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Full text of "Transactions of the Medical Association of the State of Alabama"

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TRANSACTIONS 

OF 

The Medical Association 

OF THE 

State of Alabama 

(THE STATE BOARD OF HEALTH) 

ORGANIZED 1847-MEETING OF 1917 



MONTGOMERY, APRIL 17-20 
1917 



TMB BROWlf PRIirmfO CX>1CPAMT 
1»17 



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THE MEDICAL ASSOCIATION 

OF THE 

STATE OF ALABAMA 



THE MINUTES OF THE MEETING OF 1917 



FIRST DAY, TUESDAY, APRIL 17, 1917. ' 
Morning Session. 

The Forty-fourth Annual Meeting of the Medical Associa- 
tion of Alabama convened in the Exchange Hotel, at Mont- 
gomery, at 11:05 A. M., April 17, 1917; the President, Dr. 
Henry Green, of Dothan, in the chair. 

The President: I declare the forty- fourth consecutive 
annual session of the Medical Association of the State of 
Alabama now open for the transaction of such business as may 
come before it. We will be led in prayer by the Reverend 
O. P. Spiegel, Pastor of the Christian Church, of this city. 

The Rev. Mr. Spiegel offered the following prayer : 

O Lord of Hosts, we thank Thee for every place and for every occa- 
sion where men and women have met together to consider the better- 
ment of human lives and the uplift of the human race. We 
thank Thee for these our friends and Thy friends and friends of 
each other who have come from all parts of our great State and 
nation to consider the work that is so near to their hearts. 
We pray Thy blessings, our Father, to rest upon them in their investi- 
gations and deliberations, and when these meetings are over may 
they go back feeling that they have been strengthened and helped 
by their conferences together. We pray Thee, our Father, that they 
may feel and realize that in these ministrations to human needs 
they may also be wonderfully helpful in the ministrations of our 
higher and diviner life, for who is it that has a physician without 
having the utmost confidence in him? Who is it that would send for 
a physician without he expects to take his advice? 

Our Father, may we all realize at all times that these temples of 
ours are temples of the Holy Ghost. 



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4 THE MEDICAL ASSOCIATION OF ALABAMA. 

And now we pray Thee that we may look. out of ourselves this 
morning into the great nation of which we are a part, and we humbly 
beg Thee, our Father, to bless our government, bless our President, 
strengthen him, and may he keep before his mind the righteousness 
and patience and truth and justice and love, even the love of the 
humanity of the world. 

We pray Thy blessings. Lord, to rest upon everyone who is the 
object of our prayer. Lead us and guide us and protect us and help 
us, and may we feel, O Lord, that, from the gentle waves up to 
these temples of ours, it is the workmanship of God. And when 
we have finished our course with gladness, bring us, we pray Thee, 
to Thyself in heaven above. We ask it in the name and for the sake 
of Him whose work we are and whom we serve. Amen. 

The President : Dr. P. S. Mertins, President of the Mont- 
gomery County Medical Society, will now formally welcome 
the Association in the name of the Montgomery County Medi- 
cal Society. 

ADDRESS OF WELCOME. 

Dr. Mertins: 
Mr. President and Gentlemen of the State Medical Associa^ 
tion : 

In the name of the Montgomery County Medical Society, I 
greet you and welcome you, one and all, to Montgomery. We 
are glad to have you with us, and we feel honored that you 
are here today. I say honored advisedly. During the course 
of the year we have many conventions which meet in Mont- 
gomery, but to my mind there is no meeting which has as 
great potentialities for the good of the whole people of the 
State as this convention of ours. Here from all parts of the 
State come the visitors, physicians and distinguished guests, 
all for the sole purpose of improving themselves in the arts of 
medicine, surgery and sanitation. When this convention 
adjourns and its members return to their homes, some even 
to the most rural parts of the State, they will carry with them 
the latest ideas and methods in surgery, medicine and sanita- 
tion, to the increased health, happiness and prosperity of the 
communities in which they live. It is for this reason that I say 
we feel honored in having you as our guests. 

Your President has prepared for you a program filled with 
subjects timely and of absorbing interest, and I feel sure that 



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ADDRESS OF WELCOME. 6 

we will all derive instruction from the papers which will be 
read which will lead us to better work and more improved 
methods during the coming year. 

We hope that your stay here with us will be profitable, and 
that when you return to your homes you will have only pleas- 
ant memories of your visit here. 

It had been the intention of the Montgomery County Medi- 
cal Society to entertain you this year with its old-style hospi- 
tality. About two weeks ago when the President announced 
war with Germany and word came from Washington that we 
must husband our resources, and that in the South there would 
probably be a scarcity of food supply, we felt that it would be 
unwise to spend money in this way. We had one thousand 
dollars laid aside for the entertainment of this Association, but 
the Montgomery County Medical Society felt that it would be 
best not to spend this money now, and voted it for charity and 
patriotic purposes. (Applause.) In doing this we felt that we 
were doing what you would have wished us to do, and in mak- 
ing this donation to charity we have given it in your name, and 
we feel that it is yours as well as ours. 

We are glad to see you here today, and in the name of the 
County Medical Society I extend to you again, one and all, a 
most hearty welcome and greeting. (Applause.) 

The President: We will now have an address of welcome 
by Mr. M. H. Screws, on behalf of the city of Montgomery : 

Mr. Screws : Mr. President, Ladies and Gentlemen : I feel 
entirely too humble to bear the name of the distinguished 
Mayor, and I am here only as a deputy for him, in my feeble 
manner to extend to you on his behalf and on behalf of the 
other members of the City Commission, one of whom is a 
physician, a cordial and hearty welcome to a body of men whom 
Montgomery feels honored to receive on this occasion. I trust 
that the personal assurances which you have already received 
have convinced you that you are indeed welcome to a com- 
munity that is proverbial for its courtesy, its hospitality and its 
generosity, even to the innermost temples of our homes. 

But on behalf of Mayor Robertson and on behalf of the local 
city government, I greet you at this joyous season of the year, 
in this hallowed old town, whose history is so filled alike with 
proud and sad recollections, and I bid you godspeed in the 
noble work which has summoned you hither. 



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THE MEDICAL ASSOCIATION OF ALABAMA. 

We feel that it is peculiarly appropriate that in a time such 
as the present, when not only Alabama and the South and 
America, but the entire world faces the crisis of its history, that 
a body of men carrying your noble ideals and your high intel- 
ligence and your trained skill should meet in Montgomery for 
the purpose of formulating your benevolent purposes. For 
these, my friends, are the times that try men's souls. 

I say it is peculiarly appropriate that you should meet here, 
because in other days, the days of the South's olden and golden 
history, when Alabama marshalled her warrior sons and the 
clarion call went throughout Dixie for our land to give up its 
noblest and bravest and best, all the South turned to Montgom- 
ery as its meeting place. And now, in a later day, the same 
spirit animates the bosoms of the descendants of the men who 
in 1861 gave Montgomery immortal fame as the cradle of the 
Confederacy. (Applause.) 

We are proud of our material resources, we are proud of its 
prosperity and industry which you will find on every hand, but 
you will find no true son or no true daughter of Montgomery 
who has any claim or any heritage which causes the same thrill 
as the fact that they are loyal sons and daughters of the Lost 
Cause. I wish you could have seen the magnificent outpouring 
of the citizens of this community a few nights ago, when, with 
but a few hours' notice in response to the call of the Mayor, 
there assembled at the Grand Theater here three thousand 
persons and thousands more were turned away. It was from 
start to finish one magnificent burst and pean of Southern 
patriotism. It proves what has been asserted for half a century, 
that in the crises of America to come her best asset will be the 
unyielding tenacity of Southern manhood and Southern wom- 
anhood. 

Tomorrow night, my friends, Montgomery and this section 
is again to give an evidence of its patriotism and of the fact 
that our strength is to go out to the utmost to uphold the arms 
of that noble patriot, that magnificent statesman and that peer- 
less leader of men, now gathered in our glorious President, 
Woodrow Wilson. (Applause.) My friends, even as we of 
the South look back with pride and devotion and tenderness 
upon the name of Jefferson Davis, and even as all of America 
recalls with pride the achievements of Washington and Lin- 
coln, we of the South likewise shall in years to come, with all 
believers in true democracy over the face of the entire earth. 



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ADDRESS OF WELCOME. 7 

look upon Woodrow Wilson as an exponent of human rights 
and equal freedom to all. 

In a personal sense, my friends, the citizens of Montgomery 
feel proud to have such a magnificent body of trained men as 
yourselves assemble here. We feel that we have claims upon 
the medical fraternity. In the years gone by, while Mont- 
gomery played its part upon the field of war, likewise in your 
noble science it has had a most enviable role. Yesterday I 
conversed with one of the biggest brained and biggest 
hearted men I have ever known. He is a man about 
whom I have often wondered where he picked up all the 
odds and ends of information, those little things which 
you cannot get out of text-books, but which must be 
gotten through long years of experience. I refer to Dr. 
Luther Hill. He told me something of the old days of the 
medical fraternity in Montgomery. Here it was back in thft 
fifties that Dr. J. Marion Sims began his career as an American 
physician. Dr. Sims, as you all know, is the father of modern 
gynecology. Here it was in Montgomery at the comer known 
as Five Points, and still bearing that title, that when one of 
Montgomery's women had met with an accident, he devised the 
instrument known as the Sims speculum, which physicians tell 
me has been an inestimable boon to womankind, and the means 
whereby your fraternity has been a godsend and a blessing to 
suffering womanhood. Dr. Sims, finishing here, carried this 
discovery to New York and Paris, and was received with dis- 
tinguished acclaim on all hands, reaching perhaps the greatest 
heights of fame for a physician. He reached France during 
the days of the court of Napoleon III, and in addition to the 
other honors bestowed upon him there, was appointed court 
physician to the Emperor Napoleon. Thus Montgomery, 
through a member of your fraternity, forty years ago received 
that recognition and played that part on the soil of France 
which you today, and particularly you younger physicians, will 
in the next few weeks or months be called upon to play as 
America's and Alabama's part upon that same French soil. 
(Applause.) 

Dr. Sims was at one time the President of the American 
Medical Association. Montgomery also had another President 
of the American Medical Association in the person of Dr. 
W. O. Baldwin, of fame in Montgomery in the years gone by. 
In addition Montgomery has had two Vice-Presidents of the 



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8 THE MEDICAL ASSOCIATION OF ALABAMA. 

American Medical Association, Dr. J. S. Weatherly, a man of 
great purity of character and wonderful skill in his chosen 
profession ; and Dr.' Richard Frazier Michel. Dr. Ben Baldwin 
could tell you things that would melt your hearts about that 
pure, that clean, that devoted gentleman, that knight without 
fear or reproach, the maxim of whose life was gentleness, 
kindness and courtesy, than whom we have known no purer 
citizen, no man with higher ideals of duty, no nobler concep- 
tions of the obligations which he assumed when he put the 
letters "M. D." after his name. He was the first surgeon com- 
missioned in the service of the historic Confederate army. Mrs. 
Kirkpatrick, who has made a life work of the study and com- 
piling of the legendary lore of the Lost Cause, can bear out my 
statements. In November, 1860, he took his commission from 
South Carolina, which was the first to lead the Southern States 
away from the United States,, and he participated in the bom- 
bardment of Fort Sumter and in the attack upon Fort Moultrie. 
Pursuing gallantly and bravely his task of physician in Vir- 
ginia, he had the high honor of treating that leader of men, 
that man whom the South looks upon as its ideal exponent, the 
matchless Lee. He set a dislocated limb for Gen. Robert E. 
Lee during the Wilderness campaign. Returning to Mont- 
gomery he filled in the hearts of our citizens a place apart from 
all the rest of mankind here, a place which today is kept sacred 
and reverent to all those who appreciate nobility of character 
and purity of purpose. I speak with some feeling on this mat- 
ter because I am named for that noble and gallant man. He 
was a man whose regard for his fellowmen was at all times 
in evidence. From the standpoint of skill and knowledge they 
tell me that he was without doubt the best anatomist that Ala- 
bama and perhaps the South has ever produced. And then his 
name, Michel, is a name which has a gallant history upon the 
scroll of fame in France, and that his father in the days of the 
Little Corporal was a surgeon to the Great Napoleon I and 
played there a worthy part. 

And now, my friends, in conclusion, again I wish to assure 
you of a cordial and hearty welcome to Montgomery. These 
be trying times, and upon no body of men will the burden press 
more heavily nor the call be laid more strongly than upon the 
body of physicians. I say that to you, not because you are of 
the profession, but because it is a fact that is recognized today 
upon the battlefields of Europe. Then as much as are neces- 



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ADDRESS OF WELCOME. 9 

sary the munition makers and the purveyors of food, so also 
is medical attention at the front necessary. The same gallant 
spirit which animated your Confederate soldier sires will, I 
know, animate the brave and dauntless physicians of Alabama 
in the years to come which will try them and which will sorely 
need them. 

America has produced one name which will receive undying 
fame as the result of reverses which have been borne in this 
war. Robert W. Service is known as the Alaskan Kipling. He 
was a pacifist, but when this war broke out he felt it was his 
duty to play a man's part, and he joined the Red Cross. There 
is where your activity will lie, but there, just as much as upon 
the firing line, is fame to be won and service to be rendered. 
Robert W. Service had a younger brother. This lad in Sep- 
tember last year, was killed in a charge upon the German 
trenches. This wonderful poet soul breathed out its anguish 
behind the English lines, and wrote a few stanzas that to me 
typify not only the spirit of the Canadian, but of the American, 
and not only of the Red Cross man, but what I believe is the 
sentiment of American physicians and of Alabama physicians 
when they come to play their part in the Red Cross service. 
The command of the English officers when they order their 
troops to take a trench in a bayonet charge is to "Carry on," 
and Service expresses the sentiment of the Red Cross and of 
your body, I believe, in these few words : 

It's easy to fight when everything's right 

And you're mad with the thrill and the glory, 

It's easy to cheer when vict'ry is near 

And wallow in fields that are gory ; 

It's a different song when ever)rthing's wrong, 

When you're infernally mortal, 

When it's ten against one, and hope there's none — 

Buck up, little soldier, and chortle. 

Carry on, carry on ! 

There's not much punch in your blow. 

You're glaring and staring and hitting out blind. 

You're muddy and bloody, but never you mind — 

Carry on, carry on! 

You haven't the ghost of a show ; 

It's looking like death, but while you've a breath, . 

Carry on, my son, carry on ! 



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10 THE MEDICAL ASSOCIATION OF ALABAMA. 

And so in the strife of the battle of life 
It's easy to fight when you're winning ; 
It's easy to slave and starve and be brave 
When the dawn of success is beginning; 
But the man who can meet despair and defeat 
With a cheer, there's a man of God's choosing, 
A man who can fight to Heaven's own height 
Is the man who can fight when he's losing. 

Carry on, carry on ! 

Things never were looming so black. 

But show that you haven't a cowardly streak. 

And though you're unlucky you never were weak — ■ 

Carry on, carry on ! 

Brace up for another attack. 

It's looking like hell, but — you never can tell — 

Carry on, old man, carry on ! 

There are some who drift out in the deserts of doubt. 

And some in brutishness wallow ; 

There are others I know who in piety go 

Because of a heaven to follow ; 

But to labor with zest and to give of your best 

For the sweetness and joy of the giving. 

To help folks along with a hand and a song, 

Why there's the real sunshine of living. 

Carry on, carry on! 

Fight the good fight and true; 

Believe in your mission, greet life with a cheer. 

There's a big work to do, that's why you are here, 

Carry on, carry on ! 

Let the world be the better for you. 

And at last when you die let this be your cry, 

"Carry on, my soul, carry on!" 

On behalf of the city, gentleman, I take pleasure in welcom- 
ing to Montgomery a body of men with whom it is not unmean- 
ing words upon their lips but the sentiments of their hearts and 
the practice of their lives to "Carry on, old man, carry on." 
(Prolonged applause.) 



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REPORT OF SENIOR VICE-PRESIDENT, H 

The President: Gentlemen of the Association, I feel sure 
that I voice the sentiments of the Association when I say that 
we appreciate most sincerely the words of welcome that we 
have heard. 

Dr. Edward Burton Ward, of Selma, Senior Vice-President, 
assumed the chair while the President delivered his annual 
message. 

(For address of President see Part II.) 

Dr. Green resumed the chair. 

The President : The next thing on the program is the report 
of the Senior Vice-President, Dr. Edward Burton Ward, of 
Selma. 

Dr. Ward: After listening to the address of welcome by 
Mr. Screws I am reminded of a story told of a visitor to Bos- 
ton. This visitor was rambling around in the beautiful ceme- 
tery and he came across a most magnificent monument. He 
looked at it very closely, examined it and admired it, and 
read on it this epitaph: "Here lies a lawyer and an honest 
man." He walked all around and looked closely at this monu- 
ment, and seemed to be very much interested and very much 
at sea to understand it. A gentleman walked up and said, "My 
friend, I see you are a stranger here. Have you found the 
grave of some distinguished friend?" He said, "No, I was 
wondering why two men were buried in the same grave." But 
after listening to this eloquent address by Mr. Screws I do not 
see how there could have been any question, for everything that 
Mr. Screws said was from an honest man. 

REPORT OF THE SENIOR VICE-PRESIDENT. 
E. B. Wabd, Selma. 

Vice-President Marshall, in an address at Selma, a short time ago 
said he did not know what his duties were unless he was the tail to 
Woodrow's kite and the kite could not go up without its tail. I am not 
in the same position as Mr. Marshall. In addition to being one of 
the tails of Henry Green's kite there are some right strenuous duties 
connected with this office, especially strenuous if one succeeds in 
securing a full and complete report from all the counties of the 
Southern Division. These duties I have attempted to fulfill to the 
best of my ability. 

Another year has passed since we last met in Mobile, or as the 
poet would express it: 



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12 THE MEDICAL ASSOCIATION OF ALABAMA, 

"Into the tomb of buried years 
Another vanished year hath sped. 
And like the vision of a dream, 
Tliat lingers when the dream hath fled, 
Its fading footprints dot the sifting sand 
To fade away when wavelets kiss the strand." 

I am glad to see that so many of us have been permitted to meet 
together once more, for which we should render thanks to the Great 
Physician who shapes our destinies, "rough hew them as we will." 
Yet there are some absent faces. Some have fallen by the wayside 
and gone to "that undiscovered country from whose bourne no trav- 
eler returns." Some have broken down on the road and are waiting 
for the final summons. Right here I can not refrain from paying 
tribute to one whose presence we miss today. I refer to our distin- 
guished ex-State Health Officer, Dr. Wm. H. Sanders. We can truly 
say he was a worthy successor to the gifted Cochran. He has given 
his best years to his work and has worn out his body in his earnest 
efforts toward the sanitary uplift of his State. Now his weary feet 
are rapidly bearing him down the western slope. The Medical Asso- 
ciation of Alabama can well attest the value of his work, and the 
State owes him a debt of lasting gratitude. May his remaining days 
be full of peace, may the ruthless hand of suffering fall lightly ui)on 
him, and when the summons comes to Join 

"The innumerable caravan which moves to 
That mysterious realm, where each shall take 
His chamber in the silent halls of death, 
May he go, not like the quarry slave at night 
Scourged to his dungeon, but sustained and soothed 
By an unfaltering trust, approach his grave 
Like one who wraps the drapery of his couch 
About him and lies down to pleasant dreams." 

I am glad Dr. Sanders* mantel has fallen worthily when it de- 
scended upon the broad shoulders of the Welchman. Let us render 
him our united co5peration, let us extend him the glad hand of 
brotherhood, so that his career may even transcend in brilliancy 
that of his predecessor. If we do not rally to him the laity will not 
It is at best, a most difficult task to teach people the importance of 
sanitary laws. Somehow they do not appreciate as they should the 
efforts of the doctor to perfect the physical welfare of a community. 
If they did it would not be such a Herculean task to get all-time 



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REPORT OF SENIOR VICE-PRESIDENT. 18 

health officers and other improved methods. Did you ever think of 
It, we doctors are the only class of intelligent people who work 
against our financial interests by promulgating the laws of health 
and preaching the doctrine of sanitation? I may be pardoned for 
mentioning this little tribute to the doctor. 

A writer tells how a little child once preached a wonderful sermon 
to him. "Is your father at home?" was asked a small child, on our 
village doctor's doorsteps. "No," she said, "he's away." "Where 
do you think I could find him?' "Well," he replied, with a consid- 
ering air, "you've got to look for him some place where people are 
sick, or hurt, or something like that. I don't know where he is, but 
he's helping somewhere." 

Helping somewhere! How true. 

When the mlllenium comes or the war is over we may then be 
appreciated as we should be, and take our places among the great 
of the land. Until then we must be at attention, on guard and fight 
to the end. We must stand shoulder to shoulder, ever remembering, 
"Conquer we shall, but we must first contend, 'tis not the fight that 
crowns us, but the end." 

Do you know that there is nowhere greater need for strengthening 
the golden chain of the brotherhood of man than in the ranks of the 
medical profession? To you who with young manhood's elastic steps 
are pressing forward upon the pathway of life, with eager expectant 
eyes fixed upon the summit of life's bright promises and to you my 
friends of maturer years, whose feet have climbed the hill of life 
and reached the summit, and standing for awhile, look back upon 
battles fought and victories won, and you whose heads are crowned 
with the snows of many winters and whose feet are rapidly bearing 
you down the western slope of time ; the sentiment I would offer and 
have you take into your hearts and express in your lives are these 
words of the poet : 

"Let me live in a house by the side of the road. 

Where the race of men pass by. 
The men who are bad and the men who are good. 
As good and as bad as I. 
I would not sit in the scomer's seat, 
Or hurl the cynic's ban, 
But let me live in the house by the side of the road. 
And he a friend of man.*' 

With this parting injunction I herewith submit my final report as 
Sailor Vice-President of the Medical Association of the great State 
of Alabama, and here we rest. 



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14 



THE MEDICAL ASSOCIATION OF ALABAMA, 



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16 THE MEDICAL ASSOCIATION OF ALABAMA, 

Under the head of remarks on the general condition of the society, 
very few commented. You can readily see by looking over the table 
that there Is, in some of the societies, a marked improvement over 
last year, while in some of the others there is that same lethargy 
that has characterized them in the past It is to be hoped that they 
will wake up and rally their forces and improve. From the counties 
left blank in the table I failed to secure any reports whatever, not- 
withstanding several earnest importunities. 

Autauga County — No report 

Baldwin County — ^No report. 

Barbour County — Society in fairly good condition. 

Bullock County — No report. 

Butler County — Hold monthly meetings ; attendance small ; interest 
in the society not what it should be. 

Chilton County — A wave of indiflPerence has come upon its mem- 
bers. 

Choctaw County — Condition of society much improved. Births 
came up to the expectation of the Registrar, but fell short on deaths. 

Clark County — No remarks. 

Coffee County — Our society not as good as in 1915, but we have 
infused new life in the work, and will again come forward. Negro 
woman successfully prosecuted and run out of Coffee county, but is 
now at Bellwood, Geneva county, near the CoflPee county line. Sup- 
pose they failed at Geneva because the solicitor did not know the law. 
(Perry Thomas decision.) 

Conecuh County — Fair only. 

Covington County — No remarks. 

Crenshaw County — Conditions have greatly improved during the 
last year. 

Dale County — No report 

Dallas County — Condition of society not very encouraging. Mak- 
ing strenuous efforts to get all-time health officer. Not the interest 
taken in society as there should be. 

Elmore County — As usual, this county always comes up with a 
good report, showing the good results of an all-time health officer. 
Elmore county has all-time health officer (Dr. O. S. Justice), salary 
$2,100.00. Society flourishing; more Interest than ever before. Fine 
attendance. 

Escambia County— Secretary of this society is absent serving his 
covmtey. 



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REPORT OF SENIOR VICE-PRESIDENT. 17 

Geneva County — No remarks. 

Greene County — No remarks. I suppose conditions are so bad 
Cameron ashamed to report 

Hale County — No remarks. 

Henry County — ^No report. 

Houston County — This county has an all-time health officer and 
his salary is 20 cents per capita of county population. The county 
population is right at 35,000, making his salary about $700.00 a year. 

Lee County — No remarks. 

Lowndes County — No report. 

Macon County — No remarks. 

Marengo County — Not as much interest taken as when all officers 
were elected annually. 

Mobile County — No remarks. 

Monroe County — No remarks. 

Montgomery County — No report. 

Perry County — No remarks. 

Pike County — We have a very good society and hold regular month- 
ly meetings. 

Russell County — No report. 

Sumter County — No remarks. 

Washington County — One counsellor, one practitioner of fifty-eight 
years, one not paying dues this year. 

Wilcox — The society in good condition. 

Dr. William C. Maples, of Scottsboro, then read the report 
of the Junior Vice-President. 



2M 



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18 THE MEDICAL AB80CIATI0N OF ALABAMA. 

REPORT OF JUNIOR VICB-PRBSIDBNT. 

W. C. Maples, Scothmobo. 

Mr. President and Gentlemen of the Medical AsBOdation of the State 
of Alahama : 

On examining the reports of the Vice-Presidents for the last few 
years I find there has been but little change in the status of the 
county medical societies in the Northern Division of the State. There 
is a doleful monotony about these reports, especially as regards the 
scientific work of the county societies. I am quite certain that only 
a few counties in the Northern Division are doing any scientific 
work worth speaking of. Jefferson county is In a class by Itself. 
This society meets weekly and the scientific work is of a high order. 
In counties in which there are no large towns or cities the societies 
are doing practically nothing as scientific bodies. 

There are some exceptions to the general rule, however.* According 
to the secretary's report, Bibb county has quite a live county society. 
He says: "Our society has gone from quarterly to monthly meet- 
Ings. We had a series of seven post-graduate lectures before the 
society by men of note. We had four public meetings in which public 
health matters and community welfare work were discussed." 

The secretary of Walker county reports the condition of his 
society as "very good ;" but it is doubtful If this society is doing much 
scientific work, for only nine papers were read last year at twelve 
meetings, with a membership of 48. This society has an all-time 
health officer, and doubtless there has been a wonderful Improve- 
ment in health work. There are many reasons, which it is not neces- 
sary for me to enumerate, that make an all-time health officer neces- 
sary for much health work to be done. It requires an amount of 
enthusiasm and sacrifice to have a live medical society in sparsely 
populated counties that seems to be wanting at the present, as the 
following quotations from secretaries' reports show: "Existing, 
that's all. Members will pay dues but never come to a meeting dur- 
ing the entire year," writes one. I am sorry to say that that is 
about the condition of my own county society. Another says : "Our 
society is not what it should be," and another : "Very little interest 
manifested by members." Several say: "Attendance not good as it 
should be." One secretary says : **There is but very little enthusiasm 
in the society. Several members are sore about the health officers 
holding office three years. We have been electing one each year. 



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REPORT OF JUNIOR VICE-PRESIDENT. 19 

and It was the will of the society that the practice continue. Others 
took that out of our hands, and by so doing took the life out of a 
number of our members." I am quoting what this secretary says 
because I believe this election of county health officers has been a 
bone of contention in a large number of county societies. To many 
such a conclusion may sound ridiculous, but I am certain it is cor- 
rect, nevertheless. 

As boards of health I believe there has been some improvement 
in nearly all the counties. Several of the counties now have all-time 
health officers, and in those counties, of course, there has been great 
Improvement in health work ; but everywhere the sentiment is grow- 
ing among doctors that the medical profession has a patriotic duty to 
perform in the advancement of the best interests of the people. This 
feeling is strongest among the best educated and most intelligent 
physicians, and finds a suitable response only among the most intelli- 
gent people. This Improvement in health work is largely due to 
individual effort prompted by this feeling. It is becoming much more 
frequent that doctors, in treating an Infectious disease, tell the pati- 
ent or family the nature of the disease and how it may be prevented, 
thus doing a very Important educational work. 

I have been too busy to visit any of the county societies, but I feel 
that the cause has not suffered on account of this, as I am not a 
success as a medical organizer. I have tried hard to have a good 
Society in Jackson county, and I have signally failed. 

I attach herewith a tabulated statement of condition of counties 
heard from as reported by the secretaries. 



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20 



THE MEDICAL ASSOCIATION OF ALABAMA. 



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22 THE MEDICAL ASSOCIATION OF ALABAMA. 

The Secretary, Dr. H. G. Perry, made his report as follows : 

REPORT OF THE SECRETARY. 
Henbt Gaitheb Pebby, Montoomebt. 

The Secretary respectfully submits the following report : 

Since the last meeting Dr. William Henry Sledge, of Mobile, a Life 
Counsellor, and Dr. Reuben Fletcher Monette, of Greensboro, a Junior 
Counsellor, have died. No Counsellors have resigned. All of the 
Counsellors-elect, six in number, have accepted the honor conferred 
upon them by this body, have signed the Counsellor's pledge and 
have paid their dues. 

The names of the members of the Councils and Standing Commit- 
tees are published on pages 156 and 157 of the Transactions for last 
year. It will be the duty of the incoming President to appoint one 
Delegate to the American Medical Association and one member on 
each of the Councils and Standing Committees. 

Since the publication of the Transactions, at the request of the 
Secretary of the American Medical Association, Dr. Green, our 
worthy President has appointed a Committee on Social Insurance, as 
follows : P. J. Howard, M. J. Bancroft, and G. J. Winthrop, of Mo- 
bile; J. H. Blue and F. P. Boswell, of Montgomery; W. H. Wylie, 
of Birmingham, and W. H. Blake, of Sheffield. 

The American Committee on Medical Preparedness has appointed 
a State Committee on Medical Preparedness for Alabama, consisting 
of the following: J. N. Baker, of Montgomery, Chairman; Henry 
Green, of Dothan, President Medical Association State of Alabama, 
ez-officio; H. Q. Perry, of Montgomery, Secretary; R. S. Hill and 
J. H. Blue, of Montgomery ; H. P. Cole, of Mobile ; F. Q. DuBose, of 
Selma; Earl Drennan and L. C. Morris, of Birmingham; and F. P. 
Pettey, of Albany. This Committee will make a report at the proper 
time. 

Your Secretary has responded to all calls for information, has 
distributed blanks for r^>ort8 of secretaries of county societies, has 
edited and distributed the Transactions and has endeavored to per- 
form all the duties pertaining to the office. 

The Secretary has incurred the following expenses : 
To assistance in mailing programs, circular letters, and report8..|12.60 

To postage ~ ~ ~ 6.00 

To express and incidentals — ~ 1.50 

Total $20.00 



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REPORT OF THE SECRETARY. 23 

Dr. Perry made the following report of the Publishing Com- 
mittee : 

REPORT OF THE PT'BLISHING COMMITTEE. 

The Publishing Committee had l,eOO copies of the annual volume of 
Transactions printed, which were distributed as follows: 

To members of county medical societies - 1,237 

To Gounsellora 140 

To delegates ~ '. ^ 92 

To correspondents ..^ ~ ~ 5 

To State Boards of Healths _ 50 

To libraries and medical Journals ~ 50 

Deposited in the office of the State Board of Health 26 

Total 1,600 

Respectfully submitted, 

H. G. Pebby, Chairman, 
J. N. Bakeb, 
W. H. Sandebs. 

Dr. Perry: All of you received preliminary programs in 
which there was, in addition to the papers in the regular pro- 
gram, a symposium on diseases of children, which is to be par- 
ticipated in by some members of our Association and some 
visitors from outside of the State. Through my fault, I sup- 
pose, in making up the copy for the full program this s)rmpos- 
ium was very unfortunately omitted. The papers will be called 
as they were listed in the preliminary program. I earnestly 
ask the pardon of the Association and especially of those who 
are in that symposium. 



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24 



THE MEDICAL ASSOCIATION OF ALABAMA. 



REPORT OF THE TREASURER. 

Jacob U. Ray, Treasnrer, 

In Account With 
THE MEDICAL ASSOCIATION OF THE STATE OF ALABAMA. 

April 18, 1916. To Cash on hand as per last report (See 

Transactions 1916, page 29) — $68.42 



To cash received from following Counsellors : 



1916. Apr. 14. 

Apr. 6. B. F. Bennett Apr. 16. 

Apr. 6. W. J. McCain Apr. 15. 

Apr. 8. W. C. Maples Apr. 15. 

Apr. 10. F. A. Webb. Apr. 15. 

Apr. 12. J. S. Crotcher Apr. 15. 

Apr. 12. W. H. Wilder. Apr. 15. 

Apr. 13. W. D. Partlow Apr. 15. 

Apr. 13. W. S. McElrath Apr. 17. 

Apr. 13. S. P. Hand Apr. 17. 

Apr. 13. L. C. Morris Apr. 17. 

Apr. 13. J. D. S. Davis Apr. 17. 

Apr. 13. L. R. Burdeshaw Apr. 18. 

Apr. 13. E. M. Prince Apr. 18. 

Apr. 13. J. C. Taylor Apr. 18. 

Apr. 13. D. L. Wilkinson. Apr. 18. 

Apr. 14. J. N. Furniss. Apr. 18. 

Apr. 14. J. T. Haney Apr. 18. 

Apr. 14. M. C. Schoolar Apr. 18. 

Apr. 14. A. D. James Apr. 18. 

Apr. 14. Henry Green Apr. 18. 

Apr. 14. J. R. Horn Apr. 18. 

Apr. 14. W. B. Hendrldt Apr. 19. 

Apr. 14. W. S. Brltt Apr. 19. 

Apr. 14. W. R. Jackson Apr. 19. 

Apr. 14. W. E. Morris Apr. 20. 

Apr. 14. W. M. Cunningham Apr. 19. 

Apr. 14. W. F. Betts Apr. 19. 

Apr. 14. S. W. Welch Apr. 19. 

Apr. 14. C. S. Chenault Apr. 19. 



M. S. White. 
A. J. Peterson 
N. T. Underwood 
H. J. Sankey 
S. A. Gordon 

E. G. Givhan 
J. G. Palmer 
R. H. Baird 
W. P. McAdory 
L. O. Hicks. 

J. U. Ray 
H. P. McWhorter 
W. H. Gates 
R. L. Hughes 
M. S. Davie 
J. C. McLeod 
L. P. Esslinger 
H. S. Ward 
R. L. Justice 
D. F. Talley 
J. M. Watkins 
H. W. Blair 
T. J. Brothers 

F. P. Petty 
W. T. Pride 

G. L. Gresham 
C. A. Thlgpen 
O. S. Justice 
A. L. Harlan 
H. T. Heflin 



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REPORT OF THE TREASURER, 



Apr. 20. 
Apr. 20. 
Apr. 20. 
Apr. 20. 
'Apr. 22. 
Apr. 24. 
Apr. 25. 
Apr. 28. 
May 4. 
May 5. 
May 9. 
1917. 
Mar. 7. 
Mar. 
Mar. 
Mar. 
Mar. 



7. 

9. 



9. 



J. D. Bancroft 
W. M. Faulk 
W. D. Galnee 
M. D. Smith 
S. F. Mayfield 

B. B. Sims 

C. A. Poellnits 
A. N. Steele 
J. O. Kennedy 
J. N. Bak^ 

J. L. Gaston 

Mack Rogers 
J. W. McGlendon. 
P. T. Fleming 
Seale Harris 
J. S. McLester 



Mar. 13. J. D. Heacock 

Mar. 27. J. P. Turner 

Apr. 12. W. W. Harper 

Apr. 13. F. A. Lupton. 

Apr. 16. E. B. Ard 

Apr. 17. C. A. Mohr 

Apr. 17. B. L. Wyman 

Apr. 17. E. B. Ward 

Apr. 17. E. M. Harris 

Apr. 17. Robert Goldthwaite 

Apr. 17. J. P. Stewart 

Apr. 17. R. S. Hill 

Apr. 17. C. .L. Gulce 

Apr. 17. J. L. Bowman 

Apr. 19. M. L. MoUoy 

Apr. 19. M. T. Gaines 



Total number paid to April 16th, 91 Counsellors. $910.00 

Received from Counsellors-elect: 

1916. 

May 4. J. M. Austin J^ 6.00 

May 12. li. E. Broughton 5.00 

May 13. P. M. Llghtfoot 10.00 

May 13. W. O. Collins 10.00 

May 24. W. A. Stallworth 10.00 

June 3. S. C. Cardon 5.00 

Total J45.00 

Cash received from delegates to Mobile meeting, 1916, as follows: 

Autauga — ^None. 

Baldwin— V. M. Schowalter, J. H. Hastie. 

Barbour— D. B. Faust, R. O. Norton. 

Bibb— C. P. Martin, A. N. Walker. 

Blount — J. T. Hancock, D. S. Moore, Sr. 

Bullock — None. 

Butler — R. A. Moorer, A. L. Stabler. 

Calhoun — ^W. B. Arberry, M. J. Williams. 

Chambers— W. M. Avery. 



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26 THE MEDICAL ASSOCIATION OF ALABAMA. 

Cherokee— S. G. Garden, W. A. SewelL 
Ghilton— None. 
Ghoctaw— F E. Christopher. 
Clarke— G. I. Dahlberg, J. G. Bedsole. 
Clay— None. 

Cleburne — ^Baxter Rlttenberry. 
Coffee— D. P. Prultt 
Colbert — ^None. 

Conecuh — J. W. Hagood, W. M. Salter. 
Coofia — ^None. 

Covington — L. E. Broughton. 
Crenshaw — H. A. Donoran. 
Cullman — E. D. MeAdory — Alvin Gulp^per. 
Dale— S. B. Bell. 

Dallas— S. B. Allison, W. H. Taylor. 
DeKalb— J. B. PhlUlps, W. S. Duff. 
Elmore— Virgil Dark, J. M. Austin. 
Escambia — L. B. Farrish, J. P. McMurphy. 
Etowah— W. T. Gantrell, H. V. Baskin. 
Fayette— W. W. Long. 
Franklin — None. 

Geneva— G. W. Williamson, W. F. Matheny. 
Greene — None. 
Hale — ^None. 

Henry— G. L. Wood, L. S. Nichols. 
Houston — I. C. Bates, P. G. Chaudron. 
Jackson — Hugh Boyd, M. M. Duncan. 

Jefferson — M. Y. Dabney, C. W. Shropshire, A. F. Toole, Burr Fer- 
guson, G. H. Walsh, W. S. Rountree, R. G. McGahey. , 
Lamar — ^None. 
Lauderdale — None. 
Lawrence — None. 

Lee — G. H. Cooper, C. S. Yarbrough. 
Limestone — M. W. Dupree, H. D. Powers. 
Lowndes — C. B. Marlette. 
Macen — C. E. Williams. 
Madison— W. C. Hatchett, W. B. England. 
Marengo — C. N. Lacey, T. C. Savage. 
Marion— H. W. Howell, M. C. Hollls. 
Ma rshall — ^None. 
Mobile— P. D. McGhee, Eugene Thames, J. N. Beck. 



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REPORT OF THE TREASURER. 



27 



Monroe— D. R. Nettles, J. J. Dailey. 

Montgomery— W. W. Dinsmore, G. J. Grell, P. B. Moss, C. H. RU-e. 

Morgan— R. B. Sherrell, F. L. Ghenault. 

Perry— B. L. Fuller. 

Pickens— S. H. Hill, E. B. Durrett. 

Pike — L. M. Tompkins, J. W. Beard. 

Randolph — None. 

Russell — ^None. 

St Clair— None. 

Shelby— J. L. Batson. 

Sumter— None. 

Talladega— J. A. Sims, 0. L. Salter. 

T&Uapoosa — L. B. Allen, J. T. Banks. 

Tuscaloosa — G. L. LeBaron, B. S. Carpenter. 

Walker— D. H. Chilton, J. H. Davis. 

Washington — G. C. McCrary, W. A. Thompson. 

Wilcox— P. V. Spier, E. B. Williams. 

Winston— M. L. Stephens, T. M. Blake. 



Total from 96 delegates at $5.00 each.. 



$480.00 



Received from county societies for 1916 meeting : 

Autauga « $ 10.50 

Baldwin „ 7.50 

Barbour 81.50 

Bibb - .- 22.50 

Blount laOO 

Bullock 25.50 

Butler laSO 

Calhoun - 4a00 

Chambers 12.00 

Cherokee 7.50 

ChUton 21.00 

Choctaw ~ 4.50 

Clarke ~ ~ 25.50 

Clay ~ 9.00 

Cleburne ~ 9.00 

Coffee ~ ^ 30.00 

Colbert 10.50 

Conecuh ~. 15.00 

Coosa - ~ ~ 15.00 



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28 THE MEDICAL ASSOCIATION OF ALABAMA, 

Covington ^ 89.00 

Crenshaw ^ ~ 7.50 

CuUman » 34.60 

Dale J. ~ ~ 18.00 

Dallas 49.50 

DeKalb ^ 25.50 

Elmore 27.00 

Escambia ^ 16.50 

Etowah ~ 48.00 

Fayette ~ ~... 19.50 

Franklin ~ 10.50 

Geneva ~ ~ 4.50 

Greene 10.50 

Hale - 18.00 

Henry 13.50 

Houston ~ 24.00 

Jackson 24.00 

Jefferson 393.00 

Lamar 18.00 

Lauderdale 1.50 

Lawrence 6.00 

Lee 22.50 

Limestone 13.50 

Lowndes ,. — . — 

Macon 15.00 

Madison ~ ~ 30.00 

Marengo 24.00 

Marion ~ ..- 22.50 

Marshall 3.00 

Mobile ~ ~ 81.00 

Monroe 21.00 

Montgomery 78.00 

Morgan ~ 87.50 

Perry 16.60 

PIdcens 2a50 

Pike 81.50 

Randolph ~ 28.50 

Russell 3.00 

St. Clair 24.00 

Shelby 22.60 

Sumter 19.60 



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REPORT OF THE TREASURER. 



29 



Talladega 33.00 



Tallapoosa . 
Tuscaloosa . 

Walker 

Washington 

Wilcox 

Winston 



13.50 
69.00 
22.50 
9.00 
25.50 
16.6v 



Total $1,861.50 

Rboapitulation of Receipts. 

Cash on hand last report ~ $ 68.42 

Cash received from 91 Connsellors 910.00 

Cash received from 6 Counsellors-elect 45.00 

Cash received from 96 delegates. 480.00 

Cash received from 66 counties, dues 1.861.50 $3,365.02 



Less Disbubsements. 

Paid H. G. Perry for postage and sundry exp $ 20.25 

Paid W. G. Young, Official Stenographer 225.80 

Paid F. M. Inge, expense Mobile meeting 85.00 

Paid W. H. Sanders, for room for Board Censors 10.00 

Paid C. P. Martin, for assistance at Mobile meeting 10.00 

Paid Brown Printing Co., sundry printing 129.80 

Paid J. N. Baker, President, postage and expenses 10.00 
Paid H. G. Perry, salary as Secretary to April, 

1917 400.00 

Paid W. W. Moore, dues refunded 3.00 

Paid J. U. Ray, salary as Treasurer to April, 1917 200.00 

Paid Brooks ft Crawford, consultation and advice 25.00 
Paid G. A. Thomas ft Co., premium on Treasurer's 

bond 8.00 

Paid Brown Printing Co., Transactions, cuts, post- 
age 1,793.27 

Paid Brown Prtg. Co., letter heads and envelopes 21.02 
Paid W. H. Sanders payment on note to Jerome 

Cochrane Monument Fund 200.00 

Paid St Louis Button Co., merchandise. 23.80 

Paid J. U. Ray, Treasurer, postage account to date 9.41 $3,173.35 



Balance cash on hand.. 



$ 191.67 



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80 THE MEDICAL ASSOCIATION OP ALABAMA, 

In submitting this report I wish to call the attention of the Asso- 
ciation to the following facts: 

The Transactions show members in good standing in their 

county societies to be. 1,815 

Less Life Counsellors...^ „ 40 

Less Senior and Junior Counsellors 92 

Less Delegates at Mobile 96 228 

Leaving...^ 1,587 

who ought to have paid dues at $1.50 each, while only 1,241 paid the 
State dues leaving a technical deficit of $519.00 that ought to have 
been paid to the Association. Three hundred and forty-six m^nbers 
paid no dues. 

I hope the Association will note these figures and see if there is not 
a remedy to stop this annual deficit, as the records show this manner 
of things has been going on for several years. If every member 
whose name appears on his county society roll in the volume of 
Transactions paid the $1.50 State dues it would only take a short 
time to liquidate the debts of the Association and have a reasonable 
surplus; in fact I believe that the State dues in three years could 
safely be reduced to $1.00 per member. 

The President: All these reports will be referred to the 
Board of Censors as provided by the Constitution. 

The President then called for reports of standing commit- 
tees. 

Dr. Glenn Andrews, Chairman of the Committee on Tuber- 
culosis, was not present, and this report was passed. 

Dr. W. D. Partlow, Chairman of the Committee on Mental 
Hygiene, read his report. 

REPORT OF COMMITTEE ON MENTAL HYGIENE. 

To the Alabama State Medical Asaociaiion: 

Your Committee on Mental Hygiene one year ago reported that the 
organization of The Alabama Society for Mental Hygiene had been 
effected, officers selected, constitution drafted and standing commit- 
tees appointed for the eight various phases of work to be undertaken. 

Since the period covered by that report I have the honor of re- 
porting as follows : 



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REPORT ON MENTAL HYGIENE, 81 

The Society for Mental Hygiene lias lield its first annual meeting, 
which was well attended, an extensive program of instructive essays 
and addresses on mental hygiene heard, reports and recommendations 
of the standing committees received and discussed, and officers elected 
for the present year. Some of the most important reconmiendations 
follow : 

Committee on Education — Dr. J. Y. Graham, University, Chairman : 

"Your Committee on Education is charged by the Constitution with 
the duty of informing the public as to the facts concerning the con- 
servation of mental health and urging the adoption of such measures 
as are known to contribute toward that end. The committee is 
urged, indeed required, to make use of every possible means by which 
these facts may be brought before the public; by lectures and ad- 
dresses in churches and schools and wherever an audience can be 
secured; by the distribution of printed matter on the subject; and 
by the publication of suitable acticles in the public press. The Con- 
stitution further suggests that the committees should make a study 
of the educational system of tlie State, and bring before the society 
recommendations concemlnc modifications of that system, if after 
investigation, the committee 1» convinced that in this way it can be 
better adjusted to the preservation of the mental and physical health 
of the school children. Aad flaally the committee shall endeavor to 
work out some plan whidi being incorporated in the scheme of 
public education of the Btmte, would practically and effectively en- 
lighten all children and ymitii on mental hygiene and all questions 
relating to individual aad ]Hihllc sanitation and hygiene and in any 
way it may deem best look into the problem of "Education for pre- 
vention of mental, nerpona^ and other diseases." 

Your committee f eete timt the Constitution has laid upon it a heavy 
task. 

Wliat are the f acton that lead to the impairment of mental b«dth? 
Alcoholism, the drag habit, sexual immorality, unhygienic living, 
bad heredity. The ^iumerati<Mi of these factors indicates at once 
the enormity of the task. If everyone could be induced to live an 
absolutely hygienic life, doolitless much could be accomplished in 
the improvement of mental as well as physical health. 

The committee therefore recommends that as a first step an en- 
deavor be made to acquaint the public with the established facts, — 
the facts vouched for by the specialists In these matttrs. That to 
tills end as far as possible the services of specialists be secured to 
address the public. That as much as possible of the literature of the 



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S2 THE MEDICAL ASSOCIATION OF ALABAMA, 

National Committee on Mental Hygiene be secured and distributed 
to tliose most likely to be interested.** 

Committee on Clinics and Dispensaries— T>t, B. B. Bondurant, 
Mobile, Chairman: 

"Your Committee on Clinics and Dispensaries would recommend 
the establishment, at as early a date as practicable, of a free clinic 
for mental diseases in each of the larger cities of the State, and that 
an immediate beginning be made in the cities of Birminham, Mobile, 
and Tuscaloosa. 

This can best be accomplished in Birmingham and Mobile by 
enlisting the support and obtaining the cooperation of the physicians 
who conduct the clinics for mental and nervous diseases in the 
Medical Departments of the University of Alabama, in the cities 
named, in connection with the Hillman and Mobile City Hospitals, 
according these already established clinics the moral support and 
endorsement of this society. 

In Tuscaloosa the Bryce Hospital itself offers the best possible 
opportunity for the establistmient of a psychopathic clinic and out- 
patient department. 

