vanced tuberculosis of the kidney, with stricture of the 
ureter, those strictures should be dilated at frequent 
intervals so as to establish drainage. 

Dr. Malcolm Hosteller, Columbia: 

I should like to ask a question for information. For 
seven years I have been doing roentgenology here, in con- 
nection with the hospitals, and I have continuously looked 
for cases of tuberculosis. On two or three occasions I 
have been almost sure that I had a case of tuberculosis 
from the roentgenological standpoint, but later those cases 
did not prove to be tuberculosis. For some reason, we 
have not been able to find any cases of tuberculosis in this 
vicinity, and I wanted to ask Dr. Crowell if it is true that 
tuberculosis of a kidney occurs more frequently in some 
vicinities than in others. 

Dr. Crowell, closing: 

Dr. Wyman speaks of the importance and the difficulty 
of making the diagnosis of tuberculosis of the kidney. It 
is rather tedious, and it takes time. But we can un- 
doubtedly make a diagnosis in a resonably short time by 
means of culture and the guinea-pig inoculation if we can 
not find the tubercle bacilli by smear. 

I think that in any locality that has a greater percentage 
of tub'irculosis — pulmonary, glandular or osseous — we shall 
have tuberculosis of the kidney more prevalent. Investi- 
gators have shown very definitely that tuberculosis of the 
kidney is a quite common accompaniment of tuberculosis 
elsewhere in the body. 

I was in hopes that some of the medical men would dis- 
cuss this problem, more especially the men who are in- 
terested in tuberculosis generally, on account of the ten- 
dency now to be a little more conservative, from the sur- 
gical standpoint, than formerly. 



Extraperito.veal Pathology With lNTRAPERiTO>rEAX 

Symptoms 

(J. B. Haskins, Chattanooga, in Jl. Tenn. State Med. 
Asso., Feb.) 

In one, an emotional insult will produce a visceral reac- 
tion, either unnoticed or soon forgotten, whereas the same 
stimulus to another individual will produce a distressing 
response. With such idea in mind, the correct interpreta- 
tion of the symptom of abdominal pain is not always simple 
or easy of explanation. 

A young person who has always been in good health is 
seen for the first time complaining of acute diffuse ab- 
dominal pain, vomiting, increased pulse rate and slight 
or no fever, or the pain may be so that he twists, turns, and 
groans. There is general abdominal tenderness with mus- 
cular rigidity, more marked toward the lower right quad- 
rant, the leucocyte count is elevated with an increase 
in pmns. — a classical picture of acute appendicitis and 
such a diagnosis most frequently is correct. This picture 
may be simulated by other conditions, as — poisoning from 
the bite of the black widow spider, abdominal crises in mi- 
graine, pneumonia, diaphragmatic pleurisy, pericarditis, 
herpes zoster and tonsillitis; with the onset of some of 



the acute infectious diseases — scarlet fever, measles, mumps, 
rheumatic fever, influenza and typhus fever. Chronic 
poisoning with lead, arsenic and mercury' may give re- 
ferred pain. The referred pain of Pott's disease and the 
abdominal crises in tabes dorsalis, Henoch's purpura, an- 
gioneurotic edema, urticaria, allergic reactions, arterios- 
clerosis, atheromatosis, thromboangiitis obliterans, angina 
pectoris and occlusion of the coronary, septicemia, bacterial 
endocarditis, pyelitis, pyelonephritis, renal and ureteral 
calculus — all of these have been the cause of many useless 
abdominal operations. 

Diseases of the central nervous system such as syphilk, 
transverse myelitis, tumors of the spinal cord and its 
coverings, infiltrating tumors, osteoarthritis or tubercu- 
losis of the spine, scoliosis with arthritis — all frequently 
cause pain referred to the abdomen. Thyrotoxicosis, pit- 
uitary dysfunction, heart disease, particularly right-sided 
failure ; renal infections and calculi, hydronephrosis, ure- 
teritis, ureteral stricture and periarteritis nodosa. 

Think of all the causes. 

Be ever ready to swap off good diagnostic signs and 
symptoms for better ones. 



The Treatmen-t of Angina Pectoris 

(N. C. Gilbert, Chicago, in Med. Clinics of N. A. for 
Jan.) 

Attacks may be brought on by exertion, indigestion and 
emotional upsets, or may occur in pernicious anemia, from 
insufficient oxygen for the heart muscle or in diabetes fol- 
lowing temporary hypoglycemia after insulin; in some 
patients the attacks can only be ascribed to an unstable 
autonomic nervous system. A great deal of the patient's 
future depends on what the physician says. The physician 
should try to gain a common ground of understanding 
with the patient, to encourage him and at the same time 
evaluate the factors which predispose to the attack and 
direct the patient as to how best to avoid the attacks. 

The attacks are best relieved by amyl nitrite or nitro- 
glycerine. Between attacks, most cases can be materially 
helped by theobromine and theophylline salts. Treatment 
is started with theobromine-calcium salicylate (Th:;ocalcin) 
whkh only very rarely causes distress. Tolerance to its 
puriness being acquired, Theocalcin medication is alternated 
with theophylline ethylenediamine or theophylline-calcium 
salicylate (Phyllicin), which is quite as effective clinically. 
Theocalcin is given in 7^<-grain tablets, 1 or 2 at a time 
and Phyllicin in 4-grain tablets. All the purine salts are 
best taken during the meal. Rest from medication may 
be allowed for a few days each week. 

Some patients have received treatment with the purine 
salts for as long as 11 years without having to discontinue 
medication on account of intolerance. Phenobarbital, when 
necessary, is used separately so that the dosage can be 
properly varied; a sedative effect without drowsiness is 
the aun. Digitalis is not used except where definitely indi- 
cated, since it may precipitate an attack by reducing cor- 
onary flow. Surgical methods for the prevention and treat- 
ment of anginal pain should be used in cases chosen with 
great care. 

To BE a psychiatrist (Wm. H. Bramblett, Newbem, 
Va., in Va. Med. Monthly, Jan., 1880), we must possess 
a most intimate and thorough acquaintance with all the 
diseases that flesh is heir to, together with a knowledge 
of all their varied manifestations through the nervous sys- 
tem. 



Telepathy is too doubtful a medium to replace an un- 
obtrusive and w'ell-timcd word of appreciation of a re- 
ferred patient or other marks of favor. — Editorial Wis. 
Med. JL, Jan. 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



Chondrofibroma of the Trachea 

Report of Case 

E. Trible Gatewood, ALD., Richmond, Virginia 



LIEUTARD recorded the first tracheal tumor 
in 1767. Tuerck is said to have been the 
first to observe such a tumor in the living. 
Since these observations the literature has increas- 
ingly recorded new growths of the trachea. This 
has been particularly true since the advent of the 
bronchoscope. However, chondrofibromas are in- 
frequent enough to warrant reporting. 

Semon stated the frequency relation of laryngeal 
to tracheal tumors of all tj-pes as one hundred to 
one. jMcKenzie is mentioned as having seen only 
four tracheal tumors as compared to 800 new 
growths of the larynx over a period of 23 years 
(1906-1929). Schmidt studied 2088 new growths 
of the upper air passages. Of these 748 were 
laryngeal and three tracheal. These statements 
tend to emphasize only a comparative infrequency. 

The total frequency is best summarized by 
D'Aunoy and Zoeller in their comprehensive paper 
entitled "Primary Tumors of the Trachea." They 
state, "V'on Bruns reviewed the literature in 1898 
and collected only 141 cases. Krieg continued 
this review in 1908 bringing the sum to 201 cases." 
Their search of the literature extending through 
1929 brought the total number of 
all varieties of primary new growths 
of the trachea to 351. 

iNIany observers ascribe the infre- 
quency of tracheal growths to the in- 
activity and the simple structure of 
the organ. The middle portion is 
relatively immovable and protected 
from various forms of trauma, hence 
the predilection for the extremities. 
The posterior wall is most frequently 
elected. This is probably influenced 
by the richer glandular structure and 
a consideration of the tracheal lym- 
phatic vessels. 

The ratio of recorded tumors ac- 
cording to sex is 2.3 males to one fe- 
male. Notwithstanding the enormous 
number of bronchoscopies that are 
done, increasing each year, it can not 
be denied that tumors of any variety 
of the trachea are infrequently en- 
countered. .According to a review of 
the literature by several observers up 
to 1930 there are only 65 cases of 
tracheal chondromas, osteomas and 



chondrofibromas, taken collectively, on record. 

The case for report is that of a white athletic director, 
aged 28, seen at the Johnston Willis Hospital at 7 o'clock 
on the evening of August 18th, 1934, with his family phy- 
sician. 

The patient was in a semi-reclining position, semicon- 
scious and cynosed, suffering with urgent dyspnea. His 
physician stated that the patient had been under his ob- 
servation for two or three days with mild dyspnea and 
hoarseness which he regarded as asthmatic in nature. A 
hypodermic injection of morphine was given at his ofiice 
that morning and as there was no improvement the patient 
was removed to the hospital the same day at 3 o'clock. 
Morphine and adrenalin were repeated twice later in the 
afternoon. 

Examination at 7 o'clock showed a temperature of 97.6; 
pulse, normal; respiration 12, with limited expansion and 
diminished breath sounds over the entire chest. Laryngeal 
examination with the patient in semi-recumbent position 
was normal. In view of these findings an exploratory- 
bronchoscopy was decided upon. 

Passage of the bronchoscope was met immediately by 
an obstruction which had a normal mucous membrane 
appearance. Realizing that a high obstruction of an un- 
known nature was present we resorted to a low tracheo- 
tomy. This was accomplished without any form of anes- 
thesia as the patient was then entirely insensible. Con- 
sciousness was soon regained and respiration became nor- 
mal. 




Lateral View of Growth and Low Tracheotomy. Tube in situ 



March, 1936 



CHOXDROFIBROMA OF THE TRACHEA— Gatewood 



137 




Post-operative Lateral View 



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t. 




~v V ». 




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' ' "~t: 




-^ 


/ 


.* 


'^" ■ ''■ 




% 


' 


^. A- 


V 


•• '> . 


* 


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A x.v 


" ^pr-^.- ^^ 



Examination of the upper portion of 

the trachea with a laryngeal mirror a 

few days later, the patient in an up- 

,,^^ right position, show'ed a questionable 

• ^^ mass three-quarters of an inch below 
the vocal chords. Roentgen films out- 
lined a mass apparently attached to the 
posterior wall of the first and second 
rings of the trachea. 

.An open operation was decided upon 
with insufflation ether anesthesia. A 
midline incision was made extending 
from the upper border of the thyroid 
cartilage to the fourth tracheal ring. 
The thyroid gland isthmus was severed 
and retracted. The thyroid cartilages 
of the larynx and upper rings of the 
trachea were opened. The vocal chords 
were carefully separated at their imme- 
diate anterior junction. The hard and 
large cone-shaped mass was dissected 
from the posterior tracheal wall which 
appeared to invade the anterior esopha- 
geal lumen and a portion of the pos- 
terior surface of the cricoid cartilage. 
After removing the mass completely a 
nasal feeding-tube was fixed and the 
esophageal defect sutured. The vocal 
chords were approximated and the thy- 
roid cartilages fi.xed by suturing the 
overlapping ribbon muscles to insure 
even cartilaginous union. 
Nine days later the tracheotomy tube was removed and 
the tracheotomy opening closed. Two days later the feed- 
ing tube was withdrawn and the patient resumed the nor- 
mal way of swallowing with no difficulty. The patient 
was discharged 20 days after admission with a normal 
voice. 

Histologic study of the growth by Dr. W. A. Shepherd 
showed dense fibrous tissue with small areas of cartilage 
and calcification. The gross appearance at the operation 
was mainly cartilage, covered and interspersed with dense 
fibrous tissue, resembling a chondroiibroma. 

Comment 

1. Patients presenting symptoms of tracheal new 
growths may, in certain instances, be confused 
with cases of bronchial or pulmonary lesions. 

2. New growths of cartilaginous origin are ex- 
tremely rare. 

This case emphasizes the serious mistake of 
administering morphine to certain patients 
with dyspneic tendencies. 

Professional Building 



3. 



It is only in elementan,' education that we have made 
good on the commitment of a hundred years ago. Twenty 
years ago 1S% of the secondan.' population were enrolled 
in school; now between 55 and 60% are enrolled. The 
percentage of adult population going to school has been 
increasing 1% a year for the last 15 years. — //. P. Rainey, 
Prcs. of Bucknell, in Jl. Assn. Am. Med. Colleges, Sept., 
'.i5. 



of Chondroflbroma 



At least 200 doctors, it is said, will be needed for the 
enlarged Public Health work contemplated by the Social 
Security Act. 



President's Page 




Fellow Members of the Tri-Stale Medical Association: 

My first act as president of this organization and 
my first effort to fill the President's Page in its 
Journal shall be to assure you of my appreciation 
of the honor that you have conferred upon me and 
to remind you that I am deeply conscious of my 
responsibilities. It shall be my purpose to conduct 
the affairs of the i^ssociation as you would have 
them and to that end I will lean heavily upon our 
capable and efficient Secretary and I beg you as 
individual members to let me know your wishes and 
to give me your counsel and advice. 



Uppermost in my mind are ( 1 ) the desire to see 
the medical profession of this section lead in scien- 
tific research and the spread of medical informa- 
tion, (2) the economic disturbances in the practice 
of medicine, (3) the plight of several of our medical 
schools, (4) the inauguration of group payment for 
hospital care, and (5) the need for group payment 
of medical care. However, I again assure you that 
it is my desire to serve you and before outlining or 
planning any particular project I shall expect and 
await an expression of your wishes. 

DOUGLAS JENNINGS. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



Surgical Observations 

A Column Conducted by 

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



Narcolepsy 

Until recent years narcolepsy, or Gelineau's syn- 
drome, has been regarded as a rare condition; dur- 
ing the past decade more attention has been paid 
to this subject, and it is either increasing rapidly 
or is being diagnosed more accurately. 

Many accidents of different kinds — such as auto- 
mobile accidents and accidents to those who work 
around machinery — with disastrous results to th§ 
individual and to others, may be due to attacks of 
narcolepsy. 

Approximately 80% of the cases are in men. It 
occurs with greater frequency between the ages of 
20 and 40, but may occur in one of 10 years or 
after 40. The cause is unknown; there are many 
conjectures but no one has ever demonstrated its 
cause or a connection with any other disease. 

Narcolepsy may be defined as an uncontrollable 
desire for sleep. It must, of course, be differenti- 
ated from natural sleepiness from fatigue or going 
long without sleep. 

True narcolepsy, with the sudden intense desire 
for sleep occurring in an individual who ordinarily 
sleeps a sufficient length of time each night is a 
definite clinical entity, and as such has received 
much attention and been carefully studied. 

Pyknolepsy is a similar condition and is closely 
associated with narcolepsy. In pyknolepsy the 
patient has a sudden loss of muscular tone due to 
excitement, pleasure or shock. In this case the 
muscles of the body relax and the patient may fall 
if standing — or if sitting may slump in the chair. 

The group of symptoms now known as Gelineau's 
syndrome were noted and published many years 
ago by Fischer; Wcstphal, also, reported this 
combination of symptoms before Gelineau. 

Pathologic changes are indefinite. The attacks 
of sleep have the characteristics of normal sleep, 
and the fact that the patient does go to sleep sud- 
denly, and may remain so for a second or two or 
an hour or so, appears to be about all there is to the 
condition. 

The one symptom, usually is, an irresistible desire 
for sleep which may occur at any time and any 
place. Often the attacks are ushered in by yawn- 
ing. Usually there are no premonitory signs. 

Frequently patients fall asleep in company — es- 
pecially when listening to speeches. This, how- 
ever, may be merely the individual's method of 
taking a rest when tired of listening to a tedious 
harangue. 



The patient is usually easily aroused from a nar- 
coleptic sleep and becomes conscious immediately. 
While at work he may stop for a moment and then 
awake and resume his work as usual. 

The attacks vary in frequency; five or six daily 
are not uncommon. They are more frequent from 
9:00 to 11:00 a. m., or after 5:00 p. m. Amuse- 
ment, anger, fear or worry may bring on an attack. 
For this reason many individuals who would laugh 
and enjoy themselves do not do so far fear of 
bringing on an attack. 

Patients who are subject to attacks of this kind 
frequently have disturbed nocturnal sleep. They 
may have dreams in addition to the disturbance in 
the sleep. 

Many automobile accidents are doubtless trace- 
able to this one cause. It is true that many pa- 
tients become sleepy while riding along in a car, 
due to loss of sleep and to over-exertion. In fact 
many people who just need a rest may be driving 
a car and become sleepy and drop off to sleep for 
a sufficient length of time to cause an automobile 
accident to occur. In true narcolepsy the patient, 
even if he has had plenty of sleep, may lose con- 
sciousness for a few moments and fail to make a 
turn or run off the road, crash into a tree or tele- 
phone pole or roll off down an embankment. 

Almost everyone who drives a car a great deal, 
especially on long night trips, will at times get 
sleepy while driving. In a closed car with a steady 
purring motor, one is more inclined to become 
sleepy, especially if there has been insufficient sleep 
for a night or two previously. Under such circum- 
stances a driver may have great difficulty in keep- 
ing awake. Those who have observed sleepy driv- 
ers will notice that the car will wobble along and 
sometimes run partly off the road, when the driver 
suddenly becomes wide awake again and keeps 
the car steady in the road until he again becomes 
sleepy. In narcolepsy the driver of a car may have 
had an excessive amount of sleep, but when driving 
a car may suddenly drop off to sleep long enough 
to cause a wreck. Narcolepsy may manifest itself 
at any time and any place. A victim of this serious 
disorder may even go to sleep while standing. A 
careful study of any patient is necessary to differ- 
entiate between narcolepsy and the natural ten- 
dency to sleep — from loss of sleep, fatigue or ex- 
haustion. 

The treatment of narcolepsy is now on a sound 
basis. 

Years ago a large variety of drugs were used em- 
pirically. In many cases ephedrine gave relief. 
Ephedrine sulphate, grain one-half, given three 
times daily at 8:00, 12:00 and 4:00 would aid 
greatly in keeping off attacks and often prevent 



140 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



them entirely. Of course, a minimum dose is de- 
sirable. 

Ephedrine sometimes gave only temporary effects 
due to various causes. One interesting thing that 
was noted was the fact that two patients took 
mineral oil and the attacks became more frequent 
even in the face of the administration of the 
ephedrine sulphate. By discontinuing the mineral 
oil the attacks ceased. Evidently the mineral oil 
prevented the absorption of the drug. 

In recent years various observers have added 
much to our knowledge of the treatment. Prinz- 
metal and Bloomberg, among others, advocated the 
use of benzedrine sulphate, which is almost a spe- 
cific for the condition. The dose varies from 10 to 
100 mgs. daily, divided into two or three doses. 
Many cases, however, may be relieved by one or two 
small doses in the morning. 

Given after 4:00 p. m., it may interfere with 
sleep that night. 

A well person driving a car and getting sleepy 
from natural causes, may find benzedrine sul- 
phate useful. 

This drug seems to be harmless and the only bad 
effects, after taken over a period of time, may be 
a slight nervousness or jumpiness, which effects 
immediately disappear upon discontinuing the drug. 

In the treatment of narcolepsy the minimum dose 
should be established and the patient kept on this 
indefinitely — especially when driving a car any 
distance or working about machinery or where liable 
to falls. It is extremely important that there be a 
careful differential diagnosis between narcolepsy 
and the tendency to sleep due to natural causes. 
The same treatment, however, may apply to both. 

The use of any drug over long periods of time 
should be under the direction and control of a phy- 
sician, so that optimum dosage may be given, any 
untoward effects may be noted and the drug dis- 
continued if necessary. 



ILLUMINATING BITS FROM "THE STORY OF 
MY LIFE," by J. Marion Sims, M.D. 

His Observations on Trismus 

In April, 1845, I was called to see a child in spasms for 
2 days and nights. Touching it would throw it into con- 
vulsions; laying it on its face would cause spasms; any 
noise would produce them. It could not swallow, could not 
take nourishment, and it was impossible for it to suck. 
The legs and arras were as stiff as a poker. Its face was 
drawn around so that it wore a sardonic grin. After ex- 
amining the child for a while, I ran my hand under its 
head to raise it up. While in the act of raising it, my 
hand detected a remarkable irregularity in the relations 
of the bones of the head. At the back of the head I 
found that the occipital bone was pushed under deeply on 
the brain, and the edges of it, along the lambdoidal suture, 
were completely overlapped by the projecting edges of 
the parietal bones. I immediately suspected that the spasms 



were the result of mechanical pressure on the base of the 
brain, effected by the dislocation of this bone by the child 
lying on its back. I was surprised to find that by the 
erect posture removing the pressure from the base of the 
brain the pulse could be counted, and that the respiration 
had fallen from 120 to 70. 