Your Committee, believing that the seeds of mental defect and 
insanity are often sown before or shortly after birth and believing 
that premonitory evidences of mental deficiency are present at an 
early age, recommend that all clinics and dispensaries be provided 
with facilities for the mental examination, testing and grading of 
children, and of school children in particular. The detection of 
mental deficiency at as early age as possible we would regard as a 
measure In mental hygiene of the first Importance. Tills work, 
therefore, should be extended as rapidly as circumstances permit 
until facilities for the proper examination and mental grading of 
children are provided in every county in the State. The work might 
very properly be undertaken by the medical inspectors of the schools 
or by some other qualified officer or teacher, not ijecessarily a physi- 
cian. 

Your committee would furthermore recommend that this society 
request the National Committee to make, at the earliest possible 
time, a complete mental survey of the State of Alabama; and that 
the society invite the cooperation of the State Medical Association, 
the management of the insane hospitals, the Governor, the educa- 
tional Institutions of the State and all other persons and agencies 
whose interest can be enlisted." 



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REPORT ON MENTAL HYGIENE, 33 

Committee on Survey of Defectives — Dr. Seale Harris, Birming- 
ham, Chairman: 

"The Committee on Survey or Census of Defective Children recom- 
mend that the Governor of Alabama be requested to appoint a com- 
mission for the study and prevention of mental deficiency, with the 
idea of requesting the National Committee for Mental Hygiene, the 
Rockefeller Foundation, and the U. S. Public Health Service to pro- 
vide experts on mental hygiene to make a comprehensive survey of 
the State, with the object of locating the defectives and delinquents 
in Alabama ; said commission to report to the next Legislature with 
recommendations of methods to prevent mental diseases and to care 
for the defectives ^nd delinquents." 

Other committees made equally interesting and important reports 
and recommendations, but not being of a character to be especially 
interesting to a medical body, neither they nor extracts from them 
will be incorporated In this report. 

As Secretary of the Alabama Society for Mental Hygiene I cordially 
Invite the members of our State Medical Association to lend their 
support and influence to this forward movement by becoming mem- 
bers of the Society. 

W. D. Pabtlow, 
Chairman Committee on Mental Hygiene. 

The report of the State Committee on Medical Preparedness 
was called for. 

Dr. Baker: In view of the prominence of the subject of 
medical preparedness the State Committee for Medical Pre- 
paredness, after consultation with the officers of the State 
Association, have decided that the best time to take up this 
question would be on tomorrow about noon, immediately 
after the Jerome Cochran lecture. At that time Dr. W. J. 
Mayo, who is the National Chairman of the Committee for 
Medical Preparedness, will be present, and we will also have 
an address by Col. Shriner, a regular army medical officer 
delegated to address us, and at that time, if it is the pleasure 
of this Association, will be submitted the report of the Chair- 
man of this Committee, and we will discuss more or less in 
detail the subject of medical preparedness as it relates to this 
Association. I ask that that report be postponed until tomor- 
row morning inmiediately after the Jerome Cochran lecture. 

8M 



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84 THE MEDICAL ASSOCIATION OF ALABAMA. 

The President: Gentlemen, you have heard the request of 
the Chairman of this important committee. If I hear no 
objection it will be postponed as requested by the Chairman. 

The report of the State Committee on First Aid was called 
for, but the Chairman, Dr. Inge, was not present. 

The President: This report will be passed. 

The report of the State Committee on Social Insurance, Dr. 
P. J. Howard, Chairman, was called for, but no member of the 
committee was present and therefore the report was passed. 

Dr. H. G. Perry, Chairman, read the report of the Council 
on Nosology. 

REPORT OF THE COUNCIL ON NOSOLOGY. 
H. G. Pebey, Montgomery, Chairman. 

Nosology is defined as the scientific classification of diseases with 
a view to the discovery of statistical truths concerning their history 
and natural phenomena. 

"Among the great ends of a uniform nomenclature must be reck- 
oned that of fixing definitely, for all places, the things about which 
medical observation Is exercised, and of forming a steady basis upon 
which medical experience may be safely built" 

"Nosology w^as cultivated with fer\'or one hundred years ago, and 
was believed to be a necessary part of the knowledge required for the 
practical treatment of disease." 

Many systems of nomenclature were devised by many leaders. The 
first statistical congress met in Brussels In the year 1853 and steps 
were taken which resulted in the preparation of the present Interna- 
tional List of Causes of Death, which list is due chiefly to the efforts 
of Dr. Jacques Bertillon. .This list does not claim to be a strictly 
scientific classification of diseases but a practical working list where- 
by compilers can assign medical terms to definite titles. 

Many countries, Including the United States of America have 
adopted the International List. In fact, it afl'ects more than 200 
millions of the people of the world, and makes available for compari- 
son, the statistics of all countries using It. 

The value of compilations of causes of death is materially affected 
by the accuracy of the units which go to make up such compilations. 
It therefore becomes necessary for Individual reporters of cases of 
diseases and of deaths to recognize the Importance of the subject 
and to have such an acquaintance with the International List as will 
enable them to make reports conform to Its requirements. 



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REPORT OF COUNCIL ON NOSOLOGY. 86 

This CounciJ, In Its report to the Association in 1910 recommended 
the adoption of the International List of Causes of Death. Vest 
poclcet editions of this list have been sent out by the Census Bureau 
to every doctor in the United States. In addition all doctors in 
Alabama have been furnished second copies by the State Board of 
Health. 

Notwithstanding the opportunities for gaining information noted 
above, your Council deems It wise to present at this time a brief out- 
line of some of the rules governing the reporting of diseases and 
deaths. 

It is to be regretted that the law permits the body of a deceased 
person to be uninterred under any circumstances, until the cause 
of death has been definitely determined. Such a procedure is made 
illegal in many states. Autopsy should always be required in every 
case in which there Is any doubt. The experience of the meml)ers 
of this Council Is that consent for autopsy is very much easier to 
obtain than is generally supposed. A physician owes it to himself 
as well as to his patrons to refuse to sign a death certificate until a 
satisfactory" cause of death has been ascertained. To write "un- 
known" on a death certificate Is a reflection upon the diagnostic 
ability of the attending physician. 

It Is not the provhice of this report to discuss at length the Inter- 
national List. Access to the list Is easily available. It will be 
sufficient to state that before or after a death an accurate diagnosis 
should be made and that the cause of death should be so clearly 
expressed as to leave no doubt In the mind of the compiler as to its 
proper classification. 

Indefinite terms such as are given below should be avoided. The 
reasons why they are objectionable will be apparent on a moment's 
thought. If it becomes necessary to use any of the expressions In the 
following list a brief explanation should be given stating the location 
of the injury, or of the disease, and such prominent facts connected 
therewith as will enable the death to be properly classified. 

UNDESIRABLE TERMS. 

Abscess, accident, injury, external causes, violence, drowning, gun- 
shot, atrophy, debility, decline, exhaustion, Inanltatlon, weakness, 
cancer, carcinoma, sarcoma, congestion, convulsions, croup, dropsy, 
fracture, gastritis, acute indigestion, heart disease, heart trouble, 
heart failure, hemorrhage, hysterectomy, inflammation, infantile 
paralysis, laparotomy, malignant disease, marasmus, meningitis, nat- 



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86 THE MEDICAL ASSOCIATION OF ALABAMA. 

ural causes, paralysis, peritonitis, pneumonia, ptomaine poisoning, 
tabes, tuberculosis, tumor, uremia. 

It should be borne in mind that while completeness of records of 
the occurrence of diseases and of deaths Is desirable and essential 
It Is of no more importance than the accuracy of the statement of the 
causes of death. 

A comparison of the Annual Reports of the Bureau of Vital Statis- 
tics of this State will disclose the fact that deaths are being more 
completely reported each year. But It will also be seen that the 
number of deaths from unknown causes Is much too great. 

The members of this Association have It largely In their power 
and owe It to the Association and to themselves, to wipe out this 
blot on our statistical records. 

Dr. Hugh Boyd, of Scottsboro, read the report of the Coun- 
cil on Pharmacy. 

REPORT OF COUNCIL ON PHARMACY. 
Hugh Boyd, Scottsbobo, Chairman. 

After careful and thorough analysis of the Salicylate of Soda — 
Synthetic and Natural (from oil Wintergreen) — the Council on 
Pharmacy of the American Medical Association have declared them 
identical in action and effect; likewise Phenacetln and Acetephene- 
tldln, and we see no reason why physicians should continue to pre- 
scribe the higher priced drugs. 

We heartily endorse the position of the Council in omitting Aspirin- 
Bayer from the New and Non-offlclal Remedies. The advertising 
campaign of this corporation Is truly obnoxious — and Is not done for 
either the benefit of the public or the profession, but purely from the 
standpoint of the Income of this company. We sefe no reason, how- 
ever, why physicians should ever have prescribed Asplrln-Bayer, 
when the pure preparation, Acetyl Salicylic Acid, could be easily 
obtained for half the cost of the trade-marked article. 

Since the introduction of Salvarsan, medication by the veins has 
greatly Increased. This is a great step forward and should be encour- 
aged. We wish to urge the profession to study this method more 
fully, so that In future It will be used with known drugs when occa- 
sions require. 

We also wish to advise against the use of some preparations now 
extensively advertised, of obscure composition and of questionable 



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REPORT OF COUNCIL ON PHARMACY. 87 

virtue, namely: Vlnorsen, Vlnlrorsen, Venodlne, Vin-qulnine, Vln, 
etc., etc, manufactured by the Intravenous Products Co., of Denver, 
Col. As an example we take Vlnorsen. It Is put on the market in 
regular, double, and triple strengths, and sold at $1.50, $2.00 and 
$2.50 a dose respectively. 

Its manufacturers claim for It "low toxicity" and "superior splro- 
chactoddal powers In Syphilis," and describe it as "a comparatively 
non-toxic organic arsenic compound, 5 c.c. of the solution representing 
.7 gr. of organic arsenic. (4.37 gr. metallic arsenic) and 3/250 gr. 
metallic mercury in combination." 

They claim, moreover, that "Vlnorsen combines arsenic and mer- 
cury in proportions suitable for the entire treatment of Syphilis" 
and that "It has proved to be as nearly a specific in Syphilis as is 
yet known" and "makes the interval treatment unnecessary;" and 
they boldly assert that "Venorsen does not need the usual treatment 
of mercury or Iodides, unless an intolerance to arsenic is shown," 
and "that many cases showing positive reactions will respond nega- 
tively to the Cora, Venom, Noguchl and Wasserman tests after the 
administration of 6 or 8 doses given at from 4 to 6 day Intervals." 

We have searched the literature carefully and can find no reports 
from any reputable Syphllographer or physician or surgeon to sub- 
stantiate such claims. They (the manufacturers) admit, however, 
that "mucous patches In the mouth and throat persist after a full 
course of Venorsen, even when the Spirochaeta was originally re- 
sponsible for the lesion." This admission is sufficient in itself to 
show the ineflUciency of the preparation, and that the claims are ridi- 
culous, misleading and false. 

After analyzing this preparation the Council on Pharmacy and 
Chemistry of the American Medical Association tell us that "Ven- 
orsen as now marketed is a simple solution containing 9 grains of 
sodium cacodylate, 1/40 gr. mercury blniodide and % gr. sodium 
iodide to each full dose," and declare that "no real evidence has been 
presented or found for the claim of "lower toxicity and greater 
splrochactoddal powers than other known arsenic compounds," and 
"that no justification has been found for its use in Tuberculosis or 
Pellagra," and that "a careful physician would not give mercury and 
arsenic in fixed proportions." They brand the article as an unscien- 
tific combination, and 'declare its therapeutic claims are unwar- 
ranted. 

It is a well-known fact that Sodium Cacodylate is greatly inferior 
in efficacy against Syphilis to Salvarsan and Neosalvarsan and "there 



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88 THE MEDICAL ASSOCIATION OF ALABAMA, 

appears " no reason for administering It Intravaneously." — and we 
know that no 6 or 8 doses at 4 or 5 day Intervals, or any series of 
these doses will cure a case of Syphilis. 

In this connection it Is noted with surprise and even amazement, 
that the lamented Murphy advocated the intramuscular Injection of 
Sodium Cacodylate in Syphilis rather than the use of other arsenical 
compounds — Salvarsan, Neosalvarsan, etc. While we have the great- 
est respect for his teachings, and regard most of them as superla- 
tively good, In the light of present day information, we can do no 
l^s than consider such advice, coming from such authoritative 
source, as perniciously bad. 

We deem it unnecessary to go through the whole list, Venodlne, 
Venosol, Ven-qulnine, etc., and show the fallacy of the claims of the 
producers and point out the dangers and the uselessness of giving 
Intravenously the drugs these compounds contain. 

OOBPUB LUTEUM. 

Some obstetricians believe that the non absorption of corpus 
luteum plays an Important part in the nausea of pregnancy, and have 
given 1/3 gr. of the soluble powder in normal salt solution intra- 
muscularly for its relief. This is equivalent to 2% grs. of corpora 
lutea. This dose is given once or twice daily for 4 to 7 days, then at 
longer Intervals. 

In markedly neurotic cases it seems to have a sedative effect — the 
nervous manifestations of early pregnancy being markedly con- 
trolled. 

Some cases of the pernicious type have been reported as having 
been treated successfully, but in my own hands, It was without 
appreciable effect in two cases. 

Recent reports on this preparation indicate that it is of question- 
able virtue. 

Time will not permit us to go Into details about Vaccines; but 
evidence is increasing that the effects and results obtained by them 
In the treatment of disease are due, not so much to any specific 
element a certain vaccine may possess, but to the amount or quantity 
of foreign protein It contains. 

Very favorable results were reported by Ichlkawa In 1912, and 
later by Chlckerlng, Gay and others of the Intravenous injection of 
typhoid vaccine in typhoid fever. Just as favorable results have 
been reported by Kraus, Miller and others with the intravenous 



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REPORT OF COUNCIL ON PHARMACY. 89 

iuj€ction of Colon Vaccine, solutions of protein, or albumose in this 
Injection. Good results have been obtained in Arthritis of gonor- 
rhceal origin by the intramuscular injection of sterile milk 
and of Sodium nuclelnate; and in acute, subacute and chronic arth- 
ritic conditions of various types, good results are reported following 
the intravenous injection of typhoid vaccine and proteose. 

In gonococcic conditions Culver reports more marked reaction fol- 
lowing the Intravenous injection of meningococcic vaccine than that 
of gonococcic or staphylococcic. So the reaction seems to be non- 
specific in nature and could be obtained by a like amount of any for- 
eign protein. The curative effect seems to be in proportion to the 
temperature and leucocytic reaction. The data we have on foreign 
protein indicates that its effects are mostly curative and not immuniz- 
ing. If it is shown that vaccines owe their effect to the foreign 
protein contained, the standardization of a sterile pure chemical 
preparation of some proteose will greatly simplify this form of 
medication. 

Emetin, the principal alkaloid of Ipesac, is a white amorphous 
powder. The Hydrochloride is the salt generally used. It is not so 
effective when given by mouth, is unpleasant to take, more likely 
to be followed by nausea and vomiting, and in this manner is irritat- 
ing to the Intestinal mucosa. For these reasons, it is generally 
given hypodermically suspended in normal saline solution In doses 
of % to 1 gr. It is regarded as a specific in Amcebic Dysentery and 
Hepatitis in the same sense that quinine is in Malaria and Salvarsan 
is in Syphilis. In acute cases it acts quickly and cures are usually 
permanent. It is regarded with such favor by the English surgeons 
with the British army in Egypt and Turkey, and owing to the diffi- 
culties of making an early differential diagnosis, it Is given in 
practically every case of dysentery, regardless of its type. It is 
given hypodermically In daily doses of 1 gr. or 1/3 grain, three 
times daily for 3 or 4 days, then % grain every other day for ten 
days. In cases in which encysted Amebce are suspected, % grain 
given once or twice a week for some time Is advisable. 

Protozoal infections are difficult to eradicate, especially when they 
have become chronic. Within 24 hours after the hypodermic admin- 
istration of 1 gr. emetin hydroch. its sterilizing effect is noted, 
and Entomebie reached by the circulation are usually killed. But 
in chronic dysentery the amebie have Invaded the deeper tissues, 
become disseminated and encysted, and the emetin can't reach 
them — the encysted ones — and cures in these cases, are rarely perma- 



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40 THE MEDICAL ASSOCIATION OF ALABAMA. 

nent, but merely clinical ; and days, months or years later the en- 
cysted amebae reappear In active vegitatlve form, accompanied by 
symptoms of an acute attack. For these reasons the treatment 
should be conducted along lines similar to that of Malaria and 
Syphilis — that is — continuance of emetln for some time after all 
evidence of the Infection has disappeared. Given in this way, the 
likelihood of permanent cure is encouraging. Reports show that it 
acts quicker and gives a larger percentage of symptomatic cures than 
Ipecac. 1/3 gr. of the Hydroch. given hypodermic ally equals about 30 
grs. Ipecac. Its ameblcidal effect is much lessened in opium hab- 
itues. 

Because of its immediate ameblcidal action, It lessens greatly the 
danger of complications, and casea are reported that tend to show 
its curative effect on liver abscess after formation. 

Tropical physicians agree that it will cure Amebic Hepatitis, and 
will abort or check beginning abscess formation, and after aspiration 
or drainage it has a splendid effect on the amebte in the abscess wall. 
One grain Is given immediately after aspiration and repeated for 3 
days. 

Vedder showed that emetln hydrochloride in normal salt solu- 
tion in dilutions of 1 to 10,000 Immediately kills Entomeb» His- 
tolytica present in mucous and in dilutions of 1 to 100,000 renders 
them Inactive. 

Some surgeons inject weak solutions into the abscess cavity after 
drainage. We think this unnecessary. Owing to its Irritating prop- 
erties, it is not suited for colonic irrigations. 

Bsermon and Heineman report better results In acute Dysentery 
by giving Intravenously 3 grs. of emetln hydrochloride to every 
100 pounds by body weight in 100 cc. normal salt solution. Too 
large doses or the prolonged use of small doses will cause diarrhea, 
or keep It up. 

When the Entomeba Histolytica is found in the stool of patients 
with Sprue, emetln will not only benefit, but may even cure. 

In Pyorrhoea Alvoearis, the Injection of % grain daily will cause 
disappearance of the Entomebae Buccalls from wound in 1 to 3 days 
In over 90% of cases, and In 6 days, in over 99%, 

It acts on the smooth fibres in the vessels as a vaso-constrictor, 
and is valuable in all hemorrhagic troubles, Hemoptysis, Hema- 
temesls. Hemophilia, Purpura, etc. On account of Its vaso-constrictor 
action it is said to Influence acute pulmonary congestion. It Is re- 
ported to be our best remedy in any type of hemorrhage, especially 



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REPORT OF COUNCIL ON PHARMACY, 41 

pulmonary, from Phthls and from wounds — French surgeons using 
it with success to control persistent hemorrhage from lungs in chest 
wounds. It is also used to control hemorrhage in bleeders, fmd 
cases are reported in which it cured cases of purpura hemorrhagica. 
The claims that it aborts typhoid fever in 5 or 6 days are not to be 
accepted, but that it seems to prevent intestinal hemorrhage is quite 
true. 

The report of the Council on Scientific Study, Dr. J. S. 
McLester, Chairman, was called for, but Dr. McLester v^as 
not present and the report was passed. 

The Association adjourned at 12 :50 p. m. until 3 p. m. 



FIRST DAY, TUESDAY, APRIL 17. 
Afternoon Session. 

The meeting was called to order by the President at 3:05 
p. m. 

The Secretary: As Secretary I have received a file of pa- 
pers constituting an appeal from the findings of the Etowah 
County Medical Society in a case against Dr. Appleton. 

The appeal was referred to the Board of Censors. 

The Secretary : I have a resolution : 

Be It Resolved, That we, the members of the State Association 
of Alabama, at our regular annual meeting held in the city of 
Montgomery, April 17, 1917, heartily approve and unreservedly 
endorse the action taken by President Woodrow Wilson in the pres- 
ent crisis, and earnestly pledge our mental, moral and physical sup- 
port to him and to our country's service in the attainment of his 
ideals and the perpetuation of our country's liberty and patriotism. 

The resolution was referred to the Board of Censors. 

The President: I have the following invitation, signed by 
Mr. E. J. Devinney: "As a member of the committee ap- 
pointed by Mayor W. T. Robertson to arrange for the patriotic 
demonstration to be held Wednesday, I have the honor of 
extending the Medical Association a cordial invitation to at- 
tend." 



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42 THE MEDICAL ASSOCIATION OF ALABAMA, 

On motion of Dr. Perry the invitation was accepted. 

Dr. C. W. Hilliard, Dothan, who was to have read a paper 
on "Glaucoma," was not present. 

*Dr. P. I. Hopkins, Dothan, read a paper on "Iritis." Dis- 
cussed by Drs. S. L. Ledbetter, Birmingham; William C. 
Maples, Scottsboro, Dr. Ledbetter closing for Dr. Hopkins. 

Dr. Chenault: I move you that the privileges of the floor 
be extended to all the visitors present. 

The motion was seconded and carried. 

Dr. Charles Drake, Birmingham, who was on the program 
to read a paper on the "Recognition and Treatment of Frontal 
Sinus Headache," was not present. 

Dr. P. S. Mertins, Montgomery, read a paper on "Local 
Infections of the Ear, Nose and Throat in Relation to General 
Disease." Discussed by Drs. S. L. Ledbetter, Birmingham; 
H. S. Ward, Birmingham ; Dr. Mertins closing. 

The authors of the following three papers were not present : 

"Present Day Opinions as to the Value of Salvarsan," — Dr. 
Wilbur A. Sellers, Montgomery. 

"Cystoscopy"— Dr. John O. Rush, Mobile. 

"Prostatectomy"— Dr. John T. Geraghty, Baltimore, Md. 

Dr. C. W. Shropshire, Birmingham, read a paper on "*Supra- 
pubic Prostatectomy with Mechanical Drainage." Discussed 
by Drs. John M. Wilson, Mobile ; A. N. Steele, Anniston ; W. 
F. Scott, Birmingham ; Dr. Shropshire closing. 

Dr. J. P. Stewart, Attalla, read a paper entitled, "Crippled 
Kidneys." Discussed by Drs. T. A. Casey, Birmingham ; H. S. 
Ward, Birmingham ; C. W. Shropshire, Birmingham ; William 
C. Maples, Scottsboro ; Paul P. Salter, Montgomery ; Dr. Stew- 
art closing. 

The President : If it meets with the approval of the Asso- 
ciation, we will change the time of meeting Wednesday even- 
ing to 9 :30 on account of the patriotic demonstration we are 
to attend that evening. 

Adjourned at 5:40 p. m. 



♦For all papers and discussions see Part II. 



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PROCEEDINGS. 43 

FIRST DAY, TUESDAY, APRIL 17. 
Evening Session. 

Called to order at 8 p. m. by Dr. E. B. Ward, Selma, Senior 
Vice-President. 

Dr. F. L. Chenault, Albany, read a paper on "Fractures Near 
the Elbow." 

Dr. Marcus Skinner, Selma, read a paper on "Surgery of 
the Bones and Joints." 

The two preceding papers were discussed by Dr. W. W. 
Harper, Selma. 

The authors of the following five papers were not present: 

"Surgery of Kidney"— Dr. A. S. Frasier, Dothan. 

"Renal and Perirenal Abscesses" — Dr. Paul Rigney, Court- 
land. 

"The Decompression Operation in Fracture of the Base of 
the Skull — Dr. S. R. Benedict, Birmingham. 

"Blood Transfusion"— Dr. P. B. Moss, Selma. 

"Military Surgery" — Dr. W. Earl Drennen, Birmingham. 

Dr. J. U. Reaves, Mobile, read a paper on "Chronic Gonor- 
rhoea in the Male." No discussion. 

Dr. A. A. Jackson, Florence, read a paper on "Infections 
of the Knee Joint, with Especial Reference to Treatment." 
Discussed by Dr. Mack Rogers, Birmingham. 

Dr. Paul P. Salter, Montgomery, read a paper on "Blood 
Pressure." No discussion. 

Dr. Mack Rogers, Birmingham, read a paper on "The Carrel 
Method of Using Dakin's Solution in Both Primary and Sub- 
sequent Treatment of Open Wotmds." Discussed by Dr. A. L. 
Nourse, Sawyerville; Dr. Rogers closing. 

Adjourned at 10:30 p. m. 



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14 THE MEDICAL ASSOCIATION OF ALABAMA. 

SECOND DAY, WEDNESDAY, APRIL 18. 

Morning Session. 

Called to order at 9 :15 by the President. 

The President read telegrams from Drs. Wickliffe Rose, 
New York; Paul Rigney, A. S. Frasier and John O. Rush, 
expressing regret that they could not attend the meeting. He 
also announced that he had received a letter from Dr. Floyd 
McRae saying that he could not be present. 

Dr. W. W. Harper, Selma: I wish to offer the following 
resolutions : 

Whereas, Grlminolo^sts have shown that the present treatment 
of the criminal is nnscientiflc, inhuman and unchristian ; 

Be It Resolved, First, That there be appointed a committee 
of five experts from the membership of the Alabama Medical Asso- 
ciation to act with a like committee from the Alabama Bar Associa- 
tion for the purpose of rewriting the Criminal Ck)de of Alabama, to 
the end that justice may be meted out to the criminal class. 

Second. That this Association request the Bar Association to 
appoint a similar committee. 

Whereas, Statistics show that in the school the subnormal child is 
holding back the normal child, thus delaying several years the com- 
pletion of the normal child's education ; that the scheme of studies for 
the normal child is unsuited for the subnormal, thus defeating the 
proper education of the subnormal child : 

Be It Resolved, First, That there be appointed from the Medical 
Association of Alabama a committee of five to act with a similar 
committee from the State Educational Association to revise our 
system of education; 

Second. That a copy of these resolutions be sent to the Educa- 
tional Association and that they be requested to appoint a com- 
mittee. 

The resolutions were referred to the Board of Censors. 

Dr. Clarence Hutchinson, Pensacola, Fla., read a paper on 
"Lacerated Perineum and Its Repair." Discussed by Drs. 
L. C. Morris, Birmingham; J. S. Turbeville, Century, Fla.; 
W. R. Jackson, Mobile ; Dr. Hutchinson closing. 



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PROCEEDINGS. 46 

Dr. W. R. Jackson, Mobile, read a paper on "Why Gastro- 
enterostomy Fails to Relieve." Discussed by Drs. Seale Har- 
ris, Birmingham ; L. C. Morris, Birmingham ; Clarence Hutchi- 
son, Pensacola, Fla. 

Dr. Seale Harris, Birmingham, read a paper on "The Early 
Diagnosis of Ulcers of the Stomach and Duodenum." 

As it was nearly time for the Jerome Cochran lecture, a 
recess of twenty minutes was taken at this point. 

(After reconvening) — 

The President: The hour has arrived for the special order 
of the Jerome Cochran Lecture. We are especially honored 
today in having with us the best known surgeon in the world 
to deliver this oration. I dare say that in the whole civilized 
world there is not a doctor who is not intimately informed 
regarding the name and work of the man who is to address 
us now — Dr. William J. Mayo. 

Dr. Mayo : I assure you that I esteem it a very great honor 
and privilege to appear before this society and to deliver the 
address which you have dedicated to one of the strong men 
of the past. This man is ever to be remembered in connection 
with his work in yellow fever, and also as one who had, per- 
haps, more to do with the organization of this society than 
any other man in the State of Alabama. I think it is particu- 
larly fitting at this time, when our country is facing one of its 
very great problems, that we should not only remember these 
able men of the past, but that we should look for such in the 
present, in every community and in every state — men of the 
character and ability of Jerome Cochran — who are so greatly 
needed in the most serious and difficult experience this country 
has known since the time of the Revolution. 

Dr. Mayo then delivered the Jerome Cochran Lecture. 

For lecture see Part II. • 

At the conclusion of the address Dr. W. R. Jackson, Mobile, 
moved a rising vote of thanks and appreciation, which was 
unanimously carried. 

Dr. E. B. Ward, Selma: I wish to offer the following 
resolution : 

Resolved, That it is the sense of the Medical Association that the 
Medical Association meeting may continue only three days instead of 
four. 



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46 THE MEDICAL ASSOCIATION OF ALABAMA. 

There has been a good deal of talk and discussion about the 
detention of the members here so many days, and this resolu- 
tion is offered so we can arrange that the meetings will con- 
tinue from Tuesday until Thursday. 

The resolution was referred to the Board of Censors. 

The President: The next order of business is the post- 
poned : 

REPORT OF THE COMMITTEE ON MEDICAL PREPAREDNESS. 

Dr. J. N. Baker, Montoomebt. 

Mr. Chairman and Members of the Medical Association of the State 
of Alabama : 

It Is with no little embarrassment that I appear before you fast on 
the heels of the distinguished speaker, but I feel that the magnitude 
and importance of the subject which we wish to discuss now will in 
a measure justify my appearance at this particular time. 

Dr. Mayo very beautifully expressed the position in which the 
medical professfon stands today in regard to the national crisis 
which faces our country. And in the gigantic handling and mobiliz- 
ing of the physical forces of this country there is presented to us as 
physicians all over the country an opportunity for humane and 
patriotic service which has not been presented to any members of 
this profession during this generation. Therefore, it seems that 
each and every one of us should consider this matter and go to work 
to do what we can for the good of the National Government. 

Now, I wish very briefly to outline for you what the various State 
committees and in particular what the State Committee for Alabama 
has been endeavoring to do in the way of listing and mobilizing the 
medical resources of this State. 

To begin at the beginning, in April of last year there was created 
by the President of the American Medical Association, the President 
of the American Surgical Association, the President of the American 
Colleges of Physicians and Surgeons and the President of the Na- 
tional College of Surgeons a committee known as the American Com- 
mittee on Medical Preparedness, which committee appointed for 
service in each State sub-committees, known as the State Committee 
for Medical Preparedness. That committee Is composed of nine 
members in each State Association, the President and the Secretary 
of each State association being members of that committee during 



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PROCEEDINGS, 47 

tlieir incumbency of office. The other seven men were chosen by 
this committee appointed by the presidents of these associations that 
I have just mentioned. These committees were appointed In the 
various States, and the service of this National Committee, which Is 
known as the American Committee for Medical Preparedness, and 
the services of these various State committees were tendered to the 
President of the United States. The President at that time was not 
in a position to accept the gratuitous services of bodies of this sort, 
but in August of last year, by an act of Congress, there was passed 
a bill creating what is known as the National Council of Defense. 
That Council of Defense is made up, as you all know, of six members 
of the President's Cabinet; the Chairman of the Committee is the 
SecretaiT of War. 

Associated with this Council of Defense is what is known as an 
Advisory Commission, composed of not less than seven men, each of 
whom is an expert in some civil walk of life, to aid and assist In 
arranging and mobilizing the physical forces of this country. Now 
on that Advisory Commission, as the medical executive, was placed 
Dr. Franklin H. Martin, of Chicago, and as his chief of staff is 
Dr. F. F. Simpson, of Pittsburgh. The medical end of the Advslory 
Commission of the National Council further has an Advisory Board, 
made up of the Surgeon-General of the Army, the Surgeon-General 
of the Navy, the Surgeon-General of the Red Cross, and Dr. William 
J. Mayo, Chalmian of the Medical Committee for Medical Prepared- 
ness, and Dr. Welch, of Baltimore, and several others. 

You see it takes a rather complicated organization to cover the 
work that has been outlined. 

Now to come down to the work of the State committei^s. These 
various State committees, each composed of nine men, were first 
requested to catalogue and coordinate the physicians throughout each 
State. The State (^ommittee of Alabama, as it stands today, is com- 
posed of the following men : Drs. R. S. Hill and John H. Blue, Mont- 
gomery; H. P. Cole, Mobile; F. G. DuBose, Selma; W. Earle Drenneu 
and Jj. C. Morris, Birmingham ; the President and Secretary of this 
Association, and myself acting as Chairman. 

The first work that this State Committee was requested to do was 
to catalogue and make an inventory of the doctors of our State. 
There are about two thousand physicians. We were reiiuestetl to 
base that reiwrt by selecting about two hundred medical men to 
every million of population in each State, making the number from 
Alabama letweeu three and four hundred. The State Conmiittee 



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48 THE MEDICAL ASSOCIATION OF ALABAMA. 

met, carefully went over the list of doctors in this State, and cata- 
logued them, noted the specialty of each man as we knew them, 
and sent that in for the use of the Government 

The next request that was made of this State Committee was to 
catalogue and give an inventory of the various hospitals, asylums and 
State sanitaria throughout the State. You readily understand that 
in case of a national crisis to have first hand information of all 
resources in each hospital throughout the State would be of very 
great importance. This was done, and I am very glad to be able to 
say that the various hospitals have sent in this information, and our 
records are complete in the Surgeon-General's office in Washington 
now, so far as the State of Alabama Is concerned for the hospitals. 

The next duty that this State Committee was asked to perform 
was to go still a little farther and to organize in each county in the 
State sub-committees in which the work could be still further and 
still more accurately prosecuted, so far as cataloguing and placing 
of the proper appraisement of the various men in the counties. These 
county committees have been appointed in each county in the State, 
and I am very glad to be able to report to this Association that 
nearly all of the county committees have had meetings, the subject 
of medical preparedness has been discussed, and in a great many 
instances the lists of the men who are willing to go to the front have 
been sent in. With one or two exceptions, the response has been 
beautiful and most patriotic. 

That, in brief outline, gentlemen, is what the State Committee has 
tried to do for our National Government. Now I have had frequent 
requests from all over the State, wishing that more definite informa- 
tion be given them. The War Department has not seen fit to reveal 
any of the plans which they have on foot, consequently the informa- 
tion which has sifted through to the various States has been very 
meager, but, as I gather from my correspondence with the War 
Department in Washington, there is one thing that they wish to 
accomplish as rapidly and as quickly as possible, and that is to try 
and get all of the medical men throughout the State actively inter- 
ested in the medical officers* reserve corps, which, as you already 
probably know by this time, is a special reserve corps upon the roll 
of which will be placed a member after he passes certain physical and 
mental examination, which will not be very rigid. But if these 
names are catalogued in the various counties and the men volunteer 
their service, then the Government will be in position to know exactly 
where to draft the men for the reserve corps. 



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PBOOaSDINQS. 4B 

In your work throughout the various counties you are encouraged 
to work with any organizations of the Red Cross that have been 
organized, or if no such chapters have been organized in your various 
communities, to encourage it as much as possible, and to aid in the 
Red Cross activities, for, as you know, the opportunities for service 
for the ladies and those who cannot actually go to the front are prac- 
tically limitless through the agencies of the Red Cross. We have 
found here in the city of Montgomery that the whole population, men, 
women and children, have been very eager and anxious to join the 
Red Cross, and to place themselves in a position to do at least a little 
mite towards the great cause which we probably will be called upon 
to serve. 

And, in conclusion, I wish to ofTer the following resolution : 

WhereaSj War has been formally declared by the United States of 
America upon the Imperial German Government ; 

And Whereas^ Our President has exhausted every honorable means 
before taking this final step: 

Therefore, Be It Resolved, That the Medical Association of the 
State of Alabama, in regular session assembled, heartily endorses the 
course and actions of the President, and pledges to the National 
Government its loyal and unstinted support in its prosecution of its 
every plan. (Applause.) 

The President: Dr. Baker, I might state that a resolution 
almost exactly similar was offered yesterday. 

Dr. Baker: I will be very glad to accept that as a substi- 
tute. In conclusion, I am going to ask Dr. Mayo, as Chair- 
man of the American Committee for Medical Preparedness 
to say a few words to you. 

Dr. Mayo: Ladies and Gentlemen: I assume that we are 
all good and loyal citizens of the United States, and I believe 
also that we are in sympathy with the President in what he is 
trying to do. We may disagree with him in some of his 
methods, but in the main we all have the same object in view, 
and that is, the end of the war, which must be brought about, 
not by a ccwnbination of warships to police the world, but by a 
condition of democracy which will make one and all free citi- 
zens. 

As our President has so justly said, this is a war against the 
Imperial Government of Germany, not against the German 
people, and it has taken two and a half years to convince the 

4M 



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50 THE MEDICAL ASSOCIATION OF ALABAMA. 

four and a half million Gernian citizens of this country — highly 
respected and loved by us all — of this fact, and it has taken 
the same length of time to convince the pacifists — whose opin- 
ions we respect — that the end of war will bring with it the 
development of the higher, more spiritual qualities in all people. 

This war has already brought one great benefit which the 
German people appreciate even more than we do, that is, the 
democracy of Russia. It seems to me that the underlying feel- 
ing of the German people has been a fear of that ruthless mon- 
archy to the east. But with Russia's democracy, and the great 
democracy of the United States as an example, we foresee that 
Germany will end imperial government and bring about democ- 
racy. We can also foresee the freedom of the ballot in Ger- 
many, as it is here, and the permission for the women to vote 
will forever prevent the declaration of an aggressive warfare 
by any democracy. 

I think it has been apparent from the beginning to every 
thinking man in this country that this is a war for the freedom 
of people, and it is to free our own souls that we have gone 
into it. One year before a declaration of war by the United 
States the presidents of the various medical societies appointed 
the committee of which I have the honor to be chairman. We 
have received ever>' encouragement from the President to 
further our work. This committee of twenty-eight raised among 
themselves in the vicinity of six thousand dollars and initiated 
the movement that Dr. Baker has just been speaking of. 
Twenty-two thousand physicians in the United States have 
been catalogued and are now ready for work. Nearly 100,000 
hospital beds have been pledged to this movement. Our navy 
comes first and the army next, and third in rank is the Ameri- 
can medical profession, of which we have just cause to be 
proud. The American medical profession has come forward 
in this crisis and without formal encouragement has done a 
great work. Today we are ready, from the standpoint of the 
medical profession, to prosecute a successful war. Another 
important matter must be kept in mind — to keep our medical 
schools full. Young men must be encouraged to go into the 
medical schools. Within ten years, because of the lengthening 
of the courses of medical schools, because of the increased 
expense and the length of time required to become doctors, we 
are facing a shortgage of medical men in civil life, and the 



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PROCEEDINGS. ttl 

cases of sickness in civil life could scarcely be cared for if it 
were not for the trained nurse and the better education of the 
public. 

It seems to me that the great underlying principle that we 
must support is first, the education of the people so they will 
need the care of doctors less; second, the prevention of sick- 
ness ; and third, the trained nurse to step in behind us and take 
many of the duties from our shoulders, until such a time as we 
shall have a sufficient number of doctors. 

The President: The Association will be addressed on the 
same subject, "Medical Preparedness," by Col. Shriner, a 
member of the Medical Department of the United States Army. 

Col. Shriner: Mr. President, Members and Guests of the 
Alabama State Medical Association: Some weeks ago it was 
my fortune to be ordered to this city with a view to mustering 
out the returning members of the Alabama National Guard. 
Since that time a state of war has been declared to exist against 
the German Government, and the duty of mustering out has 
been suspended. 

Our thoughts have been urgently directed to the • necessary 
preparation for the crisis which confronts us. The Surgeon- 
General, at the instigation of the Chairman of your State 
Committee on Medical Preparedness, has designated me to 
represent the Medical Department at this meeting. This duty 
I feel I can best perform by bringing before you the questions : 
How is the medical profession of this country prepared to 
assist the Government in the present war for the manning of 
the large army which we have every reason to expect will be 
created? What may we further do at this eleventh hour to 
further this preparedness? How may each individual con- 
tribute to the performance of these duties ? 

By the National Defense Act of June 3d, last year, Congress 
authorized the increase of the regular army to a total strength 
of about 290,000. One-fifth of this increase became effective 
on the first of last July. The remaining four-fifths will prob- 
ably be made effective within a very few days. We expect to 
hear at .any time that Congress has authorized this further in- 
x:rease. This increase carried with it a provision for a medical 
department based on a strength of seven medical officers to 
each one thousand of enlisted strength, giving a final total 
when the full increment have been called, of about 1,800 medi- 



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02 THB MEDICAL ASSOCIATION OF ALABAMA. 

cal officers. Of this number, not more than one-third are now 
in the service, so that even in the regular medical corps there 
will be two-thirds or about twelve hundred vacancies for medi- 
cal officers. 

These positions are open to young men not over thirty-two 
years of age at present. They are usually held for life, and 
it is required of applicants that they pass a satisfactory physical 
and mental examination before being commissioned. Hereto- 
fore a course of not less than five months' instruction has been 
given before the final commission in the medical corps has 
been issued. Under existing circumstances it is not to be ex- 
pected that this will be practicable. 

For those who enter the service at the beginning of this large 
increase the prospects of final promotion are very good. Under 
existing law medical officers enter the regular army with the 
rank of first lieutenant. By law at the end of five years they 
are promoted to the grade of captain. The grades of major, 
lieutenant colonel and colonel are attained by vacancies occur- 
ring in those grades. The Surgeon-General is an appointive 
office at the discretion of the President. 

The regular medical corps has never been sufficient for the 
care of our army in times of peace, and its work has been sup- 
plemented by the services of officers of the medical reserve 
corps on the active list. We have had from one hundred to 
three hundred of these medical reserve corps officers called 
from civil life constantly on duty during peace times. At 
present these commissions are only in the grade of first lieu- 
tenant, but the National Defense Act provides for the substitu- 
tion after June 3 of this year of the medical section of the 
officers of the reserve corps, with grades including captain 
and major. Unfortunately the opportunities for training our 
medical reserve corps officers have not been carried out very 
extensively. Correspondence courses have been provided at 
the field school for medical officers at Fort Leavenworth, 
Kansas, but they have only been instituted recently. The 
proposed course was one of four years, and it is now only in 
the beginning of its second year. 

During the summers of 1913, 1914 and 1915 practical train- 
ing was given in camps for medical officers of the reserve 
corps. This instruction was in the hands of the medical offi- 
cers of' the regular army, but only a limited number availed 



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PR00BBDINCH3. 58 

themselves of these opportunities. Provision had been made 
for five of these camps during 1916, scattered throughout the 
country from the eastern to the western coast, but these camps 
were cancelled owing to the shortage of regular medical offi- 
cers occasioned by the Mexican difficulty. Several hundred 
members of the medical reserve corps have already seen active 
service on the border and in Mexico. 

The medical officers of the National Guard have already 
had considerable experience with troops and sanitary units, 
and many have maintained during this period of activity and 
mobilization on the border a commendable degree of efficiency 
in the military aspect of their work. 

Now an army of a million men will require at the very least 
the provision which has been authorized by Congress of seven 
per thousand, or seven thousand medical officers. This is the 
minimum number for duty with the troops. So it is apparent 
that the number of medical men having previous military ex- 
perience or training will constitute but a fraction of the whole 
number engaged. Fortunately, however, military conditions 
at present offer some time and opportunity for preparation. 
Experience and instruction will be afforded at the large mo- 
bilization and training camps in the immediate future. 

Many of the reserve officers will be, by reason of their age, 
physical condition and experience, best fitted for the service of 
the interior, or with immobile sanitary formations— of course, 
I mean those that do not move with the troops, base hospitals, 
etc. The service of the zone of operations will in general be 
best performed by the younger members of the profession, and 
those who by their mode of life are fitted to adapt themselves 
to the activities and hardships of life in the field under war 
conditions. 

I would urge those who feel that the nation requires their 
services and that they can be of use to so place themselves on 
record at the earliest opportunity, and to be prepared to obey 
the call of the President the moment it is sent. The period 
from now until the engaging in actual hostilities may well be 
spent in intensive preparation, which time at most will be all 
too short. 

Find out what opportunities for service are offered, decide 
upon that for which you are by nature and experience best 
fitted, and then bend your energies to acquiring all the informa- 



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64 THE MEDICAL ASSOCIATION OF ALABAMA. 

tion you need. Do all you can to secure the service you decide 
upon, for which you decide you are best fitted. Remember 
that undue modesty is not a military virtue, and if you fail to 
get the position you desire, be prepared to render service in 
any capacity to which you may be called. 

Those expecting to enter the medical service should lose no 
time in acquainting themselves with the organization of the 
army, its rules and regulations, and the no less important, 
though unwritten, customs of the service. 

Methods of administration, especially of the various sanitary 
units, are of great importance. Most of this information is 
available in publications made by the Government, and are 
obtainable through the Bureau of Public Printing. Those re- 
quiring special attention are the Army Regulations, the Man- 
ual for the Medical Department, with Service Regulations, and 
the Hand-Book of Drill Regulations for the Hospital Corps. I 
would also recommend as instructive courses of reading 
Strawk's Medical Service in Campaign, Munson's Sanitary 
Text-Book, Munson and Morrison on Troop Leading Sanitary 
Service, and the recent text-books and current literature on 
military hygiene and surgery, especially comments and facts 
appearing in The Military Surgeon during the past two years. 

Some effort has been made by the civilian medical societies 
throughout the country to obtain military information and 
instruction as exemplified by the very commendable plan of 
military instruction published by the Clinical Club of Albany, 
N. Y. An extensive organization which you have heard out- 
lined here by Dr. Baker and Dr. Mayo has been developed by 
the civilian physicians of our country, under the auspices of 
the National Council for Defense. Since I have been in Mont- 
gomery it has been my pleasure, with the assistance of other 
medical officers on duty here, to present an outline of medical 
military service to the members of the Montgomery County 
Medical Society, and the interest and enthusiasm manifested 
by these gentlemen augurs well for their response when their 
services are called for, as will surely be the case for some of 
them in the near future. 

One of the primary lessons that we must learn as military 
surgeons is that the medical department constitutes a part, 
and a not unimportant one, in the military machine whose ef- 
forts are directed to military success which entails the destruc- 



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PROCEEDINGS, 55 

tion of the enemy. While the humanitarian phase of our work 
is universally recognized, its military importance is too often 
not fully understood. The keeping of the maximum number 
of effective troops on the firing line, the prompt removal of the 
non-effective and sick and wounded, the early and effective in- 
stitution of Sanitary measures for the preservation of the health 
of the troops, which is practically covered by the provision of 
suitable and efficient food, good water, and the control of 
infectious diseases, are duties of paramount importance. 

Some knowledge of military and sanitary tactics is necessary 
especially for medical officers in the higher grades. Since 1912 
courses of practical instruction in these subjects have been 
given to medical officers in the regular army and the National 
Guard, about equal numbers of each in all classes at the field 
school for medical officers at Fort Leavenworth. Last year 
this work had to be suspended owing to the demand for medical 
officers in Mexico and on the border. The work of this 
school is under^ the direction of qualified military instructors 
of all arms of the service. It includes practical work in the 
solution of military problems, both on war maps and on the 
actual terrain, using both the sanitary and line troops actually 
as far as possible. Plans for operations on the actual ground, 
plans based on reports of military observers in different parts 
of the world, are used in making out the practical problems 
which are solved at this school. It includes a course of prac- 
tical map making. The medical officers have shown no small 
degree of skill and aptitude in the acquisition of this ability. 
But the number of medical officers so trained, unfortunately, is 
very small. During the recent mobilization an attempt was 
made to extend the scope of this instruction by the institution 
of conferences and practical exercises throughout Texas and 
in Mexico. I believe that the time is coming when universal 
liability for military service will be prepared for by universal 
training, and that it will be required of the medical profession 
to take part in this training. This training should begin in the 
medical school. Already a number of medical officers have 
been designated to inaugurate courses of military instruction 
in the principal medical schools of our country. These courses 
should be supplemented by practical experience in the field dur- 
ing the summer when the schools are not in session, and per- 
haps during vacations later in professional life. 



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56 THE MEDICAL A8B0CIATI0N OF ALABAMA, 

In material resources the army is well prepared for the 
organized forces, both regular and National Guard. It is 
probable that equipment and supplies for the sanitary service 
of the forces to be organized can be supplied as fast as the 
organizations are made ready. Our experience in Mexico re- 
sulted in the organization of a number of sanitary units, and 
equipment still remains on hand for use in a larger organization. 
The effectiveness of modernization for ambulance companies 
was well demonstrated in Mexico. The trip from Dublan to 
Columbus, N. M., 110 miles, which would take five days for 
mule train ambulances, was sometimes made in ten hours by 
motor ambulances over rather difficult roads. This work was 
entirely in charge of medical officers, and it is due to them to 
state that no ambulance ever failed, and that the motor ambu- 
lances remained during the campaign without the loss of a 
single vehicle, and no case was lost, notwithstanding serious 
cases were included. Congress has provided four hundred 
thousand dollars for motor ambulances alone, and a number 
remain on hand ready for use. The cost of equipping a motor 
ambulance company may be estimated at about twenty-five 
thousand dollars, and the cost of equipping a motorized mobile 
hospital at a slightly greater amount. 

I take it that our profession will not be second to any in 
rendering service to the nation in its impending need, no mat- 
ter what the sacrifice in time or means or life itself. In Eng- 
land and in France the profession has been asked to render 
military service and still carry on its ministrations to the civil- 
ian population. Medical societies in England have provided 
for the care of the members called to the front, to hold intact 
the means of livelihood of their professional brethren until their 
return. A similar provision is proposed for our own country. 

Our nation has been gradually and inevitably drawn into 
this conflict. From accepting the gage of battle there would 
seem to be no choice, but one alternative, to bend the neck to 
the aggression of a foreign autocratic power. To maintain the 
principles of democracy on which our government and liberties 
rest, morally we are called on, and no matter what its cost in 
treasure and in life, let our profession stand united to render 
its full meed of service and sacrifice to the full end, no matter 
what that end may be. 



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PROCEBDiyOS. 67 

Dr. W. W. Harper, Selma, showed a case of food poison. 
The Association adjourned at 1 :30 to reconvene at 3 p. m. 



SECOND DAY, WEDNESDAY, APRIL IS. 
Afternoon Session. 

Called to order by the President at 3 o'clock. 

The Secretary stated that the Chamber of Commerce, the 
Automobile Club of Montgomery and the Rotary Club had 
invited the members of the Association to take an automobile 
ride shortly after four o'clock on Thursday afternoon. 

Dr. Chenault moved that the invitation be accepted. Car- 
ried. 

The President: Gentlemen of the Association, it is my 
pleasure to introduce to you Mrs. Thomas M. Owen, who has 
a message for the people that she wants you to carry to them. 

Mrs. Owen: Gentlemen: I have come to talk to you 
about something I know you are interested in, and that is a 
chair where we can train rural nurses. I believe that every 
physician in the State of Alabama who has any country practice 
at all realizes the need for county nurses, women who can go 
into the rural communities and do this work, and that is what 
I have gotten the privilege of the floor for a few minutes to 
talk to you about. 

About three years ago Miss Clemon, of the Red Cross Asso- 
ciaticHi, Chairman of the Town and Country Nursing Division 
of the Red Cross Association, was passing through, and I met 
her at the station in Montgomery. We talked over the neces- 
sity for such training, and she said they had an especial need 
for it in their work, and that there were no women prepared 
to do that kind of work. I, as Chairman of the Country Life 
Committee of the National Civic Life Federation of the Nation, 
felt that if we could establish a chair in one of our Southern 
schools where women could be trained for this work that it 
would be the most useful thing we could do. I at once got 
busy with friends whom I thought would be interested in the 
subject, and after I canvassed a good many institutions we 
concluded we would undertake to establish this chair in Pea- 



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68 THE MEDICAL ASSOCIATION OF ALABAMA. 

body College at Nashville, Tenn. There were a good many 
reasons that induced us to make that selection. One was its 
convenient approach to so many sections of the Southern 
States. Another was, and this was a determining factor, that 
the institution is so close to the Medical Department of Vander- 
bilt University, the city of Nashville is so well equipped with 
hospitals, and especially on account of the country life equip- 
ment at Peabody College. The million dollar country life 
school and the numerous departments in the school itself, rural 
sociology and domestic science and other things absolutely 
necessary in the course of training they would have to take, 
were already established there and there would be no necessity 
for extra expense for the training. After finding that it would 
take the income from a hundred thousand dollars to sustain 
the chair, in paying the teacher and the assistants, we talked 
about this thing to some of our friends in the North, and they 
said if the Southern States would raise five thousand dollars 
of this hundred thousand that they would undertake to raise 
the remaining ninety-five thousand. 

Now, we have not had as much success in raising this money 
as we had hoped when we started out. We put the plan and 
the program up to the Southern Medical Association, because 
we wanted their endorsement. We felt that if the authorities 
of several Southern States knew that the Southern Medical 
Association had endorsed it, it would interest and give confi- 
dence to some. But we have not been fortunate enough to get 
the states themselves to take it up. 

So as Chairman of this movement, I have taken the liberty 
of asking for a few moments to talk to you about it. You 
know that the health problems of the South are p'eculiar to our 
section. We have more hookworm and malaria, and less pro- 
ductive power per man than any other part of the United 
States ; that of course is due to the lack of a well-balanced diet, 
owing to the fact that we raise cotton crops instead of food 
crops. 

Our people do not get the right nutrition, enough variety in 
their diet, and their productive power is low. And so we need 
to build up our health conditions. I see that among your num- 
ber you have a member of the army here this afternoon, and he 
will substantiate the statement that perhaps fifty per cent, of 
the young men who volunteered to serve their nation were 



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PROCEEDINGS. 68 

turned down because they were physically unfit. It is said that 
eighty per cent, of the manhood of this section is physically 
unfit for military duty. And so the man power is not up to its 
full strength. We have so many diseases that can be pre- 
vented if we get the right kind of education to our people, 
especially the people in the rural districts. 

Now we need many women to go into the rural districts 
and give this information to the rural women. We need these 
women to aid and assist the county health officer. She will 
work with the county education department, too. She will visit 
the schools and inspect the children in the schools and instruct 
the parents of those needing special treatment. She will visit 
the homes and show the woman in the house how to take care 
of the patient, to prepare a proper diet, disinfect the house 
after the trouble is over, and all of those fundamental health 
problems. 

Now there are not many women who have been trained to 
do this work. There are only a very few places in the United 
States where they can get this training. Dr. Payne, the Presi- 
dent of Peabody College, at Nashville, told me last week that 
if he had had a trained nurse on the campus at the time Dr. 
Tate was first taken with pneumonia that man's life could have 
been spared. I do not know whether you kept up with the 
work of Dr. Tate or not, but he was the greatest man in the 
South on rural problems, and he lost his life because he allowed 
himself to be dragged out with a bad cold. But Dr. Payne 
holds that if a trained nurse had been there at the campus that 
life would have been spared. 

We know that if we can get this training for these women 
that they will go out into the rural sections and do this mag- 
nificent work. 

So my object in coming to you is to ask you to support this 
movement financially and morally and to talk it in your com- 
munities ; to say it is a good thing and ought to be done. I do 
not know what is the condition of your treasury. If any of you 
want to make a donation — Alabama's part is five hundred dol- 
lars — or if you have money in your treasury and you 
would be willing to put a little bit out for this chair, I believe 
you could not spend it for a better purpose. I simply wanted to 
plead with you to do this for the sake of humanity and for the 
sake of your own profession, because I believe these women 



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60 THE MEDICAL ASSOCIATION OF ALABAMA. 

will render a magnificent service. I know we need them, and 
I have had a number of calls for them ; counties are willing to 
pay for them, but cannot find the women. Even Mississippi, 
Louisiana and states in the Middle West have written to me 
to know if we had any women they could employ. There is 
a demand for this service, the counties will pay for it, just as 
they pay for other service. And I do not believe you could 
get any better public servants than these women who could 
help you to 'take care of your health problems. When people 
get this education they will be better and more useful to 
themselves and to the nation. And so I plead with you to 
stand by this movement for the endowment of a chair for the 
training of rural nurses at Peabody College. 

The President : Mrs. Owen would like to have an expres- 
sion of this Association as to how you feel about this movement 
that she is fostering. 

Dr. Perry: I move you, sir, that we endorse the work 
that Mrs. Owen is doing, the eflFort that she is endeavoring to 
make to raise this fund, and promise her that we will do what 
we can to assist her in the great work that she has. 

The motion was seconded and carried. 

The President read a telegram from Dr. Drennen addressed 
to Dr. Fred Wilkerson, of Montgomery : "Please have following 
read at meeting tonight. I did not know until this afternoon 
I was on the program to read a paper tonight." The Presi- 
dent stated that Dr. Drennen first declined the invitation to 
read a paper, but later, after the preliminary program appeared, 
he wrote that he would reconsider the matter, and he was then 
put on the program. The President said he had not notified 
any of the men that they were on the program, and no excep- 
tion was made in the case of Dr. Drennen. 

Dr. Giles W. Jones, America, read a paper on "The Value 
to the General Practitioner of Properly Kept Records of 
Births and Deaths." Discussed by Drs. H. G. Perry, Mont- 
gomery; A. L. Nourse, Sawyerville; T. A. Casey, Birming- 
ham ; W. H. Moon, Goodwater ; B. L. Wyman, Birmingham ; 
C. A. Mohr, Mobile; W. P. McAdory, Birmingham; A. A. 
Jackson, Florence ; E. B. Durrett, Gordo ; Dr. Jones closing. 

Dr. McAdory introduced the following resolution, which 
was referred to the Board of Censors : 



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PR0CBBDING8. CO. 

Be It Resolved, by this Association, That a form of certificate be 
adopted to be furnished the family by the health officer of the county 
upon the r^)ort of the birth of a child. 

The Secretary said he had received a communication from 
the Council of National Defense at Washington, asking him to 
impress upon the society the importance of cooperation with 
the Government in securing medical officers for the army and 
navy, and enclosing a plan for taking care of the practice of 
the men who are called to the colors. The S^retary asked 
that he be permitted to refer it to the Board of Censors with- 
out reading. This request was granted. 

Dr. William C. Maples, Junior Vice-President, took the 
chair. 

Dr. B. L. Arms, Montgomery, read a paper on "The Rela- 
tion of the State Laboratory to the Health Officer, the Physi- 
cian and the Public." No discussion. 

Dr. S. W. Welch, State Health Officer, delivered an address 
on "The Work of the State Board of Health." 

Dr. F. E. Harrington, Health Officer of Jefferson County, 
made a talk on "Rural Sanitation." Discussed by Drs. H. G. 
Perry, Montgomery; W. W. Harper, Selma; E. V. Caldwell, 
Huntsville ; J. P. Chapman, Talladega ; J. P. Stewart, Attalla ; 
T. A. Casey, Birmingham ; Paul P. Salter, Montgomery ; W. H. 
Oates, Mobile. 

Adjourned at 5 :66 p. m. 



SECOND DAY, WEDNESDAY, APRIL 18. 
Evening Session. 

This session was held at the Grand Theater, and was called 
to order by the President at 9 :30 p. m. 

The President: Ladies and gentlemen, while we feel dis- 
appointed at the smallness of the crowd here, still we feel that 
the magnificent patriotic celebration that we have just wit- 
nessed makes up for any disappointment that we may suffer 
here. Without further ado I will introduce the first speaker 
of the evening, my fellow town.sman, Dr. M. S. Davie, of 
Dothan. 



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62 THE MEDICAL ASSOCIATION OF ALABAMA. 

Dr. Davie delivered an address on "The Humanitarian As- 
pect of Scientific Medicine." 

(For Address see Part II.) 

The President: Ladies and gentlemen, it is my very great 
pleasure to introduce Major Bevans, of the Medical Depart- 
ment of the United States Army, who will speak to us on 
"Medical Preparedness." 

(For Address see Part II.) 
Adjournment. 



THIRD DAY, THURSDAY, APRIL 19. 

Morning Session. 

Called to order by the President at 9 :10. 
Dr. M. B. Cameron, Eutaw: I desire to introduce a reso- 
lution which carries with it an amendment to the Constitution : 

WhereaSy The administration of the public health affairs is of great 
Importance to every section of the State and is rapidly increasing 
as the public is educated to a proper support of it; and 

Whereas, Such administration is almost entirely in the hands of 
the Board of Censors, composed of ten members, a majority of whom 
are generally elected from only three counties in the State, the selec- 
tion of whom is often influenced by the selection of other officers of 
the Association occurring at the same time; and 

Whereas, The unequal distribution of the members of the Board 
of Censors is unfair to other portions of the State, and not to the 
best interests of the health of the general public : 

Be It Resolved, That Article 30 of the Constitution of the Medical 
Association of Alabama be amended to read as follows: 

Article 30. The President shall be elected for one year, the Vice- 
President for two years, in such way as that one vacancy only will 
occur annually by expiration of official term ; the Treasurer for five 
years; the Secretary for five years; the Censors for five years In 
such way that two vacancies will occur annually by expiration of 
official term. 



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PROCEEDINGS. 63 

One Censor shall be elected from each Congressional district, and 
they shall be elected from the districts where vacancies exist In 
numerical order of the districts as vacancies occur In the Board of 
Censors. 

The Secretary of the Association shall on the second day of each 
annual meeting of the Association announce from what Congres- 
sional districts vacancies will occur, and the delegates and counsellors 
from such Congressional districts shall hold meetings separately on 
the third day of each annual meeting and select, by majority ballot, 
the names of two counsellors from said districts and present them 
to the Association when the time comes for balloting for vacancies in 
the Board. The Association shall elect by majority ballot from the 
names submitted one of them to fill the vacancy on the Board from 
such Congressional district. 

Article 32. Officers must be elected by ballot, and without nomina- 
tion, except as indicated above. 

The resolution was referred to the Board of Censors. 

Dr. B. B. Simms, Talladega : Before you begin the reading 
of papers, there is a gentleman here from Talladega, Superin- 
tendent of the School for the Blind up there, and he would like 
to make a little talk so the doctors can understand those schools 
up there — Dr. Graves. 

Dr. Graves : Mr. President and Gentlemen : It is useless 
for me to take up time in explaining to this body the objects 
of this school, because it is killing time, and you all know it; 
but my object is this, to impress upon the minds of the Medical 
Association the importance of letting this school be known 
throughout the entire State. We are very anxious to get in 
touch with every deaf and blind child in the State, and it is 
very difficult, for this reason, because most of them are gen- 
erally in the rural districts, and they are generally of illiterate 
parentage, and they do not know anything about such a school. 
And frequently, too, we have applications to our school, espe- 
cially the deaf, to bring children there that are feeble-minded — 
and, by the way, we ought to have a school especially for feeble- 
minded children in this State. 

I have been working in this school for thirty-five years. 
When I came to Alabama we had about 40 or 50 children. This 
last year we enrolled 329 children, deaf and blind. We are 
probably getting most of such children in the school, but we 



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M THE MEDICAL ASSOCIATION OF ALABAMA. 

want all of them. The number of deaf children under instruc- 
tion now in the United States is about 15,000. These are from 
150 schools, State, sectarian and private. For the blind there 
are about 55 institutions which enroll about 4,400 students. 
You see from that that there are considerably more deaf chil- 
dren in the schools than there are blind, and yet there are more 
blind in the population of the United States than there are deaf. 
That is because over twenty-five per cent, of the blind become 
blind after they reach 21 years of age, and blindness is grad- 
ually decreasing, while deafness is not decreasing. I suppose 
if we had in Alabama today all the deaf and blind children of 
suitable age we would not have over 450 or 500 children. I 
know today twenty-five or thirty deaf children that ought to be 
in the school that are not. 

You understand that this school is supported by the State. 
The only things they have got to do is to provide for clothes 
and transportation, and after they finish school they are sent 
to Washington to the Gallaudet School. We have now two 
or three of our graduates attending the Gallaudet College, 
and we have recently organized an association for assisting 
the deaf and blind after they leave our institutions. 

Of course, you understand that most of us who have no 
capital whatever when we start out in the world are consid- 
erably handicapped, the blind and deaf especially, and we are 
trying to organize now help for such children as these. Sev- 
eral of our states have established such organizations, and we 
do not want Alabama to be behind. 

Now, I just want to say that if any of you physicians know 
of any deaf or blind children, come to me during the session 
and tell me about them so we can get in touch with them. I 
will probably visit most of those reported to me during the 
siunmer. Two years ago I was in Birmingham, and as a 
result of that visit we have today five or six children in the 
schools in Talladega that did not know anything about this 
school. Physicians told me about them and I visited the par- 
ents during the vacation. 

The Gallaudet College is supported by the general Govern- 
ment. It is named for Dr. Gallaudet. He was the founder and 
first principal of the first school for the deaf established in this 
country — and, by the way, it was established in Hartford, 
Conn., in 1817. They have just recently celebrated their one 



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PR0CBBDING8. 66 

hundredth anniversary, and his son is now Emeritus Principal 
of the school. This school is a college supported by the general 
Government, and graduates of the different schools for the deaf 
over the country are admitted by examination. The tuition 
and board are practically free; I think it costs them about a 
himdred dollars a year. The examinations are sent on to the 
different institutions, and the applicants are examined and then 
the papers are sent to Washington. They give them a regular 
academic course, and give them the degree of bachelor of arts 
and science, and they have also a course of normal training in 
the Gallaudet G^Uege where college graduates, or persons who 
can hear or talk, go there and receive instruction in teaching 
the deaf. 

There has been a great deal of change in the education of the 
deaf in the past few years. Fifteen or twenty years ago the 
oral method was considered almost a failure. Today nearly 
all of our institutions have the oral method. ' That is, they 
teach the deaf how to articulate. We take a deaf child there 
that cannot hear or talk and we teach them to articulate, and 
they by the motion of the lips can detect what you say. Al- 
though this was tried years ago— it is not new, because the 
first institutions that were established for the education of the 
deaf, one of them I think was in Glasgow, Scotland, used the 
oral method in connection with the manual method, over a 
hundred years ago. There are some schools, however, in this 
country that use the oral method entirely. But I do not think 
it is the best. Now I visited the Mt. Airy School for the Deaf 
in Pennsylvania a couple of years ago, and I had a class of five 
that the principal brought to me. Nearly all of them became 
deaf between five and twelve years of age, and I could carry 
on a conversation with them just like I could with you, but I 
asked them this question : When not communicating with the 
teacher at the school do you talk to each other, or do you write 
or use the sign method ? They said, "We use the sign method." 
So you see the oral method cannot supercede the manual. So 
we use both. Very often if a child comes to the school after 
he is twelve or fifteen years old it is impossible to teach him 
the oral method, but very often a person becomes deaf after 
reaching the age of forty-five or fifty, and they have been 
taught to read lips. I know there is a school for teaching the 

IM 



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06 THE MEDICAL A8B0CIATI0N OF ALABAMA. 

adult lip reading in Boston now, and I think it has been very 
satisfactory. 

Dr. M. B. Cameron, Eutaw: I think I would be recreant 
in my duty to the people of Alabama, and especially to the 
blind and deaf if I did not follow Dr. Graves and say some- 
thing about the institution at Talladega. It was my misfor- 
tune a great many years ago to be a member of the Legisla- 
ture of Alabama. During that term the President came up 
and asked for an appropriation, and as usual Alabama was very 
short of funds. Nevertheless, he prevailed upon the Legisla- 
ture to appoint a committee to go down there and investigate 
the school and make a report. I, for some cause or another, 
was selected as a member of that committee. My idea of the 
school at Talladega was the idea I had of the old field school 
that I attended when I was a boy eight or ten years old. I 
thought it was a wooden structure, probably with inferior 
teachers, and not much attention paid to instruction. I endeav- 
ored to get out of going there, but Dr. Johnson got me by the 
arm, put me on the train and kept me there a couple of days. 
It was a revelation to me. 

There isn't any more important thing to the people of Ala- 
bama today than this deaf and blind institution. Every child 
in the State that is deaf or blind has a privilege that is a boon 
that cannot be afforded in any other way. What did I see 
there? I saw a splendid institution, great and grand build- 
ings, with capable teachers, with an atmosphere of love sur- 
rounding the teachers and pupils that surprised me. Those 
teachers would walk out in the grounds with the children to 
meet them, and the children would run around them and grasp 
their hands. It showed there was something there besides 
instruction. I saw instruction there, not only from a literary 
standpoint, but from an industrial standpoint. They are taught 
everything, how to read and write and other things from a 
literary standpoint, and the deaf are taught draughting, print- 
ing, etc., and the blind are taught a great many things that they 
can do in after life. 

Now the State of Alabama educates every blind and every 
deaf child free of charge t6 its parents, and yet you find parents 
who are recreant to their duty and will not send them there. 
And this institution teaches them thoroughly, and the child 



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PROCEEDINGS. 07 

that comes away from Talladega is equipped to go out into the 
walks of life and do its duty as a citizen. (Applause.) 

Dr. Simms: ^I have been in Talladega a good long while, 
and understand these schools. Did any of you ever think 
about how dependent and what a nonenity you would be if you 
were bom deaf ? Suppose you had never heard a word in your 
life, where would you be, what could you do? Now that is the 
way the children come there, a great many of them are born 
deaf, and they have never heard a sound. You cannot imagine 
how dependent those children are. They soon have them talk- 
ing and reading after they go there. And those children grow 
to be farmers and dairymen ; in other words, they are of some 
use, they are not dependents, they are able to take care of 
themselves and make a living. 

Just to tell you one incident. I saw a little fellow there once 
who had been there a month or so. He had learned to say 
only a few words. He had learned what a baby was, and what 
a fly was. He was sitting at a window looking out. A gnat 
got on the window. I asked him what it was. He says, "It's 
a baby fly." 

Dr. Graves : May I add one word more ? I have been liv- 
ing in Alabama thirty-five years, and I never have met with, 
seen or heard of any one that ever did hear of a deaf tramp 
beggar who had been to the Talladega school. Now I think 
that is remarkable. I have met with several impostors, who 
protended to be deaf but were not, and I exposed them. 

Dr. John A. Lanford, New Orleans, read a paper on "The 
Value and Limitations of Blood Examinations." Discussed by 
Drs. J. S. Turbeville, Century, Fla. ; W. W. Harper, Selma ; 
W. A. Sellers, Montgomery ; W. R. Jackson, Mobile ; Dr. Lan- 
ford, closing. 

Dr. J. S. McLester, Birmingham, read a paper on the 
"Classification and Etiology of the Anemias." 

Dr. L C. Bates, Taylor, read a paper on "Chlorosis." 

These two papers were discussed by Dr. William C. Maples, 
Scottsboro. 

Dr. Chilton Thorington, Montgomery, read a paper on the 
"Differential Diagnosis and Treatment of the Leukemias." 

Dr. Fred W. Wilkerson, Montgomery, read a paper on 
"Hemophilia." 



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68 THE MEDICAL ASSOCIATION OF ALABAMA. 

These two papers were discussed by Drs. W. W. Harper, 
Selma; T. B. Hubbard, Montgomery; H. S. Ward, Birming- 
ham; H. L. Castleman, Sylacauga; W. H. Minchiner, Troy; 
Drs. Thorington and Wilkerson closing. 

The Secretary: An ordinance of the Association requires 
the Secretary, on the morning of the third day of the session 
to make an announcement in regard to the filling of vacancies 
on the College of Counsellors. At this hour I cannot say def- 
finitely the number of vacancies that will occur, for the reason 
that unfortunately we have no regulation stating a time after 
which counsellors cannot register and be credited with attend- 
ance. So that if a counsellor comes in and registers at the last 
moment on Friday morning under our present rules he has to 
be credited with attendance at the meeting. 

We have looked carefully over the list of counsellors, and it 
appears that there will be six vacancies. One counsellor has 
died. One counsellor at this meeting will be advanced to the 
roll of life counsellors. Two counsellors have failed in attend- 
ance, and one in dues. At the present time, according to the 
estimates made and published in the last Transactions, the 
counsellors are distributed among the districts as near as pos- 
sible so that there will be an equal number in each district as 
compared with the number of members in that district. Leav- 
ing out now the corrections that will be made, this is the way 
they stand: The first district has one less than its number; 
the second district has one less ; the third district has the num- 
ber to which it is entitled; the fourth district has one more 
than the number to which it is entitled; the fifth district has 
four less than the number to which it is entitled ; the sixth dis- 
trict has two more, the seventh district has two less ; the eighth 
district has the proper number; the ninth district has one 
more ; the tenth district has one less than the number to which 
it is entitled. 

Counsellors who have been dropped will make vacancies to 
occur as follows and elections will have to be provided for in 
the districts named: 

In the second district, owing to the fact that Dr. R. N. Pitts 
has failed in attendance for three years, there will be one 
vacancy. As that district has now one less than the number 
to which it is entitled the vacancy will be filled from the second 
district. 



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PROCBBDINGS. 60 

There are no vacancies occurring from the dropping of mem- 
bers in the fifth district, but inasmuch as the record shows that 
the fifth district has four less counsellors than it is entitled to 
and in an eflFort to equalize the districts, two of the vacancies, 
produced by the advancement of Dr. Wyman of the tenth, to 
the rank of Life Counsellor, and the death of Dr. Monette in 
the sixth, will be filled by members of the fifth district. 

The seventh district at present has two less than the number 
to which it is entitled. The number is reduced one further by 
the probable dropping of Dr. Baird for non-attendance, so that 
vacancy will be filled from the seventh district. 

The eighth district at present has the number to which it is 
entitled. However, Dr. Howard, of Madison county, will be 
dropped for non-attendance unless he shows up by tomorrow 
morning, which will leave one vacancy in that district, and it 
will be filled from that district. 

The principle upon which this distribution is made is this, 
that wherever a district is below the number to which it is en- 
titled an effort will be made to give that district its normal 
number, and vacancies occurring in that district or in other 
districts will be filled in the order of the districts that are low- 
est in the number of counsellors. 

The delegates and counsellors, present at this meeting from 
each Congressional district constitute a nominating committee, 
and delegates and counsellors from the second, fifth, seventh 
and eighth districts should make arrangements to get together 
today. If you will by concert of action designate an hour I 
will announce the time at which you will meet to make your 
nominations. Those nominations, of course, will be subject 
to whatever changes may occur by the coming in of any of 
these gentlemen who may be dropped for non-attendance. 

The President : You have heard the notice of the Secretary. 
Govern yourselves accordingly. 

Dr. W. S. Britt, Eufaula, read a paper on "The Use of Oxy- 
tocics in Labor." Discussed by Drs. R. J. Griffin, Moundville ; 
W. C. Maples, Scottsboro; H. G. Perry, Montgomery; Dr. 
Britt closing. 

Dr. W. A. Gresham, Riissellville, read a paper on "Puerperal 
Eclampsia." 

Dr. R. S. Hill, Montgomery, read a paper on "The Cause 
and Management of Puerperal Eclampsia." 



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'70 THE MEDICAL AB80CIATI0N OF ALABAMA, 

These two papers were discussed by Drs. W. R. Jackson, 
Mobile; M. C. Thomas, Blocton; L. C. Morris, Birmingham; 
Dr. Hill, closing. 

At 1 :05 p. m. the Association adjourned until 2 :30. 



THIRD DAY, THURSDAY, APRIL 19, 
Afternoon Session. 

Called to order by the President at 2 :30. 

Dr. Daniel T. McCall, Mobile, read a paper on "Simplified 
Artificial Feeding." 

Dr. J. H. Fellows, Pensacola, Fla., read a paper on "Acidosis 
in Infants and Children." Discussed by Dr. J. L. Bowman, 
Union Springs; Dr. Fellows closing. 

Dr. W. F. Betts, Evergreen, read a paper on "Morbidity 
Following Confinement." Discussed by Drs. T. B. Hubbard, 
Montgomery; T. J. Btothers, Anniston; L. A. Jenkins, Bir- 
mingham; L. R. Stone, Taff; J. L. Snow, Montgcwnery; Dr. 
Betts closing. 

Dr. J. U. Ray, Woodstock: I do not know how many of 
you have missed a man who has not missed a meeting of this 
Association for I do not know how many years. I know how 
busy you all have been in this hall in the scientific part of the 
meeting. But in the midst of it all I could not help missing 
this fine old war horse of the Alabama State Medical Associa- 
tion. So I decided during the lunch hour to practice what I 
preach, and that is to give a man some bouquets while he is 
living, and I have just had the pleasure of carrying up to Dr. 
W. H. Sanders a box of flowers from the Medical Association 
of the State of Alabama, and I also took the register and had 
the doctor sign his name as present at this meeting. And now 
I ask confirmation of this action by this Association. 

Dr. W. W. Harper, Selma: Mr. President, I move we 
confirm this action by a rising vote. 

Seconded and carried unanimously. 

Dr. Ray: I wish to say that Dr. Sanders asked me to ex- 
press his appreciation. He said, "Doctor, please express to the 
Association my very deep appreciation of this most elegant and 
timely remembrance." 



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PRQCBBDiyOS. 71 

Dr. Harris P. Dawson, Montgomery, read a paper entitled, 
"The Lactating Woman, Her Care, Diet and Hygiene." Dis- 
cussed by Drs. W. W. Harper, Selma; J. L. Bowman, Union 
Springs ; J. H. Fellows, Pensacola, Fla. ; Dr. Dawson, closing. 

Adjourned at 4 :25 p. m., in order that the members might 
enjoy the ride provided by the Chamber of Commerce, Rotary 
Club and the local doctors. 



THIRD DAY, THURSDAY, APRIL 19. 
Evening Session. 

Called to order by the President at 8 :16 p. m. 

Dr. W. C. Gewin, Birmingham, read a paper on "Surgical 
Operation During Pregnancy." Discussed by Drs. W. R. 
Jackson, Mobile; Watkins, Montgomery; Caldwell, Hunts- 
ville ; Dr. Gewin, closing. 

Dr. F. W. Young, Hartford, read a paper entitled, "Head- 
ache." Discussed by Drs. H. S. Ward, Birmingham; A. L. 
Nourse, Sawyerville; Scale Harris, Birmingham; C. S. Chen- 
ault, Albany; Dr. Young, closing. 

Dr. B. B. Roganj Selma, read a paper on the "Treatment of 
Drug Habits." Discussed by Drs. W. B. Partlow, Tuscaloosa ; 
and Rogan. 

Dr. Walter A. Weed, Birmingham, read a paper on "The 
Present Status of the Local Application of Radium and 
X-Rays." Discussed by Drs. L. C. Morris, Birmingham; 
Marye Y. Dabney, Birmingham ; Dr. Weed, closing. 

Dr. Marye Y. Dabney, Birmingham, read a paper on "Vicar- 
ious Menstruation." Discussed by Drs. W. P. McAdory, Bir- 
mingham ; L. C. Morris, Birmingham ; Dr. Dabney, closing. 

Dr. D. C. t)onald, Birmingham, read a paper entitled, "Acute 
Ileus Following Abdominal Operations, with Report of Cases." 
Discussed by Drs. W. C. Gewin, Birmingham; W. P. Mc- 
Adory, Birmingham; W. R. Jackson, Mobile; Dr. Donald, 
closing. 

Adjourned at 11 :20 p. m. 



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72 THE MEDICAL ASSOCIATION OF ALABAMA. 

FOURTH DAY, FRIDAY, APRIL 20. . 
Morning Session. 

Called to order by the President at 9 a. m. 

Dr. Welch: Dr. Joe Graves, of Talladega, is here, repre- 
senting the schools for the deaf and blind. He would be glad 
if every doctor in Alabama would send him the names of all 
the deaf and blind children that they know of in their respec- 
tive places of residence. 

Dr. Graves : I would just state that if any of the doctors 
know of any deaf or blind children they can give me the names 
and addresses of the children while I am here, and I will com- 
municate with them, and I would request the health oflficers 
of each county to send us those names, but especially any doc- 
tors who are here would give me these names. I will be in the 
hall all morning. 

The President : Dr. Graves also desires that the health oflfi- 
cers of the State should be requested to give him this informa- 
tion. He would appreciate it very much if the health oflficers, 
both municipal and county, would keep their eyes open and 
make a note of it and send him these names from time to time. 
I hope if there are any health oflficers present they will keep 
this in mind. 

Dr. Perry : I move that this Association request all health 
oflficers to make a list of the deaf and blind in their respective 
counties, make some eflfort to find out about them and to fur- 
nish the names of all such to the institution. 

The motion was seconded. 

The President: I suggest that the registrar send these to 
the health oflficers. 

Dr. Perry: We will gladly do that We will get out a cir- 
cular letter and send to every one of them. 

The motfon was carried. 

The President; The next order of business is the report 
of the Board of Censors. 



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REPORT OF TEW BOARD OF 0BN80R8. 78 



FORTY-FOURTH ANNUAL REPORT OF THE STATE 
BOARD OF CENSORS, INCLUDING REPORTS OF 
THE STATE BOARD OF MEDICAL EXAMINERS 
AND OF THE STATE COMMITTEE OF PUBLIC 
HEALTH. 

The Board begs to submit this, its forty-fourth annual re- 
port. 

The President's Message. 

The President has briefly and with much good taste brought 
to our attention a number of interesting topics. The discussion 
of the prevalence of malaria in southeast Alabama is both timely 
and commendable. 

First Recommendation. The President recommends that at 
least one paper on the prevailing diseases be read at each annual 
meeting and that the Registrar of Vital and Mortuary Statistics 
be appointed to read this paper. We heartily agree with the 
spirit of this suggestion and recommend its adoption. 

The President here alludes to the retirement from active 
service of our beloved State Health OflFicer, Dr. Sanders, and 
bespeaks for his successor the hearty cooperation and support 
of the doctors of the State. Indeed, a great calamity has be- 
fallen us in the retirement and resignation of our beloved and 
peerless leader. Ill health has forced him from the active 
direction of the affairs of the Association, but he yet lives to 
counsel and advise. Let us hope that his example of loyalty 
and devotion to the Association will prove an inspiration to 
those of us who come after him and compel us to greater ac- 
complishments as the years go by. 

Second Recommendation, The President next mentions the 
evils which follow as a consequence of employment of ineffi- 
cient midwives. The mortality and morbidity among infants 
and mothers is. much too high. 

He calls attention to a resolution introduced at the last meet- 
ing of the Association from the Houston County Medical So- 
ciety and recommends that a coinmittee on the prevention of 
blindness be appointed by this Association. The Board recom- 
mends the adopticm of this recommendation. 



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T4 THE MEDICAL ASSOCIATION OF ALABAMA, 

Third Recommendation. The President also endorses the 
movement to secure proper care and training for the defective 
and feeble-minded children of the State. The State Health 
Officer has been in correspondence with a gifted woman of 
Alabama on this subject, and the hope is indulged that a private 
institution of this nature will be established in the not distant 
future, and it is hoped it will serve as a nucleus for the building 
of larger things. The Board heartily endorses this portion of 
the President's message. 

Fourth Recommendation. The Board especially commends 
that part of the message which discusses the election 
of county health officers. A health system with the 
county as a unit would seem an ideal proposition, but if 
an inefficient man be chosen to lead in the work we are 
courting failure. The suggestion of the President that the 
county health officer be selected by the Board of Censors has 
merit, but it must be borne in mind that the law provides the 
method by which county health officers are elected. Each 
society possesses the authority to appoint the Board of Censors 
a committee to select for them a ocunty health officer, reserving 
the right to accept or reject such selection as they may deem 
expedient. This would appeal to the Board as a most excellent 
method of procedure. 

Fifth Recommendation. The President brings to our at- 
tention the subject of social health insurance and tenta- 
tively gives expressions to some broad and timely views 
on the subject. The Board feels that this is one of the 
problems of the future which should commend itself to 
the sober consideration of every thinking man. We 
heartily commend the President for calling the attention of 
the Association to this very important subject. The President, 
in response to a request from the committee of the American 
Medical Association, appointed a committee to report on social 
insurance at this meeting of the Association. This action of 
the President, while in line with progress and the needs of the 
hour, was somewhat out of order; it being the work of the 
Association alone to provide for committees. The Board, 
therefore, recommends that a standing committee be appointed 
to investigate the subject of social insurance and report its 
findings from time to time to the Association. 



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REPORT OF THE BOARD OF CENSORS. 76 

The Minutes of the Meetings of ipi6. 

The Board has examined the minutes of the meetings of 
1916 and finds them correct. The Board, therefore, recom- 
mends that the minutes as printed in the volume of the Trans- 
actions of 1916 be approved. 

Report of Senior Vice-President. 

The Board wishes to commend to the consideration of the 
members of the Association the report of the Senior Vice- 
President. His work has been carefully and conscientiously 
done. The Board recommends that the work of the Senior 
Vice-President during his official term be endorsed and in- 
dulges the hope that he may be spared many years in which he 
may render in the future as in the past conspicuous service 
for the Association. 

Report of Junior Vice-President. 

The report of the Junior Vice-President gives evidence of 
much labor and painstaking care in the discharge of the duties 
incumbent upon him. The successful efforts of the Junior 
Vice-President in the year just closed will make him more 
efficient in prosecuting the work in the office of Senior Vice- 
President, to which office he now succeeds. We bespeak for him 
your hearty cooperation in his work during the coming year. 
The Board recommends that the Vice-Presidents be directed 
to aid the Treasurer in collecting the unpaid dues from such 
counties as are delinquent. 

Books and Accounts of the State Health Officer. 

A standing committee appointed by the Board has examined 
the books and accounts of the State Health Officer for the fiscal 
year ending September 30, 1916, and through the term of Dr. 
Sanders, ending January 23, 1917. The Board finds that all 
the accounts are correct and the vouchers neatly filed. The 
Board, therefore, recommends the approval of these accounts. 

Book and Accounts of Treasurer. 

A sub-committee of the Board has examined the accounts of 
the Treasurer. The Treasurer has called attention to the fact 



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76 THE MEDICAL AB80CIATI0N OF ALABAMA. 

that more than 300 doctors have failed to pay theif 1916 dues, 
thereby causing a technical deficit in the income of the Associa- 
tion. 

A number of counties also have failed to settle in full their 
dues to the Association. The Board recommends that the 
Treasurer be directed to collect these outstanding obligations to 
the Association and failing to do so, he shall report to the 
Association at the next meeting, for publication in the Trans- 
actions such counties as are delinquent. 

The Report of the Secretary. 

The report of the Secretary has been found interesting and 
complete. The Board recc«nmends its approval. 

Report of the Publishing Committee. 

The report of this committee furnished the information cov- 
ering its work for the past year. The Board recommends its 
approval. 

Report of the Council on Nosology, 

The Board has reviewed the report of the Council on Nosol- 
ogy, made by its chairman, who is also the Registrar of Vital 
Statistics. The report covers the subject, and should be read 
by every member in order that a correct nosology shall be 
maintained. The Board recommends the adoption of the re- 
port. 

Report of Council on Phctrmacy. 

The report of the Council on Pharmacy is both interesting 
and comprehensive. The hope is indulged that every member 
of the Association will read this report. This report meets the 
hearty approval of the Board and we recommend its adoption. 

Committee on Mental Hygiene. 

The work of the Committee on Mental Hygiene has been a 
conspicuous feature of the work of this Association for the past 
two years. It is confidently believed that out of the investiga- 
tions of this committee great good will be achieved towards the 
amelioration of the unfortunate conditions of the class of defec- 



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REPORT OF THE BOARD OF CENSORS. 77 

tives which they are seeking to serve. The Board warmly 
endorses the report of this committee. 

At the January meeting of the Board Dr. Sanders offered 
his resignation as State Health Officer. Dr. S. W. Welch, of 
Talladega, was elected as his successor. There was some 
doubt in the minds of the Board, as to whether or not he was 
elected to fill the unexpired term of Dr. Sanders. On motion 
of Dr. Andrews the ruling of the Attorney General was sought. 
The Attorney General ruled that the present health officer was 
elected for a term of five years beginning January 23, 1917, 
there being no unexpired term to be filled. The opinion of the 
Attorney General is hereto attached (see p. 116). The Board 
recommends that its action in electing Dr. Welch State Health 
Officer be now ratified by the Association. 

About the first of April a letter was received from Secretary 
of the Navy Josephus Daniels, notifying the Board that men 
in the senior classes of Class A. medical schools were being 
called to the colors for service in the Medical Reserve Corps of 
the Army and Navy. The Secretary wished to know if the 
failure on the part of these young men to take their full four 
years' course as now required by this Board would operate 
against them in the event that they wished at a subsequent 
date to apply for examination before the Medical Examining 
Board of Alabama. A short time after this, numerous letters 
from medical institutions in different parts of the country were 
received, stating that the institutions planned to begin the 
fourth year's term the first of June, graduating the present 
junior class next January. Inquiry was made as to whether 
men graduating in this extraordinary term would be eligible 
for examination should they appear before this Board at a 
subsequent date. The Board has ruled that all disabilities of a 
technical nature arising from an extraordinary measure calling 
men to the colors should be removed. The Secretary of the 
Navy and all institutions of learning have been notified of this 
action. 

It will be recalled that at the meeting last year, in Mobile, 
the Association elected Dr. W, W. Dinsmore to the office of 
State Prison Inspector. This action was taken upon legal 



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78 THE MEDICAL ASSOCIATION OF ALABAMA, 

advice obtained by the Board at the time, and also in accord- 
ance with the provisions of the law creating the oflfice. The 
election was held last year for the reason that the term of office 
of the State Prison Inspector would expire before the next 
annual meeting of the Association. 

For the information of the Association it may be explained 
that Dr. Dinsmore has duly qualified for the office, having filed 
a bond and taken the oath of office, as prescribed by law. He 
has, therefore, already officially taken charge of the work and 
has gotten it well under way ; and there is every reason to ex- 
pect it to go forward now with increased efficiency and to the 
best interest of the State. 

The Board has large responsibility to the State in this work, 
and it is very important that there shall be no question as to the 
legality of the election which was held last year. In order, 
therefore, to remove any doubt on this point which may have 
arisen, or which might arise later, the Board submits the fol- 
lowing resolution and recommends its adoption. 

It may be explained that this resolution has been submitted to 
the Attorney General and he has advised that it is in legal form 
and entirely covers any technical questions which may arise. 
The resolution is as follows : 

Whereas, Dr. W. W. Dinsmore was elected State Prison Inspector 
at the last annual meeting of this Association for a term of six 
years beginning April 8, 1917; and, 

Whereas, in order to remove any technical question as to whether 
said election should have been held at that meeting or at the present 
meeting of the Association ; 

Therefore, Bt It Resolved, That this Association does now ratify 
and confirm the action of the last meeting in selecting Dr. Dinsmore 
as State Prison Inspector; and does now, by the adoption of this 
resolution, elect Dr. Dinsmore State Prison Inspector for the term 
of six years, beginning April 8, 1917, in accordance with the provi- 
sions of the law creating said office. 

A statute governing reciprocity was passed by the last Legis- 
lature. The time has not seemed propitious until now, to formu- 
late rules for reciprocal relations which should be established 
between this Board and the boards of other states. The Board 
of Medical Examiners has adopted the following plan under 



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REPORT OF THE BOARD OF CENSORS. 79 

which reciprocal relations may be established with all of the 
states : 

ALABAMA STATE BOARD OF MEDICAL EXAMINERS. 

BULES GOVERNING BECIPROCITT. 

The Alabama Board of Medical Examiners, where applicants are 
licensed in other states which have reciprocal arrangements consid- 
ered by this Board of substantially equal liberality with the conditions 
and requirements stated below, will admit to practice, without exami- 
nation, applicants licensed in other states who comply with the follow- 
ing conditions and requirements : 

1. All applicants for registration without examination must submit 
credentials in writing on blank forms furnished by the Board, said 
credentials to be filed with the Chairman of the Board not less than 
two weeks in advance of the semi-annual meeting at which the appli- 
cation is to be acted upon. 

2. An applicant whose credentials appear satisfactory will be so 
notified and will be required to appear in person before the Board 
at Montgomery, Alabama. 

3. An applicant must submit proof that he is a legally licensed 
physician in the State from which he applies ; provided that satisfac- 
tory proof is furnished that he has obtained a license to practice medi- 
cine from the State Board of Medical Examiners of a State with 
which this Board reciprocates; provided also that he has practiced 
medicine for at least two years prior to his application to this Board. 
He must also present proof that he is a member in good standing of 
his State Medical Association or Society. 

4. No applicant will be considered who has at any time failed in an 
examination before this Board. 

5. Applicants for registration without examination shall be re- 
quired to pay a fee of $50.00. 

6. Applicants who graduated in 1907, or prior thereto, must submit 
In writing full particulars in regard to their pre-medical and medical 
education. In the case of this group of applicants. the Board ex- 
plicitly reserves the right to accept or reject the applicant as sp^lai 
circumstances ai;id conditions may dictate. , . 

.7. Applicants who graduated in medicine, in th^.ye^rs .;1909 tp 
1913, inclusive, must present satisfactory evidence of having Jjaj^ 



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80 THE MEDICAL ASSOCIATION OF ALABAMA. 

a pre-medlcal course which shall have Inclnded four years of hl^ 
school and at least two years In a reco8:nized college, or the equiva- 
lent of such a course, and must also present a diploma showing grad- 
uation from a Class A. Medical School according to the classification 
of Medical Schools hy the Ck>uncll on Medical Education of the 
American Medical Association. 

8. Applicants who graduated in medicine in 1914 and subsequent 
thereto must present satisfactory evidence of having earned a pre- 
medlcal degree of B. S. or its equivalent from an accredited school 
conferring such degrees ; also evidence of having served an internship 
of at least one year in a recognized hospital after graduation from 
medical school. 

9. All applicants must file a duly certified certificate of good moral 
character, said certificate to be furnished on blank form supplied 
by this Board. 

An applicant's credentials shall consist of the following : 

a. Written application giving full name, age, date, and place of 
birth, residence, and two unmounted photographs of applicant 

b. Certificate of good moral character signed by two physicians 
in good standing, and one prominent layman of the community in 
which the applicant has practiced. 

c. Certificate giving full particulars concerning applicant's pre- 
medical education, said certificate to be duly signed by the school or 
college authorities authorized to sign such certificates, and duly 
sworn to before a notary public. 

d. Certificate signed by the Dean of the medical school from which 
applicant graduated stating date of graduation, said certificate to be 
stamped with the seal of the college. 

e. Statement from the Secretary of the State Medical Association 
or Society, certifying that applicant is a member in good standing of 
said Association or Society. 

f. Statement from the Secretary of the State Board of Medical 
Examiners or State Licensing Board certifying that applicant has 
been legally engaged in the practice of medicine at least two years 
prior to date of application to this Board, said certificate to be signed 
and sealed by a notary public. This certificate must embody the 
subjects in which the applicant was examined, also the grades 
awarded on the several branches. 

g. An afTidavit stating thai applicant, if licensed, will become a 
bona fide resident of this State, and stating place of intended resi- 
dence. 



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REPORT OF THE BOARD OF CENSORS, 81 

Intensive Community Work, 

The International Health Board proposed to the State Board 
of Health some years ago to donate an equal amount of money 
as that appropriated by the State Board of Health for what is 
known as intensive community work. This was conditional on 
the counties in which the work was done appropriating a stipu- 
lated sum of money to meet the appropriated sums from the 
International Health Board and the State Board. There was 
never enough money available for the State Board to finance its 
part of the proposition. Negotiations have been recently re- 
opened. It was found that there was not money enough at the 
disposal of the Board to finance the proposition. The health 
officer explained the financial condition of the Board and the 
work to be done, to his friend, Hon. H. L. McElderry, of Tal- 
ladega, requesting him to make an effort to interest his sister, 
Mrs. L. A. Jemison, a benevolent lady of Talladega, in the 
work. Mrs. Jemison very promptly donated $500.00, which 
sum will enable the Board to prosecute the work. Sufficient 
funds to begin the work in DeKalb county have already been 
contributed by Mr. W.B. Davis, of Fort Payne. It is neces- 
sary to obtain two units before the International Health Board 
will be willing to undertake the work. Efforts will be made to 
secure the other unit in northeast Alabama at the earliest pos- 
sible moment with the view of beginning the work by the first 
of May. 

The rapid evolution of public health and welfare work in the 
last few years has found its expression in various methods suc- 
cessfully in operation in different states. In view of this fact 
it was thought wise by the Board that the State Health Officer 
should visit the states of Virginia and North Carolina for the 
purposes of studying the methods employed in these states in 
their public health work. It is now the purpose of the State 
Health Officer to visit these states in the very near future. 

Quoting from the Transactions of 1916 : 

Contract Practice. 

"At the last meeting of the Association the question of contract 
practice came up for consideration, it having been brought forward 
through a report from the Jefferson County Society. 

eM 



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82 THE MEDICAL ASSOCIATION OF ALABAMA. 

By this report the Association was informed that the present ordi- 
nance is being violated by members of the Jefferson Ounty Society, 
the chief violations seeming to be as follows: 

1. Contract based on nationality, under which medical service is 
rendered members o*f a society or organization for a monthly stipend 
from each member. 