The child died. The next day we held a post-mortem 
e-xamination. I invited Drs. Ames, Baldwin, Bowling and 
half a dozen other medical men to be present at the post- 
mortem. We found that the spinal marrow was sur- 
rounded by a coagulum of blood — extravasation of blood 
between the spinal marrow and its membranes. I thought 
that this was the cause of all the symptoms, and I published 
an article on the subject, in which I elaborated a very in- 
genious theory going to show that the compression at the 
base of the brain had strangulated the spinal veins in 
such a way that the blood could not be returned from the 
spinal column, and had therefore burst through its thin 
vessels. Subsequent experience, however, compelled m,' 
to modify this view of the case, and I wrote a second 
article on the subject, showing that this extravasation was 
not the cause of the disease, but was the result. 

Such cases should be placed first upon one side and 
then upon the other, and should never be put in a cradle 
or crib at all. A new-born child especially should be 
placed upon a pillow, lengthwise of the pillow. If this 
were done always, there would be no cases of trismus 
nascentium. I have seen a great many desperate cases' 
cured in a few minutes' time, simply by placing the pa- 
tient on the side. My doctrines in respect to the path- 
ology and treatment of trismus nascentium have not been 
been adopted or accepted by the profession at large; but 

I am satisfied they are true. Dr. , of Anderson, South 

Carolina, reported in the American Journal of Medical 
Science, for April, 1875, a dozen cases that he had cured; 
whereas, before my discovery, medical literature had not 
reported a single case of trismus nascentinum having 
been cured on any recognized principle applicable to any 
other case. Truth travels slowly, but I am sure that I am 
right — as sure as I can be of anything. * This will yet be 
fully understood and appreciated by the profession. I 
consider this my first great discovery in medicine. 

His III Health 

I was very ill; the fever raged, and I didn't know how 
fo arrest its progress by the treatment with quinine. This 
was before the days of quininisra, (Sept. 18th, 1836) and 
fevers were allowed to take their course. On the 14th day 
of my illness a young Englishman, living in Montgomery, 
a druggist, happened to arrive in Mount Meigs about ^ 
sundown. Last June I was in the Creek Nation with him. 

He was told that I was going to die tonight. He came 
up to see me and asked if I had been given any brandy? 
any quinine? On my replying that I had not he sat up 
all night giving me these remedies. That was the turning- 
point in my disease. 

It was not long before the practice of the country was 
completely revolutionized. Until that day, the doctors 
were in the habit of bleeding and physicking people until 
their fever disappeared, and then giving them qumine, a 
gr. or 2, 3 times a day. Fearne and Erskine and others 
preached the doctrine of giving it always in the begin- 
ning, if possible, and giving it in sufficient doses to 
affect the system at once. It left me with an enlarged 
spleen, and I had occasional attacks of intermitten fever. 
I lost my hair but that soon grew out again. 

Eariy in July, 1840, I felt a slight chill pass over me, and 
the sensation ran down my spine. The next day I had 
no paroxysm of fever. The next day, however, a little 

•Dr. Sims %vrote this in 1SS3. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



141 



shiver ran down my back, this chill increased in se- 
verity ; 4 hours from the first sensations of chillness, I 
was in complete collapse. 

My first chill was a little trifling thing at eight o'clock 
in the day; the second was an enormous congestive chill 
at twelve o'clock in the morning; thus anticipating 4 
hours I feared the next would come at four o'clock in 
the morning, or 44 hours instead of 48 hours later. If it 
came then 1 knew that I must die. 

Dr. Holt, of Montgomery, came and told me: "Well 
you must not have another chill at four o'clock tomorrow 
morning. Thirty grs. of quinine, taken between now and 
midnight, will save you. You must take it until you feel 
a little ringing sensation in your ears; keep your bed, keep 
warm, and keep up good courage." At four o'clock, pre- 
cisely, my nose began bleeding, and that the ancients would 
have termed a critical discharge. The chill did not come. 

Six weeks after my successes with the silver suture, I 
completely collapsed. I had contracted diarrhoea, and so I 
took my family to Butler Springs. My disease could not 
be controlled, and I saw that I was on the verge of 
going into that chronic state in which, in that day, there 
was such an attendant mortality. I concluded to go to 
the North for a time. I was so weak I could hardly make 
the journey to New York. I was there during July, Au- 
gust and September (1S4Q). I returned to Montgomery in 
October, not much better than when I left, if any. Soon 
after my return I gradually grew worse. I was reduced 
to eating milk and bread, and that ran away from me 
almost like pouring water through a funnel. 

My wife suggested that I should go to Columbus on a 
visit to our relatives there. I walked around about 100 
yards to the stage office. 

Diarrhoea is a chronic disease of the climate. It is en- 
demic all through the valley of the Mississippi. It is what 
consumption is in New England. When you see in the 
South a man in vigorous health and middle life grad- 
ually wasting away, and at the end of IS months drop 
to a skeleton into the grave, you may take it for a posi- 
tive fact that he has died of chronic diarrhoea. 

I did not stay long in Columbus, for I got no better 
by the visit. 

At last we arrived at Cooper's Well. Mr. Cooper, the 
proprietor, was a Methodist Circuit Rider. He said that 
a good many people were injured by the use of the water, as 
they got impatient to get well, and consequently took too 
much of it. But, with a prudent use of the water, he was 
sure that I would reap a substantial benefit from it. 

I ate, especially, fat meat, middle meat, and salt pork — 
the latter had been salted perhaps a month before. The 
diarrhoea was checked from the time I began to be a 
partaker of the water; I had a ravenous appetite, and I 
drank the water according to the express directions. I ate 
as I had never been able to before. I remained there 27 
days, and gained 27 pounds. I was impatient to get 
away, and left too soon. The result of the sudden ar- 
resting of the diarrhoea was to bring on a dropsical effect. 
My ankles were swollen, my legs were swollen above the 
knees, and my face and hands were very bloated. Still 
I felt I was on the road to recovery, and, especially, be- 
cause the wasting diarrhoea was controlled. 

I left there on the 30th of January (1850) for New 
Orleans, where I remained about a month. I carried with 
me demijohns of the water from Cooper's Well and con- 
tinued the use of it, and also continued to eat meat all 
the time. About the first of March I returned home. 
Everybody was amazed to see the wonderful change that 
had been effected. In 2 months more I had a return of 
the diarrhoea, a good deal worse than I had pver had it 
before, and it grew worse day by day. In July I again 



returned to Cooper's Well; but the water and the 
treatment did not have the same beneficial effect that 
it had upon me during my visit there before. I remained 
there about 2 months, and then I concluded that it was 
best for me to get into a colder clime. So I immediately 
went to New York where I remained about 2 months. I 
was always a little better in New York and Philadelphia 
than in any other place. Whenever I left New York and 
went to New England I was worse. If I went to Brooklyn 
for any length of time I became worse, and always felt 
better when I got back home again to New York. 

I had supposed that in New York was better able lo 
control my diet; but subsequent observation proved that 
that was not the case. The cause of my being better in 
New York and Philadelphia than elsewhere was the fact 
of the purity of the water of those two cities. In all New 
England, where I had been, the water was hard, and hard 
water was and is very injurious to the irritated mucous 
membrane of the gastro-intestinal canal. 

At last I was compelled to go to bed. I thought that 
I should die. 

I had gone to New York during the summer of 1849, 
1S50 and 1851, with the hope that the change of climate 
would do something for me. In June, 1852, I fell down 
with a sun-stroke, after a long walk, at the corner of 
Fifth Avenue and 27th Street and was carried to my 
boarding-house. This sun-stroke reproduced my disease 
with the greatest violence, and nothing seemed to control it. 

In a state of desperation, I went to Portland, Connecti- 
cut, to visit a friend. I remained there a little while, 
but got no better, so I returned to the city and went over 
and engaged board in Brooklyn, which was the worst 
thing that I could have done, on account of the water, and 
I grew worse day by day. At last, thmking that I must 
die, I concluded to go to Philadelphia. The day after 
arriving in this city we got in a buggy and rode up through 
the Spring Garden District, in various directions, in search 
of a little house that I might rent. 

I grew worse and worse daily. I sent for my friend, 
Dr. Isaac Hays to come and see me. He said that he 
thought I had better tak cod-liver oil. It was placed on 
the mantel-shelf; I never took it. But this gave me an 
idea. I said to my wife, "Cod-liver oil is a disagreeable 
thing to take; pickled pork is a good deal more palatable. 
Don't you remember with what benefit I used it the first 
time I was at Cooper's Well, how I ate pickled pork, and 
how I gained, and how I got well from that very mo- 
ment?" 

She said "Yes;" and immediately went out and bought 
some. She boiled it, and then broiled or fried it, I do not 
know which. I had always traveled, wherever I went, with 
some of the water from Cooper's Well in jugs. So I said, 
"We will inaugurate the same diet here that we did 
at Cooper's Well, drink the water and eat salted pickled 
pork." So we began it, and, to my great surprise, in 4 
or 5 days the diarrhoea was under control. This was 
inaugurated the last of August, and in a month I was 
able to get up out of bed, and to walk about 200 yards, 
with some little help. 

In the month of October (1852) I was getting well. I 
had always gone back to Alabama in October. We de- 
cided this was too early, and so deferred return to the 
19th of December (1852). I was feehng pretty well, had 
no diarrhoea. Five days after my return I had a chill, 
the diarrhoea returned, and could not be controlled by any 
possible means. I grew worse and worse. By that time 
my throat and tongue were so ulcerated that I could 
hardly speak, and any nourishment that I took passed 



(To p. 152) 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



DEPARTMENTS 

UROLOGY 

For this issue, P. Emery Huth, M.D., Sumter, S. C. 



Diverticulum of the Urinary Bladder 
Report of a Case of Multiple Diverticulosis in a Woman 

The urologist is called to treat patients who 
complain of a symptom complex which causes him 
to feel that the cystitis is not a simply inflammatory 
matter. These patients will tell him that, aside 
from the usual bladder symptoms, there are others. 
Such a paitent will often make a determined effort 
to direct the attention toward the unusually foul 
odor which her urine has had over a period of time. 
She will also direct attention to her inability to 
completely empty the bladder except on straining, 
and that this straining is unproductive. 

Diverticula of the urinary bladder may be di- 
vided into acquired and congenital. IMost research 
workers feel that the majority of them are the 
result of lower urinary-tract obstruction acting 
upon a congenitally defective bladder muscula- 
ture. This was made more likely by the finding 
of 2% of bladders examined in autopsies of chil- 
dren under ten years being the seat of bladder 
diverticula. Young demonstrated that overdisten- 
sion of the bladder would cause diverticula to form 
and relief of the pressure permitted the bladder to 
resume its normal shape. 

Diverticula of the urinary bladder were once 
thought to be found only in the male, but it is 
r,cw found also, though less frequently in the fe- 
male. The proportion of males to females is given 
as ten to one. This has not been my experie.:ce 
a^-r that of other urologists to whom I have ad- 
dressed queries. 

Some of these diverticula of the bladder are false 
and some are true. The outpouchings vary in size 
from a small hazelnut to a size equal to or larger 
than the bladder itself. A diverticulum is rarely 
palpable because the majority are in the base of 
the bladder or in the bony pelvis out of reach of 
the examining finger. Those of the vault are less 
frequent but they are easily palpated when full. 
The false diverticula or cellules empty easily and 
have wide mouths, but the true diverticula are 
often bottle-necked and empty with difficulty ii 
at all. These latter often have a sphincteric action 
of the muscles about their orifices. In one of this 
type I noted a decided grab when I withdrew the 
cystoscope from it. 

The location of bladder diverticula may be 
anywhere in the viscus. Most of them, how- 
ever, are located in and about the base, even in 
the trigone itself. Large ones are usually single 
but the smaller ones are often multiple. These 



smaller ones tend to arrange themselves in groups 
and an attempt at symmetry is made. This is the 
case in the report which follows. 

Though there are a few symptoms which make 
the urologist aware of some cause of cystitis other 
than inflammation, there is nothing in them which 
definitely singles out diverticulum as the cause in 
a given case. It does however, make one more 
apprehensive of its existence. The chief com- 
plaints are always, when an infection exists with 
the diverticulum, those of cystitis — urgency, fre- 
quency, strangury and, at times, hematuria. When 
no infection exists the only symptom may be that of 
an obstructive uropathy or it may be found that a 
diverticulum is the cause of upper urinary-tract 
pathology. In this instance the symptoms of di- 
verticulum are merely those of the existing path- 
ological condition. There is, however, one symp- 
tom which, though not pathognomonic of diverti- 
culum, does put the urologist on guard. That symp- 
tom is the unusually foul, musty odor, to the urine. 
It is a characteristic odor which is not a usual at- 
tendant to any other bladder dyscrasia. This i% 
noted only in those diverticula which are infected. 
In an uninfected case one finds that the patient 
has periodic attacks of urinary frequency without 
any known cause. In older patients, especially in 
men, the symptoms of lower urinary-tract ob- 
struction overshadow those of diverticulum. When 
the symptoms of urgency, frequency, dysuria and 
pyuria persist after removal of obstruction at the 
bladder neck, then further examination should be 
made with diverticulum in mind. In rare instances 
hematuria may be the initial symptom of a bladder 
diverticulum. 

.As there is no pathognomonic symptom complex 
which definitely will make a diagnosis of bladder 
diverticulum, we must proceed with a complete 
routine urological examination. Cystoscopy, cys- 
tography, pyelography and mietoscopy all aid in 
making this diagnosis. The greatest aid is cysto- 
graphy. This demonstrates any and all irregulari- 
ties in the bladder outline. It may be done either 
by using an opaque medium of 5% sodium iodide 
or by using air. These two methods may be used 
either alone or combined. This latter method will 
demonstrate any retention in the diverticulum, if 
done after evacuating the bladder of the sodium 
iodide. When making cystographic examinations 
of the bladder one should make a plain film, one 
from both right and left anterior oblique direc- 
tions and another after evacuating the sodium 
iodide. If surgery is decided upon the usual blood 
chemistry and serological examinations are carried 
out. It is also essential in this instance to examine 
the upper urinary tract by pyelography to deter- 
mine the extent it has been damaged, if at all. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



143 



The treatment in each case of bladder diverti- 
culum differs from that of every other case, but 
certain essential principles are determined, accord- 
ing to which further procedures are carried out. If 
a diverticulum is not giving symptoms and is found 
only on a complete examination, no treatment is 
indicated. The cellules usually respond to con- 
servative treatment. Infection in the bladder and 
in the diverticulum must be controlled as far as 
possible prior to active surgical intervention. If 
this is not done a postoperative pericystitis will b? 
the result. This makes the outcome very doubtful. 
The lower urinary tract picture must be studied 
and the exact nature of the cause determined and 
removed before attacking the diverticulum. When 
the diverticulectomy is done the surgeon will have 
determined the exact relationship between the di- 
verticulum and the surrounding structures so that 
he will avoid them in his removal of the sac. The 
plain x-ray film will have demonstrated the presence 
or absence of a calculus and if one has been found 
it must be removed to effect a recovery from di- 
verticulectomy. 

There are many methods of operating on these 
sacs, but this paper is too brief to consider 
techniques. 

The following is a report of a case of multipl? 
bladder diverticula in a female. 

Case Report 

The patient was a white woman, aged 51, married, septi- 
para, with no history ol difficult labor and no lacer-tinns. 
Past history- was irrelevant except for an attack of malaria 
several years ago. 

Seven and a half years ago she began having som; d ffi 
culty in emptying her bladder. Soon she had to strain i; 
she voided at all. This continued for three years when she 
had a small growth removed from the urethra. The exict 
nature and origin of this growth was not de'.ermincd. Thi? 
was followed by marked improvement for four year= 
Then the difficulty in voiding returned and became progres- 
sively worse. .\s the difficulty in voiding increased it was 
accompanied by marked pain on urination and frequency 
and vesical tenesmus. At this time nocturia began, often 
twenty to thirty times nightly. In July of 1935 she had 
an attack of painless hematuria which stopped withju; 
treatment or investigation. As the urgency, frequency and 
dysuria became worse she noted an increasing difficulty in 
voiding. She frequently had to strain very hard to ex:Jel 
a few drops of urine. She states that her urine has had 
a very foul odor for a long time. There is a slight back- 
ache over the sacro-iliac joint. 

The patient appeared about the age given, very nervous 
and emaciated. There were no findings indicative of disease 
except tenderness over the bladder area and and left tubo- 
ovarian region. 

The external genitalia were normal, the introitus that 
of a multipara. On the floor of the vestibule of the vagina 
was an inflamed edematous mass extending from the left 
laljium minor to and across the external urinary meatus, 
which was completely covered by the mass which was not 
hard but extremely painful to palpation. The urinary 



meatus resembled a slit parallel to the long axis of her 
body. The lips of the meatus could easily be separated 
but fell together at once on letting them free of the exam- 
ining fingers. On vaginal examination the urethra felt 
thickened and very tender. The base of the bladder was 
indurated and gave the impression of a spongy mass above 
it, this also very tender. 

A 24-F. cystoscope was easily passed into the bladder 
and met no obstruction. Ten ounces of foul-smelling 
purulent urine was drawn from the bladder. The odor of 
the urine was very foul and musty. Several washings 
were necessary before the bladder could be cleansed suffi- 
ciently for examination. The bladder capacity was about 
300 c.c. On looking into the bladder a markedly trabecu- 
lated area was seen posterior to the bas-jond and between 
the muscle fasiculi many small cellules opened. There 
was a severe generalized cystitis. The trigone was markedly 
injected and the ureteric orifices were apparent. These 
were located on small hillocks and were functioning nor- 
mally. Just medial and superior to the left ureteric orifice 
was a deep triangular recess and medial to this was a large 
opening. The opening gave the impression that it led to 
a large diverticulum. In the retrotrigonal area eleven 
diverticula were found in one cystoscopic field. The right 
end of the interureteric bar limited another group of diver- 
ticula from the trigone. There were also many small 
diverticula in the dome of the bladder. 

At a later sitting a urethroscopic examination was made 
with an endoscopic tube, having the patient in the knee- 
chest position. Nothing indicative of obstructive lesions 
was found, the only positive finding being a pale urethral 
mucosa. 

Five-per cent, sodium iodide was injected into the blad- 
der until the patient complained of fullness and an x-ray 
examination was made in the antero-posterior, right an- 
terior oblique and left anterior oblique planes. 




Figure No. 1 i.-. an antcro-postcrior cystogram. 

This view shows that there are innumerable div'erticuia 
all about the circumference of the bladder and that there 
is one large diverticulum on the left side. Many of these 
diverticula are the bottle-neck type and some are appar- 
ently separated from the bladder. The majority of the 
diverticula are on the right side in this view. 



SOUTHERN MEDICINE AND SURGERY 




HUMAN BEHAVIOR 

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



Figure No. 2 shows a left anterior oblique cyslogram. 

The largest diverticulum can be seen to be of the true 
bottle-neck type. Those superior to it are plainly demon 
strated to be of the bottle-neck type even though they are 
small. There is no evidence of calculus. 

Treatment: The urethra was dilated to No. 30 F. and 
the bladder was irrigated with normal saline solution at 
bi-weekly intervals. After the first few treatments either 
acriflavine 1:1000 or 10-per cent, argyrol was instilled into 
the bladder following each irrigation. Immediately after 
these treatments were given the patient experienced great 
relief of all her symptoms, especially from the nocturia. 
Her urine became much clearer but retained the foul odor 
even after several treatments. She has had two attacks 
of severe cystitis which responded to the usual treatments 
at daily intervals. I was unable to determine the exact 
cause of these complications. At present the patient is 
seeing us every three or four days and the above treatment 
is being carried out. On this regimen she is improving in 
general health and the bladder is no longer the source of 
such great discomfort to her. 

Surgery was considered and discarded because we could 
not give her a favorable prognosis in the face of such 
multiplicity of infected diverticula and her own unsatisfac- 
tory condition. 

Summary 

1. A case of multiple bladder diverticula with 
infection in a female patient with no discernible 
infravesical obstruction is reported with a dis- 
cussion of bladder diverticula. 

2. Attention is directed to the exceedingly foul- 
smelling urine as a possible indication of a diver- 
ticulum. 

3. An outline of conservative treatment in this 
case is given. 



Newspapers and lay magazines and the public rostrum 
should be used freely for acquainting the public with facts 
as to what Medicine can do for people; but the use of 
either for touting any doctor or group of doctors should 
be, as it is, sternly discouraged. 