2. Contract made directly with employees of a corporation or 
manufacturing establishment, collections being made directly from 
employees, the corporation or manufacturing establishment itself 
talcing no part in the contract 

3. Contract by which employees are assessed, a physician employed 
at a salary and required to attend all persons on the list, whether 
salaried officials or managers or ordinary employees. Corporations 
or manufacturing establishments may retain whatever part they 
choose of the amount raised by assessment beyond that which is 
necessary to pay the salary of the physician. 

4. Contract that fails to define who are included under the term 
'employees,* that is, fails to define whether this term include man- 
agers and salaried officials, or not 

5. Contract that fails to define who are included under the term 
'injured,' that is, whether this term includes salaried officials and 
managers or not 

6. Contract by which hospitals furnish for a monthly stipend hospi- 
tal attention to persons, whether these persons be laborers or salaried 
officials and managers. It appears that the attending staffs of physi- 
cians of these hospitals render medical and surgical attention to all 
of the beneficiaries, rich and poor alike, without remuneration." 

After carefully considering the question of contract practice 
in all of its phases the Board believes that the best interests 
of the Association will be conserved by re-affirming its former 
rulings on this subject and reiterating its pronouncement found 
on page 43 of the Compend, and on pages 129 to 137, inclusive, 
of the Transactions of 1916. 

The following resolutions introduced by Dr. Scale Harris at 
the last meeting of the Association were introduced too late to 
be acted upon by the Board, They read as follows : 

Harris Resolutions. 
WhereaSy with the exception of three or four States, every State 
medical association in the United States publishes its owxi State 



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REPORT OF THE BOARD OF CENSORS. 88 

Jonrnal, which Journals are apparently successful financially, and aid 
in keeping up interest in organized medicine in those States : 

There fore. Be It Resolved, First, That a committee of five con- 
sisting of the Secretary, the President and three members of the 
State Board of Censors be appointed to inyestigate the advisa- 
bility of establisliing a State journal to be owned and controlled by 
the Medical Association of the State of Alabama, with the Secretary 
as editor and manager of such Journal; 

Second, That if the committee finds it practicable to establish the 
journal that the Transactions as now published be discontinued and 
published in said State Journal; 

Third, That the Association appropriate the funds now used for 
defraying the expense of the Transactions towards the maintenance of 
the State journal, providing such Journal is established; 

Fourth, Tliat the Secretary's salary be increased because of his 
services as editor when the Journars finances will warrant payment 
of a salary; 

Fifth, That the committee, if it finds the establishment of a State 
Journal practicable, be empowered to take the necessary steps towards 
establishing such a journal at once. 

The Board is heartily in sympathy with the spirit of the 
resolutions and feels that sometime in the near future it will be 
advisable to undertake such a work as is herein advocated. It 
does not agree that the Transactions should be discontinued, 
because they serve as the best method of keeping the records 
of the organization, but it does agree that a journal would be a 
great help to our work, could it be financed. In view of the 
fact that so many other things are projected by the Board for 
the incoming year it is deemed best not to take up this work at 
this time. We, therefore, advise that these resolutions be not 
adopted. 

Amendments to the Constitution Submitted By Dr. 
W. H. Sanders. 

At the last meeting of the Association various amendments, 
all looking to a general rearrangement of the provisions of the 
Constitution in reference to counsellors, were submitted by 
Dr. W. H. Sanders. It is the opinion of this Board that the 
rearrangement proposed by these amendments should be modi- 



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84 THE MEDICAL ASSOCIATION OF ALABAMA. 

fied in some respects and in order to carry out these modifica- 
tions the Board submits the following amendments as substi- 
tutes for the amendments submitted by Dr. Sanders : 

Amend Sections 1 to 8, both inclusive, of Article VI by making 
tliem read as follows: 
Section 1. Ck)unsellors shall consist : 

(1) Of all "Permanent Members" of "The Medical Association of 
the State of Alabama" as it existed prior to the reorganization of 
1873; 

(2) Of all members of the College of Counsellors in good standing 
who were elected prior to the year 1917 ; 

(3) Of such members of county medical societies in affiliation with 
the Association as from time to time may be elected to the position 
of counsellor. 

Sec. 2. The counsellors, considered collectively, shall be denomi- 
nated the College of Counsellors, and shall be graded as follows : 

(1) Counsellors-elect; 

(2) Active Counsellors; 

(3) Life Counsellors. 

Sec. 3. Counsellors-elect shall consist of those members, or dele- 
gates, not theretofore having been counsellors, who have been elected 
to the position of counsellor — they occupying the grade of counsellors- 
elect until the end of the annual session of the Association at which 
they are elected and until they have qualified as active counsellors 
as provided in the next succeeding section, and forfeiting their posi- 
tion as counsellors unless prior to the beginning of the next succeed- 
ing annual session they qualify as active counsellors as provided in 
the next succeeding section. The status of a counsellor-elect so for- 
feiting his position shall be the same as If he had never been elected. 

Sec. 4. Active counsellors shall consist of those counsellors-elect 
who have qualified by notifying the secretary of their acceptance of 
the position of counsellor and signing the counsellor's pledge, and 
upon a revision of the Roll of Counsellors by the Association have 
been placed upon the Roll of Counsellors as active counsellors; of 
those who were junior counsellors or senior counsellors at the time 
the grade of active counsellor was established ; and of those who by 
re-election have been kept on or returned to said Roll as active coun- 
sellors. When a counsellor, or one who has once been a counsellor, 
is elected again he shall be entered 'upon the Roll of Counsellors with- 
out qualifying again. 



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REPORT OF THE BOARD OF CENSORS. 85 

Sec. 5. Life counsellors shall consist of those who were life coun- 
sellors at the time the grade of active counsellor was established and 
of those who, having served as active counsellors for twenty years, 
are transferred, upon a revision of the Roll of Counsellors by the 
Association, to the grade of life counsellor. They shall hold their 
positions for life, except as in this Constlttuion otherwise provided. 
The time during which an- active counsellor served as junior coun- 
sellor, or the aggregate time during which he served as junior coun- 
sellor and as senior counsellor, as the case may be, prior to the 
establishment of the grade of active counsellor shall be counted as 
part of said twenty years in his case. The word "year" when used 
in this article means the period from the end of one annual session 
of the Association to the end of the next annual session. In deter- 
mining when an active counsellor shall become a life counsellor, his 
first term shall count as seven years, and as beginning at the end of 
the annual session at which he was first elected, whether he qualified 
before or after the date of the expiration of said annual session. 

Sec. 6. In consideration of having served the Association for twenty 
years, and of having paid dues for that length of time, life counsel- 
lors,' although entitled to the same rights in, and owing the same 
allegiance to, the Association as other counsellors, shall be released 
from the payment of annual dues, and also from the obligation of 
compulsory attendance upon meetings of the Association, imposed 
upon other counsellors. 

Sec. 7. Counsellors shall be elected at regular annual sessions of 
the Association. The total number of active counsellors and coun- 
sellors-elect at any one time shall not exceed one hundred. The first 
term of a counsellor as an active counsellor shall begin at the end of 
the regular annual session of the Association at which hq is elected 
but he shall not exercise the prerogatives of an active counsellor 
until he has qualified as provided in Section 4 of this Article. His 
subsequent term or terms, if he should be elected to succeed himself, 
shall begin at the expiration of the preceding term. The terms of 
an active counsellor shall be seven years for the first term, seven 
years for the second term, if any, and six years for the third term, 
if any. But when an active counsellor who has ceased to be an active 
counsellor is re-elected an active counsellor he shall become an active 
counsellor at the end of the annual session at which he is re-elected 
for a full length term if he served the whole of his previous term 
and, if he served only a portion of his previous term, for such a 
number of years taken in connection with the number of whole years 



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86 TBEl MEDICAL ASSOCIATION OF ALABAMA. 

served in his previous term as will make a term of seven years if it 
is his first term, seven years If it is his second term, or six years 
if it is his third term ; and his whole years of service as an active 
counsellor under previous election or elections shall be counted in 
determining when he shall become a life counsellor. Active coun- 
sellors who have become such with the abolition of the grades of 
Junior counsellor and senior counsellor shall without re-election hold 
their positions as active counsellors continuously for, twenty years 
from the end of the annual session at which they were elected unless 
they forfeit their position. 

Sec. 8. Nominations for the position of counsellor must be made 
as follows : 

On the third day of each annual session, before the hour of adjourn- 
ment of the morning session arrives, the secretary shall report to the 
Association, by congressional districts, a list of vacancies known at 
that time to exist in the College of Counsellors and of vacancies to 
occur at the end of that annual session. The delegates and counsel- 
lors in attendance from the respective congressional districts in 
which vacancies have been announced shall assemble at the respective 
places and times previously agreed upon by the president and the 
secretary of the Association, and announced at the time the secretary 
makes said report, for the purpose of making nominations for such 
vacancies. Such of said delegates and counsellors as so assemble 
shall, ipso facto, be the nominating committee for their respective 
congressional districts and shall by a majority vote of those present 
in said respective meetings nominate from among the active counsel- 
lors whose terms will expire at the end of that annual session and 
the members of the Association who are not counsellors, such a num- 
ber of eligible members from among those residing in their respective 
congressional districts as corresponds with the number of existing 
and prospective vacancies announced therein by the secretary; and 
such nominations shall be reported forthwith to the Association. In 
the revision of the Roll of Counsellors should additional vacancies 
be announced nominations to fill such vacancies shall be made as 
nearly as practicable in the same way as is provided for above. 

Amend sections 11 and 12 of Article VI by making them read as 
follows : 

Sec. 11. An active counsellor moving out of the congressional dis- 
trict from which he was elected shall thereby, ipso facto, forfeit his 
position as a counsellor. 



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REPORT OF THE BOARD OF OENSORS. 87 

Sec. 12. No obligation shall rest upon counsellors or delegates to 
TOte for the nominees proposed by the committees, they being at lib- 
erty to vote for other eligible persons from the same congressional 
districts as the req;)ectiye nominees. 

Amend section 13 of Article VI by substituting for the words 
"House of Counsellors" therein the words "Ctollege of CJounsellors." 

Amend sub-section (3) of section 14 of Article VI by making it 
read as follows: 

(3) They shall, except as in this Constitution otherwise provided, 
hold their positions for the terms herein prescribed unless removed 
by death, resignation or impeachment or for neglect of duty. 

Further amend Article VI by striking therefrom section 15. 

Should the above amendments be adopted it will be necessary 
to amend the ordinance relating to the revision of the rolls and 
this Board, therefore, recommends the adoption of the follow- 
ing ordinance : 

An Ordinance to Amend Section II of An Ordinance Entitled 
"An Ordinance In Relation to the Revision of Rolls." 

Section I. Be it ordained by the Medical Association of the State 
of Alabama, That Section II of an ordinance entitled, ''An Ordinance 
in Relation to the Revision of the Rolls*' (See page 52 of the Com- 
pend) be amended so as to read as follows: 

Section II. The order of the Revision of the Roll of the Collie of 
Counsellors. 

(1) Be it further ordained. That in like manner and after due 
consultation the committee on the revision of the rolls shall prepare 
five lists or schedules of the counsellors of the association. The first 
list shall contain in alphabetical order under the heads of life 
counsellors and active counsellors the names of all such counsellors 
as have complied with the rules of the Association in regard to at- 
tendance and dues, and against whom no charges are pending. The 
second list shall contain in like order the names of all such counsel- 
lors as may be delinquent in attendance or in dues, or against whom 
charges may be priding. The third list shall contain the names of 
all such counsellors as may have died since the last revision, or have 
offered their resignations, or have moved out of the State or out of 
their respective congressional districts. The fourth list shall con- 
tain the names of all active counsellors of twenty years standing. 



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88 THE MEDICAL ASSOCIATION OF ALABAMA, 

The fifth list shall contain the names of all counsellors-elect who have 
signed the pledge and paid the dues. 

(2) These five lists or schedules shall be designated, respectively, 
as follows: (1) The schedule of counsellors clear on the books; (2) 
The schedule of delinquent counsellors; (3) The schedule of miscel- 
laneous counsellors; (4) The schedule of active counsellors of twenty 
years standing; (5) The schedule of counsellors-elect who have 
signed the pledge and paid the dues. 

(3) That when the time arrives in the progress of the revision of 
the rolls for the secretary to call the roll of the college of counsellors 
he shall first call consecutively all the names on the first of the lists 
provided for above ; whereupon, the President shall say : You have 
heard the names of the counsellors just read hy the secretary and 
reported to he clear on the hooks. If there is no ohjection they tdll 
he passed. And the order shall be made accordingly. 

(4) Then the Secretary shall in like manner call all the names on 
the second list, provided for above; whereupon, the President shall 
say: You have heard the names of the counsellors just read hy the 
secretary and reported to he delinquent in their ohligations to the 
Association, Under the rules, and if there is no ohjection, these names 
will he struck from the roll of the college of counsellors, and of this 
they shall he duly notified hy the secretary. And the order shall be 
made accordingly. 

(5) Then the secretary shall in like manner call all the names on 
the third of the lists provided for above; whereupon, the President 
shall take such action in each case as may be appropriate under the 
circumstances. 

(6) Then the secretary shall call all the names on the fourth of 
the lists provided for above; whereupon, the President shall say: 
You have heard the list of names, as read hy the secretary of the 
active counsellors who have served as such for twenty consecutive 
years. Under the rules of the Association these counsellors are en- 
titled to he transferred to the roll of life counsellors. If there is no 
ohjection they toill he so transferred. And the order shall be made 
accordingly. 

(7) Then the secretary shall read the tLtth list provided for above; 
whereupon, the President shall say : You have heard the list of 
names as read hy the secretary of the counsellors-elect who have 
signed the pledge and paid the dues. Under the rules of the Associa- 
tion these counsellors-elect are entitled to he transferred to the roU 



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REPORT OF THE BOARD OF CENSORS. 89 

of €tctive counsellors. If there is no objection they tcUl he so trans- 
ferred. And the order shall be made accordingly. 

(8) Then the President shall say : Have all the counsellors been 
called T Is there anything else to he done in relation to the revision 
of the roll of the college of counsellors? And if there is nothing, he 
shall add: The revision of the second roll is here ended. The roll 
of the college of counsellors stands closed until the next annual session 
of the Association. 

The Board further proposes the following: 

An Ordinance to Provide far Giznng Notice of the Time and 

Places for Assembling of Delegates and Counsellors for 

Making Nominations for Vacancies in the College 

of Counsellors. 

Section 1. Be it ordained by the Medical Association of the State 
of Alabama, That the time for assembling of delegates and counsel- 
lors for making nominations for vacancies in the college of counsel- 
lors shall be 7 :30 o'clock p. m. on the third day of the annual session 
of the Association and the President and Secretary shall make proper 
arrangements for suitable places for assembling. 

The Board agrees that it is wise to make some further provi- 
sion for the election of counsellors by congressional districts 
and, therefore, recommends and suggests the adoption of the 
following resolutions : 

Be It Ordained hy the Medical Association of the State of Alahama, 
That whenever the transfer of a counsellor to the roll of life counsel- 
lors, or whenever a counsellor is dropped from the roll from any 
cause, the vacancy shall be filled as follows : 

1. If the district in which the vacancy occurs is left with a less 
number of counsellors than that to which it is entitled, the vacancy 
shall be filled from the said district. 

2. If the district from which the counsellor is dropped should still 
have the number to which it is entitled, the Board of Censors shall 
designate which district shall have the privilege of selecting a coun- 
sellor to fill the vacancy. 

3. That when it becomes the duty of the Board to apportion coun- 
sellors they shall be distributed among those districts in which the 
greater number of vacancies exist 



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90 THE MEDICAL ASSOCIATION OF ALABAMA. 

As suggested by a motion made on the floor of this body 
yesterday, the Secretary was instructed to send the following 
telegram : 

Montgomery, Alabama, April 19, 1917. 
Hon. Woodrow Wilson, 

President United States, 
Wastiington, D. C. 
The Medical Association of the State of Alabama in annual session 
assembled, recognizing the critical condition in the history of oar 
country, unqualifiedly endorse the position taken by you toward the 
Imperial German Government, and the means and measures which 
you propose in order that the United States may readily assist in 
bringing the horrible war to a speedy and successful termination. The 
two thousand members of this Association, singly and collectively, 
unreservedly offer themselves to serve in any capacity which may be 
deemed best by the properly constituted authorities. 

H. G. Pebby, 
Secretary. 
A reply was received as follows : 

The White House 
washington 

The President deeply appreciates your very generous and patriotic 
proffer of your services, and he wishes in this Informal way to ex- 
press his grateful thanks. 

Rogers Resolutions, 

A set of resolutions were introduced by Dr. Mack Rogers 
at the meeting in Birmingham in 1915. They were carried 
over to the Mobile meeting. Action was again postponed to 
the meeting now in session. The author of these resolutions 
appeared before the Board on Wednesday and requested the 
privilege of withdrawing them from further consideration by 
the Association. The Board recommends that Dr. Rogers be 
allowed to withdraw the resolutions. 

Martin Resolutions, 

Whereas, the examinations for old line life Insurance have become 
80 exacting, and« 



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REPORT OF THE BOARD OF CENSORS. 91 

Whereas, some of the old line companies have, and are making the 
fees for the said examinations the lowest possible amount, and. 

Whereas, those companies paying the said low fees, have stereo- 
typed and almost insulting letters ready printed and promptly mail 
the said letters to a physician who demands a respectable fee, and, 

Where€L8, some of the old line companies demand 100 per cent, 
^idency for a three-fifths fee, 

Be It Resolved, That on and after the adoption of this resolution, 
it is unethical for a member of this Association to make an examina- 
tion for old line life insurance for less than $5.00. , 

(Signed) 0. P. Mabtin. 

The Association adopted in 1907 similar resolutions to the 
above. The Board sees no good reason why it should not re- 
affirm its former ruling on these resolutions. See page 60, 
Transactions, 1907. 

The Btowah County Appeal. 

Charges were brought by Dr. H. L. Appleton against Drs. 
D. T. Boozer, C. L. Murphree, and W. B. Johnson, and the 
finding of the Etowah County Medical Society was in favor of 
the defendants. The matter is before this Association on ap- 
peal by the complainant. 

The charges grow out of the testifying by these three mem- 
bers for the plaintiff at Chicago in the case of the Chattanooga 
Medicine Company against the American Medical Association 
and in their final analysis involve these three propositions : 

1. That these members testified falsely. 

2. That they testified for a monetary consideration. 

3. That they testified in favor of a manufacturer and seller 
of a secret medicine or nostrum. 

As to the first proposition it must be recalled that in stat- 
ing that they would not believe a witness on oath these mem- 
bers made statements of fact which in the very nature of the 
case it would, unless by very exceptional evidence, be impos- 
sible successfully to controvert, even should prejudice or bad 
faith be assumed. And an opinion as to one's reputation for 
veracity is equally difficult of challenge. 

This Board cannot, however, accede to the position that it is 
without jurisdiction to consider a charge of moral turpitude 



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92 THE MEDICAL ASSOCIATION OP ALABAMA, 

simply because the offense was committed in court. The lia- 
bility of an offender to answer to a court of law gives him 
no immunity from answering also to this Association for his 
act insofar as that act is a violation of his duty to this Associa- 
tion. The Board considers this principle too plain for argu- 
ment. 

As to the second proposition the only compensation shown 
by the evidence is actual expenses of the trip and a per diem 
for the time required. There can be no objection on principle 
to an arrangement of this sort as there is no reason why a wit- 
ness should suffer the expenses and loss of time resulting from 
his attendance on court. It goes without saying, however, that 
in all such cases the expense and per diem items should not be 
allowed to run into figures giving the slightest ground for the 
suspicion that the nature of the testimony is influenced thereby. 
The evidence sent up in this case does not, in the opinion of 
this Board, lay these members open to criticism on this point, 
though the very existence of the controversy shows the neces- 
sity in such cases of punctilious care for appearances as well 
as for fundamentals. 

The third proposition is not so easily disposed of. A man 
cannot be condemned for testifying in a court of the land. It 
is, of course, often his highest duty to do so. If it is his duty he 
cannot be condemned for doing that duty without awaiting the 
compulsion of court process. The mere fact that the testi- 
mony of these members would indirectly aid a nostrum vendor 
in the sale of his wares does not make it absolutely necessary 
that they should refuse to testify ; but this Board cannot close 
its eyes to the fact that the voluntary attendance, the no-ungen- 
erous per diem, the nature of the evidence given at Chicago and 
the general atmosphere surrounding the whole case before the 
Etowah County Board of Censors and Medical Society, when 
taken together, must make the true friends of the best profes- 
sional ideals regret that these members should have placed 
themselves in a position to be looked on as having been "swift 
witnesses" for the vendor in connection with this case. 

Under all the circumstances it has seemed wisest to this 
Board to refrain from interfering with the decision of the 
Etowah County Medical Society, but to take this occasion 
briefly to discuss the important principles involved. It is, 



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REPORT OF THE BOARD OF CENSORS. 9ft 

therefore, recommended that the decision of the Etowah County 
Society be affirmed. 

This Board has gone over the matter fully and frankly with 
the complainant and he has decided under all the circum- 
stances not to urge the rehearing of this case in detail on ap- 
peal. At the same time the Board made it plain to the com- 
plainant that the whole case would be gone into de novo if he 
preferred. 

Attention is called to the fact that the members who are 
defendants in this proceedings are charged with having partici- 
pated in the hearing of their own case before the Etowah 
County Medical Society and of voting in their own favor at 
this hearing. It need hardly be said that if this report is cor- 
rect these members were guilty of most reprehensible conduct 
and the Etowah County Society is deserving of severe criti- 
cism for permitting such a thing to occur. An analysis of the 
vote, however, shows that the failure of these three members 
to vote would not have changed the result of the voting. 

There are charges against Dr. W. B. Johnson, one of the 
members involved in this appeal in no way connected with the 
Chicago case and these charges involve both unprofessional 
conduct and moral turpitude. These charges were dismissed 
on the theory that the defendant was not a member of the 
Etowah County Medical Society but of the St. Clair Medical 
Society. The situs of his membership should be determined 
and the case referred to the proper county medical society if 
his membership is found not to be in Etowah County. It is the 
opinion of the Board that cases of this kind should be sifted to 
the bottom so that the ultimate decision will be a full convic- 
tion or a complete exoneration. It is, therefore, recommended 
that the case involved in this phase of the appeal be remanded 
to the Etowah County Medical Society for further hearing or 
transfer as the facts may justify. 

Resolutions By M. B, Cameron, 

Whereas, the administration of the public health affairs is of great 
importance to every section of the State, and is rapidly increasing as 
the public is educated to properly support it, and, 

Wh^reaii such administration is almost entirely in the hands of 
the Board of Censors composed of ten members^ a majority of whom 



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94 THE MEDICAL ASSOCIATION OF ALABAMA. 

are generally elected from only three counties in the State ; the selec- 
tion of whom is often influenced by the election of other officers of 
the Association occurring at the same time, and 

Whereas, the unequal distribution of the members of the Board 
of Censors is unfair to other portions of the State, and not to the best 
interest of the health of the general public; 

Be It Resolved, That Article 30 of the Constitution of the Medical 
Association of Alabama be amended to read as follows : 

Article 90. The president shall be elected for one year, the vice- 
president for two years, in such way as that one vacancy only will 
occur annually by expiration of oflficlal terms ; the treasurer for five 
years ; the secretary for five years ; the censors for five years, in such 
way that two vacancies will occur annually by expiration of official 
term. One censor shall be elected from each congressional district, 
and they shall be elected from the districts where vacancies exist, in 
niunerfcal order of the districts as vacancies occur in the Board of 
Censors. 

The Secretary of the Association shall on the second day of each 
annual meeting of the Association announce from what congressional 
districts vacancies will occur, and the delegates and counsellors from 
such congressional districts shall hold meetings separately on the 
third day of each annual meeting, and select by majority ballot the 
names of two counsellors from said district and present them to the 
Association when the time comes for balloting for vacancies in the 
Board, and the Association shall elect by majority ballot from the 
two names submitted one of them to fill the vacancy on the Board 
from such congressional district. 

Article 32. Officers must be elected by ballot, and without nomina- 
tion, except as indicated above. 

In as much as these resolutions contemplate a change in the 
Constitution, they must lie over until the next annual meeting. 

McAdory Resolution. 

Be It Resolved, That the Association adopt a form of certificate 
which shall be sent to the mothers by the county health officers 
certifying the registration Of the birth of the child. 

W. p. McAdoby. 

The Board has been contemplating for some years the feasi- 
bility of adopting a certificate to be sent from the State Regis- 



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REPORT OF THE BOARD OF GEN80R8, 95 

trar oif Vital and Mortuary Statistics to mothers certifying 
the registration of the birth of every child in Alabama. The 
expense of such a procedure in view of the present financial 
embarrassment of the Board would be prohibitive. The plan 
suggested by this resolution meets the approval of the Board 
and the Board recommends its adoption, to be put into effect as 
soon as uniform ^blanks can be prepared and the necessary 
funds provided. 

Resolution of Dr. £. B. Ward, 

Resolved, That the rule be changed and the annual meeting of the 
Association be held three days instead of four, lasting Tuesday, 
Wednesday, and Thursday. 

(Signed) E. B. Wabd. 

The adoption of this resolution would require an amend- 
nient to the Constitution of the Association, hence it must lie 
over until the next meeting of the Association. 

Resolutions of Dr. W. W. Harper. 
First resolution : 

Whereas, Criminologists have shown that the present treatment 
of the criminal is unscientific, inhuman and unchristian, 

Therefore, Be It Resolved, Ist, That there be appointed a commit- 
tee of five experts from the membership of the Alabama Medical 
Association to act with a like committee from the Alabama Bar 
Association for the purpose of re-writing the Criminal Code of Ala- 
bama, to the end that Justice may be meted out to the criminal ola«3. 

2nd. That this Association request the Bar Association to appoint a 
similar committee. 

The Board commends the humanitarian spirit of this resolu- 
tion but does not see just how it can be put into concrete form. 
The Legislature alone has the power to re-write the Criminal 
Code of Alabama and it perhaps would be indiscreet to appoint 
a committee at this time to take up this matter. We, therefore, 
reconunend that the resolution be not adopted. 



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96 THE MEDICAL ASSOCIATION OP ALABAMA. 

Resolution by W. W. Harper. 

Whereas, statistics show that in the school the sob-normal child is 
holding back the normal, thus delaying by several years the comple- 
tion of the normal child's education; that the scheme of studies 
for the normal child is unsuited for the sub-normal, thus defeating 
the proper education of the sub-normal child ; 

Therefore, Be It Resolved, 1st. That there be appointed from the 
Medical Association of Alabama a committee of five to act with a 
similar committee from the State Educational Association to revise 
our system of education. 

2nd. That a copy of these resolutions be sent to the Educational 
Association, and that they be requested to appoint a like committee. 

The Association now has a standing Committee on Mental 
Hygiene that is doing a most excellent work along the line 
suggested by this resolution, and it does not seem that the work 
in hand would be facilitated by the appointment of another 
committee. We, therefore, recommend that this resolution 
be not adopted. 

The Board has received the following communication from 
the Council on National Defense: 

CorNciL OP National Defense 

WASHINGTON 

April 16, 1917. 
Dr. H. G. Perry, 

Secretary Medical Association of the State of Alabama, 
State Board of Health, Montgomery, Alabama. 
My dear Dr. Perry: 

It is extremely important that you bring the enclosed matter to the 
attention of your State Medical Society that is now in session. Im- 
press upon the society the importance of their cooperation with the 
Government at this time in securing medical officers for the Army 
and the Navy. 

Application blanks for enrollment in the service may be obtained 
by writing to this office, or to the Surgeons General of the Arlny and 
Navy. 



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BBPORT OF THE BOARD OF 0BN80B8. 97 

Looking to the protection of the practice of those who are called 
to the colorsv we wonld suggest that yon adopt some such plan as 
that outlined In the endosnre. 

Very sincerely yours, 
Fbankuot Mabtin, 

Meknber of Advisory Commission, 
Council of National Defense. 
F. F. Simpson, 

Chief of Medical Section, 

Coundl of National Defense. 

PUNISHING PATBIOnSli — A SUGGESTED METHOD OF MEETING THIS EVIL. 

Undoubtedly In the past civilian doctors who have been patriotic 
and who have served their country in the army or navy, have been in 
a measure punished for such service by finding their practice dissi- 
pated and gone on their return home. The knowledge of this has 
naturally acted in preventing many a physician entering the Officers* 
Reserve Corps of TJ. S. at this time. 

To meet this situation the committee proposes to have offered the 
following resolutions at the annual meeting of the state societies : 

(1) **Resolv€d, That the (name of state society) recognises the 
patriotism of those members of the medical profession resident in 

. who volunteer for the service of the U. S. 

Government, and in appreciation of this we recommend that should 
these members of the profession be called into active service, the 
doctors who attend their patients should turn over one-third of the 
fees collected from such patients to the physicians in active service 
or to his family." 

(2) "Resolved, Tliat the secretary of the society shall have pre- 
pared letter-blanks according to the form attached, to a number suf- 
ficient to supply those physicians who are called into active service, 
with a sufficient number, so that they can send a filled-out form letter 
to each patient or physician referring a patient, a carbon copy golog 
to the doctor who has agreed ta look after the physician's practice, 
and a second carbon copy to be sent to the secretary of the State 
society. 

The secretary of the State society is instructed to file the carbon 
copies received by him, and on notification by a physician that he has 
terminated his service with the Government and has resumed hia 
practice, the secretary of the State society shall then send out to 

7M 



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96 THE MEDICAL ASSOCIATION OF ALABAMA. 

each of the patients of the physician and doctor who have referred 
patients whose names and addresses he has received in the filed let- 
ters, a letter stating that the physician has resumed the practice of 
medicine, and requesting the patients and the physician in the name 
of the society to recognize the physician's patriotism by summoning 
him should be be in need of medical attention. 

(3) The secretary of the State society is further instructed to have 
printed and sent to each member of the profession resident and 
licensed in the State the card entitled "Agreement,** and on return 
of such signed card to him, to file it 

This method is the only one which we have been able to devise 
which can in any way meet the situation that confronts the doctor 
who is patriotic, and who is penalized for his patriotism by the loss 
of his practice. By this method the profession at large is "put upon 
its honor,** the patients of the physician are urged to retain his 
services, and this urging Is done, not in the doctor*s name, but in the 
name of the profession and as a patriotic duty. 

It is further recommended by the committee that after three no- 
tices have been sent, at intervals of one month, to each physician, a 
list of those doctors accepting such agreement shall be published in 
State Journal or otherwise. 

AOBKEMKIfT. 

I agree to abide by resolution adopted in relation to fees for at- 
tendance on patients of doctors ordered into active service for the 
Government, and to keep such books as will readily show collections 
of such fees. I further agree to ask every patient whom I have previ- 
ously treated, the name of his usual or last medical attendant and if 
such doctor Is in the active service of his Government, to turn over 
monthly or quarterly to such physician, or his family if he so directs, 
one-third of the fees collected by me from this patient. 

I further agree that when patients are referred to me by a physi- 
cian or person who has not heretofore referred patients to me, to find 
out from such physician or person to whom, In the immediate past, 
they have usually referred their patients requiring the special services 
I can render, and if such physician is In the active service of his 
country, to turn over to him one-third of the fee collected from such 
patient. This paragraph shall likewise apply to consultations. 

I further agree not to attend any patients referred to above, for a 
period of one year following the resumption of active practice by the 
physician who has been in active service. 



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REPORT OF THE BOARD OF CENSORS. 99 

In the remote chance of misunderstanding or disagreements arising 
under this resolution, I agree to submit the facts to the Board of 
elisors of the County Society and abide by their decision. 

(Signed) ^ 

Date. ~ 

After signing please mail this to secretary of State Society. 

Dr. 

Address 

PROPOSEU FORM LETTER. 

(Regular Letter-Head of State Society.) 

M 

Street...^ „ 

PostofFice. 

As a member of the Reserve Corps of the United States Army, 
Navy, I liave been ordered into active service by the Government, and 
on that account I am writing to you of this fact, so that, in case of 

illness, you may summon Dr ^ 

In my absence Dr of , 

Telephone No , has kindly consented to attend my 

patients, and I can heartily recommend him. 
Sincerely, 



Resolution adopted by (Name of State Society) : 

''Resolved, That the (Name of State Society) recognizes the patriot- 
ism of those members of the medical profession resident in 

^ who volunteer for the service of the TJ. S. 

Government, and in appreciation of this we recommend that should 
these members of the profession be called into active service, the 
doctors who shall attend their patients should turn over one-third of 
the fees collected from such patients to the physician in active service 
or to his family." 

Please Present This Letter to Any Doctor Whom You May Call 
In to Attend You. 

This is a matter provided for by the Code of Ethics of the 
Alabama State Medical Association. The Board believes that 
the profession of the State will take care of their brethren who 
answer the call to the colors without the adoption of any 



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lOD THE MEDICAL ASSOCIATION OP ALABAMA. 

stringent regulation sedcing to compel them to honorable and 
unselfish service. 

Part II of the Report of the Board of Censors consisted of 
report of examinations held by the Board of Medical Exam- 
iners, July, 1916, and the financial statement for the fiscal year 
ending September 30, 1916 ; also a report of Vital and Mortu- 
ary Statistics. 

Part III consists of the Report of the Laboratory and Pas- 
teur Institute. 

These parts of the report are submitted without being read. 

In conclusion, the Board wishes to congratulate the Asso- 
ciation upon its continued prosperity, upon the bright outlook 
before us as the State Board of Health, and to pledge our best 
efforts toward the consummation of the objects for which the 
Association was organized. 



PART II OF REPORT OF BOARD OF CENSORS. 



FINANCIAL STATEMENT FOE THE FISCAL YEAR ENDING 
SEPTEMBER 30, 1916. 

Thk State Boabd of Health, 

In Account toith 
THE STATE OF ALABAMA. 

Receipts. 

Balance on hand S^tember 30, 1915 — J$ 287.55 

Cash received from State Treasurer..... , 25,000.00 



Total $ 25,287.55 

EXPENDirUBES. 

Date Items Amount 

Oct 9 A. J. Powers, salary for week J$ 12.50 

13 C. T. Fltzpatrick, postage 15.00 

16 A. J. Powers, salary for week 12.50 

20 C. T. Fltsspatrlck, stamped envelopes 63.72 

20 J. V. Donley, expense account 25.00 



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REPORT OF THE BOARD OF 0EN80R8. 



101 



Date Items Amount 

28. A. J. Powers, salary for week 12.50 

26 Dr. Wm. W. Dinsmore, balance due on expense 

account i . 3.01 

80 A. J. Powers 12.50 

80 Dr. W. H. Sanders, October salary 416.66 

30 Dr. Wm. W. Dinsmore, October salary .._ 50.00 

30 Dr. H. G. Perry, October salary 200.00 

30 Miss Bertha Perry, October salary 75.00 

30 J. V. Donley, October salary. „ 130.00 

80 Dr. P. B. Moss, October salary „. 200.00 

80 Dr. A, Trumper, October salary _ 141.66 

30 Gummings McGall, October salary...^ 50.00 

80 Miss Rebecca Rutledge, October salary 50.00 

30 Dr. R. G. WUUams, October salary 150.00 

30 Brown Printing Co., on account 300.00 

Nov. 1 G. T. Fltzpatrick, postage. - 10.00 

2 Davant Typewriter Co., shipping typewriter 3.70 

4 Southern Express Co., October bill „ 1.29 

6 Tresslar's Studio 1.57 

6 Montgomery Map & Blue Print Co 5.60 

6 Western Union Telegraph Co., October bill 1.20 

6 Gilbert Trunk Co., case for slides, etc a75 

6 John L. Cobbs & Co., meridiandlse 28.19 

6 J. v. Donley, exi)ense account Mt. Meigs, and 

balance due ^ 6.15 

12 Dr. H. G. Perry, expense account campaign De- 

Kalb county :....... 23.01 

24 Mr. C. P. Anderson, on account rent for laboratory 50.00 

80 Dr. W. H. Sanders, November salary 416.66 

30 Dr. W. W. Dinsmore, November salary 50.00 

30 Dr. H. G. Perry, November salary > . 200.00 

30 Miss Bertha Perry, November salary 75.00 

80 Dr. R. C. Williams, November salary .. 150.00 

30 J. V. Donley, November salary 130.00 

30 Dr. P. B. Moss, November salary 200.00 

30 Gummings McGall, November salary .._ 50.00 

30 Miss Rebecca Rutledge, November salary 50.00 

30 Dr. A, Trumper, November salary 141.66 

30 Brown Printing Co., on accoimt 300.00 

30 J. V. Donley, expense account Montgomery county 5.15 



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102 



THE MEDICAL ASSOCIATION OF ALABAMA. 



D^te ItetM Amount 

Dec. 1 Dr. W. W. Dinsmore, expense aocoont, trip to 

Birmingham 11.86 

3 Montgomery Light & Water Power Ck>., laboratory 135.59 

6 Tresslar's Studio - .65 

6 D. Appleton & Ck)mpany, books for office. 3.50 

6 W. A. May & Green Mercantile Co .90 

6 Montgomery Map & Blue Print CJo. 1.50 

6 Jos. S. Wing, locksmith.... - 1.00 

6 Western Union Telegraph Co 4.07 

7 C. T. Fitzpatrick, postage 250.00 

8 Southern Express Company 1.63 

81 Dr. W. H. Sanders, December salary 416.66 

81 Dr. H. G. Perry, December salary.... 200.00 

81 Dr. W. W. Dinsmore, December salary 50.00 

81 Miss Bertha Perry, December salary 75.00 

31 J. V. Donley, December salary 130.00 

31 Dr. R. C. Williams, December salary 150.00 

31 Dr. P. B. Moss, December salary 200.00 

31 Dr. A. Trumper, December salary _ „.. 141.66 

81 Cummings McCall, December salary 50.00 

81 Miss Rebecca Rutledge, December salary 50.00 

19ia 

Jan. 8 Brown Printing Company 400.00 

8 H. M. Alexander and Company, antitoxin 100.00 

8 C. P. Anderson, rent on laboratory 50.00 

12 C. T. Fitzpatrick, postage due. 10.00 

17 W. W. Dinsmore, expense account, Atlanta 19.32 

29 Dr. W. H. Sanders, January salary 416.66 

29 Dr. W. W. Dinsmore, January salary ..... 50.00 

29 Dr. H. G. Perry, January salary 200.00 

29 Miss Bertha Perry, January salary 90.00 

29 J. V. Donley, January salary 130.00 

29 Dr. R. C. Williams, January salary 150.00 

29 Dr. P. B. Moss, January salary 200.00 

29 Dr. A, Trumper, January salary 150.00 

29 Cummings McCall, January salary „^ tSOM 

29 Miss Rebecca Rutledge, January salary 50.00 

29 Mrs. J. H. Perry, extra clerical help 26.25 

29 Miss Margaret Perry, extra clerical help 24.75 

29 Brown Printing Co., on account 400.00 



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REPORT OF THE BOARD OF CENSORS. 



108 



Date 
81 

Feb. 4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 

4 

4 



4 
16 
16 
21 
21 
29 
29 
29 
29 
29 
29 
29 
29 
29 
29 
29 
29 
29 



Items Amount 

Dr. W. W. Dinsmore, expense account 98.71 

Montgomery Ice & CJold Storage Co 3.60 

J. V. Donley, trip to Camden 18.10 

American Medical Association, bulletins 2.00 

Age-Herald Publishing Company. 6.00 

Southern Express Company..... 7.71 

Wm. H. Baldwin, Treasurer 2.94 

Davant Typewriter Company..., 8.50 

Addressograph Company .^ ~ 11.09 

Montgomery Map & Blue Print Company 1.50 

Montgomery Light & Water Power Co., laboratory 41.16 

John W. Iliff & Company 1.00 

Reeves-Owen Electric Company „ 2.00 

Western Union Telegraph Company 13.86 

Dr. S. W. Welch, expense account meeting Com- 
mittee Public Health 18.71 

Dr. D. F. Tally, expense account meeting Com- 
mittee Public Health 11.36 

Dr. V. P. Oaines, expense account meeting Com- 
mittee Public Health 21.66 

Dr. B. L. Wyman, expense account meeting Com- 
mittee PubUc Health 11.86 

J. V. Donley, trip to Moulton 25.06 

Dr. H. G. Perry, trip to GreenrlUe. 3.20 

CSias. A. Johnson, engraring 9 certificates 3.25 

J. V. Donley, ex p en s e account 6.85 

J. V. Doidey, expense account 35.00 

Dr. W. H. Sanders, February salary 416.66 

Dr. Wm. W. Dlnsmore, February salary 50.00 

Dr. H. O. Perry, February salary 200.00 

Miss Bertha Perry, February salary 90.00 

Miss Lilla Lowry, February salary 50.00 

Dr. R. C. Williams, February salary 150.00 

J. V. Donley, February salary 130.00 

Dr. P. B. Moss, February salary 200.00 

Dr. A. Trumper, February salary 150.00 

Miss Rebecca Rutledge, February salary 50.00 

CummingB McCall, February salary 50.00 

Dr. Wm. W. Dlnsmore, Prattvllle trip..... 4.80 

Montgomery Advertiser, subscription for year 7.80 



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104 



THE MEDICAL ASBOCIATION OF ALABAMA. 



Date 
29 
29 
29 
29 
Mar. 1 
14 
16 
20 
20 
31 
31 
31 
81 
31 
31 
31 
31 
31 
31 
81 
31 
5 
6 
6 
7 

10 
10 
13 
13 
13 
13 
18 
13 
18 
13 
13 
13 
15 
27 
20 



Apr. 



Items 

C. T. ntzpatrick, P. M., postage. 

Brown Printing Company, on account 

C. P. Anderson, rent on laboratory. . 

C. T. Fitzpatrick, P. M., for stamps 

Sonthem Express Ck)mpany 

Remington Typewriter Co., on new machines.. 

Dr. R. C. Williams 

Bnrroughs Adding Machine Ck)mpany 

C. T. Fitzpatrick, box rent 

Dr. W. H. Sanders, March salary.... 

Dr. W. W. Dinsmore, March salary..... 

Dr. H. G. Perry, March salary 



Miss Bertha Perry, March salary 

J. V. Donley, March salary 

Miss LiUa Lowry, March salary 

Dr. R. C. Williams, March salary .. 

Dr. P. B. Moss, March salary 

Dr. A. Trumper, March salary...^ 

Miss Rebecca Rutledge, March salary 

Cnmmings McCall, March salary 

Dr. R. C, Williams, expense account for March... 

Southern Express Company, March bill 

Brown Printing Company, on account 

Dr. H. 6. Perry, expense account Hayneville 

Dr. Dinsmore, trip to Talladega . 

Dixie Printing Company 

W. A. May & Green 

Montgomery Map & Blue Print Company, 

Addressograph Company . 

John Wiley & Sons, book . 

American Medical Association, pamphlets 

Southern Bell Telephone Company 



American Multigraph Sales Company.. 
P. M. Foltz, stereopticon slides 



Burroughs Adding Machine Company ^ 

J. V. Donley 

J. V. Donley, expense account 

Miss Lilla Lowry, salary for one-half month 

Dr. J. W. McCall, expense N. O. to Montgomery.. 
Dr. J. W. McCall, salary 2 weeks 



Afnount 

22.00 

800.00 

100.00 

10.00 

2.95 

21.00 

25.31 

25.00 

2.00 

416.66 

50.00 

200.00 

90.00 

130.00 

50.00 

150.00 

200.00 

150.00 

50.00 

50.00 

43.39 

2.68 

300.00 

1.80 

7.05 

.40 

1.80 

3.00 

1.83 

8.00 

4.62 

19.20 

4.41 

3.78 

1.50 

6w86 

15.00 

25.00 

23.12 

50.00 



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REPORT OF THE BOARD OF 0EN80R8. 



IM 



Date 



Biay 



29 
29 
29 
29 
29 
29 
29 
29 
29 
29 
29 

1 

1 

1 

8 

4 

4 

4 

4 

6 

5 

10 

19 

25 

26 



29 
81 
81 
81 
81 
81 
81 
81 
81 
81 
81 
June 8 
6 



Items 

Dr. W. H. Sanders, April salary 

Dr. W. W. Dinsmore, April salary 

Dr. H. G. Perry, April salary 

Miss Bertha Perry, April salary 

Dr. R. C. Williams, April salary ^ 

Dr. P. B. Moss, April salary 

Dr. A. Tmmper, salary for 28 days.... 
Onmmings McOall, April salary... 



Miss Rebecca Rntledge, April salary.. 

J. V. Donley, April salary 

Dr. R. C. Williams, to balance expense account 

Dr. W. H Sanders, official telegrams 

Dr. W. W. Dinsmore, expense account 

J. V. Donley, trip to Piedmont 

Brown Printing Company 

C. P. Anderson, rent in full 1916 (laboratory) 

Remington Typewriter CJo*, payment on machines 
Mercantile Paper Co., on accoont.^ 

Southern Express Company 

Western Union Telegraph Company 

C. T. Fitzpatrick, postage 

J. V. Donley, expense account 

J. V. Donley, expense account :... 

J. V. Donley, expense account 

C. A. Mohr, expense account meeting Committee 

Public Health 

R. C. Williams, traveling expenses . — 

Dr. W. H. Sanders, May salary 

Dr. W. W. Dinsmore, May salary ...... 

Dr. H. G. Perry, May salary — _ 

Miss Bertha Perry, May salary 

J. V. Donley, May salary 

Dr. R. C. Williams, May salary 

Miss Catherine Dent, May salary — 
Miss Rebecca Rntledge, May salary.. 

Cummings McCall, May salary 

Dr. J. W. McCall, May salary 

J. V. Donley, expense account — -^ 
Brown Printing Co., on account., 



Amount 
416.66 

50.00 
200.00 

90.00 
150.00 
200.00 
115.00 

50.00 

50.00 
180.00 

8.86 

7.80 

28.70 

12.41 

300.00 

130.00 

30.00 

100.00 

1.19 

20.13 

10.00 

81.54 

5.64 

8.59 

14.00 
67.15 

416.66 
65.00 

200.00 
90.00 

150.00 

150.00 
40.00 
50.00 
60.00 

125.00 
6.55 

200.00 



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loe 



THE MEDICAL ASSOCIATION OF ALABAMA. 



Date 

6 

6 

6 

6 

6 

6 

6 

6 

6 

6 

6 

6. 

6 

7 

9 

10 

10 

15 

16 

20 

20 

21 

26 

28 

30 

80 

90 

90 

90 

90 

30 

80 

30 

80 

JuJy 1 

5 

5 

5 

5 

7 



Items 

Burroughs Adding Machine CJo. 

Montgomery Map & Blue Print Co 

Remington Typewriter Ck)mpany 

Brooks & Crawford, legal services 

Little Paint Store 

John M. Todd, rubber stamp 

American Multigraph Sales Company 

Consolidated Dray Line. 

Postal Telegraph Company 

Western Union Telegraph Company 

Southern Express Company 

McGehee Brothers 

Hynson Westcott Company 

J. R. Ridlon, M. D., laboratory services 

J. V. Donley ^ -. 

Simon Bryant, carpenter work — 

Dr. H. G. Perry, expense to Opelika 

Engineering Record, subscription 

C. T. Fitzpatrick, postage due account 

Dr. P. B. Moss, 20 days' salary 

C. T. Fitzpatrick, post cards 



J. V. Donley, expense account 

Dr. W. W. Dinsmore, June salary 

C. T. Fitzpatrick, P. O. box rent 

Dr. W. H. Sanders, June salary 

Dr. H. G. Perry, June salary 

Miss Bertha Perry, June salary 

Dr. R. C. Williams, June salary 

J. V. Donley, June salary — 



Miss Catherine Dent, June salary 

Dr. B. L. Arms, 16 days' salary 

Dr. J. W. McCall, June salary 

Cummings McCall, June salary 

Miss Rebecca RuUedge, June salary... 
Dr. R. C. Williams, expense account.. 



Brown Printing Company, on account — 

H. M. Alexander, on account (antitoxin).. 

Burroughs Adding Machine Company 

Southern Express Company „. 

J. V. Donley, expense account 



Amount 

25.00 

7.48 

33J50 

40.00 

.90 

.75 

5.47 

1.69 

1.52 

5.80 

9.46 

19.40 

aoo 

122.95 

5.56 

2.25 

5.00 

6.00 

10.00 

lia65 

5.00 

8.91 

65.00 

2.00 

416.66 

200.00 

90.00 

150.00 

150.00 

50.00 

111.12 

125.00 

60.00 

50.00 

35.88 

200.00 

100.00 

25.00 

6.08 

26.84 



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REPORT OF THE BOARD OP CENSORS. 



107 



Dtkte Items Amount 

7 Dr. H. G. Perry, expense account Hale and Choc- 

taw counties - . 35.58 

14 C. T. Fitzpatrick, postage 43.72 

14 J. V. Donley, expense account -. 26.00 

17 J. V. Donley, expense account . ^ 12.38 

25 J- V. Donley, expense account 19.56 

28 J. V. Donley, expense account 8.00 

31 Dr. W. H. Sanders, July salary 416.66 

81 Dr. W. W. Dinsmore, July salary 65.00 

81. Dr. H. G. Perry, July salary..„ 200.00 

31 Miss Bertha Perry, July salary 90.00 

31 Miss Catherine Dent, July salary 50.00 

31 Dr. R. C. Williams, July salary 150.00 

31 J. V. Donley, July salary 150.00 

81 Dr. B. L. Arms, July salary 208.33 

81 Dr. J. W. McCall, July salary . 125.00 

81 Cummings McCall, July salary...... 60.00 

81 Mrs. Rebecca Cain, July salary 50.00 

Aug. 1 Dr. B. L. Arms, expense account 48.20 

8 Burroughs Adding Machine Company 25.00 

3 Dr. L. W. Johnston, expense account Jtdy 10...^.^. 9.60 

8 Dr. D. F. Talley, expense account July 10... — 16.54 

8 Dr. Glenn Andrews, expense account July 25 — r... 8.86 

8 Dr. B< L. Wyman, expense account July 10...«....^. 9.96 

3 Dr. 8. W. Welch, expense account July 10.............. 15.70 

8 John R. Tyson, legal services . . >...... 25.00 

8 Brown Printing Company, oa account....... 100.00 

8 Arthur H. Thomas, laboratory supplies. — ........... 100.00 

8 Montgomery Journal, subscription . . 6.00 

3 Weston Union Telegraph Company .. — .... 9.58 

3 Montgomery Map & Blue Print Company — ,...w..... 1.50 

8 Dixie Printing Company — 2.50 

8 Bobbs Merrill Company, book . . 1.25 

8 Progressive Electrotype Company . 8.91 

3 H. A* Loveless, drayage -~... 2.50 

8 Blec and Bng. Co «..^.«- ^*. 1.80 

8 J. Johnston Moore — .*--....... ^.^^..^ 8.25 

8 J. V. Donley, expense account... — ......,*..«.. — 20.62 

21 J. V. Donley, expense account-..^. .. — ^.. 35.28 

21 Ohas. A. J^nson, lettering certiUcatOB 12.00 



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108 



TEB MEDICAL ASSOCIATION OF ALABAMA. 



Date Itemi Amount 

28 0. T. Fltzpatrl<*, P. M., postage. . 2D.O0 

25 ^Dr. S. G. Gay, expense account 18.90 

26 J. V. Donley, expense accoonf ZM 

28 J. V. Donley, expense account 25.00 

28 Dr. Glenn Andrews, exp^ises attending Health 

Conference, Washington 68.45 

aO Dr. W. H. Sanders, August salary 416.66 

30 Dr. W. W. Dlnsmore, August salary 65.00 

81 J. V. Donley, August salary , 150.00 

31 Dr. R. C. Williams, August salary , 150.00 

31 Dr. H. G. Perry, August salary 200.00 

31 Miss Bertha Perry, August salary *,.... 90.00 

31 Miss Catherine Dent, August salary 50.00 

31 Mrs. Rebecca Rutledge, August salary 50.00 

31 Dr. J. W. McCall, August salary ^ 125.00 

81 Cummings McCall, August salary ^ 60.00 

31 Dr. B. Li. Arms, August salary 20a33 

31 Brown Printing Co., on account 100.00 

81 Burroughs Adding Machine Co., on account 25.00 

81 H. M. Alexander Co., on account 100.00 

81 C. A. Mohr, expence account, Committee Public 

Health .. 39.30 

81 Dr. S. W. Welch, expense account, Committee 

Public Health 12.08 

31 Dr. y. P. Gaines, expense account Committee 

PubUc Health . 22.55 

31 Dr. R. C. Williams, expense account 22.82 

Sept 2 Southern Express Co., July and August bills 14.86 

4 Henry Meador, extra stenographic service ...^ 4.85 

4 Dr. W. W. Dlnsmore, expense account 7.05 

5 C. T. Fitzpatrick, postage 10.00 

5 Dr. I. L. Watkins, expense account Birmingham 8.86 

6 Montgomery Map & Blue Print Company 8.80 

6 Addressograph Company 8.35 

6 Multigraph Sales Company 2.72 

6. T. Fitzwilliams & Company 12.00 

6 Dr. S. G. Gay — . — 8.50 

6 Dr. S. W. Welch a50 

6 Dr. D. F. Talley a61 

6 Western Union Telegraph Company ^. 37.69 



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REPORT OF THE BOARD OF CEN80R8. 



109 



Date Items 

G. T. Fitzpatrid^ P. M., envelopes and post cards 
Gummings McGall, extra serylces in laboratory^.. 
Dr. B. L. Wyman, expense attending meeting of 

Gommittee Public Health ... 

G. T. Fitzpatrick, P. M., stamps 

G. T. Fltzpatrick, box rent 



11 
12 
12 

14 
21 

28 

90 
3D 
30 
30 
30 
30 
30 
30 
30 
30 
30 
30 
30 
30 
30 
80 

80 

80 
80 



G. T. Fitzpatrick, postage 

Dr. R. G. Williams, 15 days' salary 

Dr. P. P. Salter, 15 days' salary 

J. O. Allen, 18 days' salary, laboratory assistant. 

Dr. W. H. Sanders, S^tember salary 

Dr. W. W. Dinsmore, September salary 

Dr. H. G. Perry, September salary 

Miss Bertba Perry, S^tember salary 

J. V. Donley, September salary 

Miss Gatherine Dent, September salary 

Dr. B. L. Arms, September salary 

Dr. J. W. McGall, S^tember salary 

Mrs. Rebecca Gain, September salary 

Arthur H. Thomas Go., laboratory supplies. 

Dr. P. P. Salter, expense account 

Dr. R. G. Williams, expense account .. — 



Burroughs Adding Machine Gompany 

Dr. S. O. Gay, expense account, meeting Gom- 
mittee Public Health 

Dr. L. W. Johnston, expense account, meeting 

Gommittee Public Health 

Brown Printing Gompany, on account 

Dr. P. P. Salter, salary September 9-15, Indusiye.. 



Afnount 
5a56 
84.00 

9.11 
10.00 
2.00 
10.60 
75.00 
62.50 
24.00 

416.06 
65.00 

200.00 
90.00 

150.00 
50.00 

208.33 

125.00 
50.00 

104.60 
14.58 
31.34 
25.00 

3.25 

4.46 

100.00 

29.16 



Total expenditures .| 25,059.51 



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no THE MEDICAL ASSOCIATION OF ALABAMA. 

RECAPITULATION. 

Balance on hand, 8^)tember 30, 1916 1 287.55 

Cash received from State Treasury, S^tember 30, 1915, to 

September 80, 1916 25,000.00 

Refunded by Myers Manufacturing Company 21.60 

Refunded by Anniston Water Supply Co 10.31 

Refunded by Decatur Water Supply Co 11.11 

Total ^ .125,330.57 

Expenditures fiscal year ending September 30, 1916 25,059.51 

Balance on band September 30, 1916 $ 271.06 



REPORT OF EXAMINATIONS HELD BY THE STATE BOARD 
OF MEDICAL EXAMINERS, JANUARY AND JULY. 1916. 

SUMMARY. 

Total number of applicants examined. 92 

Total number granted certificates . 55 

Total number refused certificates 37 

Percentage of rejections 40.2 

EXAMINATION HELD JANUARY 1916. 

Number of applicants examined 29 

Number granted certificates 9 

Number refused certificates 20 

Percentage of rejections 68.9 

EXAMINATION HELD JULY 1916. 

Number of applicants examined 68 

Number granted certificates 46 

Number refused certificates 17 

Percentage of rejections 26.6 

SUCCESSFUL APPLICANTS— JANUARY EXAMINATION, 1916. 



Culberson, Artice Edward. 
Day, Edward. 
Gaston, Robert Bernard. 
Greet, Thomas Young. 
McCall, Julius Watkins. 



Morgan, James Calvin. 
Smart, Benjamin Franklin. 
Thweatt, Daniel Harmon. 
Weatherford, Zadoc Lorenzo. 



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REPORT OF THE BOARD OF CENSORS. 



Ill 



SUCCESSFUL APPLICANTS— JULY EXAMINATION, 19ia 



Abernethy, Floyd Lamar. 
Alien, Walter Earl. 
Allison, James Monroe. 
Barker, Hiram Onias. 
Blaydes, James Elliott 
Brownlee, Leslie George. 
Bums, William Wilkes. 
Childers, Robert Jefferson. 
Cowden, Arthur McClnney. 
Deaver, Wilson Thomas. 
Farrlor, Lawrence Bryant 
Foshee, John Clinton. 
Giscombe, Cecil Stanley. 
Grady, H^iry Wil^. 
Graves, Alexander Wilson. 
Hamil, James Young. 
Hamilton, Grover Cleveland. 
Hamner, Lewis Herschel. 
Hannon, William Campbell. 
Johnson, William Perry. 
Kesmodel, Karl Frederick. 
Keyton, John Arthur. 
Lindsay, Ralph Reynolds. 
Lister, Robert Hood. 



Marlette, George Clark. 
McCrossin, William P., Jr. 
Odom, Stanley Gibson. 
Payne, Brack Coleman. 
Perry, Arthur Thaddeus. 
Phillips, Herbert Lament 
Piper, Bamie Lee. 
Pollard, Emmett Eugene. 
Porter, Ralph Emmett 
Price, Earl Sanders. 
Price, Charles Wesley. 
Randall, Clarence Cecil. 
Ross, Cecil Herbert 
Salter, Paul Pullen. 
Simpson, Harry Moody. 
Smith, Green Hampton. 
Sloan, Elihu Frank. 
Taylor, John Cephas. 
Taylor, John Francis. 
Terry, Lucius Lamar. 
Walls, Jesse James. 
Watson, Jerre. 
Windham, Lewis Anthony. 



UNSUCCESSFUL APPLICANTS AS REPRESENTED BY 
COLLEGES. 



Examination Held Januabt, 1916. 

Chicago College of Medicine and Surgery „ 

Jefferson Medical College. - 

Meharry Medical College. ^ - 

Vanderbilt University 

Birmingham Medical College ~.... 

University of Tennessee. 

Memphis Hospital ..^ . . : 

Howard University ~ 



2 

1 
3 

2 
9 

1 
1 
1 



Total.. 



„.. 20 



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lis THE MEDICAL ASSOCIATION OF ALABAMA. 

UNSUCCESSFUL APPLICANTS AS REPRESENTED BY 
COLLEGES. 

EhukMiHATioif Held July, 1916L 

M^uury Medical College 4 

Atlanta Medical College 3 

Minimippi Medical College 1 

St Louis School of Medicine 1 

University of Tennessee. 2 

Birmingham Medical College 2 

Bennett Medical College. 1 

Memphis Hospital Medical College ..__. 1 

Vanderfoilt 1 1 

University of Alabama ^^ !._ 1 



PART III OF REPORT OF BOARD OF CENSORS. 



ANNUAL REPORT OF THE DEPARTMENT OF VITAL AND 
MORTUARY STATISTICS. 

January Ist to December 81st, 1916. 

H. G. Pebby, M. D., Registrar. 
Miss Bebtha Pebbt, Assistant 

Dr. W. H. Sanders, 

State Health Officer, 
Montgomery, Ala. 

Dear Sir: — I have the honor herewith to submit the report of the 
Bureau of Vital and Mortuary Statistics for the year January 1st to 
December Slst, 1916. 

I wish to acknowledge my indebtedness to my assistant. Miss 
Bertha Perry, also to Miss Catherine Dent, Mr. J. V. Donley, and Drs. 
Dinsmore and Salter, all of whom have rendered efficient aid in the 
arduous work of compilation and illustration of this report. 

The reported death rate in the Registration Area of the United 
States Census Bureau for the year 1915 is 14.0 per 1,000 of popula- 



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BBPOBT OF THB BOARD OF 0BN80RS. US 

tion. The reported death rate for Alahama for 1915 is 10.50. For 
1916 the deat rate for Alabama is 10.45 per 1,000 of population. The 
death rate in 1916 is lower in spite of the fact that more deaths were 
reported than in the previous year. (See Table I.) The reduction 
is due to the increase in population. It will be seen that the death 
rate in Alabama approaches to a reasonable degree that for the Regis- 
tration Area. 

Complete death registration cannot be attained until the Legisla- 
ture of Alabama sees fit to enact the compulsory burial permit law 
which the State Board of Health has so earnestly recommended. . 

The birth. rate for the Registration Area of the United States for 
the year 1915 is 24.9 per 1,000 of population. The birth rate for 
Alabama for 1915 (see Table I) is 21.2, The rate for 1916 is 23.9, 
which is the highest birth rate ever recorded for Alabama, and which 
is very little below that of the United States Registration Area, By 
reference to Table XIV it will be noted that 49 of the 67 counties 
are In our "Intra-state Registration Area" for births for the year 
1916, while 55 counties reported a birth rate of more than 20 per 
1,000 of population. For the year 1915 only 34 counties were in this 
Registration Area and only 42 counties reported more than 20 per 
1,000. The registration of births is becoming more complete every 
year. 

Reportable diseases are receiving more attention and efforts to limit 
their spread are meeting with considerable success. In proof of this 
statement the following facts are submitted: 

The ten most conmion, and therefore most important, reportable 
diseases are as follows : Typhoid fever, malaria, measles, small-pox, 
scarlet fever, diphtheria, pellagra, pulmonary tuberculosis, cerebro- 
spinal meningitis and infantile paralysis. In the year 1915 there 
were reported 7,543 cases and 4,964 deaths from the causes named. 
In the year 1916 there were reported 12,377 cases of, and 4,802 deaths 
from, the above named diseases. The facts set forth Justify the 
assertion that health officers are increasing in the efficiency of their 
work. As more counties adopt the full-time health officer plan 
greater improvement in the collection of vital statistics and in the 
conservation of the health of the people of the State will surely fol- 
low. Respectfully submitted, 

p. Q. Perbt, 
RegUirar, 

Note : — For statistical tables see Annual Report State Board of 
Health 1916, pp. 129-182. 

8M 



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iU THE MEDICAL AB80CIATI0N OF ALABAMA. 

ANNUAL REPORT OF STATE LABORATORY, 1916. 

Dr. W. H. Sanders, 

State Health Officer. 
Sir: — I have the honor to transmit the following report of the 
activities of the Laboratory of the State Board of Health for the 
•year 1916. 

BEPOBT OF THE STATE LABORATORY FOR THE TEAR 1916. 

During 1916 the personnel of the laboratory force has been 
changed, with the exception of the stenographer — ^and she changed 
her name. Dr. P. B. Moss, Director since 1911. resigned to take up lab- 
oratory work in Selma. He left May 1st, for a trip to different labora- 
tories, returning June 7th, and remaining to the end of the month. Dur- 
ing his absence, at the request of the State Health Officer, the U. S. 
Public Health Service kindly detailed Dr. J. R. Ridlon to take charge 
of the work. Dr. B. L. Arms became director June 14th. April 23rd, 
Dr. A. Trumper, Assistant Bacteriologist, resigned to accept a posi- 
tion With the laboratory of the city of Philadelphia. Dr. J. W. 
McCall was secured to fill the vacancy. 

In September, Cummings H. McOall, technical assistant, resigned 
to enter school at Auburn in preparation for the study of medicine, 
Joe 6. Allen being appointed to fill the vacancy. 

The laboratory is an institution for and belonging to the citizens 
of the State. It is hoped that they will make use of it more freely 
in the future than they have in the past. Outfits for sending speci- 
mens for the free diagnosis of diphtheria, tuberculosis, intestinal 
parasites, typhoid and malaria may be obtained by any physician, 
and they will be sent the day the request is received. 

Tubes in which to submit specimens of blood for the diagnosis 
of syphilis may be obtained on request. 

Ck>ntainers for water samples may also be obtained, but it should 
be borne in mind that the bacterial examination of water is but one. 
part of the investigation of the water supply, and the sanitary survey 
of the source is by far the more important, and without this, the 
laboratory is not Justified in interpreting the bacterial findings. 

There seems to be some misunderstanding in regard to the fee 
work done in the laboratory, and in order to correct this we wish to 
state that all fees go to the State Laboratory and all the running 
expenses of the laboratory, except salaries, are paid by this fund. 



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REPORT OF THE BOARD OF CENSORS, lU 

All checks are deposited to the account of State Laboratory and 
should be made out to the State Laboratory. 

A strict account is kept and a stat^nent is rendered monthly to 
the State Health Officer of money received and paid out, the original 
vouchers being kept on file at the laboratory. The financial state- 
ment appears on page 122. 

As we frequently receive specimens without any means of identifi- 
cation, not even a l)ostmark in some instances, we would call attention 
to the following rule passed by the State Committee of Public Health 
at its meeting in July. Rule 6 — **All specimens for free examination 
must he accompanied hy the name and address of the patient from 
whom the specimen is obtained, also the name and address of the 
physician sending the specimen.'* 

BOMB OF THE LIMrTATIONS OF THE LABOBATOBT. 

To Physicians: 

This letter is prepared to point out to physicians some of the 
reasons why the Laboratory is at times unable to make requested 
examinations or to report more promptly. 

Diphtheria — ^When a swab is received it is examined at once and 
if positive is so reported from the direct swab examination. Unless 
the swab is positive the culture must be incubated and examined the 
following morning. This is the first examination work of the morn- 
ing and the reports go out on the next mall (11 :30 a. m.) Delay in 
getting a report may be caused by delay in the malls. One case has 
just come to our attention, and on looking it up it was found that a 
report which was mailed to reach the doctor no later than Thursday 
a. m. did not reach him until Friday night, but no one thought of 
placing the blame anywhere but on the Laboratory, even though the 
report was dated? It is realized at the Laboratory that a prompt 
report in case of diphtheria means much to the patient and we try 
to assist in ^very possible way. If a wire is asked for It is sent as 
soon as the diagnosis is made. Note the dates on report. 

Watcf^— Probably there is more misunderstanding in regard to 
the examination of water than any of the Laboratory tests. Appar- 
ently it is thought that the Laboratory tests water for typhoid organ- 
isms, but this is not the case. Tests for colon bacilli are made as an 
index of fecal contamination. The presence of colon bacilli does not 
of itself mean that they came from a human source, for they may 
have come. from any of the farm animals, including the fowls. 



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116 THE MEDICAL AB800IATION OF ALABAMA. 

Tjrphold only comes from human sources. A sanitary surrey of a 
water supply Is much more Important than any number of bacterio- 
logical tests, for it will determine not only if there is probable human 
contamination at present, but also if there is apt to be in the future. 
Practically every shallow well In any old community will show colon 
bacilli ; every well will unless it is thoroughly protected. 

Blood — It is surprising the number of times we are asked to ex- 
amine blood sent in a tube for malaria. For this the blood should 
be sent in on a thin film on glass slides. The films should be allowed 
to dry in the air and packed back to back. Never put a drop of 
blood on a slide and put another over it wh^i it is wet The admin- 
istration of quinine before taking the blood specimen will usually 
cause a negative report. A positive Widal is rarely obtained before 
the eighth to the tenth day of typhoid, and sometimes it is even later 
before it appears. Before a complete positive is obtained, there 
may be a partial reaction, and if this is found it is so reported with 
a request for another specimen after a few days. 

Sputum — It must be borne in mind that tubercle bacilli are not 
found in the sputum until there is a breaking down of the tissue and 
an opening into the air passages, hence in the very early stages no 
tubercle bacilli are found in the sputum. 

B. L. AB1C8. 

November 18, 1016. 

NoTS— The statistical tables are published in full in the Annual 
Report of the State Board of Health, 1916. 



APPENDIX TO REPORT OF BOARD OF CENSORS. 

Hon. S. W. Welch, 

State Health Officer, 
Capitol. 
Dear Sir: 

In reply to an inquiry of your predecessor in office under date of 
January 22nd for advice regarding the length of the term of office 
for which you were elected on January 23rd, 1917, I beg to advise 
you that under the provisions of Section 704 of the Code the State 
Board of Health is authorized to elect an ^cecutive officer, to be 
known as the State Health Officer, and to fix his term of office and 



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REPORT OF THE BOARD OF 0EN80R8. 117 

salary. In accordance with this provision, the Medical Association, 
which became the State Board of Health under the provisions of 
Section 698 of the CJode, fixed such term of office at five years. — 
Book of Rules M. A. S. A., p. 139. There Is a failure on the part of 
the Medical Association to recognize a fractional or an unexpired 
term In such office, a condition recognized by the supreme court In 
the case of State v. W. H. Sanders, 187 Ala. 79, that court expressly 
holding that there could be no unexpired term. 

This rule of law is supported by the case of Clarke v. State, ex rel. 
Graves, 177 Ala. 188, wherein it was held that In an instance In which 
the law fixes a definite term of office for a certain number of years, 
without any limitation or reference to an unexpired term, a vacancy 
occurring Is In the office and not In the term of office ; and that when 
the vacancy Is filled, the newly appointed or elected incumbent holds 
for a new and full term. 

I have the honor to advise you, therefore, that the present State 
Health Officer Is entitled to a full term of five years from the date of 
his election on January 23, 1917. 

Very truly yours, 

W. L. Mabtin, 
Attorney General. 



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118 THE MEDICAL ASSOCIATION OF ALABAMA. 



ACTION ON THE REPORT OF THE BOARD OF 
CENSORS. 



The sections of the report dealing with the President's mes- 
sage were adopted as read. 

The section of the report dealing with the minutes of the 
1916 meeting was adopted as read. 

The section of the report in regard to the report of the 
Senior Vice-President was adopted as read. 

The section of the report dealing with the report of the 
Junior Vice-President was adopted as read. 

The section of the report dealing with the books and ac- 
counts of the State Health Officer was adopted as read. 

The section of the report in regard to counties in arrears was 
adopted as read. 

The section of the report dealing with the report of the Sec- 
retary was adopted as read. 

The section of the report dealing with the report of the 
Publishing Committee was adopted as read. 

The section of the report dealing with the report of the 
Council on Nosology was adopted as read. 

The section of the report dealing with the report of the 
Council on Pharmacy was adopted as read. 

The section of the report dealing with the report of the 
Committee on Mental Hygiene was adopted as read. 

Dr. Talley then read the section of the report relative to the 
resignation of Dr. Sanders and the election of Dr. Welch. This 
section was adopted as read. 

Dr. Welch : Gentlemen of the Association, I thank you for 
this expression of your confidence and regard. I realize that 
you have conferred upon me today the greatest honor that can 
come to a doctor in Alabama, but I want you to know that I 
feel that the honor which you. have conferred upon me is com- 
pletely overshadowed by the responsibility of the great trust 
and the opportunity which you have given me to do some 
things for Alabama that are worth while. Notwithstanding 
the fact that I am entering upon my duties in the same spirit 
that the boys are now answering the call to the colors, and with 



ii 



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ACTION ON REPORT OF BOARD OF CENSORS. n» 

a degree of enthusiasm that I feel will bring me success — yet I 
cannot, succeed, gentlemen, without the hearty cooperation and 
cordial support of each and every one of you. I hope each of 
you will feel that I am depending upon you individually, and 
that you will respond to this call from me to make the public 
health work of Alabama a success. I thank you, gentlemen. 
(Applause.) 

The section of the report relating to the admission of men to 
examinations who have been graduated earlier than the end of 
the medical school year was then read. Dr. Perry moved that 
the action of the Examining Board in this matter be endorsed 
by the Association. Seconded. Carried. 

The section of the report in regard to intensive community 
work was adopted as read. 

The section of the report relating to reciprocity in medical 
licensure was adopted as read. 

The section of the report relating to the visit of the State 
Health Officer to and the study of health work in other States 
was adopted as read. 

The Chairman of the Board then read the section of the 
report in regard to contract practice. 

Dr. Welch: Gentlemen, it was pretty generally believed 
that the question of contract practice would meet with some 
discussion, and if there are any expressions of views on this 
point, I think it would be very well to express them before this 
paragraph of the report is adopted. 

Dr. McAdory: I move the adoption of this section of the 
Board's report. 

The motion was seconded. 

Dr. Baker: I hear several members asking what the pre- 
vious action of the Association has been on that matter. If 
you are going to get up a discussion of it I think the thing to 
do is to read that section of the Compend. 

Dr. Welch then read the section of the Compend relating to 
contract practice. 

Dr. Welch : Now the ruling of the Board on these resolu- 
tions of 1915 includes about ten pages in the Transactions of 
1916, and it is all summed up in a word, that each and every 
one of them is condemned by the Board as being not within 
the ruling of the ordinance on contract practice. 

The section was adopted. 



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120 THE MEDICAL ASSOCIATION OF ALABAMA . 

Dr. W. F. Scott : I would just like to ask the State Health 
Officer what is the penalty for a violation of this ordinance? 

Dr. Welch : The penalty is that imposed for any unethical 
practice. 

Dr. Scott: Then it is unethical? 

Dr. Welch : It is regarded as unethical, and the penalties 
are fixed by the code of ethics promulgated by the American 
Medical Association. Whether or not the ordinance has been 
violated is decided by each county medical society. The 
charges are referred to the Board of Censors, and after inves- 
tigation are reported to the county medical society for action. 
The penalty is affixed by recommendation of the Board of 
Censors after being adopted by the county society. 

Dr. Appleton: I would like to ask one question. Does a 
man being hired, does that come under the head of contract 
practice? Say that I go to a corporation — 

Dr. Welch : If you make your contract with the officers of 
the corporation — 

Dr. Appleton : Here is the point I am after. If I go to the 
president of that company, they have 2,000 men working for 
them, and I take the work for a stipulated salary, say 25 per 
cent of the pay roll, do I C9me under the head of an unethical 
doctor? 

Dr. Talley : It depends entirely on what sort of a company 
it is. 

Dr. Welch: The law is perfectly plain, and I would have 
to be informed of all the facts, as well as the ordinance before 
I could answer that. I would not like to make an ex parte 
statement as to whether or not a certain condition was a vio- 
lation of the ordinance. In other words, you might be mean- 
ing one thing and I might think you meant another. 

Dr. Welch then read the section of the report relating to the 
resolutions introduced by Dr. Scale Harris in regard to es- 
tablishing a State journal. 

Dr. Harris: I agree with the Board, but I would like to 
speak on that for a moment, please. Mr. President and 
gentlemen, I expect some of you wonder why it is tliat the 
editor of a medical journal published in this State is so hearti- 
ly in favor of the State undertaking the publication of a jour- 
nal. I would like to say that my sole reason for urging that 
this be done is that I believe that it would increase the effi- 



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ACTION ON REPORT OF BOARD OF CENSORS. 121 

ciency and useful of the Medical Association of the Stater of 
Alabama As editor of a journal I receive in exchange all of 
the State journals published in the South, and those from many 
other states, and I see the splendid work that those journals 
are doing for their states, and I believe that if Alabama had 
such a journal it would increase the usefulness of the Medical 
Association of this State, that it would increase interest in 
medical work, and that it would be very much better in every 
way than the publication of the present transactions. 

Now I heartily approve of postponing this question for the 
present, and I do not wish to override in any way the rulings 
of the Board of Censors, but I think it is a question that should 
be discussed and that all of us should understand, and I regret 
that I did not have the opportunity of going before the Board 
of Censors to discuss the question yesterday. I had to go back 
to Birmingham and was not here at the time when the Board 
was in session. 

Of course, it is a very nice thing to have the transactions of 
the State Medical Association ; it is a nice thing to have on the 
shelves of our book cases the series of transactions over a num- 
ber of years, but the question is now. How much do we read 
those transactions? Now, they are good and they serve their 
purpose, you understand, but the only thing is as to whether 
or not a journal would not be better. I am interested in the 
Association — I believe I am almost as much interested as any 
man in the Association, and when the transactions come to me 
I read them for perhaps an hour or two. I do not r^ad over all 
of the minutes ; the fact of the matter is that I have forgotten 
a good deal as to what has gone on at the meeting before. Now 
when a journal is published the minutes of that meeting are 
published within less than a month, and every member of the 
Association gets the minutes of that meeting and he reads 
them, and, gentlemen, I submit to you if it would not be a 
splendid thing for every member of the Association of Ala- 
bama to have within the next month this splendid report of 
the Board of Censors we are having here today. I think it 
would be very much better than waiting until November for 
them. 

Now, the question of the publication of the papers of the 
Association. Of course, they are -published in a volume and 
the members get that. Well now, how many of you read those 



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122 THE MEDICAL ASSOCIATION OF ALABAMA. 

papers? I think, gentlemen, that the papers that are read be- 
fore this Association will compare favorably with those of any 
medical association in the country. At this meeting there were 
some of the best papers that I have ever heard read here. How 
many of you are going to read those papers published in the 
transactions ? If those papers came out iyi three or four months 
I think that you would read a great many more of them. For 
instance, the splendid address of Dr. W. J. Mayo, we would all 
like to have that within a month or two, but as it is we have to 
wait until November to get it. 

Another thing : the papers that are read, are published in the 
transactions, but the Jfoumal of the American Medical Asso- 
ciation which lists every paper published in a journal in the 
United States, does not list papers published in transactions. 
Now here, for instance, a paper is read at this meeting; they 
are not listed with the Journal of the American Medical Asso- 
ciation, but if they were listed the 60,000 subscribers to the 
Journal of the American Medical Association would know that 
a paper of such a title was read before the Alabama Medical 
Association, and if one were looking up the literature on that 
question he would want to write for a reprint of that paper, 
and it is very much to the advantage of the essayists if those 
papers are published in a journal. 

Now that brings up this question as to why it is that the 
Southern Medical Journal cannot publish those papers — and 
there are a great many of them that we would like to publish. 
It embarrasses me very much that we cannot publish these pa- 
pers that are read before this Association. The Southern Medi- 
cal Journal covers sixteen states, and has obligations to all of 
them. In Texas we have nearly 1,200 subscribers. In Alabama 
we have 650, in Georgia 800. Those men in Texas that 
read papers before their State Medical Association would like 
to have their papers published in the Southern Medical Jour- 
nal. We have had offers from the Florida State Medical Asso- 
ciation and from the Mississippi State Medical Association to 
make the Journal the official organ and publish their papers, 
and a few days ago we had a letter from the secretary of the 
Louisiana State Medical Association, wanting to know if we 
would not publish their papers. Well, if we publish the papers 
read before this Association, the men connected with other 
associations will want the Journal to publish theirs, and it is a 



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ACTION ON REPORT OF BOARD OF CBN80R8. 128 

question of space. We publish sixteen original articles a 
month on an average, and we get 150 papers from the South- 
ern Medical Association a year, which practically takes up ten 
issues of the Journal, and the finances of the Journal are such 
that the size of it cannot be increased ; so that we have enough 
original articles now to last us until the November meeting, 
when we will get 150 to 175 more papers. That is the reason 
we cannot publish these splendid papers. 

Now as a medium for the State Medical Association to 
reach its members. Here is matter in which all of the mem- 
bers of the Association are interested. If the members of the 
Association were getting a journal every month the President 
could have editorials and other matter that would be of inter- 
est to these men, and they could be reached every month with- 
out extra expense. 

I realize that the question of expense is one of the most 
important things, as to whether or not the Association is able 
to run such a journal. Now if it were an experiment, I should 
say not to try it, but it is not an experiment. There are thirty 
or forty states in the Union in which the medical associations 
are publishing journals, and splendid journals at that, and some 
of them that are paying the association something besides in- 
creasing the salary of the secretary, as should be done. Of 
course, I do not mean to say that such a journal would increase 
the income of this Association very much; it is not going to 
get rich off of a journal; I cannot tell you that; but, at the 
same time, it could be published for less than it costs to pub- 
lish the Transactions now. As it is all the papers that are read 
are published in the Transactions ; all that you have got to do 
to make it a paying proposition is to get advertisements. The 
American Medical Association has a bureau of cooperative 
advertising in which they undertake to get advertising for the 
State journals, and they would almost at once get enough 
advertising to make it self-sustaining. And, of course, the 
business manager of the Southern Medical Journal would be 
glad to help to make it self-sustaining. 

Another very important thing is that it would be a medium 
for the State Board of Health to reach the members of the 
State Medical Association, and of course, every member of the 
Association is a member of the State Board of Health — I mean 
the State Health Officer and the Committee of Public Health 



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124 THE MEDICAL ASSOCIATION OF ALABAMA. 

to reach them. Every month something is done. It is a 
splendid thing for us to have reports every month from the 
State Board of Health and to get the minutes of the State 
Board of Health. The State Board would get very much bet- 
ter cooperation from the members of the Association if they 
had a medium whereby they could reach the members every 
month. And I want to say in this connection that I think 
every one of us should in our hearts and our actions pledge 
to our new State Health Officer the absolute support and 
cooperation in improving public health conditions in Alabama. 
(Applause.) I shall certain do so myself, and I will take 
this occasion to say that while I have differed with the former 
State Health Officer as to methods, I have always entertained 
for him the greatest respect If you will read what I have 
said there is no attack on the former State Health Officer, but 
simply a question of what I believed would improve conditions. 
.Now, gentlemen, we have got one of the very best State med- 
ical associations in the country. It is a fact that Alabama has 
more members in the State Medical Association in proportion 
to the number of physicians in the State than any other medical 
association in the United States. In other words, the Medical 
Association has actually gone farther in this State, so far as 
members are concerned, than any other State in the Union, 
but the question is : Is it the most efficient State Medical Asso- 
ciation ; is it performing the best service for the physicians of 
this State, as well as for the public, as it has that public func- 
tion? I get these State journals, and I have had the oppor- 
tunity of visiting most of the State medical associations in the 
South, and of sizing up something of the work that they are 
doing. I will say this, that with the exception of about four 
States out of the sixteen Southern States, the Alabama Asso- 
ciation is the best medical association, in the South, but those 
four States that I believe are doing the best work are those of 
Kentucky, Texas, Tennessee and Missouri. Now in every one 
of those States they have their State journal, and those men 
tell me that they believe that the State journal has a great deal 
to do with increasing the efficiency of their organization. It 
is my intention before the next meeting to get data on this sub- 
ject from other States, whereby I hope that we can prove that 
the State Medical Association can publish a journal with their 
present income, and I am going to give notice now that before 



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ACTION ON REPORT OF BOARD OF VBNB0R8, 126 

the next meeting I shall put in the hands of the Board of Cen- 
sors the data that I hope to accumulate. I move the adoption 
of the report. 

Dr. Baker: I would just like to say that as Secretary for a 
number of years of this Association I have given this matter 
quite a little thought myself. It is really a very important 
matter, and it is a very momentous one to decide whether or 
not to do away with our Transactions. Dr. Harris made the 
statement that he was afraid that the average member did 
not read his Transactions. I do not believe that is true. I 
believe this, that if every member of this Association will pre- 
serve the volume of these Transactions that comes out in 1917, 
and if he does simply one thing, if he will study carefully the 
report of the Council on Pharmacy he will find enough real 
meat and review of pharmaceutical pre(>arations in the last 
twelve months to guide him aright in his work. That was a 
very excellent and able report submitted by the Council on 
Pharmacy. But there are a great many other things, and I 
know from my experience that the Transactions are read and 
frequently referred to. Some men tell me it is almost their 
Bible from year to year on getting the most up-to-date and 
accurate knowledge, some men do not take many journals. So 
the doing away with the volume of Transactions we now pub- 
lish is a very serious question. We should weigh it most care- 
fully before deciding. On the other hand, the points brought 
out by Dr. Harris as to a journal being a very nice medium of 
coming into frequent touch and contact with the men all over 
the State — ^there is no question about it. Dr. Perry gets jour- 
nals from a great' many States." And it is very encouraging 
indeed to see how those journals each month give in great de- 
tail exactly what is going on in the various States. For in- 
stance, when the legislature meets they give the most accurate 
information about the legislative work the State Association 
is trying to do, and we without that journal in the State of 
Alabama get that only once a year. There afe a great many 
points pro and con, and 1 think this matter should be very care- 
fully weighed before this action is taken. 

Dr. Perry : I want to make one remark in regard to what 
Dr. Harris has said as to the time of issuance of the Transac- 
tions. Those of as who stay at home and work in the suihmer 
time get the Transactions in July. The reasbn Dr. Harris 



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126 THE MEDICAL ASSOCIATION OF ALABAMA. 

doesn't get them is that when they are issued he is off in Can- 
ada somewhere frolicking. (Laughter.) 

Dr. Welch : Dr. Harris has discussed this proposition from 
the standpoint of the man in the city with his office and a 
certain amount of leisure time every day in which he can read 
his journal or anything else that he happens to be interested in. 
I heartily agree with everything that he has said. We ought 
to have a State journal, and I believe we will have a State 
journal sometime in the not distant future, but those of us who 
live in the smaller towns and in the country do not feel towards 
the journal like the gentlemen in the centers of population. The 
journal comes to us on a day when we are very tired. It is 
thrown upon the table, and very frequently it is swept into the . 
fire and we never see it at all. We haven't time to read it. Un- 
less there is some way to preserve the articles that come in a 
journal ninety pr cent, of the country doctors never see one of 
them at all. The reading and study that he does is at times 
when he hasn't anything else to do, and that isn't very often 
unfortunately, but certainly he can't take a journal when it 
first arrives, a weekly, and read it. There isn't one in a thou- 
sand that does it. But, on the other hand, the Transactions are 
in his book-case, and at times when he has a bad case of a 
given trouble he will refer to these Transactions, and he will 
refer to them back for years and years; he has them in easy 
reach. They are in files that in many instances run back for 
twenty-five years. All articles that have been read before 
this Association on a given subject, for instance, typhoid 
fever, or any of the common troubles that we come in 
contact with every day, he refers back to his Transactions and 
compares what other men have said and the experiences of 
other men in Alabama, not from a man in a center of learning, 
not from the scientific man, but from the practical fellows that 
have difficulties and troubles to contend with just as he has. 
To the country doctor — and they are the largest quota of our 
membership — I regard the Transactions as the most valuable 
asset which the State Medical Association has ever furnished 
him, and it would be a calamity to take them away from him. 

Dr. Harris : Gentlemen, I have been a country doctor my- 
self. And I remember very well how I did when I was living 
in the country, when I had to take long rides, and had to be 
detained, for instance, at an obstetrical case, and I think just 



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ACTION ON REPORT OF BOARD OF CENSORS, 127 

about as good reading as I have done has been with the medical 
journal that I had stuck in my pocket. I would read that 
journal, and when I got back to the office I would file it. I 
think there are hundreds of physicians, I have been into their 
homes, and I have seen imbroken files of medical journals there 
over a number of years, and they could refer to those files of 
the medical journal just as well as they could to the Transac- 
tions, and I believe that they would file them. So that I think 
a journal would preserve the records and at the same time have 
the advantage of reaching the physicians each month. 

Dr. Perry : I move the adoption of that part of the report. 

The motion was adopted. 

Dr. Welch then read the section of the report dealing with 
the amendments to the Constitution submitted by Dr. W. H. 
Sanders. 

Dr. Morris : I do not understand exactly the Board's posi- 
tion regarding moving from one congressional district to an- 
other. As I understand it, there is a by-law in existence at the 
present time providing that when a counsellor moves from 
one district to another he forfeits his counsellorship unless he 
has been a counseltor for ten years. 

Dr. Welch: Counsellors will now be elected for seven 
years, and the grade of senior counsellor is abolished. If in 
any part of any one of the terms to which the counsellor has 
been elected he moves to another district he forfeits his counsel- 
lorship. 

The President: It matters not whether he has been a 
counsellor one year or nineteen years. 

Dr. Welch: He can be a counsellor for three terms. He 
forfeits only the term for which he has been elected. A coun- 
sellor is elected for the first term for seven years. If he moves 
from his district during the course of his first term he forfeits 
that part of his term of seven years which has oot yet expired. 
If he is reelected the first year after he has moved into another 
district, he gets credit for the time he served in the former 
district. When he has served the seven years he has got that 
to his credit, no matter what district he lives in. If he is 
elected to a second term of seven years and moves out of that 
district and into another district, he forfeits only so much of 
his second term as is yet unexpired. If he has served three 
years of this second term he gets credit for seven years of his 



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fig THE MEDICAL 'ASSOCIATION OF ALABAMA. 

first term and three years on his second term, but he does not 
get any credit for any part of a year. If he has served eleven 
months on his fifth year he only gets credit for four whole 
years ; he forfeits his eleven months, and if he is reelected he 
gets credit for seven years full term and four years of a second 
term. If he is elected to a third term of six years, then he 
gets fourteen years' credit to start with. Then if he serves 
three years in his third term of six years, he gets credit for 
seventeen years. 

Dr. Morris : I want to ask another question. If a man has 
served one full term of seven years and four years upon a 
second term and moves to another district, does he still forfeit 
his counsellorship ? 

Dn Welch: Yes. 

Dr. Morris: I feel that is contrary to the present rules of 
the Association. * It cuts off from a man's service promotion 
to life counsellorship, and I think it is somewhat of an injus- 
tice for a man who has served eleven years, paid $110 of his 
$200 ; he has got no more chance to be elected a counsellor from 
a new district than a man who has just come there to practice. 
I can cite a case in point, of a man who has never failed to 
attend a meeting of this Association in twenty-three years, who, 
after a service of twelve or fifteen years in the college of coun- 
sellors, moved to another district, retained his counsellorship, 
did not forfeit his rights, and did not have to start over again, 
so far as adding up to his life counsellorship in the college of 
counsellors. It seems to me a little bit Unfair to a man who 
has served seven years and served three or four years of the 
second term. I do not think he should be put on the same basis 
in the district to which he has moved as a man who has never 
served as a counsellor. I think it would be a good plan if the 
Board of Censors could provide some way by which injustice 
would not be done to a man who had served faithfully for ten 
years. The gentleman I have reference to is Dr. Scale Har- 
ris. He did not forfeit his rights ih the college of counsellors. 

Dr. Glenn Andrews : That can be rectified if it is the will 
of the Association by merely adding to that section, "Provided 
that wherever a counsellor has served two full terms, if he 
moves into another district he shall not forfeit his counsellor- 
ship." That would increase the time from ten to fourteen 
years. 



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ACTION ON REPORT OF BOARD OF CENSORS. 12» 

Dr. Appleton: How long has this ordinance been in force? 

Dr. Welch : I had the honor of introducing that amendment 
to the Constitution in 1906, because of the fact that so many 
young men were moving into the district of Birmingham from 
other portions of the State, thereby keeping out of the college of 
counsellors men who were resident there, because they kept the 
district in which Jefferson county is located always with more 
counsellors than it was entitled to, and the men who were there 
and had been doing the work of the Jefferson County Medical 
Society for years and years were absolutely excluded from any 
hope of ever getting into the college of counsellors, because 
men were moving in from other parts of the State after having 
been elected counsellors. That is why this amendment to the 
Constitution was originally adopted. It had no qualification 
when introduced, but the Board amended the motion as I first 
made it by saying that if a man had served ten years he should 
then not forfeit his counsellorship if he moved. 

This is a free country, and it seems to me that if a man feels 
that he gains more by moving into another district that he 
would lose by forfeiting his counsellorship, then it is up to him. 
It is a matter of free choice, he knows what he wants, and if 
he is elected in the fourth district and wants to move to the 
fifth or to the sixth or to the ninth district — there is where 
they almost always move to and don't ever seem to be able to 
move away any more — it does seem to me he ought to have the 
right of choice as to whether or not the advantages of moving 
to the ninth district are worth more to him than his counsellor- 
ship. This is a free country, and he ought to decide that propo- 
sition for himself. 

But the question would be of very easy solution just now 
if the Association wishes to make the change. It could be 
ordered that after having served fourteen years, if elected to his 
third term he would not forfeit his counsellorship by moving 
out of the district in which he was elected into another dis- 
trict. 

Dr. Morris: I can see how a very embarrassing position 
might arise from the adoption of this amendment. Suppose that 
in the next fifty years the position of State Health Officer 
should become vacant and we should decide to elect a man 
residing in another district, that man would have to move from 
Birmingham or Mobile, say, to Montgomery, and he is only 

9M 



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ISO THE MEDICAL ASSOCIATION OF ALABAMA. 

eligible to be State Health Officer by reason of the fact that he 
is a counsellor. If he should forfeit his counsellorship by 
having to move from his district to Montgomery where his 
office is, we might be debarred from getting the most useful 
man by reason of a little thing that don't amount to anything. 

Dr. Welch : Dr. Sanders is still a citizen of Mobile, and I 
am still a citizen of Talladega. 

Dr. Perry : The official residence is in Montgomery but it 
does not affect the private residence. 

Dr. Ray : When an ordinary member in the country moves 
from one district to another it doesn't make any difference 
whether his citizenship is in Pumpkinville or Snodunk, they 
go ahead and strike him off. He has moved from one district 
to another. (Applause.) 

Dr. Perry : I have had several questions asked me that indi- 
cate that the plan proposed is not clear to the minds of all the 
counsellors and delegates present. I wish to epitomize for a 
moment the plan as outlined. My understanding is that the 
plan proposed does not affect the standing of any life counsellor 
as now constituted or of any counsellor in the roll of junior or 
senior counsellors who are now elected or have been elected 
in the past year, so far as the termination of their service is 
concerned. That, for instance, Dr. Horn there, who is a 
junior counsellor, will go ahead and serve to the end of twenty 
years, when he will be advanced to the college of life counsel- 
lors. It doesn't affect him, but any man who is elected counsel- 
lor after the adoption of the proposed amendments will 
be elected for a period of seven years, at the end 
of which time he may be re-elected for another period of seven 
years, and at the end of that period he will be eligible for elec- 
tion again for a period of six years, to make up his twenty 
years, after the end of which he automatically goes to the col- 
lege of life counsellors. That is the substance of the provisions 
that have been read. In order to make them definite and 
cover all contingenices they have to be, like laws, surrounded 
with a good many words that sometimes make us lose the mean- 
ing and sense of the thing. But that is the essence of it. 

Dr. Oates: I just want a little information. I understand 
there is a provision in the Constitution which states that when 
a resolution is offered amending the Constitution it shall lie on 
the table for a year. Well it looks to me like a resolution was 



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ACTION ON REPORT OF BOARD OF CENSORS. 181 

offered which we will call a colt and which has been turned out 
to us a full grown horse. I may be wrong in that. Most of 
us do not know what we are discussing here, but if this resolu- 
tion has been modified to the extent that it has changed the 
meaning of the whole original resolution, I take it a good point 
of order that this should lie on the table for a year so we can 
see what it is and not jump into this thing blindly. Really I 
do not understand all of that thing in there; it may be my 
fault, but I really do not understand it all, and I really do not 
know what we are voting on, and I see some others who are 
a little higher up in intellect than I am who do not understand 
it. If it is in order I move that this part of the report be con- 
sidered at our next annual meeting. 

Dr. Welch: Dr. Oates' point is very well taken. The 
Board was not positive as to what the law in the prem- 
ises was. So we consulted the best legal adviser, the best 
authority on Medical Association law in Alabama, as to what 
was the proper course to pursue, and he advised us that it was 
perfectly legal and right where the amendment was germane to 
the sense of the resolution and the amendment already intro- 
duced, that it was perfectly proper to modify it just so the 
intent of the proposed amendment did not change the intent 
of the original amendment. Now it is perfectly proper, if the 
Association is not ready to vote on this proposition, to carry 
it over for another year, and the Board does not wish to insist 
on hurried or immediate action. If anybody wants to study it 
still further it is perfectly proper for them to do so. 