The Community's Responsibility for the 
Mentally' Sick* 

Socrates was highly intelligent, but he had no 
interest in conformity, in mass thought, and in 
mass conduct. The object of his concern was the 
individual. He encouraged individual persons to 
think: if jx>ssible, to know; and to have respect 
for their own opinions. I can scarcely think of 
Socrates as a member of any organization. Jesus 
came four hundred years later. I know of no 
reason for thinking that Jesus had the slightest 
interest in organizing any sort of movement. He 
was interested in individuals — all sorts of them — 
and He insisted that His followers continue that 
interest. 

But — we are living in a highly organized society. 
What are we going to do about it? We should try 
to fit into it and try to make some contribution 
to it without losing our identity or our self-respect. 
Perhaps the loss of one would carry along the lo^s 
also of the other. I hope I shall not be here when 
human beings become mere socialized robots. 

Not too much thought and attention is devoted 
by the public to physical health. Although the 
machine is making relatively useless the need of 
human physical strength, a sound physical struc- 
ture is still important. Emotional and mental 
states make themselves manifest through physical 
activity, and for that reason, as well as for many 
other reasons, physical disease has its effect upon 
mental health. We have discovered, of course, 
that a human being is not an assortment of pigeon- 
holes, but that physical and mental activity are 
both manifestations of life, and that what affects 
one part or attribute of an individual has its 
influence throughout the totalized organism. And 
that discovery, or confession, whichever it may 
be, is significant. It means, of course, that there 
cannot be one sort of physician who can limit his 
concern to one small portion of the body, and an- 
other sort of physician who can devote his thought 
solely to another small portion of the body. The 
body will not be treated in any such fashion — 
specialists or no specialists. The human being 
has found out that he is a unified organism; that 
the related parts of him are each and all important 
because their correlated activities give him life and 
emotions and mentality and personality and char- 
acter. And disease, whatever may be its cause 
and its nature, is due to a disturbance of such 
relationships. 



•Presented by request to the Public Health Section 
the Graduate Nurses" Association of the Fifth District 
Virginia at Saint James Parish House, Richmond, \ 
ginia. February 21st, 1936. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



For centuries mankind remained in ignorance 
of his physical body. Dissection, with its anatomi- 
cal revelations, came only lately, and physiology 
still later. For many centuries the treatment of 
the diseased body was in the hands of the unin- 
formed and the ignorant. ^len mutilated each 
other in battle, but the human body was thought to 
be too sacred for dissection and autopsy study. 
Everything about the body was looked upon as a 
mystery. 

For purposes of emphasis I am going to ex- 
aggerate by saying that our attitude towards mental 
sickness is still mediaeval. That is true. We do 
not quite think of mental sickness as belonging 
within the domain of modern medicine and modern 
nursing. Perhaps there may be something self- 
defensive and self-protective in such an attitude 
towards mental and emotional sickness. Are we 
not inclined to protest that the things about which 
we know nothing are of no importance? Occa- 
sionally, but only occasionally, some doctor makes 
inquiry of me about the nuts and the bugs and 
the crack-pots. Of course, if he knew anything 
about psychiatry he would not indulge in such 
speech. He makes use of it to protect his ig- 
norance. He cannot quite confess that he knows 
nothing at all about any branch of medicine. He 
has to keep psychiatry outside of his domain by 
deriding its claims and keeping it in the realm 
of demonism and mysticism. 

Our first duty is to try to enable ourselves to 
understand that the function we speak of as the 
mind can become disordered, and that in such a 
circumstance the individual is out of tune both 
with self and with society. For, whatever mental 
sickness may mean medically and legally, it means 
practically maladjustment at the social level. And 
because a human being constitutes a unit in the 
social organization, it has become necessary for 
society to deal with such disordered social units. 
Such activity is neither wholly altruistic nor phil- 
anthropic, for whatever is good for the unit is help- 
ful to the whole. 

Perhaps we have thought the mind too mys- 
terious or too sacred to attempt to understand it. 
Everything is a mystery in the sense that our 
understanding of it is imp>erfect. There may be 
nothing more incomprehensible about the operation 
oi the psyche than about the function of the liver, 
or of the spleen, or of a muscle. 

But it is undeniably true that the mentally sick 
person is less skillfully ministered to than the 
physically sick person. That is true, but why is 
it true? It is true largely because our thought about 
mental sickness is still largely mediaeval, therefore 
fatalistic, therefore hopeless. We do not cheerfully 
and hopefully take charge of a mental patient be- 



cause we feel that the outcome rests upxin the 
knees of the gods and that nothing rational can 
be done. Is it not true? I fear it is true, but if so, 
it constitutes a dreadful reflection upon our intelli- 
gence and our skill and our courage. Many men- 
tally sick folks recover, and remain well. 

But modern medical science has not yet been 
brought to the bedside of the mental patient. That 
statement is practically true. In the five state- 
supported mental hospitals in Virginia there are 
approximately ten thousand patients. On the 
medical staffs of these five institutions there are 
probably fewer than thirty physicians, including 
five superintendents whose duties are administra- 
tive. How much medical thought and investigation 
can be given to ten thousand sick people by twenty- 
five physicians? A solid weeks work can well be 
devoted by one doctor to one mentally sick person. 
And in those five institutions of ten thousand 
patients there are probably thirty trained nurses. 
And most of those have probably had little if any 
psychiatric training. The patients, in other words, 
are in charge of relatively ignorant and untrained 
attendants. .Are such institutions, properly speak- 
ing, hospitals, or merely places of care and deten- 
tion? I am not criticizing any individual. I am 
criticizing the attitude of society towards a branch 
of the science of medicine. I am criticizing the 
curricula in our medical schools and training 
schools for nurses. What training of consequence, 
with actual experience with psychiatric problems, 
is given either to medical students or to nurses? 
Practically none. 

Xear Richmond are two large state hospitals 
with an aggregate patient population of almost 
four thousand. In these institutions clinics in all 
the branches of medicine should be held for the 
benefit of medical students, nurses, and patients. 
Every young physician should be obliged to serve 
as a part of his interneship, certainly two or three 
months, in a psychiatric hospital. And every 
nurse should, of course, spend a part of her student 
days in a mental hospital. Such a rotating interne 
and nursing service would bring new life into the 
state hospital service, and keep the medical and 
nursing staffs in constant touch with the latest pro- 
gress in all the branches of medicine. Throughout 
the period of the depression many excellent grad- 
uate nurses have been unoccupied. Many of them 
should have been engaged on the wards of the 
state hospitals. 

In no other form of sickness is diagnosis so diffi- 
cult as in mental disease; in no other condition is 
such a demand made upon skill and tact in minister- 
ing to the sick; in no other condition is such pro- 
ductive and social incapacity encountered as in 
diseases of the mind. Mentally sick folks are gen- 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



erally not only incapable of helpin.s; themselves; 
they' often turn their energy destructively against 
themselves. It is our duty, therefore, not only to 
minister to the mentally disordered, but to deal with 
mental sickness rationally, and to divest it of mysi- 
cism and fatalism, and so invest it with intelligence 
and skill and courage and dignity and hope. 

Preventive work may be of even more importance 
in the field of mental hygiene than in the domain 
of public physical health. Yet I do not like at all 
the tendency even to think of mental sickness and 
physical sickness as if they are unrelated. It is gen- 
erally impossible to be physically sick and to be 
at the same time in wholesome and comfortable 
emotional and mental condition. .\nd each of us 
knows how susceptible the functions of the various 
organs and the work of the body as a whole are to 
emotional and mental perturbations. In man mind 
and matter are so intimately related that what af- 
fects one usually affects also the other. As a unit 
of the structure that we speak of as society we 
are concerned not primarily with the activity of 
any individual organ or group of organs, but with 
the manifestations of their correlated and har- 
monious functioning. In other and better words, 
we are interested in man the individual as a social 
totality. Except for that interest in him we are 
not concerned about his fractional functionings. We 
should be as keenly interested in the morbid, emo- 
tional condition of the patient — as exhibited by 
fear, dread, anxiety, anger, suspicion, doubt, gloom, 
despondency, or too much joy — as in the symp- 
toms of any physical disease. And we should be 
equaVly-as k«eBly--Gn the lookout for evidences of 
mental abnormality in the higher intellectual levels. 
.\11 of these things are not ony indicative of in- 
stability, but they may manifest themselves in 
physical behavior that may embarrass and stigma- 
tize the individual, and do hurt also to society. 

Preventive work is of the utmost importance in 
mental hygiene. In the school, for example, it is 
worse than futile, it is tragically wasteful and dis- 
appointing, to attempt to educate by the use of 
books the uneducable child. Efforts should be 
made otherwise to lead such a child into self-devel- 
opment — for that is what education should mean. 
After all, the educator should not be expected to 
do more than to discover the child's innate ca- 
pacity, quantitative and qualitative, and to afford 
the opportunities for the development of that ca- 
pacity. I believe, for instance, that no educators 
can accurately express by the use of any symbol 
the knowledge and the intellectual capacity of 
any student. And for that reason, marks should be 
abolished. Those who receive high marks overesti- 
mate their importance; those who do not get them 
— yyell — even the fox turned up its nose and walked 



away, remarking, as it did so, that the out-ofthe- 
reach grapes were inedible, anyhow. .And I am per- 
sonally unimpressed by the Phi Beta Kappa, the 
Golden Fleece, and other symbolizations of acade- 
mic omniscience. Let us patiently wait. Life will 
eventually mark us all on the great blackboard 
fairly accurately — at least inexorably. 

I have no respect for the frequently repeated 
statements that there are too many physicians and 
too many trained nurses. There are not nearly 
enough. The quacks and the charlatans and the 
medical humbugs exist only because we doctors 
and you nurses are not performing duties for those 
who are in need of our training and our services. 
The failure may be due to lack of opportunity; — 
those in need of us may be unable for one of many 
reasons to reach us. The failure may be due in 
some measure to our own wTong attitude towards 
our duty; our lack of skill. .And yet I read that a 
medical senator in Virginia would by legislative en- 
actment have your training made even poorer. 

Many doctors, and many nurses, too, think of 
themselves as ministers only to those who are ac- 
tually sick in body or in mind. A duty equally as 
important is to those about-to-be ill, either in body 
or in the immaterial domain. For example, suicide 
is theoretically, at least, preventable; and so also 
are many homicides. Commercial prostitution must 
be often an expression of economic inadequacy. 
Drunkenness and drug addiction are manifestations 
of maladjustment with an underlying cause that 
may not be always beyond the reach of discovery. 
The number of divorces would be infinitely reduced 
if the dysharmonious pair could me medically 
studied. A great many devotees to patent medi- 
cines, many of them habit-forming and dangerous 
to life, are really sick people — in mind, in body, or 
in both structures — who are, in their fear and ig- 
norance, making both patients and physicians of 
themselves. .\nd that is something that no sensible 
person, lay or medical, will ever do. And most 
such drug-takers are propelled by fear. And there 
should be accessible to every person who lives in 
the grip of fear some understanding nurse or doctor 
to whom that person could go for comfort and 
relief. For I believe that long-continued repressed 
fear causes more distress and suffering than phy- 
sical disease. 

Let me say finally, that in my opinion no people 
are yet civilized to whom proper educational op>- 
portunities are not available for all; to whom the 
comforts of religion are inaccessible to any; and 
to whom the science and the art of medicine, 
through nurses, and doctors, laboratories and hos- 
pitals, are not available for all, rich or poor, strong 
or weak, black or white, believer or unbeliever. But 
that domain in which understanding is most needed 



SOUTHERN MEDICINE AND SURGERY 



is the region of the immaterial — in the instincts, in 
the emotions, and in the intellect itself. About that 
aspect of man we know too little. But we should 
take steps to equip ourselves to deal as hopefully 
and as efficiently with mental sickness — pre- 
ventively and therapeutically — as we now deal with 
sickness of the body. I hope and I pray that all 
nurses may become more and more insistent that 
the mental hygiene aspects of their training be con- 
stantly enlarged, and that they demand that the 
ministrations to the mentally sick be made by 
nurses trained also in mental hygiene and not by 
untrained attendants. For, until that time comes, 
those who are sick in mind and in spirit, will dwell 
in the land of Gloom that lies in the Shadow of 
Ignorance. 



GENERAL PRACTICE 

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



The Present Status of the Arthritis Problem 
In the Annals of Internal Medicine for January 
is a review of the American and English literature 
on the subject of arthritis and rheumatism by a 
subcommittee of the American Committee for the 
Control of Rheumatism. North Carolina should 
feel proud of the fact that Dr. T. Preston White, 
of Charlotte, is one of the si.x members of this sub- 
committee. The report covers one hundred pages, 
including fifteen pages of bibliography. While 
taking a holiday enforced by an attack of laryn- 
gitis, I had time to read this review rather care- 
fully: but must confess that "I came out by the 
same door wherein I went," so far as real help in 
understanding the problem of treating a victim of 
arthritis is concerned. It is true that the rather 
positive statement was made that gonorrheal arth- 
ritis responded well to fever treatment, and that 
few of the natives of Tucson, Arizona, suffered 
from arthritis; but it has been many years since 
I have had to treat a case of gonorrheal arthritis, 
and very few of my patients have the financial 
ability or the inclination to migrate to Tucson. 
Indeed, a few to whom I broached the subject inti- 
mated that they would rather live in North Caro- 
lina with arthritis than in Arizona without it. 

The review is of value in discouraging undue 
enthusiasm about any method of treatment as 
specific, and it frankly admits that the cause of 
arthritis is still to be designated A',- and that, until 
X is discovered, the problem is still unsolved. 
The "authorities" on the subject are becoming less 
authoritative in their opinions, as witness the 
statements of one of them. "There is no one 
cause for chronic non-specific arthritis of either 
type. . . It is quite probably that a disturbed cir- 
culation is often the primary disturbance." "In- 



fection is the most important factor in the atrophic 
typ>e." "Possibly the disease (atrophic arthritis) 
cannot develop in the absence of bacteria but the 
presence of bacteria alone is insufficient in most 
cases to produce the disease, so other factors are 
of equal importance." Evidently this man is pre- 
paring to be able to say, I told you so; no matter 
what A' finally proves to be. 

Infection, "altered metabolism," diet, sulphur 
deficiency, avitaminosis, endocrine disturbances and 
neurogenic disturbances are all considered in de- 
tail — and all dismissed as not having been proved 
guilty. The now popular fetish of allergy is treated 
with scant respect in an editorial comment which 
quotes Freeman with approval: "We are work- 
ing in a fog and have as yet no clear vision. The 
word allergy is, to my mind, not a gleam of sun- 
shine breaking through, but an extra wisp of fog." 

The authors give their final conclusion, very 
sensibly, in these words: "From this mass of con- 
fusing, sometimes conflicting, data one cannot as 
yet form any conclusive ideas on the etiology and 
pathogenesis of the disease. It is obvious that . . . 
to date no one etiologic factor . . . has been con- 
clusively shown to be the prime cause of the 
disease." 

The discussion of treatment, likewise, is fairly 
well summarized in the statement that "There 
is no one specific, no one standard form of treat- 
ment. Individualized, not routine, treatment of 
each patient is required, and the patient, not just 
the disease, must be vigorously studied and cared 
for." And again, "A physician must not con- 
centrate on only one form of treatment or he will 
become a faddist. In selecting his physician a 
patient probably will do best by choosing a well- 
rounded internist." Which covers the ground as 
well as anything yet said on the subject. The 
authors are to be congratulated on the painstaking, 
conscientious effort with which they have reviewed 
the enormous mass of literature on arthritis pub- 
lished last year; for the calm, unbiased way in 
which they weighed the numerous claims and 
theories advanced; and for the crisp, clearcut, con- 
cise editorial comments which illuminated the 
reader's pathway through the long and sometimes 
dreary discussions set forth. 

.\ Cocksure Opinion 
Some time ago a wealthy lady, while taking a 
holiday in a large city in a Northern state, be- 
thought her to consult a dentist. He in turn sent 
her to a nose-and-throat specialist, who had her 
sinuses x-rayed and then insisted that an immediate 
operation was necessary to her health and hap- 
piness, if not, indeed, her very life; but she de- 
cided to postpone it for awhile, and asked him 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



to send the films and his findings in her case 
to me. 

In interpreting an x-ray film I am considerably 
dependent upon the man who makes it to tell me 
what to see; hence I do not doubt the findings, 
since the roentgenologist is a national authority. 
The right frontal, right maxillary and right anterior 
ethmoid sinuses were cloudy. The right sphenoid 
and all the left sinuses were clear. What amazed 
me, however, was the absolute cocksureness of the 
laryngologist : "Beyond peradventure of a doubt, 
most if not all of Mrs. X's nervous and glandular 
disturbances have been due to toxic absorption 
from this closed right maxillary sinus. .\lso, the 
mucous membrane changes in the right anterior 
ethmoids and frontal sinuses will subside very 
promptly after the cure of the right maxillary 
which is diseased as the result of dental infection 
some fifteen years ago. The time consumed and 
the inconvenience of the patient are so slight in the 
proposed operation that I was very much disap- 
pointed when Mr. and Mrs. X decided to return 
home as is" (sic). 

Knowing the patient's "nervous and glandular 
disturbances" somewhat better than the eminent 
one — from a rather intimate acquaintance with 
them for some years antedating the dental infection 
supposed to have started all the trouble — I find 
it difficult to subscribe to the opinion that the 
"slight operation" spoken of will perform such a 
miracle as making over the nervous system of this 
patient. From the bottom of my heart, however, 
I wish I could feel as certain of myself as this 
specialist does. It must be a grand and glorious 
feeling. If, however, he had to follow up a few 
of his operative "cures" for years afterwards, he 
would find that feeling of cocksureness gradually 
oozing away. 



The Country Doctor 

The country doctor is disappearing, and a sad 
day it will be for the country people when the last 
one has gone. 

We need country doctors on account of the doctor 
himself, for several reasons: 

1st. Because a country doctor may lead the 
happiest life of anyone in aJl medical circles, for 
he can be "a big dog in a small meat-house" and 
this to my mind is better than to be "a little dog 
in a big meat-house." 

2nd. He has a great opportunity, — that of do- 
ing his best, being his best, of doing many unusual 
but needful things which he can do as well as any 
specialist or would-be specialist. Recently I did 
an unusual and much needed minor operation, — 
one I had never done before, and will probably 
never do again. A day later I did another, the 



first of its kind I have ever done. It was to tie 
and cut off a small polypoid tumor from the setter- 
bone of a colored man. Had I been unable to do 
this service it would have necessitated in each case 
a very difficult trip to a hospital or surgeon. 

3rd. A country doctor has more time to study 
medicine in all its branches, as well as to do re- 
search work along any line. He has more time 
and opportunity to study his cases, to prepare the 
treatment he thinks best suited to the patient, to 
know what effect is desired and what effect is se- 
cured, regardless of what the drug houses claim 
for their preparations. He can study therapeutics, 
and can find out by actual experience what drugs 
will do and what they will not do. There is 
enough in the pharmacopeia to meet the need of 
any case without recourse to expensive proprietary 
preparations — 60% of all prescriptions are for pro- 
prietary preparations. In my 48 years of practice 
I have found the country doctor better up on 
diagnosis and therapeutics than his city brother, 
whenever I have found it necessary to call a con- 
sultant. 

4th. The country doctor knows his folks. He 
knows everybody in his territory, and everybody 
knows him. He knows who requires kid-glove hand- 
ling, and who the emery-wheel. He knows the 
idiosyncracies, both medical and mental of his pa- 
tients. He knows who will have nettle rash after 
a dose of quinine, and who will not tolerate tur- 
pentine. He knows where each family keeps its 
skeleton in the closet, and how much that skeleton 
affects the mental attitude of each member of the 
family. He does not look on his patients as simply 
cases, but as human beings with powers and frail- 
ties like unto his own. 

I have tried to show why the country is a good 
place for a doctor to live, looking at it from his 
own point of view, and now I will give some reasons 
from the viewpoint of the country folks themselves 
why they should have a doctor living among them. 

1st. It is so much more convenient for them 
to see him at his office or call him when a visit is 
needed. 

Knowing their doctor as they do they will meet 
him when on a visit to a neighbor to consult him 
about small ailments that do not seem of enough 
importance to demand a trip to town, — to have 
a child's tooth extracted, — to have him clip a baby's 
tongue, — to get something for an annoying head- 
ache, — to have him lance a felon. 

2nd. It is less expensive, for the country doc- 
tor, if he is wise, will dispense his own drugs, and ;, 
if he has the welfare of his constituents at heart he 
will study to provide drugs that are not ruinous 
in price. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



When a city doctor is called he leaves one or 
more prescriptions and this makes a trip to a 
drugstore necessary. Country folks can pay a 
country doctor on account many things that would 
not be acceptable to one living in town. I have 
taken on bills almost everything from a load of hay 
to a basket of cucumbers. Recently I accepted, — 
not at par however, — two Confederate bonds of 
$100 each. 

3rd. The last reason I would give for country 
doctors is that the farmers who make up most of 
the population in rural districts need a physician 
who can see and appreciate their problems and diffi- 
culties. As most country doctors are farmers them- 
selves every problem that confronts the farming 
class is their problem also. This being so, his 
patrons can, in a sense, meet him on a common 
level, and because of this he can be a leader in his 
community, and a means of uplift in civic, social 
and religious life. A country doctor has an un- 
limited opportunity for service to others. 

I quote from an article published a few years 
ago in the Raleigh Times: 

"The typical country doctor is one of the 
world's choicest spirits. Usually little is said of 
him. He is no famous specialist who operates and 
charges thousands; he issues no bulletins about 
his humble patients; he says little or nothing; but 
he does a very real work in the world, becomes a 
member of every family he visits, loves and is 
loved as few men understand endearments, and 
we can imagine no more hearty greeting than that 
which he receives when he reaches the gates of 
heaven and hears, 'Well dione thou good and 
faithful servant; enter thou into the joy of thy 
Lord.' " 

C. C. HUBBARD, Farmer, N. C. 



PEDIATRICS 

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



Meeting of the Medical Society of the State 

OF North Carolina 
. The annual meeting of the North Carolina State 
Medical Society will be held at Asheville, May 4th 
to 6th. Here in the mountains it will be Spring! 
Not so many flowers in bloom as in the Eastern 
portion of our State perhaps, but we challenge the 
rest of the State to supply as much invigoration 
from the air and other surroundings. When we 
meet at Pinehurst there is nothing to do but attend 
the sessions and go to bed. In Asheville you will 
be meeting in a resort city where entertainment will 
make it hard for you to find time to go to bed. 
Many physicians and their families will come to 
Asheville at this time as part of their vacation. 



Some will come early and we hope all who come 
\vill stay late. In an effort to help you enjoy your 
stay here with us the editor offers a few suggestions 
as to places to go and things to do. Naturally we 
hope to make the program sufficiently interesting 
to give you your fill of the newest things in 
medicine. In your spare time we offer: 

The four general hospitals — Aston Park, Bilt- 
more. Mission and Norburn — will be open for your 
inspection as will all of the numerous sanatoria. We 
are proud of our institutions for the care of the 
ailing. Aston Park and Mission are in walking 
distance from the headquarters hotel, the Battery 
Park. Biltmore and Norburn are not far from the 
hotel. An automobile will help greatly to enjoy 
Asheville. 

The doors of Grove Park Inn, known as the 
finest resort hotel in the world, are always open 
to visitors. You must include it in your tour of 
the city. You may wish to visit the Biltmore 
Homespun Industry on the grounds of the hotel. 
The trip to the hotel and return will require about 
an hour, and another hour may be spent profitably 
taking in the views and seeing the industry. Just 
beyond the hotel entrance is the auto toll road to 
the top of Sunset Mountain. Pay a small fee and 
drive to the top of the mountain over safe roads to 
witness a Western N. C. sunset. One-and-a-half 
hours is ample for this trip. 

If you enjoy a 2-mile walk just before supper, 
and incidentally to watch the sunset, try the paved 
road to the top of Beaucatcher. In the morning the 
sun will be to your back, and if you take along your 
camera you can get a grand picture of the city. 

A motor trip beyond description in this column, 
taking a full afternoon, is over the Scenic Highway. 
The road is good, but the driver had better not 
be too interested in scenery unless he stops the 
car to admire it. A camera on this trip is a neces- 
sity. Take a lunch along and enjoy life once more. 

More next month! 

Measles Prophylaxis 

If you are not already, you soon will be, in the 
midst of a measles epidemic. This is not prophecy 
for measles returns to us in epidemic form every 
two years. It is a communicable disease that is 
not controlled by quarantine. The reason for this 
is the 4-day prodromal period, from the onset of 
initial s}Tnptoms until the appearance of the rash. 
Many children go about spreading the disease dur- 
ing these four days. But measles can be con- 
trolled! 

In the large hospitals and childrens' homes it is 
being controlled by the use of immune serum. To 
prevent the disease requires larger doses of serum 
and earlier administration than is necessary to 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



modify the attack. The immunity derived from 
a protective dose of serum lasts a few weeks only. 
Poor health, acute illness at the time of exposure, 
tuberculosis, and especially the presence of an acute 
otitis media — each is an indication for complete 
protection. 

The immunity produced by an attack of measles 
is generally lifelong. This immunity is not absolute! 
Measles modified in severity by the use of immune 
serum, likewise, generally produces lifelong im- 
munity. Immune serum certainly modifies the 
disease and reduces the complications to practically 
nil. It was first used therapeutically, in the form 
of convalescent serum, by Weisbecker of Germany 
in 1896. In 1920 Degkwitz used it in a large 
series to prevent the disease. When it failed to 
protect, it was observed that the attack was greatly 
lessened in duration and severity and complications 
did not appear. From this observation has arisen 
the modern method of giving a small dose of serum 
to modify the disease. 

Whole blood from a Wassermann-free and other- 
wise healthy donor who has had measles can be 
used, but it requires so much volume that serum 
is to be preferred. One half as much of serum as 
of whole blood is sufficient. Any physician can 
prepare his own supply of serum. Allow the drawn 
blood to stand, separate the serum from the clot, 
add one drop of 5% phenol to every 40 c.c of 
serum and keep on ice. The phenol is not a sub- 
stitute for careless technique in the collection and 
handling of the serum. Naturally the more recent 
the attack of measles in the donor, the more potent 
the serum. No absolute rule as to dosage can be 
laid down, particularly if complete protection is 
desired. From a donor who had measles 15 to 20 
years ago, at least 30 c.c. serum for complete pro- 
tection. In contrast, as little as 10 c.c. of serum 
from a recent convalescent donor may be sufficient 
to completely protect. It is better to give too much 
serum rather than too little. Equally important is 
early administration. It must be given not later 
than the fourth day after exposure. 

The more frequent need is for modification of an 
attack of measles. In this instance it is best given 
on the 4th, Sth, or 6th, (not later) day following 
exposure. From 4 to 5 c.c. is an adequate dose. 
All injections are made intramuscularly. Mild 
local and systemic reactions occasionally occur, 
but are gone the next day. Serum reactions do 
not occur. 

Immune Globulin (Squibb) (Lederle) is now on 
the market in 2-c.c. and 10-c.c. packages at $2.50 
and $10.00 respectively. It is a pseudoglobulin of 
human placental extract. It is used in 2-c.c. doses 
for modification, given not later than the fourth 
day after exposure. For protection against the 



disease 3 -c.c. is advised. It is also used curatively 
in 2- to 5-c.c. doses. It seems to be more effica- 
cious just after the appearance of the rash. The 
principle behind the use of immune serum is sound, 
but the exact dosage is still to be worked out. 



SURGERY 

For this issue, George McCutchen, M.D., Columbia, S. C. 



Burns 



Burns are usually considered as a minor surgi- 
cal problem; but the fact that 25,000 persons die 
from these accidents each year is sufficient reason 
for giving them serious and critical consideration. 
The widespread dissemination of knowledge of 
Davidson's tannic-acid treatment has reduced the 
mortality gratifyingly. It cannot be doubted, how- 
ever, that Davidson failed to say the last word on 
the treatment of burns. Reports of various meth- 
ods have appeared since his publication. The gen- 
tian-violet treatment of Aldrich and the hypertonic 
saline treatment of Blair have probably received 
more proponents than have other methods reported. 
Since so many forms of treatment have been sug- 
gested one is almost forced to the view that no one 
form is applicable to all cases and that considerable 
judgment is required in the selection of treatment 
in each case. 

The general measures to be employed in the early 
burn cases are well recognized. First, relief of 
pain which is accomplished by adequate doses of 
morphine and, later, by the application of an 
escar-forming solution which sometimes gives al- 
most startling relief. Second, maintenance of body 
heat is accomplished by a heat tent, hot-water bot- 
tles, etc. The hypertonic saline bath serves this 
purpose admirably for a short while and has the 
additional advantage of aiding considerably in the 
debridement, since the obviously dead skin will 
tend to float and can be easily removed. Third, 
restoration of fluids. Underbill has shown that 
70 per cent, of the total blood volume of 5,000 c.c. 
can be lost from a 20 per cent, burn in twenty-four 
hours. This means that a person may lose 3^ 
quarts of fluid in 24 hours from a burn of one leg 
or both arms. He maintains that the fluid lost has 
the same composition as blood plasma. It has also 
been shown that large amounts of chlorides and 
alkaline elements of the blood are lost through the 
kidneys. These facts serve as a rational basis for 
giving fluids in abundance by transfusion, by in- 
fusion of saline and glucose solutions, or by ad- 
ministration of fluids by mouth. Fourth, debride- 
ment. This should always be superficial, removing 
only that tissue which is obviously dead and which 
comes away easily. Extensive debridement may 
destroy many valuable islands of epithelium and 



SOUTHERN MEDICINE AND SURGERY 



151 



hair follicles on the burned area and always has a 
tendency to augment the shock. Greases, oils, etc., 
should be removed gently but thoroughly with 
ether or alcohol. Fifth, application of escar-form- 
ing solutions. The reasons for the application of 
such a solution are well known and will be men- 
tioned in order of importance. It prevents fluid 
loss. It prevents further bacterial contamination. 
It gives relief from pain. It precipitates or fixes 
the products of protein destruction in the burned 
area. The importance of this factor has never been 
satisfactorily determined since no one has been able 
to definitely incriminate the elements of protein de- 
generation in the causation of the toxic symptoms 
in burns. 

Gentian violet has all the advantages of tannic 
acid with several virtues not possessed by the latter 
agent, and these advantages prompt us to make a 
plea for its use. First of all, gentian violet is much 
more bactericidal than tannic acid, and since active 
infection on a burned area is a devastating hin- 
drance to good end results this factor gains prime 
importance. Second, gentian violet promotes or 
stimulates epitheliazation and thus lessens the like- 
lihood of scar formation. And third, the escar 
has a tendency to soften quickly if infection does 
appear beneath it and thus serves for easier detec- 
tion of this complication. In all of the cases which 
we have observed there was a definite tendency to 
diminution in scar formation and the development 
of infection. The main argument raised against 
the use of gentian violet is the fact that it stains 
bed linen. This difficulty can usually be obviated 
by the exercise of a little ingenuity. No attempt 
should be made to treat old burns, that is, from 
two to three days old or after active infection has 
become apparent, with any escar-forming solution. 

The hypertonic saline baths have been reserved 
for those cases which are first seen after infection 
has developed on the burned area or those which 
have developed infection under an escar. It may 
be well to insert at this point a warning about the 
close observation which should be exercised in 
watching for the appearance of infection under 
any kind of escar. The crust should be sounded 
daily and opiened at the first sign of fluc- 
tuation. A rise in temperature should make one 
suspect the presence of infection in a burn more 
than 12 hours old, but the best index of beginning 
infection is an increase in the sedimentation rate 
of these patients. This test should be run at fre- 
quent intervals after the first 72 hours and until 
all danger of infection has passed. The fact that 
infection is not recognized early and the proper 
treatment for this complication instituted as soon 
as it develops is responsible for a great many of 
the complications which are generally attributed to 



burns. If infection does appear, it is best to insti- 
tute saline baths and to remove the escar gradually 
and gently. It is impossible for islands of epithel- 
ium to proliferate when they are bathed in pus held 
on the granulating area by a thick escar. Saline 
baths have advantages over wet dressings. They 
do not traumatize the granulation tissue. The re- 
moval of small islands of epithelium during the 
process of dressing change is avoided. There is 
also the great advantage, frequently overlooked, 
of allowing active and passive motion to a degree 
that would be impossible with any other method 
of treating this granulating surface. This factor is 
very important in the prevention of contractures 
and subsequent disfigurement. They also serve as 
an ideal mode of preparing the area for skin graft- 
ing which should be done as soon as the granulat- 
ing surface is ready and the progress of epitheliaza- 
tion of the area has come to a definite standstill. 

It is probable that the mortality and morbidity 
of burns can be reduced still further by the use of 
more judgment in the selection of methods in han- 
dling each individual case and by the early recog- 
nition and treatment of infection when it develops. 
Some of the disfigurement which has always been 
a sequel of burns can be prevented by the insti- 
tution of active and passive motion early, and 
grafting the area as soon as granulations are in 
good condition and the process of epitheliazation 
has ceased. 

None of the ideas which we have set down are 
essentially new or original. They represent only an 
effort to apply basic, well recognized methods to 
the cases which they reasonably seem to fit, and to 
emphasize the fact that burns can be a real prob- 
lem requiring painstaking care, tireless observation, 
and discriminating judgment for their proper han- 
dling. 



GYNECOLOGY 

Chas. R. Robins, M.D., Editor, Richmond, Va. 



Relation of Chronic Cervicitis to Infection 
OF the Urinary Tract 
An extremely interesting paper* with this sub- 
ject appears in the January number of Surgery, 
Gynecology and Obstetrics. The authors base their 
observations on a series of 400 cases of women pa- 
tients suffering from urological conditions. The 
frequency with which urinary symptoms are found 
in women and the resistance of these symptoms to 
treatment are matters of common observation. For 
this reason this paper is particularly valuable, and 
the following digest is offered as a summary of 
the main points. 



*By Herrold, Ewert and Morgan. 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



The authors had found that the treatment of 
granular urethritis and polypoid excrescences by 
fulguration, dilation and the application of silver 
natrate relieved many of these patients of their 
symptoms, but with the lapse of time there was a 
recurrence of symptoms in a certain percentage of 
these cases. The report of Winsbury-White show- 
ing a direct lymphatic connection from the cervix 
to the urethra and the floor of bladder was ac- 
cepted as establishing a route for extension of in- 
fection from the cervix to the urinary tract. The 
cervix had already been recognized as a chronic 
focus of infection for systemic disease. Moench 
found streptococci to be the most common bacteria 
present in chronic cervicitis. Maryan likewise found 
in a high percentage of infection, streptococci, of 
the group enterococd, whose main characteristic is 
their ability to resist heat of 60° C. for a longer 
time than other streptococci. 

Of the 400 patients studied, 32 had some or all 
of these symptoms: frequent and burning urination, 
intermittent deep pain at the neck of the bladder, 
low back ache; and, less frequently, radiating pains 
into the groin, the thigh and upward along the 
course of the ureter. Many of these patients had 
pronounced leucorrhea. This syndrome is fre- 
quently described as irritable bladder. 

It was their observation that bacteria may be 
found in all urine passed by patients with irritable 
bladder, by making careful smears and culture of 
the urinary sediment, although in many instances 
the smears do not reveal more than an occasional 
pus cell. 

Twenty-nine of this series of 32 patients were 
followed long enough to permit of analysis. Coagu- 
lation of the cervix was done in each instance. A 
second or third coagulation was done on a few 
of the patients. The results as measured by relief 
of symptoms relative to the urinary tract are di- 
vided into two qlasses. The first included those who 
showed no improvement or but slight improvement. 
There were five of each, ten in all. The second class 
included those who reported marked improvement, 
11 ; or complete relief, 8. Therefore, it may be noted 
that 19 of 29 patients had a satisfactory clinical 
response. 

In the total series of 29, there were 12 patients 
in whom the cultures revealed colon bacilli in the 
urine, alone or associated with other organisms, 
while 17 had predominant bacterial flora of mostly 
cecal types, usually streptococci. Further analysis 
indicated that 7 of the 10 non-responsive patients 
were those with colon bacilluria, while 14 of 19 who 
had satisfactory relief of symptoms were infected 
with organisms other than the colon bacillus. This 
would seem to lend support to the view that the 
secondary focus in the urethra and bladder is the 



result of continual inoculation by way of the lym- 
phatics from the cervix. 

Cultures made from the cervix and from urinary 
sediment seemed to be identical. 

An excellent description of chronic cervicitis and 
of the technique of coagulation make the paper 
quite complete. A definite method of dealing with 
irritable bladder by removing the cause is advo- 
cated and the treatment has been followed by a 
convincing number of cures. 



J. MARION SIMS 
(Prom p. 141) 

through me like water, and almost unchanged. Even 
miUc was not digested. 

Early in February (1853) I had given up all hope. 

I left Montgomery for New York about the first of May 
(1853), so near dead that no one thought that I would 
ever get to New York. I had to lie down all the way on 
the railway train. The diarrhoea was uncontrolled. We 
went to Richmond, Virginia, without stopping, the journey 
being a ver>' fatiguing one for me. I determined to go 
from there to Rockford Island* Springs. I stopped at Lex- 
ington, and sent to the springs for the water. I remained 
there a week, but did not derive any great benefit from 
it. I concluded it would be about as well for me to tak» 
the water with me as to stay there, and so I left, and went 
on to New York. 

I spent the summer partly in New York and partly in 
Middletown and Portland, Connecticut; and then, in Sep- 
tember, we returned to New York to seek a home. 

Some people have given me the credit of coming to New 
York with the express purpose of establishing a great hos- 
pital devoted to the diseases of women and their treat- 
ment. When I left Alabama for New York I had no idea 
of the sort in the world. I came simply for a purpose, the 
most selfish in the world — that of prolonging my life. I 
saw that I could not live in any other place than New 
York, and for that reason, and no other, I came. 

During the winter my health was tolerably good; but 
I could eat no salt food, and even butter had to be de- 
prived of its salt. I could eat no condiments, not a par- 
ticle of pepper nor any vinegar; no fruits, and not a bit 
of sweetmeats. The least variation from this rigid diet 
would reproduce the diarrhoea. In walking on the street, 
if I ever stumbled once, I would fall flat to the ground, 
with no power to rise. 



•Rockbridge Ahim. — Editor. 

EDITOR'S NOTE.— From this time on to his death in 
1883, Dr. Sims' health, while never robust, was equal to the 
demands of a very active life. Some have thought that he 
must have suffered from pellagra. Here are set down all 
the statements in his autobiography which would seem to 
bear on his symptoms and his own ideas as to their causa- 
tion. 



Think of the possibility of cancer of the larynx in every 
case of husky voice, and look for it. 



Everything that gUtters is not gold. Not every protru- 
sion, from the anus is an internal hemorrhoid. — F. C. Smith, 
Philadelphia, in Med. Rec, Dec. 8th. 



If you have an ax'erage practice hardly a day goes by 
that you do not let at least one patient go through your 
hands with intestinal parasite infestation undiagnosed be- 
cause unsuspected. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



1S3 



THERAPEUTICS 

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



The Christian Festschrift 
A remarkable book has just appeared: Medical 
Papers Dedicated to Henry Asbury Christian, Phy- 
sician and Teacher, from his present and past asso- 
ciates and house officers at the Peter Bent Brig- 
ham Hospital, which was presented him on his 
sixtieth birthday, February 17th. It might well 
be called The Medicine of the Future. Probably 
no man since Osier has trained so many able men 
who are pushing back the boundaries of medical 
knowledge. It is a volume of 1,000 pages with 
an introduction in the form of a presentation 
speech signed, "I. C. W.," presumably Dr. I. 
Chandler Walker of Boston who was Dr. Christian's 
original First Assistant Resident at the time the 
Peter Bent Brigham Hospital was opened. The 
last contribution is entitled "Henry Asbury Chris- 
tian. An Appreciation." signed "W. T. V.," pre- 
sumably Dr. Warren T. Vaughan of Richmond. 
This last article gives a most interesting sketch of 
Professor Christian's great life and work. Be- 
tween the introduction and the final paper are 
100 scientific papers, many of which record strik- 
ing, even startling, advances in medical knowledge. 
The contributors are from almost every State in 
the Union, and practically every important medical 
school is represented with a very few exceptions. 
One of the remarkable things about the book is 
the brevity of most of the contributions. 102 con- 
tributions in 1,000 pages means an average of less 
than 10 pages per contribution. This no doubt 
deHghts Dr. Christian, who is a master at com- 
priessing much into little space. The book is 
edited by Dr. Robert T. Monroe, whose address 
is Peter Bent Brigham Hospital, 721 Huntington 
Ave., Boston; and its cost is ten dollars. The 
writer ordered his copy from Dr. Monroe. He 
does not know whether the work is generally on 
sale to the public, or whether only copies ordered 
in advance were printed. The book will doubtless 
furnish many topics for discussion in this column, 
for the papers teem with original ideas and sug- 
gestions for further thought. 

For the present, the writer is especially interested 
in mentioning a few of the high spots in Dr. Chris- 
tian's remarkable career. 

Born in Lynchburg and graduated at Randolph- 
Macon College, Dr. Christian was a young teacher 
of Science when he decided to study medicine at 
Johns Hopkins University. In his first year there 
he wrote a paper on anomalous muscles in the 
neck, and published it the following year. 