Dr. Ray: I move that this part of the Board of Censors' 
report be deferred until next year for action. 

The motion, duly seconded, was adopted. 

Dr. Welch: Here follows a section containing some ordi- 
nances intended to make operative the amendments just pro- 
posed. I take it that these ordinances are also deferred until 
the next meeting of the Association and are not to be read now. 

Th/5 President: All this will be published in the Transac- 
tions, gentlemen. 

The Chairman of the Board then read the recommendation 
of the Board on the resolutions introduced by Dr. Mack Rogers 
at the 1915 meeting. The action of the Board was sustained. 

The section of the report relating to the resolution intro- 
duced by Dr. Martin was adopted as read. 



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182 THE MEDICAL ASSOCIATION OF ALABAMA. 

The section of the report dealing with the Etowah county 
appeal was adopted as read. 

The section of the report relating to the resolutions intro- 
duced by Dr. McAdory was adopted as read. 

The section of the report relating to the resolution intro- 
duced by Dr. E. B. Ward was adopted as read. 

The section of the report in regard to the resolution offered 
by Dr. Harper relating to criminal laws was adopted as read. 

The section of the report relative to the resolution offered by 
Dr. Harper in regard to the subnormal child was adopted as 
read. 

The Chairman of the Board read the resolution from the 
Council for National Defense. 

Dr. Welch : These resolutions were sent out by the Council 
on National Defense. They request this Association to pass a 
resolution requiring the members of the Association to take 
care of the practice of all such men as volunteer for service 
in the army and navy on the plan of giving either to the 
man in the service or to his family, as he may re- 
quest, one-third of all the fees that accrue from practice 
among his patients. It is required that the man send to the 
President of the Association a list of the families which he 
attends, and that this list be sent to the doctors in the immedi- 
ate community from which he volunteers, and that they be re- 
quired to take care of him while he is absent. That is in a few 
words what is contained in the resolution. When the volunteer 
returns he must give notice to all of the community that he is 
there and ready to take up his work again ; and that the other 
doctors in the community pledge themselves not to answer a 
call to the family of his clientele for one year from that time. 

Dr. Baker : This is a very important matter. A resolution 
very similar to that has just been adopted by the Maryland 
Medical Society. They realize the importance of trying to pro- 
tect the interests of those men who go to the front and the 
interests of their families by the men who are left behind at 
home, and even though this Association at the present time 
does not outline any definite plan whereby this should be done, 
I wish to urge, as Chairman of the State Committee for Medi- 
cal Preparedness in Alabama, that when you gentlemen go back 
honje you take this sentiment with you, that it is the bounden 
duty of those men left behind to protect the interests of those 



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ACTION ON REPORT OF BOARD OF CBN80RS. 188 

men who go to the front. The salaries of the majority of the 
men who will go to the front will not be sufficient to care for 
the needs of their families, and when they put down their work 
to serve their country I am sure that every man in this house 
is more than willing to do the right thing to protect their inter- 
ests at home. I am going to urge you when you go home to 
communicate with your county societies, have a meeting and 
bring this matter before them, and take in each county some 
definite step looking to the end outlined in these resolutions. 

I had in this morning's mail a communication from the 
Council of National Defense in Washington, which requests 
that the State Committee have a meeting at once and select a 
number of men who will be delegated the duty at once of visit- 
ing various county societies and making mental and physical 
examinations of applicants who wish to join the reserve corps. 
That answers for you a question asked me a number of times, 
When will definite steps be taken ? They will be taken at once, 
and, gentlemen, all of you should try and have your county 
societies organized so that when the representative of the State 
Committee comes into your county you will be prepared to 
render him every possible aid. (Applause.) 

Dr. McAdory. I move the adoption of this section of the 
report 

Seconded. Carried. 

Dr. Welch : There was also a resolution introduced by Dr. 
Cameron, amending the Constitution in the manner of electing 
members to the Board of Censors, making them elective in the 
ten congressional districts. It will have to lie over until an- 
other year. It will be published in the Transactions. 

Dr. Welch then read the section of the report in regard to the 
election of the State Prison Inspector. 

Dr. Perry: I move the adoption of this section of the re- 
port and the resolution. 

Dr. H. S. Ward : I second the motion. 

Carried. 

Dr. Welch : Part II of the report consists of the Financial 
Statement and the Report of the Board of Examiners. 

Dr. McAdory : I move that the reading of the second part 
of the report be omitted. 

Carried. 



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184 THE MEDICAL ASSOCIATION OF ALABAMA, 

Dr. Welch : Part Three consists of reports of the Laboratory 
and the Pasteur Institute, and of the Department of Vital and 
Mortuary Statistics. 

Dr. McAdory: I move the adoption of Part Three of the 
report. 

Seconded. Carried. 

Dr. Morris: I ihove the adoption of the Report of the 
Board of Censors as a whole. 

Seconded. Carried. 

The Secretary : Before taking up the regular order of busi- 
ness, I have a communication just sent in from the Alabama 
Dental Association, stating that they have adopted a resolution 
providing for the appointment of a committee for the purpose of 
conferring with a like committee from this body to offer sug- 
gestions in the interests of public welfare, and to arrange a 
plan whereby they, as a profession, might be able to assist the 
State Board of Health. 

Dr. McAdory: I move that this resolution be referred to 
the Board of Censors, with power to act. 

Seconded. Carried. 

Dr. Talley : Does that mean they are empowered to appoint 
the committee? 

Dr. McAdory : If they want to. 

Dr. Welch : I would just like to inquire if it is proposed for 
the Board of Censors to take action upon this proposition now 
or at its July meeting? The Board of Censors adjourned sine 
die, and it is a rule of this Association that resolutions intro- 
duced at this meeting be put off until the next meeting of the 
Board of Censors. 

The President: The Chair understands that the Board of 
Censors has been given full power to act at once or to appoint 
the committeee at once if they wish. 

Dr. C. A. Mohr : I wish to offer the following resolution : 

Resolved, That the appreciation of the Association be expressed 
through the State Health Officer to those two generous citizens of 
Alabama, Mrs. L. A. Jemison, of Talladega, and Mr. W. B. Davis, of 
Fort Pajme, for their liberal contributions which makes it possible 
for the Board to continue the Intensive community work. 

The resolution was adopted. 



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PROCEEDINGS. 186 

The President: The next order of business is the revision 
of the rolls. The secretary will call first the roll of county 
medical societies. 

The Revision of the Rolls, 

The Secretary : All of the county societies have discharged 
all their obligations to the Association except as follows : 

Delinquent in Delegates : Choctaw, Clay, Colbert, Fayette, Greene, 
Henry, Lamar, Limestone, Macon, Marshall and Sumter. 
Delinquent in Reports From Secretary: Marshall. 
Delinquent in Dues : Clay, DeKalb, Lawrence and Marshall. 

The President : You have heard the names of those coun- 
ties which are delinquent in their obligations. If there are no 
objections, the officers of this Association will be directed to 
use diligence in ascertaining and in correcting the causes of 
such delinquencies. We will now proceed to the revision of the 
roll of counsellors. 

Revision of the Roll of Counsellors. 

The Secretary: Schedule (a) All counsellors are clear of 
the books except those whose names appear on schedules b and 
c as follows: 

The President: You have heard the statement of the Sec- 
retary relating to counsellors clear of the books. If there be no 
objection they will be passed. 

The Secretary: Schedule (b) The following counsellors are 
delinquent as stated : 

Baird, R. H., delinquent In attendance; Howard, I. W., delinquent 
In dues ; Pitts, R. N., delinquent In attendance and In dues. 

The President : You have heard the names of the counsel- 
lors just read by the Secretary and reported as delinquent in 
their obligations to the Association. Under the rules, and if 
there is no objection these names will be struck from the roll of 
the college of counsellors, and of this action the persons con- 
cerned shall be duly notified by the Secretary. 

The Secretary: Schedule (c) The following counsellors 
have died since our last annual meeting : 



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186 THE MEDICAL ASSOCIATION OF ALABAMA. 

William Henry Sledge, Mobile, a life counsellor, and Reuben Fletch- 
er Monette, of Greensboro, a Junior counsellor. 

The President : You have heard the names of those of our 
brother counsellors who have died. Let us cherish their mem- 
ories and emulate their virtues. Peace to their ashes. I hereby 
appoint Dr. C. A. Mohr to convey to the family of Dr. Sledge 
the regrets of this Association, and Dr. H. G. Perry to perform 
the same service in the case of Dr. Monette. 

The Secretary : 

Schedule (d) B. L. Wyman has served 10 years as senior coun- 
sellor. 

Schedule (e) E. B. Ward has served 10 years as Junior counsellor. 

Schedule (f) W. A. Stallworth, L. E. Broughton, J. M. Austin, 
P. M. Lightfoot, S. Q. Garden, and W. O. Ck)llins have served one year 
as counsellors-elect, have paid their dues and have signed the coun- 
sellor's pledge. 

The President: You have heard the three schedules just 
read. If there are no objections the counsellors named will be 
advanced as provided by the Constitution. Have all the coun- 
sellors been called? Is there anything further to be done in 
relation to the revision of the roll of the college of counsellors ? 
If not, I declare the roll of counsellors closed until the next 
annual meeting of the Association. 

The Secretary: There is no change in the roll of corre- 
spondents. The names of correspondents are in the Transac- 
tions. 

Election of Officers. 

The President: The next order of business is the election 
and installation of officers. The officers to be elected are a 
President, a Vice-President for the Southern Division, two 
members of the Board of Censors for five years, to fill the 
places of Dr. Sanders and Dr. Wyman, and five counsellors. 
When the time comes the Secretary will read out the districts 
from which the counsellors are to be elected. First in order is 
the election of a President for the next year. I will appoint 
Drs. Ray and McAdory as tellers. 

The balloting for President resulted as follows: W. D* 
Partlow, 64 ; W. W. Harper, 7 ; W. R. Jackson, 1 ; E. D. Bon- 



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PBOOBBDINas. 187 

durant, 1. Dr. Partlow having received the highest number 
of votes cast, was declared elected President for the ensuing 
year. 

The balloting for Junior Vice-President resulted as follows : 
W. F. Betts, 62; W. W. Harper, 2; J. L. Bowman, 6; L. E. 
Broughton, 2. Dr. Betts, having received the highest number 
of votes cast, was declared elected. 

The President: The next in order is the election of two 
members of the Board of Censors to fill the vacancies by the 
expiration'of the terms of Drs. Sanders and Wyman. 

Dr. L. C. Morris: As I understand it, the resignation of 
our State Health Officer, Dr. W. H. Sanders, was handed to 
the Board of Censors in January of this year, and was accepted, 
and Dr. Welch was selected as his successor, and was elected 
by this Association today. Dr. Sanders* position upon the 
Board of Censors expires today. As a slight testimonial 
and evidence of our appreciation of the splendid service 
that has been rendered this Association in the past by 
Dr. Sanders, as a slight evidence of our devotion to 
him, I would like to move, Mr. President, if I am in order, that 
Dr. Sanders be reelected to the Board of Censors by acclama- 
tion. 

Dr. Baker: The sentiment expressed in Dr. Morris' sug- 
gestion is very gracious, and yet it is against the rules of this 
Association to put any one in nomination. So the sentiment 
can still be at work and we can vote in the usual manner. 

Dr. Morris: Under those conditions I will withdraw my 
motion, but I hope it is not necessary to say any more. 

The balloting for two members of the Board of Censors 
resulted as follows: W. H. Sanders, 57; B. L. W)rman, 54; 
Seale Harris, 2 ; L. C. Morris, 1 ; O. S. Justice, 2 ; W. P. Mc- 
Adory, 1 ; R. M. Cunningham, 1. Drs. Sanders and Wyman 
were declared elected for the ensuing five years. 

Dr. McAdory : I move that we suspend the rules and that 
the Secretary be instructed to cast the ballot of this Association 
for five counsellors. 

The following members were elected counsellors, the Secre- 
tary casting the ballot : 

2nd District — P. V. Spier^ of Wilcox county. 

5th District — N. G. James, of Lowndes county ; H. B. Dish- 
eroon, of Randolph county. 



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138 THE MEDICAL A8B0CIATI0N OF ALABAMA. 

7th District — J. C. Martin, of Cullman county. 

8th District — F. L. Chenault, of Morgan county. 

The President : I declare the gentlemen whose names have 
just been read by the Secretary duly elected as counsellors- 
elect. 

The President appointed Drs. Baker and Morris to escort the 
newly-elected President to the platform. 

The President: Gentlemen, it gives me great pleasure to 
introduce to you Dr. Partlow, your President for the ensuing 
year. 

Dr. Partlow : It is not my purpose, gentlemen, to take up 
any of your time by a speech. I merely want, in a word, to 
express my profound gratitude for the honor you have con- 
ferred upon me, for the confidence you by this action bestow 
in me, and to assure you that I understand that this carries 
with it a responsibility which I fully appreciate. I consider this 
the greatest honor ever conferred upon me, and I assure you 
that I shall at all times during this year be interested in the 
welfare of this Association, and shall do everything within my 
power to make the next annual meeting a success. I realize, as 
you all do, that the success of a meeting depends more upon the 
loyalty and cooperation of the members of the Association than 
it does upon the President. I therefore ask the continued 
interest and cooperation of every member of the State Associa- 
tion, and particularly is this necessary for this year, as no 
doubt the effects of the strenuous times and the war will be 
felt by this Association as well as by the country at large. I 
therefore urge and insist that we have your continued interest 
and cooperation. (Applause.) 

Dr. Walker : I am instructed by the Jefferson County Med- 
ical Society to extend a cordial invitation to this Association to 
hold your next meeting in Birmingham. 

Dr. Mohr: I move that this cordial invitation be accepted: 

The motion was seconded and carried. 

Dr. McAdory : I think it would be hardly fair for this Asso- 
ciation to adjourn without passing a resolution of love, best 
wishes and regrets that Dr. Sanders could not be here, and I 
therefore move that the Secretary prepare such a resolution 
and have it suitably engrossed and delivered to Dr. Sanders 
and published in the daily papers. 

The motion was seconded and adopted. 



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PR0CEBDING8. 189 

Dr. Ray : I move a resolution of thanks to the Automobile 
Club, the Rotary Club and the doctors of Montgomery for the 
automobile ride tendered the Association on Thursday. 

Seconded. Carried. 

Dr. Caldwell : I would like to offer a vote of thanks to the 
Medical Society of Montgomery County, the press of Mont- 
gomery, and the manager of this hotel, for the efforts that they 
have put forth and the entertainment they have given. 

Dr. McAdory : I would like to make an amendment to that 
motion, that the Association commends the Montgomery Coun- 
ty Medical Society for cutting out all entertainment. 

Seconded. Carried. 

At 12 :20 p. m. th.e Association adjourned sine die. 

A Copy of the Resolutions Sent Dr, W, H, Sanders By Order 

of the Medical Association of the State of Alabama, 

April ip, ipiy. 

Whereas, Dr. W. H. Sanders, on account of iU health, reeigned as 
State Health Office and as Chairman of the Board of Censors, which 
positions he has graced so long and filled with such marked ability 
and success, therefore, 

Be It Resolved by the Medical Association of the State of Ala- 
bama, in annual session assembled. 

First, That we hereby tender to Dr. Sanders the assurance of the 
appreciation, esteem and affection of every member of this body ; 

Second, That we indulge the hope that he may soon recover his 
usual health and be spared many years to give us the benefit of his 
wisdom and counsel; 

Third, That in his declining years he may be sustained and com- 
forted by the knowledge that he has been true to every trust, and 
valiant in his efforts for the advancement of organized medicine and 
for the welfare of the people of the State of Alabama. 

Unanimously adopted. 

Hbnby Gbeen, M. D., 
President. 
H. G. Pebby, M. D., 

Secretary. 



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146 THE MEDICAL AB800IATI0N OF ALABAMA. 

REGISTRATION IN MONTGOMERY. 
1917. 



The following members and visitors attended the annual meeting: 

Life Ck)nNSELL0BS. 

H. Q. Perry Montgomery 

S. G. Gay Selma 

Glenn Andrews . Montgomery 

B. J. Baldwin Montgomery 

W. H. Moon , Goodwater 

R. L. Sutton. Orrville 

B. D. Bondurant Jfoblle 

M. B. Cameron Ehitaw 

L. W. Johnston Tuskegee 

J. B. Wilkinson PrattvlUe 

WyattHeflln Birmingham 

J. T. Searcy Tuscaloosa 

J. A. Howie . Eclectic 

D. B. Gason. OdenvUle 

W. H. Sanders Jf ontgomery 

L. Lfc Hill Montgomery 

I. L. Watklns. 3fontgomery 

Geo. P. Waller Montgomery 



Total, la 



Active Couitbellobs. 



Henry Green Dothan 

S. W. Welch Talladega 

Chas. A. Mohr Mobile 

D. F. Talley Birmingham 

B. B. Ward Selma 

B. M. Harris RusseUvllle 

W. D. Gaines. LaFayette 

J. L. Gaston Montgomery 

J. U. Ray Woodstock 

A. N. Steele. ^nnlston 



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ACTIVE COUNSELLORS. 



141 



O. S. Justice.. 



W. C. Maples... 
Robert Goldthwalte«^ 

W. D. Partlow. 

J. N. Baker. 

J. R. Horn. 

W. S. McBlrath 

John P. Stewart 

H. S. Ward. 

Sam P. Hand. 

L. E. Broaghton 

Hugh W. Blair 

G. L. Greeham 

Mack Rogers 

J. M. Austin 

C. A. Thigpen 

R. S. Hill 

J. O. Kennedy 

W. M. Cunningham.. 



..Central 
.Scottsboro 

Montgomery 

.Tuscaloosa 



Montgomery 

LuTeme 

Cedar Bluff 

Attalla 

Birmingham 

JDemopolis 

Andalusia 

Sheffield 

Andalusia 

Birmingham 

Wetumpka 



Montgomery 

Montgomery 

....: Kennedy 

Cordova 



P. T. Fleming Enterprise 

T. J. Brothers Anniston 

J. M. Watkins Troy 

Lewis C. Morris Birmingham 

Seale Harris Birmingham 

Jas. S. McLester „ Birmingham 

J. L. Bowman Union Springs 

E. B. Ard. Ozark 



W. F. Betts 

S. A. Gordon 

W. H. Oates... 



Evergreen 

Marion 

Mobile 



W. P. McAdory 

Jas. P. Turner. 

H. J. Sankey 

M. D. Smith 



W. W. Harper. 

John N. Fumiss.. 

B. F. Bennett 

W. B. Hendrick... 

R. Ia Justice . 

W. R. Jackson 



^ Birmingham 

Cropwell 

Nauvoo 

Prattville 

Selma 

Selma 



Louisville 

Hurtsboro 

Geneva 

Mobile 



C. A. Poellnitz.. 



..Greensboro 



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Google 



142 THE MEDICAL ASSOCIATION OF ALABAMA. 

P. M. Llghtfoot ^ Shorter 

M. C. Schoolar Birmingham 

C. S. Chenault Albany 

L. O. Hicks „ ^ Jackson 

M. S. Davie ^ Dotlian 

H. P. McWhorter Collinsvllle 

B. B. Simms Talladega 

A. L. Harlan ^ ^ ^ Alexander City 

E. G. Glvhan ^ Montevallo 

S. F. Mayfield « ^ ^ Tuscaloosa 

W. S. Brltt Eufaula 

M. L. Malloy Eutaw 

W. M. Faulk Tuscaloosa 

Total, 64. 

Delegates. 

Delegates in attendance at Montgomery session, April 17-21, 1917 : 

Autauga — J. E. Wilkinson, Jr., Prattvllle. 
Baldwin — Joseph Hall, Bay Minette. 
Barbour— vr, P. Copeland, Eufaula ; G. O. Wallace, Clio. 
Bibh—S. C. Meigs, CentervUle ; M. C. Thomas, Blocton. 
Blount — D. S. Moore, Oneonta ; C. L. Stansberry, Oneonta. 
Bullock— T. J. Dean, Union Springs. 
Butler— A. L. Stabler, Greenville; C. Wall, Forest Home. 
Calhoun— R. T. McCraw, Oxford ; C. H. Cleveland, Annlston. 
Chambers — T. H. Haralson, Cusseta. 
Chilton— J. P. Hays, Clanton. 
Cherokee— L.. R. Stone, Tafif ; S. C. Tatum, Center. 
Choctatc — None. 

Clarke — J. A. Klmbrough, Thomasville; J. G. Bedsole, Grove Hill. 
Clau — None. 

Cleburne— U R. Wright, Heflin. 

Coffee — B. J. Massey, New Brockton ; W. A. Lewis, Enterprise. 
Colbert — None. 

Conecuh — W. M. Salter, Rep ton. 

Coosa — J. E. Harden, Rockford ; A. K. Whestone, Rockford. 
Covington — B. C. Stewart, Opp ; J. C. McLeod, 0pp. 
Crenshaw — M. L. Morgan, Honoraville; F. M. T. Tankersley, Lu- 
veme. 
Cullman — J. C. Martin, Cullman; Chas. Hayes, Cullman. 



Digitized by VjOOQIC 



DELEGATES. 148 

Dale — J. L. Reynolds, Ozark. 

Dallas— J. M. Donald, Marion Junction ; B. B. Rogan, Selma. 

DeKalh—lj. McWhorter, Collinsvllle. 

Elmore — J. S. Harmon, Elmore ; S. P. Moon, Elmore. 

Escambia — R. A. Smith, Brewton; F. L. Abemathy, Flomaton. 

Etoicah — I. C. Ballard, Gadsden; John Shahan, Gadsden. 

Fayette — ^None. 

Franklin — Jas. Copeland, Red Bay ; W. A. Gresham, Russellvllle. 

Geneva — M. E. Doughty, Slooumb; H. C. Riley, CoflPee Springs. 

Greene — None. 

Hale— A. L. Nourse, Sawyervllle. 

Henry — None. 

Houston — R. H. Mooty, Columbia ; L. Hllson, Webb. 

Jackson — A. Zimmerman, Larklnsvllle. 

Jefferson — C. W. Shropshire, Ira J. Sellers, A. A. Walker, W. F. 
Scott, Z. B. Chamblee, W. C. Gewln, all of Birmingham. 

Lamar — None. 

Lauderdale — A. A. Jackson, Florence; S. S. Roberts, Florence. 

Lawrence — W. R. Taylor, Town Creek. 

Lee— M. D. Thomas, Opelika ; C. S. Yarborough, Auburn. 

Limestone — None. 

Lotcndes — N. G. James, Haynevllle; G. C. Marlette, Hayneville. 

Macon — None. 

Madison — E. V. Caldwell, Huntsvllle. 

Marengo — C. N. Lacey, Demopolls. 

Marion — John L. Wilson, Hackleburg; D. M. Slzemore, Guin. 

Marshall — None. 

Mobile— J, M. Wilson, P. D. McGhee, J. O. Rush, all of Mobile. 

Monroe — J. J. Dalley, Tunnel Springs. 

Montgomery— M, ft. Kirkpatrlck, C. B. Laslie, C. H. Rice, F. W. 
Wllkerson, all of Montgomery. 

Morgan — F. L. Chenault, Albany. 

Perry— R. C. Hanna, Marlon. 

Pickens— A. M. Walker, CarroUton ; E. B. Durrett, Gordo. 

Pike—Lu R. Boyd, Troy. 

Randolph — J. M. Welch, Wadley. 

Russell— W, T. Joiner, Plttsvlew ; R. F. Elrod, Cottonton. 

Bt. Clair— B. F. Smart, Odenville. 

Shelbys, D. Motley, Calera. 

Sumter— None. 

Talladega — J. A. Sims, Renfroe; J. P. Chapman, Talladega. 



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144 THE MEDIO AL ASSOCIATION OF ALABAMA. 

TaUapooBo—J. O. Griffin, Alexander City ; B. W. Hart, Dadeville. 
Tuscaloosa — M. Moody, Toscaloosa ; J. J. Dnrrett, Toscaloosa. 
TFalfcef^—G. W. Jones, America. 
Washington — J. Chason, Chathom. 

Wiloox — E. E. Williams, Ackerville; P. V. Spier, Furman. 
Winston — R. L. Hill, Lynn ; T. M. Blake, Double Springs. 
Total, 9a 

MSMBDtS. 

T. Brannon Hubbard _ 3fontgomery 

J. H. Holly — Samson 

J. U. Reeves Jfobile 

W. A. Clark. „. JPine Barren, Fla. 

P. I. Hopkins ^ ^ J>otlian 

P. S. Mertlns Jblontgomery 

Arthur Johnson Clanton 

J. G. Gilchrist : BranUey 

D. P. Mixson ;. Skipperville 

B. F. Rea LaFayette 

F. H. McConnlco Montgomery 

H. J. Bumham Birmingham 

W. V. Stough _ Montgomery 

W. W. Dlnsmore. Montgomery 

Chilton Thorington Jklontgomery 

R. J. Griffin Moundville 

B. F. Anderson Montgomery 

F. C. Stevenson Montgomery 

J. W. Black JEJnsley 

J. Louis Snow Montgomery 

S. L. Ledbetter Birmingham 

Hugh Boyd Scottsboro 

D. S. Moore Birmingham 

G. C. Reynolds Brundidge 

C. L. Muprhree. Gadsden 

K. B. WUliams Cecil 

I. L. Johnston Samson 

E. Tankersley Samson 

Howard P. Rankin Jfidway 

W. B. Johnson Birmingham 

G. J. Greil. Montgomery 



Digitized by VjOOQIC 



MEMBERS. 145 

I. A. Black, Midland City 

Gibson Reynolds „ Montgomery 

J. P. Merrill. « ^ Dozler 

R. L. Huddleston ^ Speigner 

H. li. Appleton _ Gadsden 

H. Priest „ Montgomery 

T. A. Casey ~ ~ Birmingham 

B. L. Arms ^ Montgomery 

S. T. Miller „ „ ^ Tantley 

Oscar Johnson ^ „, Fltzpatrldc 

James Reld .^ Clayton 

W. M. Blair Gantt 

J. R. Penton „ Central 

F. P. Boswell Montgomery 

E. R. Smith ^ ^ ^ ^ „ Andalusia 

W. J. Love..: „ Opelika 

L. H. Mayo Pine Hill 

W. S. Sanders Troy 

B. F. Thrower. Enterprise 

C. H. Chapman Geneva 

Jno. A. M. Nolen. „ _ ^ Equality 

J. A. R. Chapman ^...Kellyton 

W. A. Stanley — Enterprise 

A. J. L. Dennis „ Jfontgomery 

F. W. Galloway ..^ „ Florala 

G. H. Cooper ^ Opelika 

B. S. Chapman Montgomery 

W. W. McGehee. « Montgomery 

H. B. Wilkinson Jblontgomery 

H. S. Persons Montgomery 

A. H. Montgomery ^ Montgomery 

J. J. Walls Alexander City 

J. W. McCalL Montgomery 

Harris P. Dawson » Montgomery 

S. Klrkpatrlck ^ Selma 

M. Y. Dabney ^Birmingham 

P. E. Godbold. Pine Hill 

L. D. Parker. _. Andalusia 

J. H. Blackwell ~ Birmingham 

Robert B. Beards „..Troy 

B. R. Bradford Dixon's Mill 

10 M 



Digitized by VjOOQIC 



X46 TEE MEDICAL ASSOCIATION OF ALABAMA. 

;r. W. y'enn..^ Eufaala 

H. B. Upcliurch ^ ^.... Carrollton 

Homer S. Bruce. ^ Opellka 

Wm, Q. Thigpen. ^. .Jlontgomery 

E. S. Sledge « Mobile 

Virgil Dark „ ^ „ Eclectic 

Isham Kimball Auburn 

A. R. Allen „ Fort Mitchell 

Ed. T. Glass ^ Birmingham 

D. J. Long „ Mobile 

H. L. Castleman 1 Sylacauga 

H. W. Jordan Red XiCvel 

A. W. Ralls ^ Gadsden 

L. T. Lee. ~ - „ » ^ Ck)leanor 

T. Y. Greet ^ ^Gadsden 

J. W. Fleming, Jr. ^ ^. Lockhart 

E. W. Rucker, Jr ., Birmingham 

W. B. Harrell ~ Thomaston 

J. W. Hooper — Roanoke 

H. B. Dlsharoon Roanoke 

W. B. Tatum Montgomery 

O. L. Cramton...„ — Mobile 

F. F. Blair ....Flat Top 

L. A. Jenkins : ~ Birmingham 

P. M. Kyser , Birmin^iam 

T. C. Donald .Bessemer 

H. A. Leyden Anniston 

W. A. Haggard „ - Brooklyn 

R. C. Dickinson Brundldge 

J. F. Bean ~- Brundldge 

C. P. McEathem ~ Banks 

James Kenan - Selma 

Monroe A. Maas - — Selma 

R. G. Shanks Autaugaville 

Marcus Skinner — Selma 

W. M. Tankersly Hope Hull 

J. C. Mason Snowdoun 

B. S. Carpenter ...Yojande 

French H. Craddock — Sylacauga 

W. E. Prescott Birmingham 

Jno. D. Johnston ~ ~ Brundidge 



Digitrzed by VjOOQIC 



umpms. 



m 



W. C. Howell.^ 
G. M. Taylor.^ 



Dothan 

^PrattvlUe 



R. B. Hagood 

L. V. Stabler. 

H. A. Donovao „ 



Lowndesboro 

Greenyllle 

Patsburg 

Hope HuU 

Tallassee 

.Wetumpka 

.. — Troy 



Frank Shackleford 

Jesse Gulledga..- 

W. M. Gamble. 

W. H. MInchlner 

R. H. Watson Georglana 

M. li. Watkins. Glenwood 

W. E. Kay MaplesviUe 

A- D. Wallace PlantersvlUe 

N. E. Sellers „ Ajinlston 

F. W. Young. .^ Hartford 

W. B. Westcott ~ ~ .Montgomery 

G. B. Collier Tuskegee 

R. H. Coker. Tallassee 

S. E. Jonrdan Highland Home 

C. W. C. Moore Talladega Springs 

L. H. Ledbetter. Goodwater 



W. B. Cram.. 



^.Fort Deposit 

Geo. S. Gilder „ Carbon Rill 

V. H. Williams ^Mper 

Jno. A. Kendrick GreenTllle 

Greo. A. Tranum Brantley 

J. Hall Jones Oak Hill 



L. M. Walker 

J. I. Reid 

G. R. Lee. 



W. P. Magrader.. 



, Burnsville 

Montevallo 

Arkadelphla 

- Tuskegee 

C. W. Brasfield. Linden 

James G. Donald. ^ Pineapple 

Wm. S. Johnson Notasulga 

R. C. Curtis „ Loachapoka 

W. A. Parrlsh Midland City 

Joe Banks, Jr Dadeville 

K. B. Goggans... ..Hacklebur^ 



L. H. Moore..... 

W. M. Shaw 

Thos. F. tpaylor.. 



.^Orrville 
.......Iciio 

...Dothan 



Digitized by 



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148 THE MEDICAL ASSOCIATION OF ALABAMA. 

G. H. Moore Opellka 

J. R. Haigler Montgomery 

I. D. Wood ^Sylacauga 

S. T. Cousins Equality 

W. W. Perdue ^ Mobile 

J. M. Anderson ^ Montgomery 

C. B. Marlette ~ ^ ^aynevUle 

W. D. Nettles ^ Garland 

C. N. Pamell ^ ^ Maplesvllle 

J. L. Smith Montgomery, R. F. D. 2 

W. H. Harrison Midway 

H. G. Sellers Birmingham 

J. S. Tillman: ^ ^ ^ Clio 

L. B. Allen „ A.lexander City 

N. B. Dean .v J^lexander City 

H. B. Searcy Tuscaloosa 

D. C. Batson — Gantfs Quarry 

S. B. Bell Ozark 

A. L. McClendon ^ Waverly 

M. J. Bancroft - Mobile 

Milton L. Wood ^ Montgomery 

J. W. Maddox..: Wadsworth 

C. S. Strock. „^ Verbena 

Walter A. Weed Birmingham 

J. W. Hagood Evergreen 

Ira J. Sellers ^ Birmingham 

Jesse L. Weldon ^ Lanette 

C. T. Pollard ~ Montgomery 

S. D. Suggs ~ Montgomery 

W. D. Mixson Midland City 

D. C. Donald ^ Birmingham 

J. H. Kimbrough ., Lowndesboro 

J. M. Lowrey ~ ~ Birmingham 

F. H. Craddock Sylacauga 

J. W. Sewell Titus 

A. D. Cowles ^ Ramer 

R. L. Mllligan .Montgomery 

J. H. Blue Montgomery 

F, M. Thlgpen ~ .Montgomery 

I. C. Bates Taylor 

P. P. Salter — .Montgomery 



Digitized by VjOOQIC 



VISITORS. 



149 



L. B. Farish 

Marion Inge. 

M. D. Thomas — 

L. R. Boyd. 

Total, 199. 



...Brewton 

. MobUe 

Op^ika 

Troy 



V18ITOB8. 



Dr. J. P. Ellsberry — .Montgomery 

Dr. W. G. Young ^ Washington, D. C. 

Dr. S. L. Reld. ...Owensboro, Ky. 

Miss Helen Templeton „ Birmingham 

Rev. O. P. Spiegel Montgomery 

Maj. E. R. Schrelner, Surgeon U. S. Army Washington, D. C. 

C. B. Dyar ^ Atlanta, Ga. 

R. B. Seay ^ New Orleans 

W. G. Hanes .....Montgomery 

Horton Chamblee L Birmingham 

Edward Day Orrville 

James L. Bevans Major, U. S. Army 

Kenneth Wood Leslie, Ga. 

P. H. Boweth Saratoga, N. Y. 



Dr. Clarence Hutchinson... 

Miss Lucile Hart 

J. E. Pearson 

Dr. Jno. A. Lanford 

R. R. Meriweather 

J. Lee Holloway 

H. C. Wilson. 

J. T. Watt 

Norman Gunn. 



Pensacola, Fla. 

Dadeville 

Wetumpka 

...JSew Orleans, La. 

— Macon, Ga*. 

Montgomery 

Montgomery 

Auburn 

Jasper 



Boyd Gilbert Goodwater 

Dr. J. S. Turbeville...- Century, Fla. 

C. 0. Watklns Pine Apple 



Dr. W. F. Whitehead... 



Dr. W. R. Rankin.. 
Jewett Motley 



..Columbus, Ga. 
— Montgomery 
Calera 



Frank F. Perry, D. D. S.. 

Dr. WuL J. Mayo 

Total, 82. 



..Montgomery 



..Rochester, Minn. 



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150 THE MEDICAL ABSOCJATION OF ALABAMA. 

SxnCMABT. 



Life CJounsellors 

Connsellors 

Delegates 

Members 

Visitors 



18 
64 
96 
. 199 
32 



Total - „ „ 409 



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Google 



THE LIFE COUNSELLORS. ibi 

THE ROLL OF THE COLLEGE OF COUNSELLORS. 
Revision or 1917. 



THE LIFE COUNSELLORS. 

Andrews, Glenn, Montgomery — Selma session 18d3 

Baldwin, Benjamin James, Montgomery — Anniston session 1886 

Bel|, Walter Howard, Brookside — Birmingham session 1894 

Blake, Wyatt Ueflin, SheMeld— Montgomery session 1892 

Bondnrant, Eugene Dubose, Mobile — Birmingham session 1894 

Brockway, Dudley Samuel, Livingston — Mobile session 1882 

Cameron, Matthew Bunyan, Eutfiw — Selma session 1893 

^a^pn, Davis Eimore, Ashvllle — ^Huntsville session......... %886 

DeWeese, Thomas Peters, Gamble^ ^ines — Birmingham session 189Q 

puggar, Reuben Henry, Galiion — Montgomery session 1883 

Frazer, Tucker Henderson. Mobile-^Mobile session 1895 

Gaines, Vivian Pendleton, Mobil? — Selma session .. 1879 

Gay, Samuel Gilbert, Selma— Selma. session J893 

Goodwin, Joseph Andersop, Jasper— Mobile session J872 

Goggans, jisimes Adrian, Alexander City— ^Birmingham session.. :t883 

garrison, William Groce, Birmingham— Montgomery session ^896 

^eflin, Wyatt, Birmingham— Selma s^ion................„ 18^3 

Hill, Luther Leonidas, Mpn^omery— J^ontgomery session 1888 

powle, Jaines AugustUQ^ Eclectic — Mobile session ^895 

Inge, Biarry TutwUer, Mobile— Greenville session 1885 

Johnston, Louis WiUla^, Tuskegjee — Moiiile session....^.... |895 

Jones, Capers Capehart, Eapt Lake— Montgomery session 1881 

Jpnes, Julius, ^pciiforij — Montgomery session. 1896 

^oon, William Henr^, Goodwatj^r— Selma session 1893 

^fcWhorter, George Tlgjilman, Riverion — Birmini^ham session.. J902 

farke, Thomas Duke, BIp mlnjgham — Selma session.......... 189^ 

perry, Henry Gajther, Montgomery— Blrjningiiam session 1894 

Redden, R<^bert James, SuUi^ent — Tuscalposa session „ 188t 

Robinson, Thpmas Franklij^ Bessemer:— Montgomery session 1896 

Sanders, William Henry, Mobile — Eufaula session J878 

Searcy, James Thomas, Tuscaloosa — Selma session 1884 

Sholl, Edward Henry, Birmingham — ^Huntsvilie session 1880 

Stovall, Andrew McAdams, Jasper — Mobile session. 1881 



Digitized by VjOOQIC 



162 THB MEDICAL ASSOCIATION OF ALABAMA. 

Sutton, Robert Lee, Orrville — Mobile session 1895 

Waller, George Piatt, Montgomery — Montgomery session 1896 

Watklns, Isaac LaFayette, Montgomery — Selma session 1893 

Whaley, Lewis, Birmingham — Anniston session 1886 

Wilkinson, John Edward, Prattville — Montgomery session 1892 

Williams, John Hartford, Columbiana — ^Birmingham session 1894 

Wyman, Benjamin Leon, Birmingham — Selma session.. 1897 

Total, 40. 

THE SENIOR COUNSELLORS. 

Ard, Erastus Byron, Ozark — ^Montgomery session 1900 

Baker, James Norment, Montgomery — ^Montgomery session 1905 

Bancroft, Joseph Dozier, East Lake — Mobile session 1899 

Bennett, Benjamin Franklin, Louisville — Birmingham session.. 1898 

Betts, William Frank, Evergreen — Mobile session 1904 

•Blair, Hugh Walter, Sheffield — Mobile session 1904 

Britt, Walter Stratton, Eufaula — Montgomery session 1905 

Burdeshaw, Lee Roy, Headland, Mobile session 1904 

Davie, Mercer Stillwell, Dothan— Mobile session 1904 

Davis, Jno. D. S., Birmingham— Birmingham session..... ....: 1906 

Fleming, Portet ThomAis, Enterprise — Selma sesision..... 1901 

Oaston, Joseph Lucius, Montgomery-r-Moblle session 1899 

Givhan, Edgar Gilmore, Montevallo— Talladega session.... 1903 

Goldthwaite, Robert, Montgomery — Birmingham session 1902 

Green, Henry, Dothan— Montgomery session 1900 

Guice, Charles Lee, Gadsden — ^Mobile session — 1899 

Harlan, Aaron LaFayette, Alexan'r City — ^Birmingham session 1898 

Harper, William Wade, Selma — Birmingham session 1902 

Harris, Elijah McCullough, Russellville — Mobile session 1904 

Harris. Seale, Birmingham— Talladega session . ... 1903 

Hill, Robert Somerville, Montgomery — ^Birmingham session 1898 

Jackson, William Richard, Mobile — Birmingham session 1906 

Justice, Oscar Suttle, Central — Mobile session 1899 

Justice, Robert Lee, Geneva— Montgomery session — 1900 

Maples, William Caswell, Scottsboro — ^Montgomery session 1900 

Morris, Lewis Coleman, Birmingham— Birmingham session 1902 

McCain, William Jasper, Livingston — ^Birmingham session 1898 

McClendon, Joseph Wyley, Dadeville— Birmingham session 1902 

♦Dr. Blair has died since the revision of the roll. 



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THE JUNIOR COUNSELLORS. 168 

Palmer, Jeesle Gary, Opellka — Mobile seBsion 1904 

Pride, William Thomas, Madison— Mobile session 1899 

Ray, Jacob Ussery, Woodstock — Birmingbam sessioti ^ 1906 

Schoolar, Milton Carson, Birmingham — Birmingham session.... 1902 

Slmms, Benjamin Brltt, Talladega — Selma session.! 1901 

Steele, Abner Newton, Annlston — Montgomery session 1905 

Talley, Dyer Flndley, Birmingham — ^Birmingham session 1902 

Thigpen, Charles Alston,. Montgomery — Montgomery session 1900 

Ward, Edward Burton, Selma — Birmingham session 1907 

Webb, Francis Asbury, Calvert — Mobile session 1904 

Welch, Samuel Wallace, Talladega— Mobile session 1899 

Wilder, William Hlnton, Birmingham- Talladega session 1903 

Wilkinson, David Leonldas, Moutevallo — Birmingham session.... 1902 
Total, 42. 

THE JUNIOR COUNSEM.ORS. 

Austin, James Maxwell, Wetumpka — Mobile session « 1916 

Bowman, Jas. Luther, Union Spring? — Montgomery session 1914 

Brothers, Thos. J., Annlston — Montgomery session..... 1914 

Broughton, L. El, Andalusia — ^Moblle session ,...." .. 1916 

Cardon, i^. G., Center— Mobile session _ 1916 

Chenaolt, 0. Sidney, Albany — Mobile session 1913 

Collins, W. O., Berry— Mobile session — , ^... 1916 

Cmtcher, John Sims, Athens — Birmingham session 1915 

Cunningham, Wm. Moody, Corona — Birmingham session 1912 

Esslinger, Levi Pickett, New Market^ — Birmingham session .. 1912 

Faulk, William M., Tuscaloosa — Mobile session 1913 

Fumiss, John Neilson, Selma — Birmingham session 191^ 

Gaines, William D., Lafayette — Mobile session ~., 1913 

Gaines, Marlon Toulmln, Mobile — Mobile session 1913 

Gordon, Samuel A., Marlon — Mobile session 1913 

Gresham, George L., Andalusia — Mobile session 1913 

Hand, Samuel P., Demopolis — Birmingham session 1915 

Haney, Jas. T., Tuscumbla — Montgomery session 1914 

Heacock, Joseph Davis, Birmingham — Birmingham session 1912 

Heflln, Howell T., Birmingham — Montgomery session 1914 

Hendrlck, Walter Branham, Hurtsboro — Birmingham session.... 1915 

Hicks, Lamartine Orlando, Jackson — Mobile session..... 1Q10 

Hughes, Robert Lee, Annlston — Birmingham session 1915 

Home» Joseph Robert, Luveme — Birmingham session. 1912 



Digitized by VjOOQIC 



iU THE MEDICAL ASSOCIATION OF ALABAMA. 

James, Ashley D., Pennington — Birmingham session 1915 

Kennedy, John (Dscar. Kennedy — Birmingham session 1909 

Llghtfoot, Philip Malcolm, Shorters— Mobile session 1916 

Lupton, Frank A., Birmingham — Mobile session 1913 

Malloy, Martin Luther, Eutaw — Montgomery session 1908 

Mayfleld, Surry T., Tuscaloosa — Montgomery session 1914 

Mohr, Charles A., Mobile — Birmingham session 1909 

Morris, William E., Georglana — Mobile session. 191? 

McAdory, Wellington Prude, Birmingham — Montgomery session 1911 

McElrath, WUllam Sparge, Ce4ar Bluff— Montgomery session.^. 1908 

McLeod, J. C, Bay Mlnette-r-Montgomery session..^ 1911 

McLester, James Somerrllle, Birmingham — Mobile session 1913 

McWhorter, Horace Puckett, CollinsTllle — ^Birmingham session 1915 

Oates, William Henry, Mobile— Mobile session „ 1913 

Partlow, William Di^psey, Tuscaloosa— Birmingham session.. 1909 

Peterson, Albert Jefferson, Goodwater— Mobile session 1910 

Pettey, Frank Paul, New Decatur^-Birmlngham session 1909 

ioellnltz, Clias. A., Greensboro— Montgomery session 1914 

rlnce, Edward Mortimer, Birmingham — Birmingham session.. 1909 

ogers, Mack, Birmingham — Mobile session...* '„ L 1910 

gaiikey, floward J., Nauvoo — Montgoinerjr session. '. 1914 

^tallwortfi, "Vfr". A., Beatrice— Mobile session........ ^.l _. 1916 

gtewart, itblin Pope, Attalla — Montgomery session..... . 1908 

$mith, Malcolm 1)., Prattville — Montgomery s^lon..... 19l4 

ij^aylor; Joseph Calhoun, llaleyville — Biirmingham session . 191^ 

^urner, Jain^ Ferry, ^Cropwell — Birmingham session...... '. 1912 

ppderwood, t^lmroa 1^, liusseilviHe— ^Montgomery session 1914 

ivard, Henry Silas,' Birmingham — tiirmlngiiam session. '.'. 1915 

"^atkln's, James Monroe, Troy— Birmingham session i^ljS 

White, Marvin S., Hamilton— Mobile session : :...:....... 1913 

Total; 64. 

cbuNsfeLLOttS-ELECdr. 

Second District, 

Phillip V. Speir Furman, Wilcox County 

Fifth District, 

tlenry Beauregard Dlsharoon _ Randolph County 

Norman Gilchrist James Haynevllle, Lowndes County 



Digitized by VjOOQIC 



BVMkARY, ife 

Seventh District. 
Jamee Cordie Martin ^.OuUman, Cullman County 

Eighth District. 

« 

Frank L. Chenault ^..Albany, Morgan County 

Total, 5. 

sijBiMAltT. 

Life Connfi^ors ., 40 

Senior GptuuseUors 42 

Junior CouuBeUors 54 

CouniBeUora-Elect 5 101 

Total 141 



Digitized by VjOOQIC 



166 THB MEDIO AL A8B00IAT10N OF ALABAMA. 



THE ROLL OF THE COLLEGE OF COUNSELLORS BY 
CONGRESSIONAL DISTRICTS. 



On this roll the names of the Counsellors are giyen by Congres- 
sional Districts. It is Intended to serve as a guide in the election 
of new Counsellors, witn a view to the distribution of them In ap- 
proximate proportion to the number of members in the several dis- 
tricts. It is not considered to be good policy, and it is not consid- 
ered to be fair and right, to give a few large towns greatly more 
than their pro rata share of Counsellors. The calculations are based 
on the nearest whole number. According to the Transactions of 1917, 
there are 1,739 members in the county medical societies. That would 
give one Counsellor to every 17.3 members. 

FIB8T DISTBIOT. 

County, Members, Ooun8ellor^ 

Choctaw 15 

Clarke 26 

Marengo ^ 17 

Monroe 19 

Mobile ^ 64 

Washington ^ „ 13 

Total members ^ 164 9 

This district has the number to which it is entitled. 

Names of Counsellors — A. D. James, Choctaw; L. O. Hicks, Clarke; 
S. P. Hand, Marengo ; W. R. Jackson, C. A. Mohr, M. T. Oaines and 
W. H. Gates, Mobile; F. A. Webb, Washington, W. A, Stallworth, 
Monroe. 

SECOND DISTRICT. 

County, Members, Counsellors. 

Baldwin ~ 14 1 

Butler ~ 18 1 

Conecuh 16 1 

Covington 28 2 

Crenshaw 14 1 

Escambia ~ 23 



Digitized by VjOOQIC 



BOLL OP THE COLLEGE OF OOVVBELLORB, 157 

Montgomery 69 5 

Pike 26 1 

WUcox ...^ ^ 82 1 

Total ^.. 240 13 

This district has one less than the number to which it is entitled. 

Names of Counsellors— J. O. McLeod, Baldwin; W. B. Morris, 
Butler ; W. F. Betts, Conecuh ; G. L. Gresham, Covington ; J. R. Horn, 
Crenshaw; J. N. Baker, R. Goldthwaite, R. S. Hill, J. L. Gaston, 
C. A. Thigpen, Montgomery; J. M. Watklns, Pike; L. B. Broughton, 
Covington ; Ross Spelr, Wilcox. 

THIRD DISTRICT. 

County. Members. Counsellors. 

Barbour „ 26 2 

Bullock „ : 16 1 

Coffee 18 1 

Dale A 14 1 

Geneva 34 1 

Houston 88 2 

Henry 18 1 

Lee 19 1 

RusseU 18 1 

Total 191 11 

This district has the number to which it is entitled. 
Names of Counsellors— B. F. Bennett and W. S. Britt, Barbour; 
J. L. Bowman, Bullock; P. T. Fleming, Coffee; B. B. Ard, Dale; 
R. L. Justice, Geneva; M. S. Davie and Henry Green, Houston; 
L. R. Burdeshaw, Henry; J. G. Palmer, Lee; W. B. Hendrlck, Rus- 
seU. 

FOURTH DISTRICT. 

County. 

Calhoun ~ 

Chilton 

Cleburne 

Dallas 

Shelby . 

Talladega ^ 

Total . — 150 



nhers 


Counsellors. 


37 


3 


15 





8 





42 


3 


20 


1 


28 


2 



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15§ TEB ¥BDWAL A8^0pi4'fXO^ OF 4J,ABAMA. 

This district has the numbar to which it is aitltled. 

Names of Couhsenors—T. J. Brothers, R. L. Hughes and A. ^. 
Steele, Calhoun; J. N. Fumlss, W. W. Harper and B. B. Ward, Dal- 
las ; B. G. GlThan, Shelby ; B. B. Simms and S. W. Welch, Talladega. 



FIFTH DI8TBI0T. 

County, Members, Counsellora. 

Autauga 11 % 

Chambers 21 1 

Clay 19 

Coosa 16 

Elmore 23 2 

Lowndes 18 1 

Macon .....: 8 1 

Randolph 19 1 

Tallapoosa 30 3 

Total 159 10 

This district has one more than the number to which it is entitled. 

Names of Counsellora — ^M. D. Smith, Autauga; W. D. Gaines, 
Chambers; O. S. Justice, Elmore; A. L. Harlan, J. W. McClendon 
and A. J. Peterson, Tallapoosa ; J. M. Austin, Elmore ; P. M. Light- 
foot, Macon; H. B. Dlsharoon, Randolph. 

SIXTH DISTBICT. 

County, Members. Counsellors. 

Bibb 20 1 

Greene 10 1 

Hale 11 1 

Perry 10 1 

Sumter ~ 17 1 

Tuscaloosa 42 3 

Total 110 8 

This district has two more than the number to which It is entitled. 

Names of Counsellors — J. U. Ray, Bibb; M. L. Malloy, Greene; 
C. A. Poellnitz, Hale; S. A. Gordon, Perry; W. J. McCain, Sumter'; 
W. M. Faulk, S. F. Mayfleld and W. D. Partlow, Tuscaloosa. 



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nOLl OF THE COLLEGE OF COUNSELLORS. }69 

SEVENTH DI8TBICT. 

County. Members. Counsellors. 

Blount '.. 13 

Cherokee ^. ~ 11 2 

Cullman ^ „ 23 1 

DeKalb ^ ^ 22 1 

Etowah - 85 2 

Marshall ^*. - 28 

St. Clair ._ 19 1 

Total ...^ 151 7 

This district has one less than the number to which it is entitled. 

Names of Counsellors — W. S. McElrath, Cherokee; J. C. Martin, 
Cullman ; H. P. McWhorter, DeKalb ; C. L. Guice and J. P. Stewart, 
Btowah; J. P. Turner, St Clair; S. G. Cardon, Cherokee. 

EIGHTH DISTRICT. 

County. Members. Counsellors. 

Colbert 14 2 

Jackson - ., 21 1 

Lauderdale 20 

Lawrence 11 

Limestone -. ~ ~ 12 1 

Madison 35 2 

Morgan - 32 3 

Total 145 » 

This district has the number to which it is entitled. 

Names of Counsellors^*^. W. Blair and J. T. Haney, Colbert ; W. 
C. Maples, Jackson ; J. S. Crutcher, Limestone ; L. P. Esslinger, I. W. 
Howard and W. T. Pride, Madison ; C. S. Chenault and F. P. Pettey» 
Morgan. 

NINTH DISTBICT. 

County. Members. Counsellors. 
Jefferson 290 17 

This district has the number to which it is entitled. 
Names of Counsellors— 3. D. Bancroft, J. D. S. Davis, F. A. Lup- 
ton, J. D. Heaco<±, Seale Harris, L. C. Morris, W. P. McAdory, 

•Died since roll was revised. 



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160 THE MEDICAL ABSOQIATION OF ALABAMA. 

E. M. Prince, Mack Rogers, M. 0. Schoolar, B. L. Wyman, D. F. 
Talley, W. H. Wilder, J. S. McLester, H. T. Heflin, H. S. Ward and 
D. L. Wilkinson. 

TENTH DI6TKI0T. 

County. Memhera. Counsellors. 

Fayette 12 1 

Franklin 25 • 2 

Lamar 15 1 

Marion .^ 19 1 

Pickens 22 

Walker 46 2 

Winston - 10 1 

Total ^ 149 8 

This district has the number to which it is entitled. 

Names of Counsellors — ^B. M. Harris and N. T. Underwood, Frank- 
lin; J. O. Kennedy, Lamar; M. S. White, Marion; W. M. Cunning- 
ham and H. J. Sankey, Walker ; J. C. Taylor, Winston ; W. O. Collins, 
Fayette. 



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OBITUARY RECORD 

FROM APRIL 1ST, 1916, TO JUNE 15TH, 1917. 



Calhoun — R. L. Bowcock,, AnnlstOD. 

Clay— J, T. Manning, LinevUle. 

Colhert—H. W. Blair, Sheffield. 

Crenshaw — W. P. Ejilght, Luveme. 

Cullman — Thos. W. Barcllft, Cullman. 

Dallas— W, H. Taylor, Central Mills. 

DeKalh—B. E. KiUlan, Collbran. 

Elmore — E. H. Robinson, Elmore. 

Etoicah — G. W. Morgan, Keener. 

Hale — R. F. Monette, Greensboro. 

Jackson — Geo. T. Hays, Pisgah. 

Jefferson — W. M. Avery, Pratt City; Ralph M. Russell, Birming- 
ham ; S. W. Aeton, Trussville, and H. T. Oliver, Birmingham. 

Lauderdale — S. D. Paulk, Cloverdale; C. M. Watson, Florence. 

Lawrence — W. J. McMahon, Courtland. 

Lee — O. M. Steadham, Auburn. 

Lotcndes — O. G. Bruner, Fort Deposit 

Madison — Felix Baldridge, Huntsville. 

Marengo — A. B. Stone, Linden; G. H. Wilkerson, Demopolis. 

MobUe—W. H. Sledge, Mobile ; R. H. vonEzdorf , New Orleans ; E. S. 
Feagin, Mobile. 

Montgomery — W. F. Sadler, Montgomery; Jas. T. Rushln, Mont- 
gomery; A. J. Harris, LaPine. 

Randolph — M. D. Miles, Dingier ; Wm. Weathers, High Shoals. 

Shelby— O. B. Black, Wllsonville; C. W. Williams, Coalmont. 

Talladega — R. M. Bailey, Silver Run. 

Tuscaloosa — R. H. McGee, Rock Castle. 

Total deaths, 86. 



11 M 



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162 THE MEDICAL ASSOCIATION OF ALABAMA. 



SCHEDULE OF THE ANNUAL SESSIONS AND 
PRESIDENTS SINCE THE RE-ORGAN- 
IZATION IN 1868. 



Selma— Albert Gallatin Mabry 1868 

Mobile— Albert Gallatin Mabry 1869 

Montgomery— Richard Frazer Michel 1870 

Mobile— Francis Armstrong Ross 1871 

Huntsville— Thomas Childress Osbom 1872 

Tuscaloosa— George Ernest Eump^ 1873 

Selma— <}eorge Augustus Eetchum 1874 

Montgomery— Job Sobieeki Weatherly 1875 

Mobile — ^John Jefferson Dement 1876 

Birmingham— Edward Davles McDaniel 1877 

Bufaula — Peter Bryce . . 1878 

Selma— Robert Wlckens Gaines 1879 

Huntsville — Edmund Pendleton Gaines 1880 

Montgomery — William Henry Anderson 1881 

Mobile — John Brown Gaston 1882 

Birmingham— Clifford Daniel Parke 1883 

Selma — Mortimer Harvey Jordan 1884 

Greenville— Benjamin Hogan Rlggs . 1885 

Anniston — Francis Marlon Peterson 1886 

Tuscaloosa — Samuel Dibble Seelye : 1887 

Montgomery — Edward Henry Sholl . 1888 

Mobile— Milton Columbus Baldridge 1889 

Birmingham — Charles Higgs Franklin 1890 

Huntsville— William Henry Sanders . 1891 

Montgomery — Benjamin James Baldwin . — 1892 

Selma — James Thomas Searcy : 1893 

Birmingham — ^Thaddeus Lindley Robertson 1894 

Mobile— Richard Matthew Fletcher . 1895 

Montgomery — William Henry Johnston 1896 

Selma — Barckley Wallace Toole 1897 

Birmingham— Luther Leonldas Hill 1898 

Mobile — Henry Altamont Moody 1899 

Montgomery — John Clarke LeGrande 1900 

Selma — Russell McWhorter Cunningham 1901 



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SCHSDULB OF THE ANNUAL SESSIONS, iM 

Birminghain— Bdwin Lesley Marechal 1902 

Talladega — Glenn Andrews 1908 

Mobile — ^Matthew Bnnyan Cameron 1904 

Montgomery — Capers Capehart Jones 1905 

Birmingham — Eugene DuBose Bondurant 1906 

Mobile-— Geo. Tighlman McWhorter 1907 

Montgomery— Samnel Wallace Welch 1908 

Birmingnam — Benjamin Leon Wyman 1909 

Mobile— Wooten Moore Wllkerson 1910 

Montgomery— Wyatt Heflin Blake — 1911 

Birmingham — ^Lewls Coleman Morris 1912 

Mobile— Harry TntwUer Inge 1918 

Montgomery— Robert S. HiU 1914 

Birmingtiam — B. B. Simms > 1916 

Mobile— J. N. Baker 1916 

Montgomery — Henry Green 1917 



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lU 



THE MEDICAL A8B00IATI0N OF ALABAMA. 



THE ROLL OF OFFICERS. 



Revision of 1917. 



PRESIDENT. 
William Dempst Pabtlow.... 7. Tuscaloosa 

VICE-PRESIDENTS. 

Senior — William C. Maples ^.Scottsboro 

(Term expires 19ia) 
Junior — William Franklin Betts — Evergreen 

(Term expires 1919.) 

SECRETARY. 

Henby Gaitheb Pebbt ^ - Jdontgomery 

(Term expires 1918.) 

TREASURER. 

James Usseby Ray Woodstock 

(Term expires 1918.) 

THE STATE BOARD OF CENSORS. 

AcTiNo AS A State Boabo of Medical Examinees, and as a State 

Committee of Public Health. 

Welch, Samuel Wallace, Chaibman of the Boabd, (Offi- 
cial Residence ) Montgomery ^ 1914-1919 

Sandebs, William Henby, Montgomery 1917-1922 

Wyman, Benjamin Leon, Birmingham ^ 1917-1922 

Talley, Dyeb F., Birmingham 1916-1921 

Johnston, Louis W., Tuslcegee 1916-1921 

MoHB, Chables a.. Mobile. „ 1915-1920 

Gaines, Vivien P., Mobile. 1915-1920 

Watkins, Isaac L., Montgomery 1914-1919 

Andbews, Glenn, Montgomery 1913-1918 

Gay, Samuel G., Selma 1913-1918 

STATE HEALTH OFFICER. 

Samuel Wallace Welch „ Montgomery 

(Term expires 1922.) 



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Google 



THB ROLL OF OFFICERS. 165 

DELEGATES TO THB AMERICAN MEDICATi ASSOCIATION. 

Welch, S. W., Montgomery 1917-1920 

Moody, Eael F., Dothan...^ ^ 1916-1918 

Hnx, Luther L., Montgomery . 1916-1918 



NEXT PLACE OF MEETING— BIRMINGHAM. 
TIME OF MEETING— THIRD TUESDAY IN APRIL, 1918. 



COUNCILS. 



Council on Nosology, 

H. G. Perry, Chairman, Montgomery 1916-1920 

E. M. Mason, Birmingham 1916-1919 

D. L. WllMnaon, Birmingham 1913-1918 

Thos. D. Parke, Birmingham 1917-1922 

M. T. Gaines, MobUe 1916-1921 

Council on Pharmacy. 

Hugh Boyd, Chairman, Scottsboro 1915-1920 

J. J. Peterson, Mobile...- 1916-1919 

C. A. Mohr, Mobile. 1913-1918 

L. E. Bronghton, Andalusia ., 1917-1922 

P. O. Chaudron, Dothan.... 1916-1921 

Council on 8cien4iflo Study, 

J. S. McLester, Chairman, Birmingham 1916-1921 

T. B. Hubbard, Montgomery 1915-1920 

W. G. Harrtson, Birmingham.... 1914-1919 

L. C. Morris, Birmingham 1913-1918 

W. M. Faulk, Tuscaloosa 1917-1922 

Standing Committee on Tuberoulosia. 

Glenn Andrews, Ctiairman, Montgomery 1913-1918 

J. L. Bowman, Secretary, Union Springs. 1915-1920 

J. S. Beard, Troy 1915-1920 

C. A. Mohr, MobUe. 1915-1920 

W. W. Harper, Selma. 1914-1919 



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166 THE MEDICAL ASSOCIATION OF ALABAMA. 

C. C. Jones, East Lake.- ^ ^ iai4-1919 

G. T. McWhorter, Rlverton 1914-1919 

B. L. Wyman, Birmingham 1913-1918 

S. W. Welcli, Talladega « ~ 1913-1918 

State Committee on Mental Hygiene, 

W. D. Partlow, Chairman, Tuscaloosa 1915-1920 

C. M. Rudolph. Birmingham...^ — 1916-1921 

J. T. Searcy, Tuscaloosa..^ 1915-1919 

W. M. Faulk, Tuscaloosa 1915-1918 

E. D. Bondurant, Mobile 1917-1922 

State Committee on First Aid, 

W. S. Roundtree, Chairman Birmingham 

J. N. Baker, Secretary ., Montgomery 

W. W. Harper Selma 

Cunningham Wilson Birmingham 

Loyd Noland ~ Birmingham 

F. P. Petty - Albany 

State Committee on Prevention of Blindness, 

S. L. Ledbetter, Chairman. Birmingham 

Charles A. Thigpen, Secretary Montgomery 

W. Q. Harrison. „ Birmingham 

R. A. Wright - ^....Mobile 

Thomas F. Huey Anniston 

H. B. Searcy _ Tuscaloosa 

State Committee on Social and Health Insurance, 

Glenn Andrews, Chairman Montgomery 

S. W. Welch Montgomery 

L. C. Morris Birmingham 

W. R. Jackson _ Jloblle 

J. N. Baker „ Montgomery 

H. T. Inge. Mobile 

Correspondents. 

Garnett, A. F „ _ Hot Springs, Ark. 

Peavy, Julius F ~ * _Atmore, Ala. 

Wyeth, Juo. A .......New York 

Coley, Andrew J Oklahoma City, Okla. 

Gorgas, Wm. C Washington, D. C. 



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PART IK 
Medical and Sanitary Dissertations and Reports. 



MESSAGE OF THE PRESIDENT. 



Henbt Gbeen, M. D., Dothan. 

Members of the Medical Association of the State of Alabama : 
It is my very pleasant duty and privilege to greet you again 
and to submit my annual message as President of this distin- 
guished and honorable body. 

I feel keenly my inability to maintain the high standard 
which has been set by my able predecessors, but being a firm 
believer in "Safety First," I promise, in one respect at least, to 
give you the best message to which you ever listened. It shall 
be the shortest. 

The year just passed has been a very quiet one in our organ- 
ization. There has been no State Legislature in session, hence, 
our system has not been threatened by the law-making powers. 
No epidemics, save one, have devastated our population. In 
the southern part of the State malaria has sent many to un- 
timely graves, and has cost us thousands of dollars through 
disability of our working population. In the section of the 
State from which I come there have been at least ten times 
the usual number of malarial cases. This condition of aflFairs 
was probably the direct result of the extensive rainfall last July. 
Every place that would hold water was filled, and became a 
breeding place for all varieties of mosquitoes. There is little 
doubt that many infected anopheles have been carried over and 
that they will get in their destructive work again the coming 
summer. Every member of this Association should constitute 
himself a committee of one to teach the people practical facts 
jabout the prevention of malaria. In this connection, I wish to 
renew a recommendation of Ex-President Welch made in 



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198 ME88AGB OF THE PRB8IDBNT. 

1908, that at least one paper be presented each year setting 
forth the nature of the most prevalent diseases in the State, to- 
gether with suggestions for their prevention and control. I 
would further recommend that the State Registrar of Births, 
Deaths and Infectious Diseases be selected for this work. 

One of the saddest events of the year has been the enforced 
retirement of our beloved State Health Officer, Dr. W. H. San- 
ders. As you are all perhaps aware, continued ill health dis- 
qualified him for the arduous duties pertaining to his oflFice. By 
his retirement the State has lost its most valuable public servant. 
I wish to commend Dr. Samuel W. Welch, who has been 
selected by the State Board of Censors as Dr. Sanders' worthy 
successor, and to bespeak for him your hearty cooperation and 
active assistance. 

While conditions are much better for the preservation of 
the health and lives of lying-in-women and their babies than 
they were a decade ago, still infant mortality and morbidity 
among mothers following confinement is entirely too high. 

This, in my humble opinion, is due, in a large measure, to 
incompetent and untrained midwives and midwifery nurses. 
While not nearly so many confinements are attended by mid- 
wives as was the case ten years ago, still a large percentage of 
our babies are delivered by midwives. As a rule, these mid- 
wives are ignorant, superstitious and filthy, and hence a menace 
to the life and health of every woman and baby with whom 
they come in contact. The same may be said of the average 
midwifery nurse. It seems to me that something might be done 
to improve the service offered by these women. The highly 
trained nurse does not solve the problem, except for the com- 
paratively small number of people in affluent circumstances. 
The price of her services is absolutely prohibitive to the rank 
and file of the women who are doing most to keep up our birth 
rate. At the last meeting of this Association a resolution em- 
anating from the Medical Society of Houston county was of- 
fered by me, requesting the Board of Censors to prepare a bill 
and try and secure its passage in the next General Assembly, 
regulating the practice of midwifery in Alabama. I trust that 
this resolution will meet with their approval and yours. 

Inasmuch as a large percentage of blindness is preventable 
and inasmuch as a great number of doctors and midwives are 



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HENRY GREEN. 169 

extremely careless in caring for the eyes of the newborn, I 
would recommend that a standing committee on the prevention 
of blindness be constituted by this Association. 

Another recommendation made by Dr. Welch in his mes- 
sage deserves our hearty support. I refer to the establishment 
of an institution or institutions by the state for the care of the 
weak-minded and degenerate members of our population. With 
the proper kind of institution this unfortunate class might be 
taken care of as they should be, and at the same time be made 
self-supporting. 

A matter of extreme importance to our public health system 
is the selection of our County Health Officers. For many years 
the custom in most counties has been to give this important 
office to some member of the Society for any reason other than 
his fitness for the position. "He is a good fellow, needs it, and 
let's help him out by giving him this office" was the slogan* 
The result in most instances, was a health officer who content- 
ed himself with drawing the little pay the county commission- 
ers allotted him and sending in such reports as came to him 
without any eflFort on his part. Gentlemen, the time has passed 
for such slip-shod methods. The time has arrived when we 
must have health officers who are not alone willing to put push 
and energy into the work, but who are trained in matters re- 
lating to public health work. The full time health officer is an 
urgent necessity. No longer must it be a side line. In order to 
obtain the services of men of this kind, we must have more 
money to pay them. We cannot hope nor expect to obtain ex- 
pert full-time health officers for the wages that have been paid 
our "side-line" men.' I trust that every member who hears or 
reads this message will go home resolved to do what he can to 
get an increased appropriation sufficient to pay a full-time 
health officer in his county. Until this is done, Alabama must 
perforce lag behind in the procession. Doctor Baker, in his 
presidential message last year recommended that the county 
health officer be selected by the Committee of Public Health 
and that the Committee of Public Health report its selection to 
the County Medical Society for final action. In my opinion 
this was a wise recommendation. It would certainly do away 
with "log-rolling" to an appreciable extent. Give this commit- 
tee full power to go out of the county if necessary to secure a 
suitable man. Of course it is desirable to select a man from 



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170 ME88A0E OF THE PRESIDENT. 

the county to be served if practicable. I respectfully urge the 
adoption of the recommendation of our last ex-president. 

I desire to make use of this opportunity to call your atten- 
tion to a matter of vital importance to the profession to which 
we belong, as well as to the public, I refer to social insurance 
and its schemes for rendering medical services to the laboring 
classes as well as to paupers. That some form of health insur- 
ance will soon be proposed in Alabama is a foregone conclu- 
sion. I shall not attempt to discuss the desirability of such a 
measure, nor the diflFerent methods that are proposed or in 
force in other states of the Unicwi, but will simply call your 
attention to some salient facts in regard to the general question. 
I remark in passing that personally, I am opposed to the prin- 
ciple involved on the ground that it is distinctly paternalistic in 
its tendency. That there is a demand for state insurance does 
not speak well for economic conditions. Whether this opinion 
is correct, does not alter facts. At present, the United States 
is practically the only nation of first rate importance in which 
some form of social insurance is not in force. In several states 
workmen's compensation laws have been passed and are in 
force, and in all probability some form of health insurance will 
be added to these at an early date. The American Medical 
Association has a committee on social insurance, and their find- 
ings and reports may be obtained from the secretary of that 
organization. This committee recommended that similar com- 
mittees be appointed by the various State Associations. Ac- 
cordingly I have appointed seven members of our Association 
a committee on social insurance. I trust that this committee 
has a report ready for this meeting. The physician should be 
the most interested as well as the best informed class of men 
in the country on this very important question. Not only are 
they personally, vitally interested for their own sake, but 
should be for the sake of the public. The great mass of doc- 
tors seem not to be giving the subject the interest and study 
they naturally would be expected to give to a question that af- 
fects them and the public at large, to the extent that this one 
does. I most earnestly urge that every member of the Med- 
ical Association of the State of Alabama inform himself thor- 
oughly on the question of social insurance, paying especial at- 
tention to the various schemes proposed for the care of the sick, 
the selection of physicians for this service and their remunera- 



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HENRY GREEN. 171 

tion. The time for evincing this interest and securing this in- 
formation is right now, before the masses of the people have 
obtained their opinion from politicians seeking personal profit 
from some particular proposed scheme. When the agitation 
begins, the doctor should by mature study and consideration of 
the various phases of the questicms involved, inform himself so 
well that he will be able to present his opinions with force and 
conviction to those with whom he comes in contact. 

This great republic in which we live, the greatest nation on 
earth, is today threatened by a foreign foe. The principles of 
government for which our forefathers bled and died are being 
assaulted. Long continued peace and prosperity have render- 
ed us somewhat careless and indifferent in the matter of pre- 
paredness for national defense. We are in war. How many 
realize this fact? Never before has such an opportunity pre- 
sented itself to the present citizens of the United States to show 
to the world that they are endowed with the same courage, and 
are actuated by the same noble and patriotic sentiments as ac- 
tuated our forefathers in 1776 and 1861. There is special op- 
portunity for the medical man. The Army and Navy need 
25,000 medical officers. Will Alabama furnish more than her 
share? I believe so. 

I want most heartily to congratulate the Medical Society of 
Montgomery county for their sanity and poise in dealing with 
the matter of entertainment for the members of the Medical 
Association of Alabama, at this session. Their action in elim- 
inating unnecessary and expensive entertainments was timely, 
and will meet with the approval of every member of this or- 
ganization. 

Now, in conclusion, gentlemen, allow me to again voice my 
profound thanks for the honor you have bestowed upon me, 
and for the loyalty and cooperation you have accorded me as 
your president. I crave your kind indulgence for whatever 
shortcomings I may exhibit as your presiding officer during 
this session. 



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IMPORTANCE OF SEPTIC INFECTION IN THE 
THREE PLAGUES. 



William J. Mayo, M. D., Rochester, Minnesota. 

The three plagues are syphilis, tuberculosis and cancer. In 
each of these sepsis plays a most important part. In the diag- 
nosis of syphilis it is so important a factor that, unless it exists, 
we may not recognize the process as syphilis. As regards tu- 
berculosis, it is almost an axiom that people die not from the 
tuberculosis, but rather from the associated sepsis. In cancer 
sepsis renders many cases inoperable and produces painful and 
offensive conditions in advanced disease. 

The introduction of the microscope marks the beginning of 
modern medicine and has formed the scientific basis upon 
which the whole structure has been reared anew. The relation 
of micro-organisms to disease processes has undergone pains- 
taking study and is still the subject of exhaustive and profitable 
research. Holmes,' many years ago, in a striking paper on bac- 
terial infection, picturesquely divided bacteria into three 
groups, the saphrophites, the obligates, and the facultative 
bacteria. 

The saphrophites are those which live only on dead tissue, 
but have great significance in connection with the various ul- 
cerative processes in which sloughing takes place. The toxic 
material produced by the action of the saphrophites on the dead 
and dying tissue still connected with the human body has an 
exceedingly deleterious chemical effect and as a result adds 
greatly to the virulence of organisms attacking the living 
tissues. 

The obligates, of which the tubercle bacillus is a good exam- 
ple, are obliged to live on living tissue. Obligates are usually 
slow in their action and do not always produce the death of 
their host. Where the host is killed it means the death of the 
microorganism, as its food supply is thereby destroyed. 

The facultative bacteria can live on the living or exist as a 
saphrophite on decayed tissues. This group, comprising the 



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WILLIAM /. MAYO. 178 

most acute and destructive organisms, has no regard for its 
host, as its food supply is safe. 

If there is a yellow peril it lies in the ability of the older races 
to resist disease. They have developed an immunity to unhy- 
gienic conditions greatly in excess of the occidental races and 
would survive not by reason of intellectual fitness but by ac- 
quired resistance to pathogenic organisms. Their unhygienic 
methods of living, however, expose them to epidemics of dis- 
ease due to facultative bacteria, such as cholera, which may be- 
come a world-wide scourge at any time. 

We look on alcoholic drinks as an unmixed evil, and justly 
so, if there is a safe water supply. If there is not a safe water 
supply we must not forget that animal life is poisoned by the 
material resulting from its own existence. The Italians drank 
wine and lived when infected water would have caused their 
death, and the Teutonic races drank beer which is at least a 
sterile drink. The Nomadic tribes continued to live because at 
frequent intervals they moved away from their filth. Pure 
water is the great agent of temperance. The consumption of 
alcoholic beverages in Vienna was reduced 40 per cent per cap- 
ita after a good water supply was obtained. 

It has been a stock joke to speak of "laudable pus" as an ex- 
ample of the ignorance of the fathers in medicine. Today we 
have a different way of expressing the same idea and say that 
in the living body under certain conditions an immunity to 
pyogenic bacteria is developed in the tissues after some days, 
which attenuates the virulence of the organisms and makes the 
pus produced relatively sterile and innocuous. 

We have slowly learned that it is best to allow phlegmons in 
certain situations to develop a local immunity and by coagula- 
tion necrosis safely work a way for the pus to discharge to the 
surface. In the olden day this was spoken of as allowing the 
abscess to become "ripe." Experience has shown that a too 
early incision may spread the infection and delay instead of 
hasten the cure. 

Staphylococci are always present in the superficial layers of 
the skin and any surface infection may be complicated by pyo- 
genic infection which may completely mask the original or- 
ganism. 

Among the most interesting and important of the newer re- 
searches in bacteriology are those of Rosenow^* showing that 



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174 IMPORTANOE OF SEPTIC INFECTION, 

one type of bacteria may be transformed into another, and 
forcing home the great truth that our knowledge of bacteria, 
of which we have been so justly proud, has been based on form 
rather than function. Morphology has told us the botanical 
class, but long ago we found that it did not tell the virulence; 
that a streptococcus of erysipelas is not distinguishable from 
that of a superficial and mild infection. Rosenow**, in his re- 
markable work, has been able by cultural methods to transform 
streptococci into pneumococci or a diplococcus indistinguisha- 
ble from it, and back again into streptococci and to train these 
organisms at his command, so to speak, to specifically attack a 
certain anatomical portion of the body and only that portion — 
one culture being developed to attack only the heart, another 
only the joints or the muscles, etc. 

The colon bacteria in the living body perform a function in 
the large intestine. On them depends the acidity of the colon, 
the normal secretions of which are alkaline. Yet this bacteria 
under certain conditions may become most deadly, being one 
of the causes of peritonitis. Again, the living body can be 
enured to its presence, as shown by the results of typhoid vac- 
cination and the acquired resistance to colon infection in fecal 
fistulas in which nature herself has secured a partial immuni- 
ty. All known affective bactericides as, for example, carbolic 
acid and bichlorid of mercury, are more destructive to the host 
than to the bacteria. The remarkable investigations of Carrel' 
on the sterilization of infected wounds by the use of a 
weak antiseptic solution have developed a new principle in 
wound treatment. Vaughan believes that bacteria are not veg- 
etable, but a link between and connecting plant and animal life. 

SYPHIUS. 

"Unto the second and third generation" — how fitly this old 
quotation describes syphilis. In this transmission syphilis is quite 
unlike tuberculosis and cancer, neither of which is hereditary. 
The discovery of the Spirochaeta pallida and the newer meth- 
ods of straining are a great weapon of defense against this 
plague and, aided by the Wassermann reaction, we are for the 
first time in a position to combat the disease eflfectively. 

The relative position of the spirochaeta among living forms 
has not been completely settled, but, reasoning from analogy, 



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WILLIAM J. MAYO, 176 

it should be a protozoa. In the earlier day there was no dis- 
tinction made between microorganisms of the vegetable world 
(bacteria) and microorganisms of the animal world (proto- 
zoa). Of late the protozoa have had most effective study be- 
stowed upon them and our knowledge is recent and accurate. 
The tremendous importance played by the ameba, Plasmodium 
malariae, hook-worm disease, etc., in the health of the people is 
now well understood. We have been able to discover a direct 
poison for all or nearly all of these animal parasites — emetin 
for ameba, thymol for hook-worm, quinine for the Plasmodium 
of malaria, to say nothing of those larger parasites such as the 
tape-worm, for which male fern is specific. No such specific 
remedies exist for the vegetable parasites (bacteria). How- 
ever, there are certain immunizing processes which develop re- 
sistance in the living body and which tend to destroy bacteria. 
A study of these bacterial conditions has developed the field of 
serology in which attacks on bacteria and their toxins are made 
by means of vaccination with immunizing substances. The de- 
structive eflfect of mercury and salvarsan on the spirochaeta 
without destroying the host is of the greatest importance in 
establishing syphilis as a protozoal disease. 

It is undoubtedly a fact that within twenty-five years malig- 
nant forms of syphilis have not been so common as in former 
times. Two reasons have been advanced for this ; one that the 
people are gradually becoming syphilized and are developing 
special immunities by virtue of heredity and acquired protect- 
ive agencies based on the general theory of the survival of the 
fittest and, second, that syphilis is much better treated now than 
it used to be. But how can we account for the high percentage 
of people with terminal changes in the central nervous system 
— tabes and paresis ? Certainly there is no diminution of these 
syphilitic manifestations. On the contrary, they appear to be on 
the increase. Curiously enough, this does not hold true for the 
pure-blooded negro in whom spirochetal infection of the nervous 
system, — paresis, tabes, etc. — are extremely rare, while syphilis 
of the vascular system of the negro resulting in aneiiroisms, 
etc., is greatly increased over the white race. 

The typical chancre and the accentuated secondaries are said 
by Comer* to be due not to the spirochaeta alone, but to com- 
plicating sepsis. The people of all countries today are far 
cleaner in this than in former generations, and through im- 



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176 IMPORTANCE OF SEPTIC INFECTION. 

proved hygienic knowledge take far better care of small sores 
and abrasions than was formerly the custom. The chancre, 
therefore, will probably be treated with strict cleanliness and 
often by antiseptic substances, so that it may not assume that 
typical hardness in the base due largely to sepsis. The failure 
to develop this characteristic may cause failure in the diagnosis 
of syphilis. For the same reason the secondary signs and symp- 
toms may be exceedingly mild and therefore the primary and 
secondary stages of the disease may not be detected. The ten- 
dency of the infection is to travel along the nerve sheaths into 
the central nervous system and the first symptom of syphilis 
known to the patient may be premonitory of tabes or peresis — 
a terminal condition for which the resources of our art have 
only ineffective remedies. 

It is a great misfortune that syphilis has been considered a 
venereal disease and therefore carries a stigma with it. As a 
matter of fact in a high percentage of cases the source of in- 
fection is extragenital; lips, fingers and abrasions at different 
parts of the body are the means of communication and the fail- 
ure to elicit a venereal history frequently throws the diagnosti- 
cian off his g^ard. 

We see a few cases every year of surgeons who have infect- 
ed a finger with syphilis during operations on syphilitic 
patients. The chancre often does not develop the typical char- 
acteristics because of the care of the surgeon naturally gives to 
minor abrasions. Moreover, as his personal hygiene is good 
he may slip through the secondary stage scarcely aware of the 
nature of the condition. Then cc«ne visceral lesions or lesions 
of the central nervous system. Occasionally, however, exactly 
the opposite prevails. The surgeon acquires syphilis and viru- 
lent septic infection at the same time. In this case the syphil- 
itic infection is masked by the septic involvement which, how- 
ever, does nbt prevent the eventual development of constitu- 
tional syphilis. The latter remains grafted in the body after 
the septic manifestations have disappeared. If these accidents 
happen to the surgeon without being recognized, how much 
more is the ordinary individual liable to the same misfortune. 

The importance of the early diagnosis of chancre cannot be 
overestimated. Systemic infection does not take place until 
from 5 to 15 days after the development of a chancre. In the 
beginning the disease is local and by proper treatment can be 



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WILLIAM J. MAYO. IT* 

cured. After a positive Wassermann is obtained the great op- 
portunity has passed. Prolonged treatment may or may not 
eventuate in a cure, and this brings up the very important con- 
sideration that in the chancre the spirochaeta exist and can be 
readily secured for microscopic examination. The diagnosis of 
chancre should be made through the discovery of the spiro- 
chaeta, not on the induration of the base. Every suspicious in- 
fection should be subjected to careful bacteriologic investiga- 
tion as otherwise the patient may suffer irreparable damage. 

Hale White^* gives the following table of the relation of 
syphilis to the general death rate, showing that even among 
patients who have been subjected to two years' treatment the 
death rate by decades is nearly twice as high, to say nothing of 
the miseries and horrors of a loathsome disease : 

Class I. Syphilis certain, thoroughly treated; 2 years^ continu- 
ous treatment and i year's freedom from symptoms. 

Actual Expected 

deaths. deaths. Ratio 

Certain syphilis between 3 and 6 
years prior to application^.: 13 

Between 5 and 10 years 34 

More than 10 years . 53 

Class 2. Not thoroughly treated or no details given. 

Certain syphilis between 2 and 5 

years priors to application 

Between 5 and 10 years 

More than 10 years...: 

. Class 3. Doubtful syphilis. 

More than 2 years prior to appli- 
cation .^.:. ...-._ ... 67 48.71 138% 

It is a curious fact that terminal syphilis in man affects the 
nervous system more frequently than in women and often pur- 
sues a more malignant course. In women, as a satanic recom- 
pense, it is the great abortionist or carries dreadful misfortune 
to her children even unto the second and third generations. 

12X 



9.32 


139% 


19.56 


174% 


24.42 


217% 



44 


15,52 


284% 


54 


25.52 


212% 


76 


59.09 


129% 



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178 IMPORTANCE OF BEPTIO INFECTION. 

In the army syphilis has been very largely prevented by the 
use of a 50 per cent calomel ointment ( 34 lanoline and ^ vase- 
line or lard), which was first introduced into the French army. 
It was found experimentally and clinically by Metchnikoff^ 
that if applied within five or six hours after inoculation, pre- 
vention was absolute. Further by adding to the calomel oint- 
ment 3 per cent each of camphor and pure carbolic acid, Neis- 
serian infection as well appears to be prevented. 

The septic factor in syphilis is a subject for reflection. In 
those acquiring the disease accidentally and extra-genitally the 
chancre will probably not be recognized in the primary stage 
and the cleaner the person affected the less chance that it will 
be recognized in the secondary stage, while those venereally 
affected and dirty have the best chance of prevention of sys- 
temic infection, and, if systemic infection does take place in the 
unclean by reason of the greater virulence of the secondary 
stage it is more probable that it will be detected early and thus 
they will secure thorough and adequate treatment. 

In abdominal surgery we unexpectedly meet with visceral 
syphilis, most commonly of the liver or stomach. Most of these 
cases are diagnosed as cancer. For this reason, when in doubt, 
a piece of tissue should if possible be secured for microscopic 
examination. While this may not definitely determine that it is 
syphilis, it at Jeast will prove that it is not cancer. In the large 
majority of these cases the Wassermann reaction is present 
although if the patient has been recently treated it may be 
absent. 

In certain situations in the body spirochetes can secure a 
habitat which enables them to resist specific medication to a 
considerable degree. In the cerebrospinal nervous system the 
lymphatic arrangement is independent of the general lymph 
system and the spirochetes in this locality are not readily af- 
fected through the blood stream. Hence the attempt to reach 
and destroy them by means of intradural injections. In the 
glands of the skin, spirochetes are fairly secured against inter- 
nal medication and may from this sequestered situation reinfect 
the body. Hence the very great value of the inunction method 
of mercurial therapy. In the spleen spirochetes may obtain a 
foothold from which it is difficult to dislodge them and from 
there reinfect the liver. Syphilitic splenomegalies with hepatic 
gummata are notoriously difficult to cure. In four cases of 



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WILLIAM J. MAYO. 17^ 

this' description, all with positive Wassermanns and marked 
anemia and in which repeated salvarsan injection, thorough 
mercurial and iodid treatment of months duration failed to im- 
prove the condition, we removed the greatly enlarged spleen. 
In three, spirochetes were found in the spleen and in three 
there were gummas of the liver. The improvement in the con- 
dition of these patients was immediate and striking. They 
were promptly cured. 

In regard to treatment : Suspicious sores should be subject- 
ed to examination for the spirochaeta and if they are present 
with a negative Wassermann the disease should be treated as a 
local condition by the direct application of salvarsan emulsion 
or calomel ointment and one or two preventive salvarsan injec- 
tions. Lesions of syphilis may occasionally fail to disappear 
under salvarsan. 

Sometimes the condition becomes constitutional before the 
disappearance of the primary sore. This must be borne in 
mind in the treatment of lues as a localized infection. For this 
reason, a Wassermann should be taken at intervals and the 
patient watched for signs of constitutional infection. Many 
instances of the failure of salvarsan to cure syphilis are record- 
ed, with eventual cure by means of mercury, especially mercu- 
rial inunction. As a matter of fact, arsenical preparations have 
at various periods in the world's history been acclaimed the 
cure for syphilis, to be later discarded for mercury. 

The value of the Wassermann reaction in diagnosis is very 
great, but the personal equation is a more prominent factor 
than in other serologic tests. Blood drawn at the same time 
and sent to several serologists may lead to different opinions. 
However, in our experience a strong positive Wassermann 
made by a competent man is fairly certain. Before subjecting 
the patient to prolonged treatment, this test should be con- 
firmed by a second and a third examination. Many a man has 
had his mind poisoned and his life ruined by a too hasty diag- 
nosis and treatment of syphilis. Unfortunately a negative find- 
ing has no such value. Syphilis may be present without the 
Wassermann, especially if the patient has been recently treated. 

In certain situations syphilis leads to chronic irritation and 
cancer, as in the keratosis linguae preceding cancer of the 
mouth, especially in smokers, and it is well known that tuber- 
culous persons bear syphilis badly, while the syphilitic are 
prone to tuberculosis. 



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tm IMPORTANCE OF SEPTIC INFECTION. 

Rarely does syphilis imitate cancer, and the supposed fre- 
quency of such imitation often leads to prolonged treatment of 
cancer for syphilis until the patient finally comes to the surgeon 
in a hopeless condition. The Wassermann reaction renders 
such dalliance inexcusable. 

TUBERCUW>SIS. 

Those afflicted with tuberculosis usually die from the asso- 
ciated sepsis rather than from the disease. One of the common 
exceptions to this rule occurs in ca3es of tuberculous meningi- 
tis in which the products of bacterial action are confined in a 
bony box and produce pressure. The influence of sepsis on 
tuberclulosis is most pernicious. In preantiseptic times the 
opening of tuberculous abscesses, so-called cold abscesses, was 
looked upon with great disfavor and it was well understood 
that such a procedure would be followed promptly by what was 
known as hectic, picket-fence temperature and general physical 
loss. Older writers called attention to the fact that when a 
cold abscess opened spontaneously it did not give rise to hectic 
but that hectic always followed an incision. Nature evidently 
contrived some valvular method of drainage which permitted 
the escape of contents without admitting pyogenic organisms, 
a method which the surgeon could not imitate. It is true today 
that no matter how careful the after-care may be the incision 
and drainage of such abscesses is practically always followed 
by septic complications. It is for this reason that cold ab- 
scesses were aspirated and after removing as much as possible 
of their contents the opening was sealed. This is still good 
practice. In many cases iodoform emulsion or formalin and 
glycerin was injected with the hope of sterilizing the cavity. 
Today such abscesses, under strict aseptic precautions, are 
often opened by a free incision, thoroughly cleared out, and 
then filled with salt solution or are mopped out with iodoform 
and glycerin, tincture of iodine, or glycerin and formalin, and 
sutured completely. These procedures, however, have very 
little to commend them over the early practice of simple aspi- 
ration. Cold abscesses, as .a rule, have their origin in bony 
tuberculous lesions, although they may be seen in other situa- 
tions, as in connection with the fascia lata. 

Modern methods of treatment of tuberculous bones and 
joints by rest and mechanical support have greatly reduced the 



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WILLIAM J. MAYO, 181 

number of tuberculous abscesses, and aspiration of those which 
form has reduced very materially the number of cases in which 
the abscess opens spontaneously. In earlier times cases of 
tuberculous sinuses were very common and the patients often 
maintained a fair degree of health for years. One of the most 
pernicious practices was to probe such a sinus. This probing 
was almost invariably followed by a septic infection. Fortu- 
nately, this practice has become obsolete and such sinuses can 
now be injected with Beck's paste of Morison's Bipp* so that 
a radiogram may be taken which will show its ramification far 
better than by probing, and the injected substances may have 
a healing effect. 

The behavior of tuberculosis in the peritoneal cavity is great-' 
ly influenced by the presence of sepsis. Tuberculous peritoni- 
tis is secondary to a local lesion, usually in the fallopian tubes 
or intestinal tract or in the retroperitoneal glands. Pure tuber- 
culous infection of the peritoneum will seldom cause extensive 
adhesions. This variety is most often seen in. connection with 
tuberculosis of the fallopian tubes. It should not be forgotten 
that tuberculous peritonitis is a symptom and not a disease ; it 
is in reality a conservative process. The ostia of the fallopian 
tubes in tuberculosis are usually open, as shown by Murphy.^ 
In gonorrhoea, the extremity of the tubes are nearly always 
closed ; hence no extensive peritonitis as a rule will be found. 
Tuberculous and gonorrhoeal salpingitis practically always in- 
volve both tubes while pyogenic infections of the tube are often 
single. The products of tuberculosis of the mucous membranes 
of the tubes pass out through the open abdominal ends into the 
peritoneal cavity. The peritoneum promptly undertakes to re- 
move them, and the resulting reaction with the accumulation of 
ascetic fluid we speak of as tuberculous peritonitis. It was 
known for a long time that if the ends of the fallopian tubes 
were open the tuberculous peritonitis would be of the ascitic 
form,- but if the tubes were closed there would be no tubercu- 
lous peritonitis, the material being retained within the tube and 
forming tuberculous pus tubes, sometimes of huge size and 
containing typical tuberculous whey-like fluid. The ovaries are 
not often involved in this process — usually there is only a sur- 

♦Bipp: Bismuth, 1 ounce; Iodoform, 2 ounces; Petroleum Paste, 
Q. 8. The name is formed by the initial letters of Bismuth, Iodoform, 
and Petroleum Paste. 



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182 IMPORTANCE OF SEPTIC INFECTION, 

face infection similar to that on the intestine and the perito- 
neum generally. The proper treatment, therefore, is to remove 
the tuberculous tubes, leave the uterus and ovaries, and close 
without drainage. 

If drainage is used we may have the development of sinuses 
often followed by mixed infection from some intestinal focus 
and finally in many instances prolonged suppuration or fecal 
fistula. 

The old idea that tuberculous peritonitis could be cured by 
drawing off the fluids and that some special influence was cre- 
ated by exposing the peritoneum to air or by pouring in gly- 
cerin, iodoform, oxygen, or what not, was based on a miscon- 
ception. Cure did not often result when the fluid was drawn 
off with a trochar, but, if an incision was made cure often fol- 
lowed whether or not any other special treatment was applied. 
This was because when the abdomen was opened the fluid was 
removed thoroughly and the ends of the fallopian tubes, pre- 
viously separated from the surrounding parts by reason of the 
fluid, had an opportunity to become adherent to some neighbor- 
ing point on the peritoneum so that closed by these adhesions 
they no longer drained the tuberculous debris into the perito- 
neal cavity. This tubal retention could often be detected by the 
gradual development of tuberculous pus tubes after the ascites 
had disappeared. Such tuberculous pus tubes in the course of 
time encapsulate and may heal themselves but usually remain a 
source of grave danger of general systemic tuberculosis. 

Tuberculosis of the peritoneum having its origin in the in- 
testine is liable to be a mixed infection from the start and is 
peculiar in the fact that instead of large quantities of fluid it 
develops a distended abdomen filled with adhesions. Some of 
these greatly distended abdomens feel almost wooden and on 
attempting to open the peritoneal cavity it will be found almost 
completely obliterated by adherent coils of intestine. This con- 
dition has been given many names according to the extent and 
virulence of the complicating sepsis which varies from the com- 
pletely adherent type in which there is no free cavity of the 
peritoneum below the transverse colon and those milder and 
attenuated types in which free fluid is found with compara- 
tively few adhesions. This very interesting condition was long 
a puzzle to me but I finally secured three cases in so early a 
stage that colon and other pus bacteria were found with the 



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WILLIAM J. MAYO, 188 

tubercle bacilli. A little later the septic infection could not 
have been detected because the colon and other bacteria, having 
a shorter life than the tubercle bacilli would have been de- 
stroyed and in the later stages only the tuberculous condition 
could be detected, although the adhesive process had been 
caused by the septic complication. 

The effect of sepsis on tuberculosis is well shown in the so- 
called hypertrophic tuberculosis of the large intestine, especial- 
ly of the cecum. Here a huge tumor with enormous thicken- 
ing in the submucosa may give a picture to the naked eye that 
is almost typical of carcinoma. In some of these cases the 
abdomen has been opened, the condition inspected and diag- 
nosed as carcinoma and on account of the enlarged glands — 
the enlargement of which is due usually to sepsis, however, 
rather than to tuberculosis — the patients have been considered 
inoperable. They may, however, live for years, supposedly 
examples of the slow course of carcinoma of the cecum, or, if 
obstruction supervenes, a colostomy is done. Splendid results 
follow radical operation in these cases. 