Graduating at Hopkins, Dr. Christian entered 
Dr. Frank B. Mallory's laboratory in Boston. He 
worked with him for two years and with Dr. 
Councilman three years. At the age of only 32, 
he was made Hersey Professor of the Theory and 
Practice of Physic, succeeding his chief. Dr. Reg- 
inald Fitz, sr.; at the same time he was made Dean 
of the Medical School. Then came the building 
of the Peter Bent Brigham Hospital, one of the 
greatest teaching hospitals in the whole world. Dr. 
Christian had already studied at Greifswald, Ger- 
many, but this was not enough. He, and every 
one of his original officers at the Brigham, toured 
Europe before the hospital was completed, getting 
the latest information available. The party in- 
cluded Dr. Christian, Physician-in-Chief to the 
Brigham; Dr. Channing Frothingham, the first 
Chief of Staff; Dr. Francis W. Peabody, Resident 
Physician; Dr. I. Chandler Walker, First Assistant 
Resident; and Dr. Reginald Fitz, jr.. House Officer. 
Wherever something of special interest was found, 
one of the party dropped off and learned what 
there was to know about it so he could bring it 
back to Boston. Dr. Christian brough back the 
first electrocardiograph to be installed in a general 
hospital in America. He thought he would find one 
in the hospital in Leyden, but they referred him to 
"a fellow named Einthoven who worked over in 
the Department of Physiology, quite a distance 
away!" 

The author of the "Appreciation" lists nine 
points of special excellence pertaining to the Peter 
Bent Brigham Hospital, from its beginning. These 
were: 1) A continuous service with the same phy- 
sicians always in charge. 2) The Brigham was 
the first hospital to have both a graded house of- 
ficer system and a graded resident staff. 3) The 
interne worked in the out-patient department only 
after finishing in the wards, thus giving a transition 
from hospital work to practice. 4) This was the 
first hospital in which all records were dictated in 
detail and the house officer was given a copy of 
the record of every patient that had been under 
his care when he left the service. 5) The system 
of Physicians-in-Chief pro tempore was first inaug- 
urated here. For one week in each year, some in- 
ternationally famous man is invited to live in the 
hospital and spend the week making rounds, lec- 
turing, living with the staff, and throwing out ideas 
and criticizing methods and diagnoses to broaden 
their viewpoint. Our own Dr. Wm. deB. MacNider 
has been honored with this position. 6) The 
Brigham was the first hospital in Boston to use 
the standard nomenclature of diagnosis, and it is 
now using the new National Nomenclature. 7) 
The medical service is freed from unnecessary in- 
hibitions and prohibitions. It is assumed that 



1S4 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



those working in the hospital are doctors and 
gentlemen. 8) The Staff Rounds became an in- 
stitution widely copied by other hospitals. 9) 
Last, but not least, was the great influence of "the 
Professor" himself. He himself says that his great- 
est contribution to medicine has been the training 
of men. One has only to see him at work at the 
Brigham to know that this is true. The list of 
his old boys contains many of the most brilliant 
investigators of the country, noted men in almost 
every State as well as in Canada. Many honors 
have been heaped on him, perhaps the greatest 
being the Presidency of the Association of American 
Physicians in 1934; though this book dedicated to 
him must warm the cockles of his heart, great 
teacher that he is, as almost nothing else that has 
come into his life, for it exhibits not only the love 
and loyalty of his past and present associates, but 
a quality of work done by them that can make him 
justly feel that they are carrying on the torch he 
has given them to illumine the whole world. 

ORTHOPEDIC SURGERY 

John Stuart Gaul, M.D., Editor, Charlotte, N. C. 



The a, B, C's in the Treatment of Fractures 
OF THE Long Bones 

A. Always reduce fractures of long bones by 
use of traction and counter traction applied in 
the direction of the long axis of the bone. 

B. Break up the impaction in a Colles' frac- 
ture and then reduce the fracture, making 
certain the plane through the articular surface 
of the lower end of the radius is at an angle 
of 30 to 37° to the long axis of the radius. 

C. Colles' fracture often has associated with it 
a fracture of one of the carpal bones, or a frac- 
ture of the head of the radius. Unrecognized 
and untreated they give much trouble. Look 
for them! 

D. Delayed union occurs in from }4 to 4% 
of fractures. There are general and local 
causes for it. The general causes are tubercu- 
losis, osteomalacia, rickets. Local causes are 
gumma, carcinoma, sarcoma, osteomyelitis, 
faulty position of fragments, interposition of 
soft parts and too-strong traction applied. 

E. Epiphyseal separation frequently occurs at 
the lower end of humerus, in children who have 
had injuries about the elbow joint. Fractures 
of the condyles or epicondyles frequently are 
associated with it, or occur alone. .Accurate 
reduction of these injuries is essential. Make 
certain the lower end of the humerus is carried 
forward sufficiently far, or there will be bony 
impingement, causing marked limitation of 
motion in the elbow joint. Look for injuries 



to other than bony structures. The median 
nerve may have been injured, the brachial ar- 
tery torn, the antecubital veins injured; or 
there may be an accumulation of blood and 
serum beneath the bicipital fascia. .All these 
complications demand prompt treatment, or 
disaster will result. These injuries should be 
put up in the Jones position, with a strip of ad- 
hesive plaster about the arm and forearm. 
The radial pulse should be palpable at all 
times. 

F. Fracturedislocation commonly occurs in 
Bennett's fracture — at the base of the thumb; 
fractures about the elbow joint; fracture of 
the upper third of the ulna, with dislocation of 
the head of the radius; fractures of the lower 
end of the radius; fractures about the shoul- 
ders; fractures of the semilunar bone; and 
fractures about the malleoli. It is good prac- 
tice to reduce the dislocation first and then 
align the fragments. 

G. Gas gangrene is a complication of com- 
pound fractures and particularly of gunshot 
fractures, and more particularly of fractures 
about the rectum. It should be looked for 
and if the patient's economic status will not 
permit him receiving the combined antitoxin 
against gas gangrene and tetanus, he should 
receive the tetanus antitoxin, and upon the 
first appearance of air in the tissues he should 
receive radical treatment. 

H. Humerus shaft fractures are easily reduced 
and handled in a Jones Humerus Traction 
Splint. 

/. Infection will surely take place in compound 

fractures if the wound is left open. It is bet- 
ter to remove the detritus consisting of dirt, 
clothes and devitalized tissue under aseptic 
precautions and then to suture the wound 
tightly without drainage. You can always 
open the wound later if necessary, but too 
many times it is done unnecessarily! 

J. Joints are meant to move. If a fracture ex- 
tends into one, the joint surfaces should be 
held apart with traction. Restoration of func- 
tion should be attempted as early as the given 
conditions warrant. 

K. Knee-joint fractures give bad results because 
a tibial condyle is crushed down and not ele- 
vated, or a condyle of a femur is displaced 
and not brought back to its normal position. 
The result is poor weight-bearing function and 
the setting up of an arthritis. Again a cru- 
cial ligament may be torn, or a semilunar car- 
tilage fractured, and both go unrecognized. 
The result is an unstable weight-bearing joint. 

L. Local anesthesia in the form of novocaine, 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



injected into the fractured line, under sterile 
precautions, will save the patient much pain, 
and abolish much of the muscle spasm, making 
reduction of the fracture easier. 

M. Malignant edema is easier prevented than 
treated. It means an anerobic infection, com- 
plicating a compound fracture. Clean out the 
wound by excising dead tissue. If it appears, 
long radial incisions are necessary with re- 
moval of whole muscles. Prevent it! 

N. Neck-of-femur fractures do so well with 
nailing of the fragments that we are not justi- 
fied in the expensive methods we formerly used. 
The nailing procedure produces no shock, the 
patient can sit up in bed, and with crutches 
can be put out of bed in a few days. Results 
are as good if not better, the bugbear of hypo- 
static pneumonia in the aged is largely elim- 
inated, and the economic saving to the patient 
is considerable. 

0. Over treatment of fractures can and does 
occur. It is better to have good function with- 
out anatomical reduction, than to have anatom- 
ical reduction without function, because of in- 
jury to soft structures in the obtaining of the 
perfect reduction. 

P. Paralysis is associated with fractures and 
may appear immediately because the trauma- 
tizing force which produced the fracture has 
injured a nerve trunk, or it may appear later 
because the callus has caught the nerve trunk. 
The common sites for this complication are 
the shaft of the humerus with the musculo- 
spiral nerve involved, the internal condyle of 
the humerus with the ulnar nerve involved; 
the lower end of the humerus with the median 
nerve involved and fractures of the head of the 
fibula with the p>eroneal nerve involved. Al- 
ways look for these complications, note them 
down and call them to the attention of the 
patient's relatives. To do so will prevent mal- 
practice suits. 

Q. Queer ideas enter patients minds when 
doctors talk too much about how some other 
doctor has treated a fracture. A lawsuit 
af^ainst a doctor usually follows. 

R. Reduction of fractures is accomplished easier 
before swelling and muscle spasm occur. Re- 
duction and splinting eliminate the swelling 
to a great extent. If swelling is marked fol- 
lowing reduction and splinting be sure you 
have a complicating factor. Look for it and 
protect the circulation from the swelling and 
pressure against the splinting device. If a cast 
has been applied split the cast. 

S. Sprain fractures — those occurring about the 
ankle, elbow, wrist, knee and shoulder joints 



will give more trouble than frank fractures. In 
this type of injury a small portion of bone is 
torn away by a ligament or tendon. Strap- 
ping with adhesive is not sufficient. A plaster 
cast will give greater comfort to the patient 
and, usually, an excellent result. 

T. Traction and counter traction can be ef- 
fectively made by fastening the body to a 
stationary object by means of a sheet. Using 
your body as a powerful lever and tractor, 
having someone hold the extremity flexed 
against your body, your hands are free to 
do any manipulating necessary. 

U. Ulna fractures, particularly of the upper 
third, require good reduction to avoid distress- 
ing disability. A dislocation of the head of 
the radius is frequently associated. Fractures 
of the olecranon should be treated with the 
forearm in extension. 

V. Volkmann's ischemic contracture is a fairly 
frequent complication of fractures about the 
elbow. Abnormal swelling about the joint, 
trauma to the median nerve, compression of 
blood vessels and blood and serum collecting 
beneath the bicipital fascia are the precipitat- 
ing factors. Unusual pain or discoloration or 
coldness of the hand requires immediate in- 
vestigation. 

W. Walking casts in case of fractures of bones 
of the leg are appreciated by patients because 
of the economic factor and for many other 
reasons. 

X. X-rays are looked upon by the courts as a 
necessary part of the treatment of fractures. 
Acquittal in a malpractice suit is hard to ob- 
tain if x-ray examinations have not been 
made. 

Y. Youth is resilient; age fragile. Warn your 
elderly patients to take precautions as to stairs, 
bath tubs and in streets. 

Z. Zeal in attention to what appear to be minor 
details brings its own reward in the treatment 
of fractures. 



EYE, EAR, NOSE AND THROAT 

Frank C. Smith, M.D., Editor, Charlotte, N. C. 



Visual Requirements for Drivers of 
Automobiles 

With state licenses for automobile driving re- 
quired in North Carolina and her sister states we 
will soon have to consider the minimal visual re- 
quirements for safe automobile driving. 

While it is difficult to determine the percentage 
of automobile accidents due to impairment of the 
visual function, those of us doing an active ophthal- 
mological practice have such cases brought to 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



our attention not infrequently. In the past week 
two cases came under observation which illustrate 
the danger of impaired vision while driving. In 
the first instance the driver of a truck recently 
side-swiped several cars, three in one day. He was 
brought in by an inspector for the company who, 
while riding with him, had to grab the steering 
wheel when he realized the car was about to collide 
with another car. While the driver realized he had 
hit several cars he had no idea why. He was 
found to have lost the right half of each visual 
field. The other case was sent in by a lawyer to 
see if the patient had not damaged his sight in an 
automobile accident. The boy had only 10/200 
vision, right, and 20/148, left, due to near-sighted- 
ness which had never been corrected. Immediately 
the question arose as to whether the one suing 
should not be the one sued because he certainly 
does not have sufficient vision to drive safely. 

It may be wise to inform ourselves as to how 
other states are meeting this problem of minimal 
requirements for safe automobile driving. 

The law is most stringent in Delaware where 
one must have 20/20 vision in one eye, or a 20/30 
vision in the better eye and at least 20/40 vision 
in the poorer eye, with or without correction. 

Ohio and Minnesota issue no permits if there 
is blindness in one eye, and these states require 
at least 20/40 vision in each eye. 

In California you must have at least 20/50 vision. 

Connecticut requires 20/70 vision with both eyes, 
or a 20/50 vision in one eye, the other eye being 
blind. 

The District of Columbia requires a minimum 
of 20/40 vision with both eyes and a field of 
vision of 140° or more. 

For an unrestricted license in Maryland you must 
have a minimum visual acuity of 20/70 in each 
eye and a field of vision of 140°, together with 
binocular vision. If the applicant has only 20/70 
vision in one eye and not less than 20/140 vision 
in the other eye, a license may be issued for day- 
light driving only. The civil service, police and 
fire departments require 20/20 vision in each eye 
without glasses. 

Visual acuity is the first consideration. R. E. 
Mason whose eyes are normal fogged his vision 
with plus lenses then on a bright day and at night 
with legal headlights determined how far away he 
could read the regulation stop sign with both 
eyes open. 



With the speed of the modern automobile we 
realize how necessary it is to be able to distinguish 
objects cltearly at some distance if we are to 
avoid accidents. According to these tests a person 
with normal vision can read a stop sign at 255 ft. on 
a bright day, but no farther than 75 ft. at night 
under normal conditions of driving. The minimum 
vision permitted in states with regulations is 20/70, 
which enables the sign to be read at 100 ft. in the 
day time but no farther than 25 ft. at night. It 
would seem unsafe for one to drive at night if he 
cannot read a stop sign more than 25 ft. away. 

To test the effect of narrowing his visual fields 
Mason painted the periphery of the lenses he wore 
and came to the conclusion that no one should 
drive who has a field of vision less than 125° in the 
horizontal arc with one or both eyes. 

The importance of a visual field of reasonable 
size is illustrated by a school teacher who had five 
wrecks within eighteen months and felt the other 
fellow was to blame each time until on examination 
he saw that he could not see to the right out of 
either eye due to a parietal lobe tumor which was 
removed. 

A chart giving the speed of the car, how many 
feet the car travels per second at a given speed and 
how many feet are required to stop at a given speed 
with two wheel brakes and four wheel brakes is of 
value when studied with the figures already given 
showing how far a stop sign can be read day or 
night, with a given visual acuity. 



Speed 
of car 


Ft. traveled 
per sec. 


Ft. required 
to stop at stated speed 
Two-wheel Four-wheel 
brakes brakes 


10 


14.67 


9 


5 


20 


29.34 


39 


21 


30 


44.00 


87 


47 


40 


58.70 


155 


82 


45 


66.00 


196 


104 


SS 


80.70 


294 


155 


60 


88.00 


349 


185 


65 


95.30 


409 


217 


70 


102.60 


475 


252 


7S 


109.90 


544 


289 


80 


117.20 


619 


328 


100 


146.60 


968 


514 





Day 


Night 


20/20 


2SS ft. 


_ 75 ft. 


20/30 


200 




20/70 


100 


25 


20/100 


74 




20/200 


50 





From these figures we see that one with normal 
vision (20/20) could travel at the rate of 70 miles 
per hour with four-wheel brakes or 50 miles per 
hour with two-wheel brakes and stop between the 
time of reading a stop sign and reaching that sign 
in the day time, but his speed would at night have 
to be reduced respectively to less than 40 and 30 
miles per hour. 20/70 is the minimum allowed in 
any state requiring visual restrictions and this ap- 
pears too low since such an individual would have 
to drive at 45 miles per hour in the day time as 
compared with 70 miles per hour for an individual 
with normal vision, while at night his speed would 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



1S7 



have to be reduced to 2 5 miles per hour as compared 
to 40 miles per hour. Such an individual should 
probably receive a license limited to day driving. 

A 26-to-l ratio of night driving over driving in 
the day indicates clearly the increased hazard which 
is largely one of seeing. The normal eye contracts 
very rapidly in the glare of a headlight but dilates 
very slowly in comparison. The period of two or 
three seconds of indistinct vision after a glaring 
light passes represents the time it takes the pupil 
to dilate which is necessary to see at night. Eye 
fatigue is much more pronounced at night than in 
the day time, the constant straining in the effort to 
see tires the whole nervous system with a tendency 
toward drowsiness, then sleep if continued. We 
have been speaking of normal eyes but we must re- 
member that conditions which reduce vision in day- 
light often reduced it far more in poor light. There 
are persons with normal vision in good light who 
have to be led about at dusk. Such conditions are 
usually hereditary but many diseases produce lesser 
degrees of night blindness. 

As individuals each of us is sure that these figures 
cannot apply to us yet 36,000 people were killed in 
1934 by drivers who felt just as we do. Since 
20,000 of these fatalities from automobile accidents 
occurred at night when only 25% of automobiles 
are in operation, night driving is an immediate 
problem which will require the enforcement of 
rigid restrictions if such mortality rates are to be 
reduced within reasonable limits. 



HOSPITALS 

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



The R. N. and Hospital Meetings 
The author has visited hospital meetings of all 
kinds and descriptions for a number of years. The 
following is not a criticism but an observation. 

The hospital associations were formed to bring 
together hospital owners and administrators in- 
terested in profiting by each other's experiences. 
The majority of the membership of the association 
have been doctors. As time went on these physi- 
cians who felt that they were getting valuable 
information would take along their superintendents 
and supervisors. For a while all went well; then 
the doctors would have real sick patients that they 
would not want to leave, and so they sent their 
superintendents and supervisors to the meetings, 
more often than otherwise the hospital paying their 
expenses and always continuing their salaries 
straight through while they were gone. 

There used to be discussed at the earlier meetings 
the cost of food and how to preserve it, the cost 
of materials and supplies, what make was the most 
satisfactory, the names of the most reliable and 



durable instruments, the composition of inside and 
outside paint and which is most satisfactory, the 
best method of collecting from poor patients, the 
best psychology to use on the dead-beat and, last 
but not least, how to render the best service to the 
sick. Today at the meetings, which are predomi- 
nantly attended by the nurse superintendents and 
supervisors, you will hear discussed at length the 
following subjects: 

Salaries of the nurses. Which hospitals should 
be allowed to run training schools for nurses. Nurse 
maids. Hours on duty. Scrub maids. Graduate 
dietitians. 

Is it any wonder that economical hospital own- 
ers and administrators are beginning to lose their 
interest in the hospital meetings when those things 
are discussed that tend to create friction at home 
rather than harmony, and how to spend more 
money than the hospitals collect. In short, without 
realizing it the nurses are drifting into the customs, 
opinions and ways of the labor unions. 

At the hospital meetings there are representatives 
from various types of hospitals operating in many 
different localities, and under entirely different cir- 
cumstances. It is absurd to try to standardize the 
salary of the graduate nurses employed in the hos- 
pitals. One nurse may be worth twice as much as 
another in any given institution. For example, a 
nurse who is willing to turn her hand to anything 
that comes up, whether it be giving an anesthetic, 
making a blood count or helping a patient into an 
automobile when he or she is discharged from 
the hospital, is the type of nurse who should draw 
the biggest salary, and she usually does. Just as 
is the case of the physician, income should be 
based upon actual service and not upon a degree 
such as M.D. or R.N. 

The matter of nurse maids has grown up re- 
cently to be a popular topic. Some graduate nurses 
feel that they have reached the stage when it is 
beneath their dignity to tidy up the dresser, dust a 
chair or comb a patient's hair. They do not realize 
that if such things are going to make the patient 
feel better it never has been and never will be be- 
neath the dignity of a true nurse. Nurse maids, if 
they are intelligent, will gradually assume all of 
the work of the graduate nurse except that of ac- 
tually giving medicine and after a reasonable length 
of time the graduate nurse is going to find her 
services for that purpose less in demand. 

Standardization of the nurse's training has 
reached a stage that it is assumed that the pupil 
nurse has no time to do any scrubbing and clean- 
ing whatsoever. She must spend a good part of 
her time learning the theory of nursing, the history 
of the nursing profession, and other allied subjects. 
What time is left out of the short number of hours 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



that she is supposed to be on duty is set aside for 
practical nursing. If a girl while in high sccool 
can afford to go home and help her mother and 
sisters wash dishes, polish furniture, prepare meals 
and keep the house clean, why is it such a crime 
for this same girl to help keep house for the sick 
people in the hospital? 

The writer is making an earnest plea that the 
hospital meetings be well attended by operators and 
owners who see all the subjects with unbiased eyes, 
but who realize that the hospital is built and main- 
tained in order that sick people might be well 
treated, and that no hospital can possibly succeed 
which spends more money than it is able to collect. 
If such meetings were held with large attendance 
of both nurses and doctors, and if both would call 
a spade a spade when discussing these matters, the 
meetings would be more profitable to all parties 
concerned. 

The hospital should be considered as a family 
which must work in harmony and sympathy 
throughout. Its part in the hospital association 
may be likened to one merchant's part in a mer- 
chants' association; that is a merchant must con- 
duct his own affairs successfully before he is ex- 
pected to give advice to other merchants. 



RADIOLOGY 



Wright Claskson, M.D., and .^llen Barker, M.D., 
Editors, Petersburg, Va. 



Radio-curability of Tumors 
The eradication of a neoplasm by means of irra- 
diation is not entirely dependent upon the tumor's 
sensitiveness to the ray. All tumors are sensitive 
to sufficiently large quantities of roentgen or ra- 
dium irradiation and they can be entirely destroyed 
by this method of treatment. The question to be 
answered in each individual case is, can all of the 
tumor cells in the patient's body be destroyed with- 
out causing permanent disability, or death of the 
patient? Therefore, in order to decide intelligently 
upon the advisability of attempting to cure a pa- 
tient suffering with a neoplastic disease by the use 
of irradiation, one must consider many factors in 
addition to the probable radiosensitiveness of the 
type of cells found in the growth. 

The radio-curability of a tumor may be adverse- 
ly influenced by large quantities of fat surrounding 
the mass, by the presence of infection, by the in- 
vasion of surrounding bone or cartilage, or by 
metastases which are inaccessible or located in some 
vital organ. 

Lymphnodes are usually able to resist a malig- 
nancy for a certain length of time and therefore 
they often retard the spread of a cancer, but once 
the malignant cells succeed in penetrating the gland 



capsule they may rapidly become disseminated. 
Likewise a surgical procedure, undertaken prior to 
adequate preoperative irradiation, may by divid- 
ing the IjTnph channels cause a widespread dissem- 
ination of malignant cells. 

As a general rule, young robest individuals suc- 
cumb more rapidly to cancer than do old thin ones. 
This is probably due to the endocrine activity in 
the young. For the past si.x years, we have arri- 
diated the gonads and the pituitary gland of prac- 
tically all of our patients with generalized malig- 
nancy'^ and with markedly beneficial results. 

As a control, in April, 1933, we intentionally ir- 
radiated only the breast and axilla of one patient, 
aged 49, who had an advanced carcinoma of the 
breast with pulmonary metastases. The local lesion 
responded well, but the patient's general condition 
continued to decline. When the treatment was be- 
gun, the patient weighed 130 pounds. On April 
23rd, 1935, she weighed only 117 pounds. She 
was menstruating regularly. Her appearance was 
cachectic. A roentgenogram of her chest showed 
extensive metastases throughout both lungs, and 
she was so dyspneic as to be totally disabled. 

While she was in this state, 2200 r units of roent- 
gen irradiation were directed to her ovaries and 
2000 r units to her pituitary gland. Absolutely no 
other treatment was given the patient. 

The improvement was almost astounding. Today, 
ten months later, she is apparently in good condi- 
tion. Recent roentgenograms show a marked retro- 
gression of the lung metastases. She has gained 
13 pounds in weight, is able to do her housework 
and she feels strong and well. 

Many other factors influence the radio-curability 
of tumors. For instance, long-continued low-in- 
tensity irradiation is less harmful to skin cells but is 
quite deadly to sensitive tumor cells. 

Pedunculated tumors, and all very vascular tu- 
mors, usually respond well to irradiation, while 
those imbedded in scar tissue usually show consid- 
erable immunity to the rays. 

The size and the location of a growth are im- 
portant. For example, a relatively radioresistant 
tumor 3 cm. or less in diameter, located on the 
skin, may safely be given sufficient irradiation to 
completely destroy the neoplasm together with a 
small border of the surrounding healthy tissue, but 
the likelihood of trophic disturbances makes it un- 
wise to administer this dose to a neoplasm involv- 
ing a large skin area, particularly if the growth 
happens to be overlying a bony prominence or some 
sensitive vital organ. 

Perhaps the most discouraging typ>e of growth 
to treat is one that has previously been rendered 
radio-incurable by the improper administration of 
roentgen or radium rays by some one who prac- 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



159 



tices a little radiology along with a little of every- 
thing else and who is consequently not capable of 
properly irradiating neoplastic diseases. Tumors 
thus treated may respond temporarily, but they 
soon become radioresistant and begin to grow 
again. Curable cancers are thus rendered abso- 
lutely hopeless. Such cases are constantly being 
referred to radiologists, who in these cases can give 
the patient only temporary relief. 

Bergonie and Tribondeau- in 1905 called atten- 
tion to the radiosensitiveness of cells during mito- 
sis. They believed that the sensitivity of the cell 
varied directly with its reproductive capacity and 
inversely with its degree of differentiation. Experi- 
ence has proven, however, that there are many ex- 
ceptions to this rule. In this connection, Packard^ 
calls attention to the fact that lymphocytes are 
highly susceptible, although their power of repro- 
duction is very limited, and that bacteria and yeast 
cells are resistant, although they are comparatively 
undifferentiated, and are capable of long-continued 
cell division. 

Ewing^ has classified tumors in decreasing order 
of radiosensitivity as follows: "(1) lymphoma, 
(2) embryonal tumors, (3) cellular anaplastic tu- 
mors, (4) basal cell carcinoma, (5) adenoma and 
adenocarcinoma, (6) desmoplastic tumors, such as 
squamous carcinomas and fibrocarcinoma, and (7) 
fibroblastic sarcoma, osteosarcoma, and neurosar- 
coma." 

DesjardinsS divides neoplasms into three main 
groups: "(1) radiosensitive tumors, growths the 



radiosensitiveness of which is greater than that of 
the skin; (2) moderately radiosensitive tumors, 
growths the radiosensitiveness of which approxi- 
mates that of the skin; and (3) radioresistant tu- 
mors, growths the sensitiveness of which is less than 
that of the skin." He states, as a fundamental law, 
that each variety of cell in the body has a specific 
range of sensitiveness to roentgen rays or radium. 
He also says, ''The sensitiveness peculiar to each 
kind of cell appears to be related chiefly to the 
natural life cycle. Thus the lymphocytes, the meta- 
bolic cycle of which among human cells is the 
shortest, are also the most radiosensitive, and the 
nerve cells, the life cycle of which is the longest, 
are also the most resistant to irradiation." He 
classifies cells according to their radiosensitiveness 
in the following order, from the most sensitive to 
the least sensitive: lymphoid cells; polymorphonu- 
clear and eosinophilic leucocytes; epithelial cells; 
endothelial cells; connective tissue cells; muscle 
cells; bone cells; fat cells; nerve cells. 

Geschickter", speaking before the Eastern Con- 
ference of Radiologists meeting in Baltimore re- 
cently, gave a new classification of the radiosensi- 
tiveness of tumors, based on the tissue of origin. 
He states that while the radiosensitiveness of tissues 
does not always vary directly with the amount of 
anaplasia, this rule does hold true when com- 
paring tumors derived from the same type of tissue. 
Therefore the radiosensitiveness varies directly with 
the amount of undifferentiation, when comparing 
tumors belonging to any one of the major subdivi- 
sions shown in his classification. 



Geschiokter's Classification of Tumors 



1, TUMORS OF ECTODERM 
la. Ectodermal derivatives 



(RS*) Tegmental tumors (Epidermoid) 

Appendal tumors (Basal) 

Breast — anterior pituitary 



2. TUMORS OF NEURECTODERM 



(RR) 



Neuroblastic 

Glial 

Sheath tumors 



(Sympathetic) 



(Melanomas) 
(Neurofibromas) 



3. TUMORS OF ENTODERM 



(RR) 



Digestive tube 

Biliary 

Pancreatic 



4. TUMORS OF BRANCfflAL ENTODERM 



(RR) Branchial 

Bronchiogenic 

Thyroid and Parathyroid 



5. TUMORS OF SOMATIC MESODERM 



(RR) 



Voluntary muscle 

Connective tissue (bone, cartilage, etc.) 



6. TUMORS OF CELOMIC MESODERM 



(RS) Mesothelium 

Genito-urinary (gonads, kidney, uterus, prostate) 
Celomic mesenchyma (angioblastic) (smooth muscle) 



7. BLASTODERMAL TUMORS 



(RS) 



Choriomas 
Teratomas 
Sex cell? 



•RS=Radiosen8ltlve ; RR=:Radloreslstant 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



Geschickter expressed a dislike for the term "tu- 
mor bed," and he stressed the fact that the rate of 
spread of a tumor determines its operability. He 
explained why cancer cells in muscle tissue seem 
so much more radioresistant than those in lymph- 
nodes by stating that cancer cells in muscle tissue 
follow the intramuscular septa and through muscu- 
lar action are rapidly carried away from the sur- 
face and thus becoming more inaccessible to irra- 
diation they appear to be more radioresistant. 

We believe that Geschickter's conclusions are 
correct and that his new classification of tumors, 
whereby he determines their radiosensitiveness by 
their cell of origin, will prove extremely valuable to 
all who are interested in this subject. 

In conclusion, we wish to emphasize the fact that 
the radio-curability of tumors is dependent upon 
many interrelated factors and therefore in order to 
treat neoplastic diseases successfully, one must be 
well trained in the entire science of radiology and 
likewise possess a broad knowledge of tumor path- 
ology. 

References 

1. Cl-^rkson, Wright and Barker, Allen: Five- Year 
Cure of Mammarj' Carcinoma with Multiple Metasta- 
ses to Bone, to be published in Am. Jl. Roentgenol, 
and Rad. Tlierapy. 

2. Bergonie, J., and Tribondeau, L.: The Science of Ra- 
diology. 

3. Packard, C: Biologic effects of Roentgen Rays and 
Radium. The Science of Radiology. 

4. E-iviNG, J.: Editorial, J. A. M. A., Feb. 24th, 1934. 

5. Desjardins, a. a.: A Classification of Tumors from 
the Standpoint of Radiosensitiveness. Am. Jl. Roent- 
genol, and Rad. Therapy, Oct., 1934. 

6. Geschickter, C: Address before Eastern Conference 
- of Radiologists, Jan. 31st, 1936. 

PRACTICAL PRACTICE NOTES 
From C. C. Hubbard, M.D., Farmer, N. C. 

A thing which might be helpful to other doctors— Dr. 
Jeff D. BuUa, Trinity, N. C, R. F. D. 1, told me to use 
saturated solution salicylic acid in alcohol twice a day in 
cases of athlete's foot. I never saw it fail. In bad cases 
use it freely at night when the shoes will be off, and use 
boric acid solution in the morning— using soap and water 
both at night before using the salicylic mbrture. I use it 
in skin diseases of the fungus type. I find it good in dan- 
druff. 

S. T. 37, 1 part to 3 parts of water, is an excellent thing 
for nasal catarrh sprayed in nose twice a day. Also with 
1 Rhinitis (full strength Rhinitis) spray every 2 hours till 
a Uttle dryness of mouth, then every 4 to 6 hours. Have 
seen it abort many colds. 

I often think we do big harm by using new drugs in 
place 'of the old. When I used ammonium chloride in big 
doses every 4 hours in pneumonia, as much as the stomach 
would bear, I had a much smaller death rate. Now we 
seldom hear of muriate of ammonium or the carbonate in 
lung troubles. When I really want a man to get well I put 
him on muriate of ammonia and potassium bromide every 
4 hours day and night to point of nausea. 

I have not used tincture digitalis in 2 years or more. I 
give the fresh leaves in capsules (3 gr.) 



INTERNAL MEDICINE 

W. Bern-.\rd Kinlaw, M.D., F.A.C.P., Editor Pro Tern, 
Rocky Mount, N. C. 



Some Early Medical PosT-OpER.ATrvE 
Complications 

During the early hours following a major opera- 
tion in which one of the general anesthetics, aver- 
tin, or spinal anesthesia has been used, there may 
be a complication of a medical nature, which, if 
discovered early, will change the prognosis and 
lessen the number of post-operative days in the 
hospital, ilost of these are respiratory or cardio- 
vascular in nature, or due to shock. Post-opera- 
tive shock is usually a part of the surgical proce- 
dure and is treated as such, but these cases fre- 
quently will cause considerable worry as to wheth- 
er the heart is not going bad, or whether a lot of 
stimulation including digitalis is indicated. Pro- 
vided the cardiovascular system was all right prior 
to operation, this type of case will usually respond 
to glucose (10%) in the vein, with adrenalin or 
pituitary extract. The foot of the bed is elevated 
and other general measures for shock carried out 
until the low pressure has been brought back near- 
er a normal figure. There is usually no dyspnea; 
no rales are heard at the bases of the lungs, and 
the neck veins are not distended; so digitalis is 
not indicated. 

When the temperature jumps to 102 to 105, 
twelve to twenty-four hours after some abdominal 
operation, naturally the surgeon does not think 
anything (in the average clean case) can be in 
the abdomen to account for it. The chest is where 
most of the explanation is usually found, and if 
carefully examined will reveal atelectasis — from a 
small area to a whole lung. We discontinued the 
use of carbon dioxide after operation the first of 
the year, on the theory that the increased inspira- 
tion produced might suck mucus, etc., deeper into 
the smaller bronchi, but we cannot see any differ- 
ence unless we are seeing more of this complica- 
tion without its routine use than with it. One 
cannot expect the classical signs such as displaced 
heart (to the affected side), decreased expansion 
on one side, etc., to find the cause of fever. There 
is frequently a small area in the back or axilla 
which reveals practically no breath sounds and 
when turned on the opposite side and given carbon 
dioxide there usually comes forth the tjqjical grey- 
green thick sputum that forms so quickly in these 
cases. Due to the thickness of the sputum, a re- 
turn of the condition is not unlikely and it^niust 
be watched and treatment continued for several 
days. Nitrous oxide and spinal anesthesia seem 
to be associated with a larger percentage of these 
complications; however, we have not analyzed a 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



161 



large series of cases yet. A recent visitor to one 
of our hospital staff meetings reported three cases 
of death within twelve hours after operation, all 
in operations on the tongue. Avertin was used in 
all three cases. The use of avertin in selected cases, 
supplemented with ether, has given us very few 
complications to worry about. Post-operative lobar 
pneumonia is very, very seldom seen if the atelec- 
tasis is recognized and treated. 

There is a condition frequently seen by the medi- 
cal man after some major operation when the sur- 
geon wants to push "all the hypoclysis the patient 
can take." That would be all right, but when the 
internist sees them there are numerous fine bub- 
bling rales throughout the chest and there is still 
saline in puddles under the skin of the upper chest 
and axilla. The nurse has given more than they 
can take. Taking out the needles and giving con- 
centrated glucose (20-30 per cent.) in the vein 
will usually clear up the chest condition. 

It is (or probably it is not, when given serious 
thought) remarkable how few real cardiac compli- 
cations occur following even long, serious opera- 
tions. Careful heart study and a history of what 
it could stand before operation is a great help in 
telling what it is doing after operation. Our elderly 
men with angina are having their thyroids removed 
with good results. Our toxic-thyroid cases with 
fibrillation are greatly benefited by thyroidectomy 
with seldom a circulatory mishap, and our hyper- 
tensive cardiovascular cases can have gallbladders 
or large renal calculi removed with very little car- 
diac embarrassment. 

An occasional case of auricular fibrillation is 
seen after some major operation in a patient who 
was perfectly well, apparently, prior to onset of 
recent acute condition and was doing his work 
without cardiac symptoms. These cases in persons 
under forty are usually cleared by the time they 
have had three doses of quinidine, but they should 
have a longer convalescence and be observed for a 
longer period of time because of the fact that there 
is usually some organic heart change even in pa- 
roxysmal fibrillation. In pelvic operations, even 
more in those on the extremities, an uncommon 
complication is a pulmonary embolism, and a sud- 
den attack of dyspnea may be the only symptom. 
The prognosis depends on the size; oxygen therapy 
and sedatives are indicated. 

In all chest complications a nasal tube to the 
stomach, to keep gas at its minimum and prevent 
toxic dilatation by hot water injections to it sud- 
denly, even if removed quickly, is certainly very 
helpful in treatment. 



MANACE3krENT OF AnAL FlSSURE 
(C. E. Hall, Atlanta. In Jl. Med. Asso. of Ga., Feb.) 
Anal fissure is of common occurrence, and causes pain 
and disability. 

Non-traumatic fissures or ulcers result from some in- 
fection: epidermophytosis, chancroid, chancre, secondary 
syphilis, gonorrhea, tuberculosis and granuloma. Diagnosis 
depends upon the historss the clinical manifestations; and 
smears, cultures and blood tests. Treatment includes the 
proper therapy for the underlying causative disease. 

The great majority are from constipation, straining at 
stool, passing of foreign bodies in the stools, or rough 
instrumentation. 

With antiseptic precautions 2 or 3 c.c. of 1% novocain 
is injected beneath the fissure. For prolonged anesthesia 
the tissues beneath and surrounding the lesion are then 
infiltrated with 1% diothane. When the anesthesia is 
complete the fissue is cauterized with 10 to 20% silver 
nitrate. 

The after treatment consists of ample mineral oil to insure 
easy bowel actions, hot sitz baths 2 or 3 times daUy, and 
daily applications of mild antiseptics. Heahng will take 
place in the majority of cases in 10 days to 2 weeks by 
these simple measures. If not, the fissure must be treated 
as a chronic lesion. 

A traumatic fissure is chronic if it is of more than a 
few days duration and presents a sentinel pile or skin 
tab, purulent infection, connecting sinuses, infected anal 
crypts with hypertrophied papillae or induration of the 
surrounding tissues. 

Treatment must relieve pain and spasm, also establish 
adequate drainage. The involved area is infiltrated, a small 
quantity of 1% novocain is injected for immediate effect 
plus a sufficient quantity of 1:1000 nupercain solution for 
prolonged effect— usually 10 to IS c.c. is sufficient. 

It is sufficient to anesthetize merely the involved area of 
tissue. When the anesthesia is complete a bi-valve and 
retractor is inserted and adjusted to give clear view A 
careful search is made with a hook-shaped probe for sinuses 
or involved anal crypts, and any that are found are excised 
with scissors. More often than not an infected anal crypt 
will be located beneath a chronic anal fissure, and adequate 
dramage will not be obtained unless this crypt be excised 
Next, an incision is made with a sharp scalpel, beginning 
above the fissure at the ano-rectal or papillary line, and 
extending longitudinally downward to the anus, and thence 
externally for a dktance of V/. to 2 inches on the perianal 
skm. The depth of the incision is J^ inch and is sufficient 
to sever those fibers of the sphincter which decussate pos- 
teriorly. These fibers constitute a tendinous band— the 
Pecten band. Sufficient relaxation is obtained without 
dividing the entire sphincter. 

AU overhanging edges of skin and mucous membrane 
with the sentmel skin tab, are freely ablated with scissors. 
The retractor is now wtihdrawn and the wound packed 
with a small piece of vaseline gauze in order to keep the 
edges of the incision separated and to control the slight 
hemorrhage. A firm cotton pad is applied to the anus 
and the patient confined to bed 12 to 24 hours. A move- 
ment is allowed after 24 hours. 

Dress the incision daily, being sure it heals from bottom. 
Mild antiseptics are applied locally and any excessive 
granulations kept down with silver nitrate. The skin por- 
tion of the incision is kept open until the mucous mem- 
brane of the anal portion is entirely healed. Ample mineral 
oil renders the stools soft, and frequent hot sitz baths ari 
valuable aids in promoting healing. Generally, the patient 
is able to return to his usual occupation after 2 or 3 days 
and healing is complete in 2 weeks. 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



!••^•5••5•^•♦♦•■^•^•M~^•^•^~^* 



President's Page | 

Medical Society of the State of North Carolina % 



For many years members of our profession inter- 
ested in legislative matters touching the physicians 
of North Carolina, have urged the necessity of hav- 
ing more doctors in both the Senate and the House. 
This, of course, is a difficult objective to obtain 
because the physician's life being such an individ- 
ualistic one, he cannot, in the vast majority of 
cases, drop his practice for the indefinite period 
during which the General Assembly is in session. 
As a result, we have always been tremendously 
nnder=represented in the legislative bodies of our 
State. 

If it is impossible to have a considerable number 
of physicians (it is estimated that a total of about 
twenty in both houses would satisfy our needs), 
there is another avenue open to us; namely, to 
select as our representatives in the General Assem- 
bly individuals who will be favorably disposed to 
the desires and objectives of the medical profes- 
sion. Physicians as a class occupy a particularly 
respected position in their several communities and 
if, individually and collectively, they exercise their 



influence in the selection of candidates for the legis- 
lature, there is little doubt that the right sort of 
men will be chosen. 

The demand of the medical profession of North 
Carolina upon the legislative powers of the Gen- 
eral Assembly have never been excessive. These 
demands have been of two kinds: the furtherance 
of legislation that is favorable to the medical pro- 
fession and the blocking of legislation prejudicial 
to it. Space does not permit comment upon the 
excellent work done by the Legislative Committee 
of the Medical Society of the State of North Cato- 
lina, but this work could be extended and immeas- 
urably facilitated if care were taken that the in- 
coming legislators be chosen with an eye to their 
attitude toward the profession of medicine. I urge 
each and every physician throughout the State to- 
bear this in mind when candidates announce them- 
selves, and I urge the organized units of the State 
:Medical Society to operate collectively in order to_ 
further a condition more advantageous to our per-* 
sonnel throughout this commonwealth. 

—PAUL H. RINGER. 



VV^'^t^i-^ 



*' uo 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



163 



Southern Medicine and Surgery 

Official Organ of 

Tri-State Medical Association of the 

Carolinas and Virginia 

Medical Society of the State of 
North Carolina 



James M. Northincton, M.D., Editor 



':")-- 



-Charlotte, N. C. 



-Charlotte, N. C. 



Department Editors 

Human Behavior 
James K. Hall, M.D ,^ _ ^..._ -Richmond, Va. 

Dentistry 

W. M. Robev, D.D.S - -Charlotte, N.C. 

Eye, Ear, Nose and Throat 

Eye. Ear and Throat Hospital Group - Charlotte, N. C. 

Orthopedic Surgery 

0. L. Miller, M.D ) 

John Stuart Gaul, M.D.) 

Urology 
Hamilton W. McKay, M. 
Robert W. McKay, M.D. 

Internal Medicine 

W. Bernard Klnlaw, M.D Rocky Mount, N. C. 

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

Therapeutics 
Fbederick R. Taylor, M.D 

Obstetrics 
Henry J. Langston, M.D 

Gynecology 
Chas. R. Robins, M.D. .^ -Richmond, Va. 

Pediatrics 
G. W. KuTSCHER, JR., M.D. - Asheville, N. C. 

General Practice 

WiNCATE M. Johnson, M.D Winston-Salem, N. C. 

Clinical Chemistry and Microscopy 
C. C. Carpenter, M.D. „ Wake Forest, N. C. 



.High Point, N.C. 
— -- Danville, Va. 



R. B. Davis, M.D. 



Hospitals 



Greensboro, N. C. 

...Albemarle, N. C. 



Pharmacy 

W. L. Moose, Ph. G...- _ 

Cardiology 

Clyde M. Gil,more, A.B., M.D. - - -Greensboro, N. C 

Public Health 
N. Tnos. Ennett, M.D 



Allen Barker, M 
Wrichi Clarkson 



I.D. 1 
<:. M.D./ 



Radiology 



-Greenville, N. C. 
— Petersburg, Va. 



an^^gVven' careful' r^o^n^.'S °^.*^'i» . Jo"'-nal are requested 



The Columbia Tri-State Meeting 
Despite interference by influenza among our 
members and their patients and the terrible state 
of many of our roads, the recent meeting in South 
Carolina was one of the most enthusiastic and suc- 
cessful in Tri-State history. 

Looking back over a meeting we like to be able 
to discern distinquishing features. The feature 
which most emphatically distinguished this get-to- 
gether of doctors for the general good was a spirit 
to encourage family doctors to do things for their 
patients, and to give out helpful information as to 
how to do certain of these things. 

This spirit characterized the offerings of our 
guest speakers and of our own members, affording 
a happy illustration of the pronounced reaction 
from the over-emphasis of specialism of a few years 
back, of general recognition in this Association that 
the function of specialists is to advise in or manage 
cases of unusual difficulty. 

Our scientific sessions were instructive and en- 
joyable and, outside the classroom, our resourceful 
and energetic Committee on Arrangements provided 
handsomely. 

A thought comes up that it may be well to hold 
our annual meetings ten days or so later, as our 
present meeting-time conflicts with a meeting of 
medical educators and, so, nearly every year, we 
are deprived of the participation of Dr. Robert 
Wilson, Dr. W. C. Davison and many others. 

The number of new members and reinstatements 
IS gratifying and Dr. C. H. May, of Bennettsville, 
S. C, and Dr. J. E. Smithwick, of Jamesville, N. C. 
are entitled to special thanks for their zeal 'in this 
cause. The Tri-State Medical Association is not 
recruited automatically through additions to the 
various County medical societies, as is the case 
with the State societies. On one occasion we in- 
duced a good doctor to join his State society as a 
preliminary to getting him into the Tri-State. This 
does not work in reverse. So there's a special obli- 
gation on every Tri-State member to bear his As- 
sociation in mind along through the year and tell 
those doctors with whom he comes into intimate 
contact that he would be glad to have them in 
with us, that they will find welcome and that we 
all can help each other. So, do not depend on the 
Membership Committee; everybody lend a hand. 
Finally, payment of annual dues is now in order 
and every member who sends in his dues without 
waiting for a statement saves the treasury just that 
much and puts himself to no inconvenience. Along 
with your dues, send your ideas of how the Associa- 
tion can add to its usefulness in promoting the best 
in medical practice and in goodfellowship among 
practitioners. 



SOUTHERN MEDICINE .\ND SURGERY 



March, 1936 



President Jennings 

The Tri-State Medical Association has chosen 
for its highest office a doctor who is known in his 
good home town as physician and surgeon, and he 
wears both titles worthily. 

Douglas Jennings was born in Bennettsville, 
graduated in Charleston, served his internship at 
Roper, practiced three years of general medicine at 
McColl and ten years of it in Bennettsville; then, 
after special work in surgery, he was placed in 
charge of the Marlboro County General Hospital, 
and under his management and leadership this in- 
stitution has been developed into a heaUh center 
worthy of the excellent Marlboro County Medical 
Society. 

Perhaps ahead of either physician or surgeon 
would come the word, student, as an apt descrip- 
tive term; for Dr. Jennings is tireless in keeping 
in the van of medical progress, and he exercises a 
discriminating judgment in holding fast to what is 
good until something of proved superiority is of- 
fered in its stead. 

The Marlboro General Hospital with Dr. Jen- 
nings at its head affords an inspiring lesson in the 
soundness of the concept of the county hospital as 
the center of, and the means of improving, medical 
service throughout the county; for he is not one 
of those extremists who hold that every sick person 
should be in a hospital. 

Dr. Jennings knows at first hand the problems of 
the doctors of this Section; he has demonstrated 
that he knows how to solve them satisfactorily in 
his own practice. He believes in medical organiza- 
tion and that the main purpose of such organization 
is better health care. His service in this office will 
be good for the Association and good for the pa- 
tients of the Association's members. 



Dr. Hubbard as a Representative Faaiily 
Doctor 

In this issue those interested in genuine medicine 
will find a piece by a genuine medicine man — a 
good doctor, a good man to have about when there's 
something wrong with you. Peculiarly apt it is 
that the place of habitat of this good doctor is call- 
ed Farmer. 

This Country has gone a long way— many of us 
think on the wrong road— since Thomas Jefferson 
spent his life in unselfish planning for the greatest 
happiness of a nation of Farmers. It seems that 
everybody is in favor of farmers getting more for 
their produce, provided nobody has to pay more 
for cotton, tobacco, flour, meal, meat, eggs, poultry, 
fruits or vegetables; just as indulgent mothers al- 
low their children to go in swimming provided they 
don't get wet in so doing. 



Once in a while an individual comes out under a 
headline 'Tf I were God." Here there is no in- 
clination to indulge in such a phantasy; but I 
have a very definite idea of what I would do, if I 
were a farmer. If there were no local organization 
of the Grange I would organize one. Then the 
ideas would be put forward, vigorously supported, 
and widely dessiminated, that every farmer and his 
family agree to: (1) buy nothing that he can do 
without: a) call it frequently to attention that 
patched clothes are just as warm as unpatched, 
and offer prizes (homegrown) — at meetings of the 
Grange to the farmer or farmer's wife, at school 
or Sunday school to the farmer's child — who has 
the most-patched garments; b) under no circum- 
stances buy a vehicle that does not derive its power 
from horse, mule, ox or man; c) arrange that far- 
mers who have skill as mechanics, carpenters, 
plumbers, tinners, masons, painters and so on swap 
labor so as to keep the price of such services in 
the hands of farmers; (2) set about bringing pres- 
sure to bear on well-to-do farmers — ^who, custom- 
arily, immediately they become well-to-do, identify 
themselves with bankers and merchants — to re- 
member that they, themselves, are farmers, and 
that it is incumbent on them to provide money for 
financing purchases of necessary fertilizers and 
other farm supplies in wholesale quantities and at 
wholesale prices, and for marketing whenever the 
farmers choose rather than when the time-mer- 
chants choose. 

If the farmers of this State and Section would 
resolutely determine not to buy a thing beyond 
what they and their families are bound to have, 
and stick to it for a year, they would find the high- 
and-mighty city merchants and bankers well dis- 
posed to show the farmers a lot more consideration, 
and the newspapers would pipe low on what is 
"being handed the farmers," and how wrong it is 
for city workers to have to pay as much for a 
farm product as it costs to produce it. 

Salute patches as badges of merit — whether on 
men, women or children — and the reaction that 
will grow out of this vdW get the foot of the banker 
and the merchant off the neck of the farmer and 
his family, and give them an independence they 
have not enjoyed for a century. 

Although you may not perceive it at first, this 
fits in with what Dr. Hubbard has to say in this 
issue. 

This journal believes in farmers and the doctors 
of farmers, and it hopes to see the time that these 
doctors, and all other family doctors, will require 
that all the strings of the health skein of every in- 
dividual patient be put into the hands of his family 
doctor — that preventive medicine and surgery, gen- 
eral medicine and surgery, and special medicine 



SOUTHERN MEDICINE AND SURGERY 



16S 



and surgery, be all done by the family doctor or 
at his direction and by consultants of his choosing. 



Which We All Appreclite, and From Which We 
Take Heart 

Dr. J. M. Northington, 
Charlotte, N. C. 

Dear Dr. Northington: 

I am enclosing you check for Medical Journal, and 
want to tell you that I take five journals, including A. M. 
A., Southern Medical and Virginia Monthly, but like 
Southern Medicine and Surgery better than any and get 
more out of it. Something interesting in every number of 
your journal and the thing that I like most is the good 
common sense and practical information it contains for 
the general practitioner. 

The Original Articles are of a high order, and surely 
must be well selected; so much better than the average 
journal. I always find something interesting, too, among 
the .■\bstract5 News Items and Surgical Observations are 
worth their space in the journal. I wonder why so many 
journals are lacking in Department Editors, such as write 
condensed, easily and quickly read and understandable 
editorials in Soiithern Medicine and Surgery. It would be 
a stupid mind indeed that wouldn't be interested in the 
editorials of James K. Hall and Wingate Johnson. Some 
other good writers are Frederick Taylor, Tucker, Langston, 
W. L. Moose, Ennett, Kutscher, the Davise? — in fact all. 

And now for the last, and certainly not the least, why 
I like the journal is the breezy editorials, by the Editor, 
and of course I accuse you of being solely responsible 
for them. I certainly admire the stand you take for the 
medical profession. We are certainly in need of more 
out-spoken, hard-hitting defenders of our profession who 
will carry our cause (fight) to the enemy, the politicians 
who want to get control of our noble profession. I admire 
just 100% the position you take with regard to State 
Medicine and Sickness Insurance, the latter the first step 
to State Medicine. I certainly hope you'll continue as 
Editor of the journal. I fear, yea — almost know — another 
could not be found to take your place. 

I wish the Tri-State held their meetings in the Spring 
instead of Winter. .'\s it is I rarely ever can get off to 
attend their meetings. 

In conclusion I wish for the Editor, the Tri-State Asso- 
ciation and Southern Medicine & Surgery, that the best 
of all things may be theirs throughout the coming year. 

Most sincerely, 
Floyd, Va. C. W. THOMAS. M.D. 

Feb. nth, 1936. 



The .\merican Assocmtiox of the History of Medicine 
Note. — Through the courtesy of it.s Secretary a cordial 
invitation is extended each reader of this journal to come 
into the membership of the American Association of the 
History of Medicine. — J. M. N. 

You are cordially invited to active membership in this 
Association which recently completed its eleventh successful 
year of affiliation with the International Association of the 
History of Medicine. 

The .American Association holds an annual meeting with 
afternoon and evening (dinner) sessions and its officers 
anticipate a future of regional meetings of interested groups 
in various cities of North America. 
Membership, .'51.50 annually. 
— with subscription to Medical Life, ,$2.50. 
— with subscription to either Janus (German) or 
Aesculape (French), $4.50. 



— with subscription to both foreign journals, $7.50: to 
all three, $S.0. 

The Membership Committee is made up of Drs. Walte r 
C. Alvarez, Rochester; Charies S. Butler, Brooklyn; C. N. 
B. Camac, New York City; Felix Cunha, San Francisco; 
Harvey Gushing, New Haven; Edward H. Gushing, Cleve- 
land; Elliott G. Cutler, Boston; Howard Dittrick, Cleve- 
land; Jabez H. Elliott, Toronto; John F. Fulton, New 
Haven; Roland Hammond, Providence; James D. Heard, 
Pittsburgh; James B. Herrick, Chicago; Edgard F. Kiser, 
Indianapolis; Charles F. Martm, Montreal; W. S. Middle- 
ton, Madison; Hilton S. Read, .Atlantic City; David Ries- 
man, Philadelphia; Walter R. Steiner, Hartford; Henry R. 
\'iets, Boston; Gerald Webb, Colorado Springs; Carl V. 
Wcller, .Ann .Arbor; Bernard Wolf Weinberger, New York 
City. 

Dr. William S. Middleton, president the University of 
Wisconsin, Madison; Dr. J. G. Beardsley, secretary, 1919 
Spruce St., Philadelphia. 

Next meeting May 4th, 1936, at Haddon Hall Hotel. At- 
lantic City. 



.After Cholecystectomy 

(T. F. Hahn, DeLand. in Jl. Fla. Med, Assn., Feb.) 

Not all cases of chronic cholecystitis, with or without 
stone, are cured by cholecystectomy, and some are not 
helped at all. 

-After cholecystectomy a compensatory dilatation of the 
common duct takes place within a few months and takes 
care of the balancing of bile pressure formerly regulated by 
the gallbladder. Some have pain with this readjustment, 
usually attributed to spasm of the sphincter. 

Stones in the hepatic or biliary ducts may have escaped 
observation at operation. 

Graham found only 60% well after gallbladder operations 
in which no stones were found. Many patients never need 
any medical treatment after cholecystectomy, but few have 
persistent and intractable symptoms. 

-After cholecystectomy symptoms are more likely to be 
due to infection than to stone. 

We must decide if the symptoms are due to disturbed 
biliary function, incomplete surgery, recurring infection, 
stricture of the common duct, adhesions or spasm of the 
sphincter of Oddi. 

Attention to oral and intestinal hygiene, regular habits, 
moderate e.xercise, deep breathing, avoidance of constipa- 
tion, freedom from mental strain are all details which the 
physician must supervise. Removal of foci of infection 
is as important as it was before cholecystectomy. The 
prevention of biliary stasis is very important; it can be 
accomplished by stimulating bile flow by means of bile 
salts and duodenal tube drainage. The value of methena- 
mine and other so-called bile antiseptics is questionable. 
The treatment of reflex gastric disturbances is medical; 
alkalis, antispasmodics or dilute hydrochloric acid is indi- 
cated. Sedatives are valuable in the nervous and irritable 
patient. Careful adjustment of the activities and energy 
of the nervous patient is required. In no case is there any 
short road to relief. 

Diets should be low protein and high carbohydrate; fats 
are to be avoided. Frequent feedings and prevention of 
rigid dieting arid food fads are to be insisted upon. 



In the early ye,vrs of the 19th century the Medical 
School of the University of Pennsylvania was occupying a 
building which had been erected in 1792 by the State of 
Pennsylvania, as a home for the President of the United 
States when Philadelphia was the capital of the nation. — 
JL Ind. Slate Med. Assn., Mch. 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



NEWS ITEMS 



Spring Postgraduate Cunics Medical College of 

Virginia, Richmond 

Monday, April 6th, 1936 

S:30 p. m.— Focal Infection and Elective Localization, 
Dr. Edward C. Rosenow, University of Minnesota, Roch- 
ester, Minnesota. 

Tuesday, April 7th, 1936 

10-10:30 a. m. — The Importance of Alveolar Infection in 
Focal Infections, Dr. Harry Bear, Dean, School of Dentis- 
try. 

10:30-11 a. m.— The Importance of Tonsils and Nasal 
Accessory Sinuses in Focal Infection, Dr. Karl S. Blackwell, 
Professor of Otolar>'ngology. 

11-11:30 a. m. — Focal Infection and Eye Disease, Dr. 
Emory Hill, Professor of Ophthalmology. 

11:30-12 m.— Focal Infection and Chronic Arthritis, Dr. 
Donald M. Faulkner, Associate in Orthopedic Surgery. 

12-12:30 p. m.— Focal Infection and Infections of the 
Genito-Urinary Tract, Dr. A. I. Dodson, Professor of 
Genito-Urinary Surgery. 

12:30-2 p. m. — Luncheon, Cabaniss Hall, as guests of 
the college. 

2-2:30 p. m.— Focal Infection and Diseases of the Nerv- 
ous System, Dr. L. S. Meriwether, Neuro-Pathologist. 

2:30-3 p. m. — Focal Infection and Cardio-Vascular Dis- 
ease, Dr. William B. Porter, Professor of Medicine. 

3-3:30 p. m.— Round Table Discussion of Symposium. 
Discussion led by Dr. William B. Porter, Professor of Med- 
icine. 

8:30 p. m. — Streptococci in Relation to Diseases of the 
Nervous System, Dr. Edward C. Rosenow, University of 
Minnesota, Rochester, Minnesota. 

Members of the profession are cordially invited. There 
is no registration fee. 



Dr. L. R. Broster, surgeon to Charing Cross Hospital, 
London, addressed the Richmond Academy of Medicine 
February 10th. The subject was Eight Years' Experience in 
Surgery of the Adrenal Glands. 

While in Richmond, Dr. Broster was the guest of Dr. 
Frank L. Apperly, pathologist of the Medical College. 
Dr. Broster, who is a native of South Africa, holds both 
academic and professional degrees from Oxford University 
and is a former Rhodes scholar. 

Richmond Academy of Medicine, regular meeting held 
on February 2Sth, at 8:30 p. m. Scientific Program: Re- 
port of Proceedings of International Society of Surgery at 
Cairo, Egypt, with Travel Notes, Dr. J. SheUon Horsley; 
The Neurological Aspects of Pellagra, Dr. Beverley R. 
Tucker. 



The Staff of The M.^ry Eliz.weth Hospital, Raleigh, 
N. C, announces the association of Kenneth Dickinson, 
M.D., General Medicine and Surgery; R. H. H.^ckler, 
M.D., Diagnostic and Therapeutic Roentgenology; and 
Harold Glascock, jr., M.D., General Medicine and Sur- 
gery. 



Meeting of the staff of the McGuire Clinic on Feb. 
18th, at 8:30 p. m., in the Library of the Clinic Building. 
Program: Is Chronic Appendicitis a CUnical Entity?, Dr. 
W. P. Barnes; Report of Verj- Unusual Gallbladder, Dr. 
W. Lowndes Peple; Full Term Extrauterine Pregnancy 
with report of seven cases. Dr. H. H. Ware. 



Gill Memorial Eye, Ear and Throat Hospital, Roa- 
noke, Virginia, will give its Tenth Annual Spring Graduate 
Course in Ophthalmology, Otology, Rhinology, Laryngol- 
ogy, Facio-Maxillary Surgery, Bronchoscopy and Esopha- 
goscopy, April 6th-llth. 



Dr. Roger G. Doughty, Columbia, Dr. J. W. Tankers- 
ley, Greensboro, and Dr. Julian A. Moore, Asheville, 
addressed the Southeastern Surgical Congress at New Or- 
leans last week. 



Buncombe County Medical Society, Asheville, Feb. 
17th, City Hall Bldg., Pres. Parker in chair, 41 members 
present, visitor Dr. Mellencroft of Black Mountain. 

Address by Dr. Walter R. Johnson on Painless Jaundice, 
discussion by Drs. Crow, Schoenheit, Moore, Cocke and 
Parker, closed by the essayist. 

Dr. Huffines of the Committee on .\wards for the be-t 
paper of the year recommended that the president appoint 
two additional members for this committee to review the 
papers written by our members during the year and award 
the prize. Dr. Moore moved the society establish an 
award for the best paper written by a member during the 
year and a committee of five members be appointed by 
the chair to review the papers and make the award, sec- 
onded by Grantham, carried. 

Dr. Swann moved the society have one of its regular 
meetings soon at the society librarj' room in the Arcade 
Building, carried. 

The society take notice of the fact that tonight one of 
our members is being honored as President of the Tri- 
State Med. Soc. meeting at Columbia, S. C, and authorized 
the secretary to send a telegram to Dr. C. C. Orr. 

Buncombe County Medical SociETy, Asheville, regular 
meeting the evening of March 2nd at the City Hall Bldg., 
Pres. Parker in the chair, 40 members present, visitor Dr. 
Carey Harrington, of the Oteen Med. Staff. 

Paper by Dr. Karl Schaffle on Nervous Disorders Asso- 
ciated with Pulmonary Tuberculosis. Discussion by Drs. 
Mark A. Griffin, L. G. Beall, Herbert, Ringer, Huston and 
White. 

The secretary presented the application for membership 
in the society of Dr. Carey L. Harrington, referred to 
Board of Censors. 

The president announced the personnel of the Commit- 
tee on Awards as Drs. Carr, C. H. Cocke, Huffines, Schoen- 
heit and Hollyday. 

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



Mecklenburg County (N. C.) Medical Society (1), 
special meeting, evening of March 2nd. Report was heard 
from the Committee on Hospital Savings .Association Plan, 
Dr. Andrew Blair, chairman. The plan as modified was 
voted as acceptable to the membership of the Society. It 
was also voted that plans of the Hospital Care Association 
and any other such association having essentially the same 
features has the endorsement of this Society. 

Dr. Wm. .Allan, chairman of a Committee on Additional 
Hospital Facilities in Charlotte, reported for the committee 
a recommendation that the Society resolve that there is a 
pressing need for a 300-bed endowed hospital. After lib- 
eral discussion such a resolution was passed by unanimous 
vote. 

(2) The evening of March 3rd, regular meeting. The 
Society was addressed by Dr. Geo. Wilkinson of Greenville, 
S. C, on Conditions of Hypoinsulism; by Dr. R. S. Cath- 
cart, of Charleston, on Historical Surgery. A large turnout 
to hear these distinguished guest-speakers. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



Eli Lilly and Company 

FOUNDED i 8 76 

IMakers of ^Medicinal Products 




Clinical results obtained with Undenatured 
Bacterial Antigens, Lilly (U B A), indicate 
that they are more specific than ordinary 
vaccines, that they produce a prompter 
therapeutic response. 

Undenatured Bacterial Antigens, Lilly 
(UBA), contain in unaltered form the native 
antigenic substances of the bacterial cell. 
The method used in their preparation was 
developed by Dr. A. P. Krueger, of the 
University of California. 

Particularly timely: Respiratory UBA in 
5-cc. and 20-cc. vials for subcutaneous and 
intracutaneous use, and Respiratory UBA, 
Topical, in 20-cc. vials. 



Prompt Attention Qiven to Projessional Jncjuiries 

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



Please Mention THIS JOURNAL When Writing to Advertisers 



168 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



The Robeson Cotjnty Medical Society, meeting Feb- 
ruary 7th, heard Dr. R. D. McMiUan, Red Springs, on 
Public Indifference to Physical Welfare, and Dr. J. E. 
Boone of the South Carolina State Hospital, Columbia, on 
Malaria for Syphilis Therapy. 

Dr. C. T. Johnson, Red Springs, president of the society, 
presided. Dr. H. M. Baker, Lumberton, was host. Dr. 
N. 0. Benson, secretary, in reading the minutes, called 
attention to action taken by some other county societies 
on hospital insurance, and President Johnson appointed 
Drs. R. D. McMillan, J. A. Martin and S. Mclntyre, the 
two last-named of Lumberton, a committee to report at 
the next meeting. 



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

With the recently elected president, Dr. L. P. Thackston, 
presiding, the regular monthly meeting of the Edisto Med- 
ical Society was held February 27th at the Hotel Eutaw, 
Orangeburg, S. C. The society is composed of physicians 
from Orangeburg, Calhoun and Bamberg Counties and 
each of these counties was well represented at the meeting. 
Dr. L. C. Shecut, of Orangeburg, read a paper on typhus 
fever, tracing the history, symptoms and the treatment of 
the disease. The society regretted the absence of Dr. A. W. 
Browning of Elloree, who is at present at the Tri-County 
Hospital in Orangeburg, where he underwent an operation 
several weeks ago. 

Work of the Crippled Children's Society of South 
Carolina was discussed February 28th before members of 
the Charleston Rotar>- Club by Dr. Frank A. Hoshall, 
Chairman of the Mayor's Committee on work for crippled 
children and Assistant Professor of Orthopedics in the 
Medical College of the State of South Carolina. 

Of widespread interest is the approaching wedding of 
Miss Betty Barnwell of Charleston to Dr. Samuel Eugene 
Miller which will take place March 10th. Dr. Miller is a 
graduate of the Medical College of South CaroHna and 
interned at Roper Hospital last year. 

Miss Dessie Strawborn of Donald became the bride of 
Dr. S. R. Hickson of Fairfax in a simple ceremony at 
Beldoc February 14th. 

Dr. and Mrs. William Evans, jr., of Bennettsville have 
returned home after spending a week in Florida. 

Dr. and Mrs. E. F. Mikell announce the birth of a 
daughter. Hazel Anne, Tuesday, February 11th, at the Bap- 
tist Hospital. Mrs. Mikell and baby have returned to their 
home in Oak Court, Columbia. 



Dr. S. B. McPheeters has been elected Health Officer 
of Wayne County to succeed Dr. C. Fletcher Reeves, re- 
signed. Dr. McPheeters is a native of Rockbridge County, 
Virginia. He is taking a special course in pubhc health 
work at the University of North Carolina, and will assume 
his new duties April 15th. 



Dr. Milton J. Roslnau, director of the Division of 
Public Health of the University of North Carolina, ad- 
dressed the Greensboro Nursing Council on February 11th. 



Dr. W. Ambrose McGee announces his return to Rich- 
mond, 616 West Grace street, prepared to study and treat 
Allergic Diseases of children and adults in addition to 
continuing his practice of Pediatrics. 



Dr. Soitthgate Leigh, prominent Norfolk surgeon, was 
stricken with apople-xy March 5th, while attending a Civic 
meeting and died shortly afterward. A more extended 
notice will follow. 



Deaths 

Dr. C. H. C. Mills, well beloved Charlotte obstetrician, 
died suddenly at his home the morning of March 5 th. A 
more extended notice will follow. 



Dr. H. C. Grubb, jr., of Churchland, near Lexington, 
North Carolina, died of a pistol wound at his home, Feb- 
ruary 10th. He was twenty-nine years of age, a graduate 
of Wake Forest College, and in medicine of Temple Uni- 
versity. 

Dr. Samuel L. Perkins died February 27th at his home 
at Wilkesboro, N. C, following a serious illness of several 
days. 

He was 76 years of age, a son of the late Dr. David 
Perkins, of Ashe County. He was graduated in ISOl from 
Baltimore Medical School and practiced in Baltimore, later 
moving to east Tennessee, the State of Oregon and back to 
Jefferson, in Ashe County. 



Dr. L. V. Grady, of Wilson, died of pneumonia Febru- 
ary 21st at the home of a relative in Bladenboro. He 
was stricken Feb. 15th while en route to Florida with 
Mrs. Grady. A native of Seven Springs, in Wayne County, 
Dr. Grady was 47 years of age. He was one of the foun- 
ders of the Carolina General Hospital in Wilson and was 
prominent in his profession. Dr. E. C. Grady, Elm City, 
is a brother. 



Dr. Willcox Ruffin, 33, Norfolk, died February 28th of 
complications following injuries sustained February 19th. 
He had just returned from a hunting trip. In some man- 
ner, his shotgun fell as he opened a closet in his home, 
inflicting the injuries. One foot was later amputated and 
he was given several blood transfusions. His condition was 
considered favorable until the night before his death. 

Dr. Ruffin was a son of the late Dr. Kirkland Ruffin. 
He was educated at the Virginia Episcopal High School 
and the University of Virginia and later received the Uni- 
versity of ■ Minnesota fellowship at the Mayo Clinic at 
Rochester, Minn. He returned to Norfolk three years ago 
and had since been specializing in surgery. 



Dr. H. T. Pope, dean of the medical profession in 
Lumberton, died unexpectedly at his home February 12th. 
He had been indisposed for a few days, but he prescribed 
for patients who came to see him on the 11th and was not 
considered seriously ill until a short while before he died. 

Receiving his medical training at the North Carolina 
Medical College at Davidson, Dr. Pope entered the prac- 
tice of medicine when 25 years old and enjoyed a large 
practice for 39 years. No person was ever denied medical 
attention by Dr. Pope. 

Dr. Pope was largely instrumental in organizing the 
Robeson Medical Society. He was chief of the obstetrical 
department of Baker Sanatorium and taught obstetrics for 
15 years, endearing himself to the young women with whom 
he came in contact there. He was also a member of the 
medical staff of Thompson Memorial Hospital. 

The stores were closed and all business suspended in 
Lumberton during the funeral services. 



Our Medical Schools 



University or Vircinia 



At the meeting of the University of Virginia Medical 
Society on January 13th, Dr. W. C. Spain, of New York 
City, spoke on the subject of Hypersensitiveness to Com- 
mon Foods. On January 20th, Dr. Tracy J. Putnam, of 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



yo(\v^sj^AWl 




M E L L I E 

2112 LOCUST 



in Rheumatoid Arthritis 

is ANALGESIC, ELIMINATIVE 
and RESTORATIVE 

Arthritis is recognized as being merely a local reflec- 
tion of systemic disease variously manifested in the 
form of myositis, neuralgia, iridocyclitis, headache, 
neurasthenia, etc. 

Improved peripheral circulation, effective diuresis, 
sedation and analgesia fortify and intensify the tonic 
and anti-rheumatic action of Tongaline. 

Through systemic approach with salicylate action 
in synergistic combination, Tongaline overcomes the 
symptoms of influenza and arthritis. 

An interesting digest of the literature entitled 
"Relation of Metabolism to Rheumatism and Rheu- 
matoid Arthritis" will be mailed free upon request. 



R DRUG 

STREET, ST. 



COMPANY 

LOUIS, MISSOURI 



Boston, spoke on Hydrocephalus. 

On February 1st, Dr. Lawrence T. Royster spoke before 
the Raleigh .\cademy of Medicine on the subject of Acute 
Nephritis in Childhood. 



DurE 



On January 23rd, Dr. C. F. Strosnider, President-elect 
of the North Carolina Medical Society, talked to the fac- 
ulty and students on Organized Medicine and Medical Eth- 
ice. 

On January 30th and 31st, Dr. Alfred Blalock, Associate 
Professor of Surgery, Vanderbilt University School of 
Medicine, lectured on Shock and Lymphatic Obstruction, 
respectively. 



Medical College of Vircinia 



Dr. W. T. Sanger, president, and Dr. Lewis E. Jarrett, 
superintendent of the hospital division, attended the annual 
congress on Medical Education and Hospitals in Chicago 
February 17th and 18th. 

Dr. M. B. Jarman of Hot Springs was a recent college 
visitor. 

Dr. L. R. Broster, chief surgeon of the Charing Cross 
Hospital of London, and prominent endocrinologist, re- 
cently lectured to the students here. 

There were 4,844 patient visits to the outpatient de- 
partment during the month of January, these visits being 
made by 2,210 individual patients. 

Dr. Grant Van Huysen has recently joined the staff of 
the college in the capacity of associate in anatomy. 

Dr. Fred J. Wampler has been appointed medical ad- 



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visor for the Works Progress Administration of Virginia. 
The annual Stuart McGuire Lectures and the spring 
postgraduate clinics will be held April 6th and 7th. Dr. 
E. C. Rosenow, Director of Experimental Bacteriology, 
Mayo Foundation, Rochester, Minnesota, will lecture the 
night of April 6th on Focal Infection and Elective Locali- 
zation. During the day of April 7th the clinics will h-^ 
held by members of the college faculty and at night Doctor 
Rosenow will lecture on Streptococci in Relation to Dis- 
eases of the Nervous System. 



Meeting in annual session in Raleigh, February 22nd, 
the University Medical Alumni of the Oi.d University 
Unit of Raleigh elected Dr. J. R. Hester, Wendell, as 
their president for the coming year. The group holds its 
meeting on Washington's birthday each year. 



170 



SOUTHERN MEDICINE AND SURGERY 



March, 1936 



Dr. Hubert A. Royster, dean of the old school, was host 
to the alumni gathering, attended by 15 of the 81 alumni 
of the Raleigh medical unit, discontinued some years ago. 
Other officers named were Dr. W. W. Green of Tarboro, 
vice president, and Dr. Robert P. Noble of Raleigh, re- 
elected secretary-treasurer. 

New officers of the association are to select the place for 
next year's meeting at a later date. 

Those attending the alumni meeting included: Dr. Roys- 
ter, Dr. Hester, Dr. Green, Dr. Noble, Dr. J. M. Buckner 
of Swannanoa, Dr. M. L. Matthews of Sanford, Dr. L. V. 
Dunlap of Albemarle, Dr. J .8. Talley of Troutraan, Dr. 
A. G. Woodard of Goldsboro, Dr. Battle A. Hocutt of 
Clayton, Dr. C. A. McLemore of Smithfield, Dr. A. C. 
Campbell of Raleigh, Dr. Z. M. Caviness of Raleigh, Dr. 
C. B. Wilkerson of Raleigh and Dr. A. E. Riggsbee of 
Durham. 



BOOK REVIEWS 



THE 193S YEAR BOOK OF PEDIATRICS, edited by 
Isaac A. Abt D.Sc., M.D., Professor of Pediatrics, North- 
western University Medical School; .\ttending Physician, 
Passavant Hospital; Consulting Physician, St. Luke's Hos- 
pital, Chicago; with the collaboration of Arthur F. Abt, 
B.S., M.D., Associate in Pediatrics, Northwestern Univer- 
sity Medical School; Associate Attending Pediatrician, 
Michael Reese Hospital; Attending Pediatrician, Chicago 
Maternity Center; Attending Physician, Spauding School 
for Crippled Children, Chicago. The Year Book Publishers, 
Inc., Chicago . $2.25. 

The editor opens with an elaborate article on 
Progress in Infant Feeding. Breast Feeding is con- 
sidered best by Grulee, of Chicago; Davison, of 
Duke, advocates whole lactic acid evaporated milk. 
It is conceded that there are plenty of vitamins in 
a normal diet. A new diagnostic sign of scarlet 
fever is described: on the outer edge of the auricle, 
on the helix, and on the nail wall of the fingers 
and toes there are tiny vesicles with a water-clear 
content as early as the 2nd day. Infants should be 
vaccinated against smallpox between the 3rd & 
6th mo. Glucose seems to be the only remedy in 
diphtheritic myocarditis. Present studies have 
failed to disclose any relationship between a num- 
ber of dietary factors, including vitamins, and the 
incidence or severity of colds. Hyper- as well as 
hypothyroidism must be looked for in children, 
even small children and infants. The gravity of 
appendicitis in infancy is emphasized. 

Wise selection has been made of the articles to 
be abstracted, and the editorial comment is dis- 
criminating. 



RADIUM TREATMENT of Skin Diseases, New 
Growths, Diseases of the Eyes and Tonsib, by Francis H. 
Williams, M.D. (Harv.), S.B. Massachusetts Institute of 
Technology; Senior Physician Boston City Hospital; Fel- 
low American Academy of Arts and Sciences; Emeritus 
Member Association .'\merican Physicians; Member Societe 
de Radiologic Medicale de France; Corresponding Member 
K. K. Besellschaft der Aerzte in Wien; Honorary Member 
.American Society of North America, etc. Author "The 
Roentgen Rays in Medicine and Surgery" (3 editions). 



1901-1903. With 12 illustrations. The Stratford Co., Bos- 
ton, 1935. $2.00. 

The result of a 30-year experience in the use of 
this still wonderful agent, this book commmands 
attention as the work of a master. 

Part I treats of the nature and properties of 
radium, of measurements and of the use the ele- 
ment in superficial conditions; Part II with diseases 
of the eyes and eyelids; and Part III with throat 
conditions. 

The author's elaborate training in physical 
science fitted him unusually for work with this ele- 
ment, with which he has been on terms of the great- 
est intimacy through its developmental period and 
on to its great triumphs. 



A MANUAL OF THE COMMON CONTAGIOUS DIS- 
EASES, by Phtlip Moen Sttmson, A.B., M.D., Assistant 
Professor of Clinical Pediatrics, Cornell University Medical 
College; Visiting Physician, Willard Parker Hospital; Chief- 
of-Staff, The Floating Hospital of St. John's Guild; Asso- 
ciate Attending Pediatrician, The New York Hospital; 
School Physician, The Horace Mann Schools, 1919-1923; 
President the School Physicians Association, 1928-1930. 
Second edition, thoroughly revised; S3 engravings and 3 
plates. Lea and Febiger, Philadelphia. 1936. 

It is commonly said that it is not necessary to 
carry medical facts in your mind, that it is neces- 
sary only to know where to find them in your li- 
brary. To a great extent this is true; but it does 
not apply everywhere. In cases of common con- 
tagious diseases it is esssential that doctors know, 
and, at the first examination, be able to give proper 
directions. 

The author has given us such a book and has 
revised it to date. The chapters are headed Princi- 
ples of Contagion, Serum Reactions, Diphtheria, 
Vincent's Angina, Scarlet Fever, Measles, Rubella, 
Whooping cough, Mumps, Chickenpox, Smallpox, 
Vaccination against Smallpox, Meningococcus Men- 
ingitis, Poliomyelitis and (especially valuable) 
General Management of Contagious Diseases. 

The author says he includes Vincent's Angina 
in the book because of its resemblance to diphthe- 
ria, and that the two diseases not infrequently co- 
exist. His attitude toward preventive injections in 
poliomyelitis is one of conservatism. 

The book is built on wide observation and sound 
reasoning. 



Homatropine not Satisfactory for Children 
(M. S. Harding, Indianapolis, in Jl. Ind. State Med. Assn., 
Mar.) 
I wish to register my objection to the practice of depend- 
ing upon hematropine in the refractions of children. It 
seems that some oculists very frequently use this drug as a 
mydriatic in these cases, I have had occasion to recheck 
many of these cases and have long since come to the con- 
clusion that we cannot use homatropine, in children, with 
any success. 



March, 1936 



SOUTHERN MEDICINE AND SURGERY 



171 




INHALANT 

No. 77 



An Ephedrine Compound used as an inhalant and 
spray, in infections, congested and irritated condi- 
tions of the nose and throat. Relieves pain and con- 
gestion, preventing infection, and promotes sinus 
ventilation and drainage without irritation. 

Description 
Inhalant No. 77 contains Ephedrine, Menthol, and 
essential oils in a Paraffin oil. 

Application 

Can be sprayed or dropped into the nose as directed 
by the Physician. 

Supplied 

In 1 ounce, 4 ounce and 16 ounce bottles. 



Burwell & Dunn Company 

Manufacturing Pharmacists 
CHARLOTTE, N. C. 

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



The Treatment or Pneumonia est Early Childhood 



The problem is a challenge to our ingenuity and re- 
sourcefulness. 

I consider it of utmost importance though difficult to 
put children to bed when they have fever until entirely 
well; an afebrile period of 48 hours after a respiratory 
infection before a child is allowed out of bed — then 1 or 2 
hours the first day, with a convalescent period of 3 days 
before he is allowed to go to school. 

The air should be between 65 and 68° by thermometer 
placed near the child. Permit light clothing: it is exhaust- 
ing to struggle under many layers of clothing and bed 
covers. Moistened, plain steam inhalations are useful, or 
volatile oils may be added to the water. Inhalations 
should be continued as long as there is distressing cough 
or scanty secretions. In the milder cases sufficient relief 
may be obtained by allowing a kettle to boil constantly 
in the sick room. 

As much nourishment as the digestive apparatus can 
tolerate, milk, broths, soft eggs, purees, creamed vegetable 
soups, scraped beef, jeUy, junket, custard, and fruit juices. 
If milk is vomited, boil, or give smaller amounts of food 
at 4-hour intervals. 

Counter-irritation when pleural pain and cough are 
prominent. Mustard plasters are most effective, varying 
strength with age. 

A child will rarely voluntarily take sufficient water; 
offer orangeade, lemonade, canned fruit juices or bottled 
soda water, given as such or diluted with water. 

A sponge bath at 90° given under the covers often gives 
refreshing sleep of several hours. An ice bag to the head 
and a tepid sponge bath can transform a delirious patient 
into one enjoying a quiet sleep. The bath begun at 95° 



FOR 



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The majority of the phy- 
sicians in the Carolina^ 
are prescribing our new 
tablets 



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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