In tuberculosis of the kidney the septic infection is responsi- 
ble for many of the most grave symptoms. In doing a neph- 
rectomy, if there is a mixed infection, the ureter should be 
drawn up if possible and stitched to the skin, as it is very diffi- 
cult to sterilize the stump even with the actual cautery or pure 
carbolic acid, and secondary mixed infection of the kidney 
space may lead to a long-continued sinus or later result in the 
necessity of removing the ureter. This will happen more often 
if the cavity is drained following nephrectomy. Fortunately a 
large majority of tuberculous kidneys for which nephrectomy 
must be done are examples of pure tuberculosis without septic 
complication. Many are supposed to be spontaneously cured 
because the patients for a long time have had tuberculous 
debris with tubercle bacilli in the urine, which condition grad- 
ually clears up and the symptoms are relieved. The tubercu- 
lous kidney has not undergone spontaneous cure; the ureter 
has become blocked, the kidney has become converted into a 
closed tuberculous sac in pure culture and is called a "dead kid- 
ney," though capable of renewed activity at any time or of 
causing systemic infection. In these cases the ureter can be 
injected, if it still has a lumen, with 5 to 10 mm. of 95 per cent 
carbolic acid, the end of the ureter tied and dropped into the 



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134 IMPORTANCE OF 8EPTI0 INFECTION. 

wound. The wound should then be filled with salt solution 
and completely sutured, quite as we would treat the peritoneal 
cavity or a tuberculous abscess cavity. Even if tuberculous 
material has soiled the wound, this is safer treatment than to 
drain. The salt solution is picked up with extreme rapidity 
quite as if it were given subcutaneously and even a quart or 
more in this way will be quickly absorbed. The tuberculous 
material which may be present is absorbed and destroyed while 
it is in the non-active state. However, if it has an opportunity 
to culture in the wound and especially if it has the assistance of 
sepsis in breaking down the tissues such as might be intro- 
duced by a drain, this favorable condition would not obtain. It 
is true that this practice is spmetimes followed after some 
weeks by a sinus but even so the ultimate damage from mixed 
infection is minimized by the delay. 

Vaginal section was at one time very popular for pelvic in- 
fections, and justly so for those phlegmons due to ordinary 
pyogenic organisms, such as occur after puerperium or after 
abortion. The opening and draining of a pelvic infection from 
tuberculous tubes by an incision through the vagina causes 
most serious after affects and often the patient loses her life, 
not at once, but later through mixed infection, multiple fistulas 
eventually opening into the bowel and prolonged septicemia. 

The influence of septic complications introduced by drainage 
as shown by these few examples is quite parallel to the knowl- 
edge of the ancients in regard to the treatment of cold abscess 
in that in both instances the pernicious effect of drainage in 
permitting a mixed infection of tuberculous lesions is evident. 

In 1899 I published an article on "Localized Tuberculosis of 
the Intestine."' At that time it was not believed that primary 
localized tuberculosis limited to any portion of the intestinal 
tract ever occurred and that it was always the result of human 
tuberculosis, usually frpm swallowed tuberculous sputum. I 
stated at that time that in my opinion bovine tubercle bacilli in 
milk was responsible for many of these infections. I called at- 
tention to the fact that in the country districts pulmonary 
tuberculpsis was comparatively rare but that localized tubercu- 
losis — in bones, joints, intestines and glands — was exceedingly 
common, that it was customary to use raw milk as a regular 
article of diet and that a considerable percentage of milk cows 
were infected with tuberculosis. 



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WILLIAM J. MAYO. 185 

There is a regretable tendency at the present time to make a 
diagnosis of tuberculosis on insuflficient evidence and we are 
constantly meeting with neurasthenic patients who have spent 
months in tuberculosis sanitariums for supposed tuberculosis 
who give no adequate history of tuberculosis and have no x-ray 
or other evidences of the disease, the diagnosis having been 
made from a rise of evening temperature of a degree or so. 
The neurasthenic person may have a slight raise of evening 
temperature by the month or year from 99 to even as high as 
100 or 100.5. This temperature with the anemia and dimin- 
ished respiratory action has been too easily accepted as evi- 
dence of tuberculosis. 

It has long been noted that the tuberculous patient had more 
than an average immunity to cancer — Murphy^® showed that 
this is due to the accompanying leucocytosis and advised meas- 
ures to produce leucoc)^osis as an aid to the cure of cancer. 

CANCER. 

Much of the cachexia of cancer is due to associated sepsis 
and the pain in the large majority of cases comes from septic 
infection. However, in the later stages and especially where 
there are metastatic deposits, nerve-pressure may be the cause 
of very severe pain, as in "paraplegia dolorosa." But the rule 
holds good that in the primary growth the action of saphro- 
phites on the necrosing tumor and the pyogenic infection of the 
surrounding tissue already sadly crippled by the malignant 
change are the causes of the greatest distress and hasten the 
death of the patient. In internal situations, such as in the liver, 
where the growth is not exposed to infection, the tumor will 
often reach very large proportions and the patient will die 
without severe suffering. Pierce Gould* found that in the 
Hopeless Cancer Division of the Middlesex Hospital, London, 
careful attention to cleanliness and antiseptic measures gave so 
much relief that morphia was seldom required ; even further, 
that not only were the patients relieved of their pain, but the 
symptoms were so greatly ameliorated that they gained in 
strength and flesh. 

The mortality following operations for cancer is to a great 
extent influenced by the amount of sepsis present and especial- 
ly by the character and virulence of the invading bacteria. By 
reason of the virulent streptococci present in its sloughing re- 



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lg% IMPORTANCE OF SEPTIC INFECTION, 

cesses, cancer of the cervix uteri gives a high mortality follow- 
ing radical operation. Without question the relief given by the 
various methods of applying heat in cancer of the uterus is due 
not only to the destruction of the growth itself but also to the 
destruction of the bacteria present. 

The fatality which has marked operations for cancer of the 
large bowel and rectum is largely due to pathogenic bacterial 
infection, especially streptococci, and the most frequent cause 
of death following operation is sepsis.f It was the fatality of 
immediate resection of such growths especially beyond the 
splenic flexure, which lead to the two-stage operation of 
Mikulicz,', Bruns* and Paul", in which the diseased portion of 
the large bowel is lifted from its bed with the fat and glands, 
brought outside the body, and left in this position until it heals 
in. It can then be cut away and after the parts have been re- 
stored to a reasonable degree of cleanliness the continuity of 
the intestine is brought about by an operation largely extra- 
peritoneal. In this way the mortality has been reduced more 
than one-half. In the rectum the same result is obtained indi- 
rectly by first doing a colostomy and subsequently carefully 
cleansing the lower fragment for some days before doing the 
radical operation. This again reduces the mortality by one- 
half. Thus an apparently inoperable growth in the rectum, 
fixed and adherent, will often be so benefited two weeks fol- 
lowing a colostomy as to become operable. 

There is a type of cancer which is often called inflammatory 
-—a hard, indurated cancerous ulcer, foul, and covered more or 
less with sloughing material, with an extensive inflammatory 
zone, brawny and red. If operation is attempted in this condi- 
tion the patient is seldom cured of the disease. Metastasis 
often quickly takes place and the lymphatics of the skin in the 
vicinity become loaded with cancerous material from the cut 
surface. However, if such a condition is treated by coagula- 
tion with the actual cautery as advised by Percy,^* the parts 
will become clean and healthy, the bacteria and cancer both 
having been destroyed ; then when the induration and inflam- 
matory zone have completely disappeared the entire area can 
be removed with plastic repair of the defect. In this way a cure 
can be effected in cases which would otherwise be hopeless. 

We may say that cancer is malignant in proportion to the 
ratio of cells to the stroma, the cells representing the cancer. 



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WILLIAM J. MAYO, 187 

the Stroma the resistance of the patient. Many patients have 
comparatively little resistance to the cancerous cell, but react 
vigorously to a bum, throwing out an enormous amount of con- 
nective issue which may strangle the few cancer cells that 
have not been destroyed by the cautery itself. 

Heretofore we have not given sufficient attention to the 
septic complications of cancer, especially in their relation to 
preparing the field for operation, and it is probable that some 
of the success of the use of radium and the X-ray both as a 
palliation and as a preparation for later surgical procedure 
has been due to the fact that they relieve the associated sepsis. 

In conclusion let me again say that sepsis is secondary only 
to the original lesion in the destructive effects of syphilis, tuber- 
culosis and cancer. 

REFERENCES. 

1. Bland-Sutton, J.: The surgeon of the future. Lancet, 
1914, ii, 289-294. 

2. Corner, E. M. : Sepsis in the recognition and non-recog- 
nition of syphilis. Lancet, 1914, ii, 491-492. 

3. Carrell, Alexis. 

4. Gould, A. P. : The treatment of inoperable cancer. Lan- 
cet, 1913, i. 216-219. 

5. Holmes, Bayard. 

6. Mayo, W. J. — Localized tuberculosis of the intestine, a 
report of seven cases operated upon. New York Med. Jour., 
1899, Ixx, 253-258. 

7. Metchnikoff, E. and Roux, E. : Etudes experimentales 
sur la syphilis. Ann. de Tlnstitut Pasteur, 1906, xx, 758-800. 

8. Mikulicz, J. von and Bruns, P. von: In Bergmann, E. 
von, Bruns, P. von and Mikulicz, J. von : A system of prac- 
tical surgery. New York, Lea, 1904. 

9. Murphy, J. B. : Tuberculosis of the female genitalia. 
Am. Jour. Obst. 1902, xlviii, 737-754. 

10. Murphy: Rockefeller Institute. 

11. Paul, F. T.: Colectomy. Brit. Med. Jour., 1895, i, 1136- 
1139. 

12. Percy, J. F. 

13. Rosenok, E. C. : Transmutation within the steptococ- 
cus-pneumococcus group. Jour. Infect. Dis., 1914, xiv, 1-32. 

14. White, W. H.: Abstract of Bolingbrooke lecture on 
prognosis. Lancet, 1914, ii, 141-145. 



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THE HUMANITARIAN ASPECT OF SCIENTIFIC 
MEDICINE. 

Evening Address Before The Medical Association of Alabama, 
Montgomery, Wednesday, April 18th, 1917. 



M. S. Davie, M. D., Dothan. 

According to any genuine test of efficiency, any institution, 
organization, or profession justifies its existence exactly in 
ratio to its willingness and ability to render service to human- 
ity. No man or combination of men has any right to sustenance 
or recognition on any other basis than this. 

Since all men and combinations of men are trustees to the 
public for allegiance to certain assumed and delegated princi- 
ples, it is right and proper that an account of this stewardship 
be rendered from time to time. 

This evening being set apart for the discussion of things of 
interest to the general public, and not purely scientific, it be- 
comes a fit occasion to briefly inventory some of the things 
which the profession has acccwnplished, and to present some of 
the men who have accomplished them. 

In a roll call of this kind and in the time at my disposal, 
there is no room for the cataloguing of embellishments- The 
wealth and possessions of organized medicine, the intellectual- 
ity and extraneous accomplishments of its individual members, 
and other collateral thoughts, are of much interest, but not 
obligatory to the issue, The Humanitarian Aspect of Scientific 
Medicine. 

It is fair to say, prefatorily, that the type of physician rep- 
resented here this evening, is the only one who has ever ren- 
dered service to humanity. The various sprouts and offshoots, 
claiming to heal the sick, and cure disease, are, when they use 
the truth, which is seldom, handling stolen thunder; thunder 
stolen from the type of physician belonging to this organiza- 
tion. 

In this day of so-called commercialism, it is rather frequent 
to estimate things from a material standpoint. In submitting 



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M. 8. DAVIB. 189 

any proposition for consideration, the query, Does it pay? is 
likely to arise. While I choose to hold to the higher value of 
intangible things, and suggest the commercial estimate as not 
entitled to first thought, yet, it is axiomatic that a country's 
health is its greatest asset, and on this basis, it is conservative 
to say, the profession of medicine and surgery, as conducted 
today, is the one profession necessitous to civilization. 

Any student of history will recall the plagues and pesti- 
lences which have scourged humanity in former centuries. How 
cities, countries, nations, have been decimated by the riotous 
and unrestricted activities of the Grim Reaper. As late as 
1796 small pox made frequent visits to the courts of Europe, 
attacking the very flower and beauty of royalty, with an ap- 
palling mortality, leaving its survivors so hideously disfigured 
that they were repulsive to their associates and a perpetual 
sorrow to themselves. 

In the latter part of the eighteenth century, the son of a 
Gloucestershire clergyman, Edward Jenner by name, and a 
friend and pupil of John Hunter's, had a conversation with a 
dairy maid which set him to thinking. From her he learned 
that milkmaids who contracted cowpox from milking their 
cows, were immune to smallpox. Jenner communicated this 
information to Hunter, asking his opinion, and received the 
sage reply, 'TDon't think, try ; be patient, be accurate." So he 
set about collecting observations in 1778, and on May 14, 1796, 
"performed his first vaccination upon a country boy, James 
Phipps, using material from the arm of the milkmaid, Sarah 
Nelms, who had contracted cowpox in the usual way. The 
experiment was then put to the test, by inoculating Phipps with 
smallpox virus on July 1st, and the immunization proved suc- 
cessful." "In 1802 and 1807 Parliament voted grants amount- 
ing to twenty thousand pounds to Jenner in aid of prosecuting 
his experiments." Though he was attacked with great bitter- 
ness by some of his contemporaries, who, it has been said, 
"acted upon the parliamentary principle that the duty of the 
opposition is to oppose." 

The perusal of pre-antiseptic surgery reveals one long night- 
mare of agony and disaster. Hardly any truly surgical condi- 
tion, of today's parlance, but what was safer than the procedure 
to correct it. No amount of operative skill or anatomical 
knowledge could render abdominal surgery anything but a 



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IdO HUMANITARIAN ASPECT OF MEDICINE. 

proposition of deadly peril. Woman, with her frequent pelvic 
disorders, had to suffer, or take chances practically prohibitive. 
The accident and injury details of today's industrialism would 
have entailed a septic death rate so immense as to make eco- 
nomic progress an impossibility. 

This was the condition of things when Joseph Lister had his 
attention drawn to Pasteur's investigations of fermentation 
and putrefaction. Lister is "the last and greatest of the inter- 
esting line of English Quaker physicians." William Sharkey 
and Thomas Graham, two canny Scots, and teachers of Lister, 
advised him to go up to Edinburgh and take up surgery under 
the great Syme. He followed their advice and in 1854 became 
Syme's assistant and subsequently his son-in-law. He was 
early impressed with the stupendous mortality of septicemia, 
pyemia, erysipelas, tetanus, and hospital gangrene, and in his 
statistical compilations of 1864-66 he showed the death-rate 
from amputation to be 45 per cent. These were the days of 
"laudable pus," yet Lister's heart turned to a Hippocratic heal- 
ing by first intention as the surgeon's ideal, and he was con- 
sumed with an ambition to make this the normal outcome of 
surgical procedure. 

Believing all wounds should be rendered militantly antisep- 
tic, and realizing Pasteur's heat sterilization an impossibility 
here, he conceived the idea of introducing chemical antiseptics 
into wounds. After trying out chloride of zinc and the sul- 
phites, he chanced upon carbolic acid, and, "on August 12, 
1865, he employed it in a case of compound fracture with com- 
plete success." Two years later he recited two year's work in 
two papers, the second one entitled "On the Antiseptic Princi- 
ple in the Practice of Surgery." As usual, a storm of criticism 
was heaped upon his methods, and among his assailants was 
no less a light than Lawson Tait, the distinguished Birming- 
ham gynecologist. 

Not only was surgery in the pre-antiseptic days unspeakably 
disastrous in its frightful mortality, but the physical torture of 
surgical manipulation prior to general anesthesia was equiva- 
lent to the direst atrocities of the Spanish Inquisition, or the 
torture chamber performances of any country or age. In 
March, 1842, Dr. Crawford Williamson Long, of Danielsville, 
Georgia, "removed a small cystic tumor from the back of the 
neck of a patient" under sulphuric ether, and, on October 16^ 



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M. 8. DAVIE, 191 

1846, at the Massachusetts General Hospital, Boston, Mass., 
Dr. John Collins Warren removed a "congenital but superficial 
vascular tumor, just below the jaw, on the left side of the 
neck," under sulphuric ether, administered by a dentist, Dr. 
William Thomas Green Morton, of Charlton, Mass. 

So, with the use of ether from 1844, and the knowledge of 
antisepsis from 1865, surgery goes forward with- a progress 
which reads like an Oriental romance, until today, the formerly 
impossible has become so possible that it is being done as a mat* 
ter of routine by men in all the villages of the world. In fact, 
it has been recently observed by a distinguished author, that 
the genius for method and system as used by the brothers, 
Charles Horace and William James Mayo, "has made Listerian 
surgery almost as reliable a science as bookkeeping." 

Prior to 1900 the mortality from typhoid fever in any mili- 
tary encampment was frequently greater than the deaths from 
shot and shell. Then it occurred to the Sir Almroth E. Wright 
to make a suspension of dead typhoid organisms and inoculate 
people against this disease, and the suffering and economic loss 
incident to this infection were wiped out. That is, so far as 
our ability to control the disease is concerned. 

Dante's Inferno was an exquisite poet's dream compared to 
the suspense of the hydrophobia victim before Pasteur, in July, 
1885, inoculated the Alsatian boy, Joseph Meister, with an at- 
tenuated virus and thereby protecting him from developing this 
unspeakable disease, though this boy had been "bitten all over 
by a rabid dog." 

Think of the infinite pitiableness of the mother who had to 
stand by and see her child die, struggling with sibilant gasps, 
in the death-throes of laryngeal diphtheria before 1890, when 
Emil von Behring, a Prussian army surgeon, "demonstrated 
that the serum of animals immunized against attenuated diph- 
theria toxins can be used as a preventive or therapeutic inocula- 
tion against diphtheria in other animals, through a specific 
neutralization of the toxin of the disease." 

And, what a holocaust was our fourth of July celebration 
before the discovery of tetanus antitoxin. 

The literature of no profession, nor the chronicles of no age 
contain examples of more superlative patriotism or unswerving 
devotion to duty than the conduct of Dr. James Carroll, of the 
United States Army Yellow Fever Commission, in working 



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192 HUMANITARIAN ASPECT OF MBDIOINE. 

out the mosquito theory of yellow fever. "In 1900, when an 
army medical commission was appointed to investigate the 
cause and mode of transmission of yellow fever among the 
American troops stationed at Havana, Carroll was appointed 
second in command." Dr. Walter Reed was chairman of this 
commission, his associates being Drs. James Carroll, J. W. 
Lazear, and a Cuban immune physician, Aristides Argramonte, 
Dr. Reed has technical credit for discovering the mosquito as 
the intermediate host, and the agent in transmission of yellow 
fever, but soon after this commission took up its work, the 
question of experimenting upon human beings arose. Where- 
upon Dr. Carroll immediately volunteered to be the subject 
of this human experiment. He was bitten by several mos- 
quitoes infected from yellow fever patients. Three days later 
he developed a virulent type of the disease, and barely escaped 
with his life. In the beginning of his illness Dr. Carroll told 
the nurse how he acquired the disease, and upon his recovery, 
in looking over her notes, he found this statement, "Says he got 
his illness from the bite of a mosquito — delirious." During 
the height of his illness he developed an acute cardiac dilata- 
tion, from which he never recovered, dying from an organic 
heart lesion 7 years later, September 16, 1907. No mart can 
show greater love for his profession, or greater love for his fel- 
low-man, than to sacrifice his life to further the ends of science 
and remove suffering and premature death from future genera- 
tions. 

And so the roll call might go on indefinitely, much beyond 
the limits of our time and patience. I merely wanted to bring 
to your minds the altogether correct idea that the profession of 
medicine and surgery of yesterday, today, and tomorrow, is, 
from an economic and humanitarian standpoint, the best invest- 
ment in any country today. The practice of medicine and 
surgery is necessitous to civilization ; without it there could be 
no progress. It naturally follows that whatever gives further- 
ance, both in finance and understanding, to this profession, has 
best served the interests of the race. 

What we most need right now is education for the people. 

It is right and proper that every organization have rules and 
regulations for governing the deportment of its members. 
There is hardly a problem which may confront a physician 
today, which did not confront, in approximately the same way, 



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M. 8. DAVIE. 193 

some* physician last year, or, at least, the principle involved has 
been into court many times before, and has been intelligently 
decided for future guidance. 

So a set of rules has been worked out by our profession to 
determine the conduct of its members, and which is known as 
our Code of Ethics. The why and wherefore of these rules is 
not always obvious to the laity, and some of them are thought 
quite peculiar. 

Ethics is merely "the science of right conduct and charac- 
ter," or the choosing of the right in contradistinction to the 
wrong. The differentiation of right and wrong is not always 
a question of intelligence or morals — it is quite often a matter 
of these things — plus information. The public should be frank- 
ly informed about our Code of Ethics. 

The laity has learned that reputable physicians do not adver- 
tise. There are many wise and wholesome reasons for this, as 
all informed and thoughtful members of our profession know. 

While this rule should be jealously and zealously guarded, 
for the welfare of our profession, and much more for the wel- 
fare of the public, yet it should be so distorted as to suppress 
the beneficent accomplishments and resources of our profes- 
sion as such. 

On the contrary, every avenue of publicity, and every re- 
source and ingenuity for using the same, should be employed 
for enlightening the public as to what humanity may receive 
and should demand from our profession. 

Once the general public becomes thoroughly enlightened on 
these matters, the ignorant members of our profession will be 
subdued and the standard everywhere raised. 

The education of the public is one of the most urgent duties 
before, our profession today. The opposition to needed health 
legislation and the support given to quacks and unscientific 
sects and cults is largely due to ignorance of the enormous 
advance in scientific medical knowledge in the last forty years. 

We need to put some elementary pedagogics into this mat- 
ter. Let us assume, for it is an assumption of fact, the pub- 
lic knows very little about the real status of scientific medicine 
of today. What it needs is to be told facts and shown how 
modern scientific medicine diflfers from the empirical knowl- 
edge of previous generations and how this increased and more 
certain knowledge has come about. It needs to be shown 

18 M 



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194 HUMANITARIAN ASPECT OF MEDIOINB, 

that at the bottom of our present knowledge of medicine He 
bacteriology, pathology and chemistry; that these sciences are 
just as positive as are electricity or civil engineering, and that 
the modern scientific physician is just as positive and has just 
as good reason for being positive in his methods and conclu- 
sions as the electrical engineer or the man who builds a bridge 
or digs a tunnel. Let us quit scolding and go to teaching the 
public. We have the knowledge. Let us use the philosophic 
calm which belongs to greater knowledge. 

When this educational foundation has been laid, and the 
public understands that the scientific medical profession is per- 
fectly sincere in its efforts to prevent disease, it will be ready 
to give its much needed cooperation and almost anything may 
be accomplished. 

Not only do I recommend a press bureau for enlightening 
the public as to what our profession has to offer to mankind, 
but I further submit that we should inform the general public 
as to the pathologic possibilities of many so-called trivial con- 
ditions. 

For example, the public should be told that the micro-organ- 
ism which produces tonsilitis is the one which frequently causes 
endocarditis, arthritis and nephritis, further developing to it 
the criminality of allowing children to have diseased tonsils. 

The public should know it has no right to decree that this or 
that is trivial, and, therefore, any physician or method may do 
for the same. It should know that only the best talent in our 
profession is good enough for any condition which may arise. 

Now I have outlined briefly some of the most important 
things the medical profession has accomplished in preceding 
generations, and I wish to show even more briefly a few of 
humanity's needs which constitutes the physician's responsi- 
bility today. 

"In the United States an average of 685 babies die every 
day, or 250,000 a year. The coffins for babies who die an- 
nually in this country, if placed side by side, would make a 
solid row 95 miles long. 

In the United States there are 630,000 preventable deaths 
a year, or 1,726 every 24 hours, or twelve Titanics a week. 

There are 2,900,000 persons constantly sick in this country. 
This is a loss annually to the nation of over $3,000,000,000, 
enough to build seven Panama Canals a year. 



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M. B. DAVIE. 196 

Tuberculosis alone costs more than the expense of the entire 
Federal Government. At the present rate at last 5,000,000 
of the people now living in the United States will die of tuber- 
culosis. 

Typhoid fever costs the nation $350,000,000 annually. 

There are 3,000,000 cases of sickness from malaria every 
year in the United States, causing a loss of $160,000,000. 

Of the 892,000 persons of all ages taken at random in the 
United States and examined for hookworm, 34 per cent were 
suflFering from this disease. It is estimated that South Caro- 
lina alone suffers a loss annually of $35,000,000 from the low- 
ered vitality of her workers caused by hookworm. 

At least 190,000 persons in the United States are constantly 
ill from syphilis, while 30 per cent of the insanity of this coun- 
try is due to this disease. 

There are over 275,000 idiots, imbeciles and moron in the 
United States. 

For every nine millions of white people in the United States 
there are 160,000 deaths annually, while for nine millions of 
negroes there are 266,000 deaths. The loss to the United States 
from preventable sickness and death of negroes is over $700,- 
000,000 a year." 



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MEDICAL PREPAREDNESS. 



Majob James L. Bevans, Surgeon U. S. Army. 

Mr. Chairman, Ladies and Gentlemen: Those of you who 
know something or have studied the psychology of the crowd 
know that mobs go by a direct route toward the accomplish- 
ment of a very definite objective. Armies are a little like mobs 
in that they recognize only the laws of force. Nations at war 
also demonstrate a little bit of this same seeking after a definite 
objective, except that instead of showing it as mobs show it, 
they show it in the form of cooperation and patriotism which 
is not seen in these bodies. 

Our own nation now is at war, and I think you all have 
noticed the increased spirit of cooperation and patriotism on 
account of the fact that war exists. Although I am a com- 
plete stranger in Alabama and in Montgomery, I have observed 
marked signs of a fine spirit here, a spirit of patriotism such as 
we see in the nation, a spirit of cooperation. You have an 
unusually fine spirited body of troops. The medical examiners 
who have been working many of them have noted that there 
are less claims for disability, for instance, and they are not 
seeking unworthy means of discharge. Some one has said 
that they have shown a marked improvement in their physical 
condition as a result of six months on the border. This fact 
alone proves that they have cooperated in the eflforts at disci- 
plining and training them. I never have seen among audiences 
such manifestations of patriotism as I have seen here on the 
playing of the National Anthem. Over and over again it has 
been observed. 

The statistics also show that Alabama is the first State in the 
number of its volunteers. Many communities are boasting 
just now of the large increase in membership for the Red 
Cross. I noticed in the paper the other day that Bridgeport, 
Conn., for instance, claims to have added twenty thousand 
members in ten days, fourteen per cent, of its population. 
Ridgewood, N. J., says that they have added two thousand 



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MAJOR JAMES L. BEVAN8. 197 

members in two weeks. Montgomery has not yet obtained its 
charter for a chapter of the Red Cross, nor has it started its 
campaign of work, but the other night they obtained 275 
members in ten minutes, which I believe is the record. (Ap- 
plause.) 

The doctors also have been interested in the work, and for 
the last month have been attending nearly every night classes 
of instruction in military medicine, and the increasing audi- 
ences and the large enthusiasm manifested I think shows among 
the doctors the same spirit which animates the general popu- 
lation. 

I conclude therefore that the spirit to serve is present in 
Montgomery and in Alabama, and what you really want to 
know is how and when and where to serve, in some little detail. 

Long ago armies had no means of relief whatsoever for the 
wounded. Frequently the inhabitants cared for some of 
those who fell, the fighting force itself was depleted by the fact 
that men had to care for comrades who were struck, and many 
others died mostly as a result of lack of attendance. The kindly 
people of that time gave a great deal of attention to the sub- 
ject of relief to the wounded. Two hundred conferences and 
conventions were held in the four centuries before the date of 
the Geneva Convention to consider means of ameliorating the 
conditions of the wounded, but they came to nothing because 
tliere was no international law to enforce their recommenda- 
tions. The kings and generals of that day regarded the 
wounded as a part of the inevitable consequences of war. It 
was not until the time of the Napoleonic wars that Barons, 
Larrie and Percy finally gave the world a definite medical de- 
partment for the French and German armies. During our own 
Revolution, in the days of Washington, the relief to the 
wounded was by means of regimental organizations and was 
imperfect and fragmentary because it was not organized for 
the army as a whole instead of by regiments. 

In 1863 Lauterman in a series of circulars announced a plan 
which he afterwards was allowed to put into force for carrying 
for and transporting the wounded for entire armies. His 
plan is the basic plan followed by all the armies of the world 
today, all of them following the original plans of this American 
surgeon. 

It was in 1863 that the nations of the world met at Geneva, 
Switzerland, at what is called the Geneva Convention, to study 



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198 MEDICAL PREPAREDNB88. 

this very question, and they made definite recommendations 
which nearly all of the nations of the world have now become 
adherents to. One interesting exception is in the case of Tur- 
key. Not being a Christian nation, Turkey refused to accept 
the emblem, which is a red cross, but in every way they have 
become adherents to the convention, and have as their sign in 
place of our red cross, the crescent. It was in compliment to 
Switzerland that the national banner of that country with 
reversed colors was taken as the flag of the Red Cross. 

Among other important recommendations was the one to 
establish in each nation a committee or society called the Red 
Cross Society or Committee, and it was announced at that 
time, and it has always been true since, that the chief object 
of that society is to serve as a channel of communication be- ^ 
tween the people and the army. In our own country there is 
a well established, powerful National Red Cross Society. The 
army of the United States has a well organized medical de- 
partment. You in Alabama should take especial pride and 
interest in the medical department of the army, because of its 
distinguished chief, who is a native of this State, our Surgeon- 
General Gorgas. 

Now, to get down to details, the medical department of the 
regular army consists at all times, in peace and war, of sev- 
eral branches. The first one is called the medical corps, which 
is made up of the surgeons who serve in the regular army. 
Back of that and to piece it out, is the medical reserve corps. 
Then there is the medical corps of the militia, and that of the 
additional army which is now being thrashed out by Congress, 
and which we all hope will be formed by selective conscription 
and not by volunteers. (Applause.) In addition to these, there 
is the dental corps, the name of which explains itself ; the hos- 
pital corps, made up of the enlisted men who go as orderlies, 
nurses, attendants, drivers and laborers ; and the nursing corps, 
made up of trained female nurses. 

Entirely distinct from the medical department of the army 
and navy comes the Red Cross Society, which supplements it 
and helps it with funds, personnel and material when such 
things are needed. 

Under very special circumstances also it is provided that the 
army may accept the volunteer aid of individuals. Outside of 
this one exception, the Red Cross is the only organization 
which is allowed to offer aid to the army. 



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MAJOR JAMBS L. BEVAN8. 199 

Every resource of the country must be mobilized in war, and 
medical resources are prominent among them. Someone has 
said within the last day or so that for every soldier on the 
battle line there must be five stay-at-homes engaged in fur- 
nishing him with pay and food and clothing and medical essen- 
tials and the other necessities of his life. Such a development 
of all the resources of a country means organization, and al- 
though the question of the organization of the resources of the 
country was mentioned quite fully this morning, I want briefly 
to go over it again. 

First, as a result of the action of several medical societies 
representing fully ninety thousand of the physicians of the 
United States, the American Committee of Physicians for 
Medical Preparedness was formed. Next, and entirely inde- 
pendent, the Council of National Defense came into existence. 
Later the Council of National Defense named an Advisory 
Commission. The Council of National Defense consists of 
certain cabinet officers, and is semi-official. The Advisory 
Commission is made up of many sections, about as follows: 
One on medicine ; one on labor ; transportation and communi- 
cations; science and- research, which deals chiefly with engi- 
neering; raw materials, minerals and metals; munitions and 
supplies, including food and clothing. You have noticed every 
day extensive articles with reference to these various sections 
of the Advisory Commission. For instance, one which at- 
tracted attention the other day was the naming of Mr. Hoover, 
who has so distinguished himself in Belgium, as director of 
the subsection dealing with foods. 

The medical section of the Advisory Commission has been 
so overwhelmed with work recently that it is just now naming 
a general medical board, which is subsidiary to it. So if you 
get the sequence of events, you have got a general medical 
board acting under the Advisory Commission of the National 
Defense Council; it is a little bit complicated and may get 
more so, but they have an enormous work to do. 

The original Committee of American Physicians had named 
state and county committees, and they are now acting under 
the direction of the National Council of Defense. They are 
helping the Government to get ready, and they know, for 
instance, that if the regular army of today was brought up to 
war strength, as it probably will be within the next ten days 



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800 MEDICAL PREPAREDNESS. 

or two weeks, that a thousand physicians for the regular army 
will immediately be necessary. They also know that if the 
President calls for as many as five hundred thousand men that 
thirty-five hundred additional physicians will be needed, and 
that if he calls for two million men, from twelve to fourteen 
thousand more will be necessary. This represents ten per cent, 
of all the physicians of the country, but a much larger per- 
centage of those who from age and physical condition are 
available for field service of the rough sort which war brings 
about. 

The shortage in the regular army the War Department hopes 
it will fill from the graduates of 1912, 1913, 1914, 1915 and 
1916. The army requires one year's internship. The navy 
I am told has waived this, and therefore, probably will accept, 
a little later, graduates from 1917. The qualifications for 
surgeons for the regular service are that they shall be Ameri- 
can citizens, graduates of a reputable medical college, persons 
of good moral character and correct habits, and that they shall 
be under thirty-two years of age. They pass a written exam- 
ination and a physical examination before a board and at the 
nearest army post or convenient place to which they are sent, 
and if they are successful, go to a post-graduate coprse at the 
Army Medical School, lasting nine months, and at the end of 
that time they have another written and oral examination, and 
if they pass are then taken into the regular army. 

For the information of those who are interested, the position 
of surgeon in the regular army is a life position, and at sixty- 
four such persons are retired on three-quarters pay. 

The course at the Army Medical School is a matter of inter- 
est to medical men in that it now represents one of the best 
laboratory courses in the country. 

Outside of the regular corps there is the reserve corps, 
which will be enormous in case of active war, and from it will 
be drawn the proper personnel required by the regular army, 
the additional army and all the other branches. Just now 
they are taking candidates for the reserve corps between the 
ages of twenty-two and forty-five. They are in the ranks of 
lieutenant, captain and major. Information with reference to 
the reserve corps may be obtained by writing a letter asking 
for it, addressed to the Surgeon-General of the Army, Wash- 
ington, D. C. The qualifications are exactly those for the 



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MAJOR JAMEB L, BEVAN8. 201 

regular corps, except that the examination is an oral one of 
less severe nature and lasting a much shorter time. The com- 
missions in the reserve corps formerly could be accepted with- 
out the necessity of active service following, but now if one 
accepts a commission in the reserve corps he may be compelled 
to serve when called upon. Therefore, it is a question of some 
seriousness to accept such a commission. 

I think that it will not be at all difficult to get all of the 
physicians needed by all the different branches of the service 
if there can simply be a spreading of the word among the 
doctors that they are wanted. But those who are going in 
should certainly be prepared for the life which is coming to 
them. It needs special reading and special instruction, fol- 
lowing perhaps one of many plans, but in every town in the 
State classes should be going at this very moment, as they 
are in Montgomery, preparing those doctors who care to enter 
the life. In Albany they have followed a special plan, which 
may be obtained by any one interested by addressing the Clini- 
cal Club of Albany, N. Y. 

One of the functions of the medical section of the Advisory 
Commission is to keep us Americans from making some of the 
mistakes which the British army made at the beginning of the 
war three years ago. For instance, the British allowed mem- 
bers of medical faculties to go immediately to war, and they 
encouraged undergraduates to take the same course. They 
broke up the schools of medicine, in other words, and when 
the much greater demands of later years came the flow of 
graduates had ceased. We are planning through the Advisory 
Commission to keep the faculties of the medical schools to- 
gether and to advise the young men to graduate and then go 
in full-fledged physicians. In Italy, taking advantage of the 
mistake of the British army, they are receiving wounded for 
treatment in hospitals attached to medical colleges, so that the 
undergraduates are both serving their country and getting spe- 
cial schooling in the care of gunshot wounds. They are then 
graduated direct into the army. 

Now in addition to the places open for the doctors, there is 
the nursing corps and the hospital corps, both of which have 
reserve corps similar to the relationship between the reserve 
corps and the medical corps. The army takes nurses only 
after examination, both physical and mental. She signs a 



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202 MEDICAL PREPAREDNESS, 

contract pledging her to serve a number of years. Those who 
join the reserve corps come in under the temporary contract, 
simply agreeing to serve if called upon. 

The demand for hospital corps men is very great. Recently 
the Advisory Commission has asked that every physician inter- 
est himself in getting some young man of proper physical char- 
acteristics and age to go into the hospital corps. Druggists 
are much needed. Motor ambulance drivers are needed, men 
who know anything at all about hospital service and first aid 
are needed. They should be sent for further information to 
the nearest recruiting station, and if they ask for the doctor 
at the recruiting station they will get the information that they 
want. 

Now, for those who cannot serve at all in the organized 
military forces there are plenty of opportunities. The Red 
Cross is the chartered official society offering many openings 
for all sorts of people, men and women. It is well adapted for 
both military and civilian relief. Those interested in the hu- 
manitarian side of the question of relief to the wounded as dis- 
tinguished from the purely mercenary military side, will find 
useful work with the Red Cross. They should apply for lit- 
erature giving all of the different openings and plans, to the 
Secretary of the Red Cross at Washington, D. C. There is 
work to be done both at the front and in home territory and 
at the place of the person's own residence. The Red Cross 
is glad to receive subscriptions, large or small, and will receive 
them for general purposes or for specific purposes, if the sub- 
scriber so desires. If you can do nothing else, either in the 
way of personal service or subscriptions, at least joint the Red 
Cross in your local chapter, paying one dollar for the privilege, 
and if there is no chapter in your home town, then it becomes 
your duty to form one and join the one that you form. 

I have tried to give a few definite details in regard to the 
various medical services. If war really becomes active oppor- 
tunities will spring at you, and instead of having to hunt a 
place to serve, the place to serve will hunt you. 

I should like to close with the closing words of the address 
which President Wilson delivered to the people the other day : 
"The supreme test of the nation has come. We must all speak 
and act and serve together." (Applause.) 



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IRITIS. 



p. I. Hopkins, M. D., Dothan. 



The purpose of this paper is to stress the importance of 
the early recognition of this condition. Iritis is an inflamma- 
tion of the iris and is one of the common affections of the eye. 
It may be congenital or acquired, traumatic or idiopathic, pri- 
mary or secondary, simple or complicated, acute or chronic, 
and may attack one or both eyes. While almost always amen- 
able to treatment, if recognized in its inception and judiciously 
managed, it usually impairs the sight more or less seriously, 
and permanently damages the integrity of the eye if allowed 
to run its course unchecked, or if improperly or tardily treated. 
It is of the first importance therefore, that its true character 
should be recognized at the outset, and that the required thera- 
peutic measures should be resorted to without delay. A diag- 
nosis of iritis is commonly not a difficult matter and indications 
for its treatment are usually plain. It is nevertheless true 
that it is frequently confounded with other forms of inflamma- 
tion of the eye and improperly treated; and in consequence 
the patient becomes partly or entirely blind. 

Symptoms: Generally speaking the presence of iritis is to 
be suspected whenever, without increase of intra-ocular ten- 
sion or other evident cause, pain in and around the eye, usually 
worse at night and accompanied by peri-corneal subconjunc- 
tial injection, a contracted pupil and photo-phobia. This train 
of symptoms does not necessarily indicate the presence of iritis, 
but it should put us on our guard and make us search carefully 
for other evidences of its existence. A dull appearance of the 
iris with a change of color and more or less swelling of its 
tissue; immobility of the pupil and perhaps loss of its circular 
form; less of transparency of the aqueous humor and fre- 
quently of the cornea as well, with dullness of vision ; adhesions 
between the margin of the pupil and the capsule of the lens, 
which, however, are frequently not evident until a mydriatic 
has been used; and in severe cases a grayish opacity of the 



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204 IRITIS. 

pupil from the deposition of lymph on the lens capsule. These 
changes should be sought for and if found establishes the diag- 
nosis beyond question. Pain in iritis is referred to the eye, 
the nerve-exits around the orbit, the temple or to the side of 
the nose along the course of the nasal nerve. Pain may be 
entirely absent or may be so excruciating that the patient begs 
for relief. The eye is tender on pressure, especially at a point 
about two millimetres behind the comeoscleal junction near 
the middle of the upper lid. Accommodation is impaired. When 
the deeper structures of the eye are involved, which condition 
is called irido-cyclitis, the chain of symptoms is as mentioned 
above, with increased severity to which is added edema of lid, 
cloudiness of vitrous and floating particles in same. 

Diagnosis : Iritis is often mistaken for acute catarrhal con- 
junctivitis. The diagnosis being made by the following points: 
conjunctivitis presents a discharge, redness is situated poste- 
riorly, the iris responds to light, vision is not affected, tension 
of the eye is not changed, color and lustre of iris is normal. 
Whereas, in iritis absence of discharge, redness at corneal mar- 
gin, occasional increased tension, small and muddy pupil and 
with the use of oblique illumination, slight changes in the 
corneal tissue of the iris, and in many cases adhesions between 
iris and lens are found. In severe cases too much dependence 
cannot be placed on the peri-corneal injection as the whole con- 
juctiva is often injected. One very important point is the dif- 
ferentiation of glaucoma and iritis the main ppints are dilated 
pupil, patient usually over middle age, increased tension, shal- 
low anterior chamber, cornea is anaesthetic, and the use of 
opthalmoscope shows excavation of the head of the optic nerve 
and pulsation in the retinal arteries. 

Varieties : Serous, plastic and pharencymatous. 

Causes: Trauma is often a cause, but the disease is gen- 
erally due to come constitutional vice. Other causes are 
syphilis, which represents about 50 per cent of all cases. Rheu- 
matic iritis represents 30 per cent, which has for some of its 
underlying causes gonorrhoea, pyorrhoea, septic teeth and ton- 
sils, accessory sinuses, endometritis, otitis, auto-intoxication, 
typhoid fever, bronchitis and pneumonia. 

Exudative iritis is the most frequent form of gonorrhoeal 
iritis, the chief sign being profuse exudate of lymph into the 
anterior chamber. Relapses are due to reinfection as in the 



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p. /. HOPKINS. 206 

gonorrhoeal form from uncured urethritis and prostatitis. 
Pyorrheal iritis according to some authors is a very frequent 
source, the sympathetic type should also have mention. 

Remembering the regional anatomy of the eye, with the close 
relationship of the nasal accessory sinuses, the very thin walls 
albw an extension of inflammation by continuity or through 
the many venous and lymph channels. 

Treatment : The chief indications in the treatment are first 
hy local and constitutional remedies to control and overcome 
as quickly as possible the inflammation, and secondly, by the 
use of mydriatics to keep the pupil widely dilated for 3 to 4 
weeks, so that adhesions shall not form between the posterior 
surface of the iris and the lens capsule. 

For the latter purpose atropine is the sovereign remedy, and 
as a rule, should be preferred to more recent mydriatics. The 
addition of dionin and cocaine aids the action of atropine, has- 
tens the absorption of exudates, diminishes intra-ocular ten- 
sion, and relieves pain. It often occurs that patients are seen 
after adhesions have taken place. We must attempt to secure 
dilatation which will necessitate the forced use of mydriatics 
with the internal administration of large doses of mercury, 
iodide of potash, sodium salicylate, quinine, appropriate nasal 
treatment, good dentistry, removal of tonsils, attention to the 
prostate and urethra or other foci that we may determine, 
from a most thorough and painstaking examination. The in- 
telligent use of vaccines will be in order. There are numbers 
of other points in treatment but the object of this short paper 
was to bring to your attention the importance of early diag- 
nosis. 

DISCUSSION. 

Dr. S. L. Ledbetter, Birmingham: The reporter has cov- 
ered the ground pretty well, so far as the nature, history, symp- 
tomatology, diagnosis and treatment are concerned, and if 
there is anything else left, I do not know exactly what it is. 
There are some few features, however, that I will discuss 
briefly. 

Dr. Hopkins stresses the importance of early recognition, 
and inasmuch as glaucoma is a condition the pathology of 
-which is to a certain extent in doubt, it is not always easy to 



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206 IRITIS. 

make a diflFerential diagnosis between an acute inflammatory 
glaucoma and an irido-cyclitis. The diagnosis is not a difficult 
matter in ordinary plastic iritis, however, and in this type early 
diagnosis is especially important on account of the rapidity with 
which adhesions form. 

The doctor mentions irido-cyclitis or serous iritis. The term 
serous iritis is not used very much any longer ; it is not a term 
used to apply to iritis pure and simple, because it has been 
determined definitely that serous iritis is really a cyclitis, and 
that the iritis is only a complication of a cyclitis. The anatomi- 
cal relation between the two bodies, the iris and the ciliary 
body, is so close; in fact, the inner coating of the iris is also 
the inner coating of the ciliary body, and the two form a part 
of the same tract ; and consequently a disease aflFecting the one 
will be very apt to affect the other, and in nearly all cases of 
cyclitis of any type whether serous or suppurative, in nearly 
every case we have more or less iritis as a complication. So 
that the two go together and the treatment of one would be 
put down as the treatment of the other. Irido-cyclitis, with a 
dark, cloudy vitreous, and a sluggish, heavy iris, with involve- 
ment of the choroid, really becomes one of the most serious and 
dangerous troubles with which we have to contend. The sim- 
ple or plastic iritis, which is due to a variety of infections 
which the doctor mentioned in his paper — if treated properly 
from the beginning — is quite easily handled. 

If it is due to a specific infection, of course, the treatment is 
largely constitutional. However, the local treatment adds 
quite a good deal to the comfort of the patient, and helps in 
the cure, though that is a secondary consideration. We find 
in a great many cases that the measure which relieves the pain 
and makes your patient comfortable helps toward a cure. 

Making a differential diagnosis along those lines is a very 
essential point in the cure of the disease, and it is absolutely 
necessary, or should be, that every physician be able to recog- 
nize the early s)miptoms of iritis and cyclitis, because what you 
do must be done quickly, otherwise your results are not satis- 
factory. Once the pupil is blocked with a deposit of lymph 
covering the capsule and binding down the iris to the anterior 
capsule of the lens, that eye can rarely be again a very useful 
or serviceable eye. Because to remove the membrane you have 
to uncover the lens, break up aldhesions and get rid of your 



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p. /. HOPKINS. 207 

lens, which is not always an easy matter. Of course, you can 
remove the cataract, but you are much more apt to get an iritis 
following your operation, with a closing up of your pupil space. 
So that, while you may do a good cataract operation, your re- 
sult is not always satisfactory and results are the things we are 
after. 

There are two things you want to do: first, recognize the 
condition, and then the cause. If it is due to a specific trouble 
your treatment is simple. You treat it as you would a specific 
condition anywhere else, with the local treatment, of course, 
for comfort, and as an aid to internal medication. 

The essayist did not mention blood-letting and leeches. I 
have used leeches a good deal, and I am still using them, but 
not as frequently as I once did. Still we now and then run 
across a case, a very painful condition, in which a leech helps 
very much. If you keep the iris drawn well out from the center 
of the pupil you do not get adhesions, and when the inflamma- 
tion has subsided you have a good clear open pupil in the ma- 
jority of cases. 

One of the most difficult types of iritis to treat is the puru- 
lent or suppurative type. Now, you all know something of the 
anatomy of the iris. It is composed very largely of fibrous tis- 
sue, connective tissue, with a vascular layer and the pigment 
cells and the muscles. Of course, if you get much plastic mate- 
rial deposited in the iris those muscles are very much impaired ; 
they lose their usefulness ; they are heavy, and the pupil does 
not respond to light as it should. 

There is another type of iris trouble that the doctor did not 
lay any particular stress on. Perhaps he does not see very 
much of it, but in the cities among the poorer people you do 
see it, and that is the tubercular type. There have been quite 
a number of things used in the treatment of that form of trou- 
ble. I have used the vaccine treatment quite a good deal, and 
I think in some cases I have gotten very excellent results. In 
other cases I did not seem to get very much out of it. 

As to local applications! Of course, we are all taught to 
use hot compresses, but in some cases they do not give the 
results desired. 

End results are the things you have to look to, and in order 
to get good end results you have got to recognize your condi- 
tion early. 



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208 IRITIS, 

Dr. William C. Maples, Scottsboro : I wish to tell of a case 
that I recently had. This was a woman about thirty-five years 
old. The history showed that she had had two or three other 
attacks. When I saw it I made a diagnosis of rheumatic iritis. 
The pupil, however, was not greatly contracted. There was a 
dull look about the eye, and I could make out considerable in- 
creased tension. It was a question with me whether I was 
right in my diagnosis, whether I did not have an inflammatory 
type of glaucoma. But I put a solution of atropine in the eye, 
and the pupil dilated just a little and stopped. I continued the 
atropine until her throat got pretty dry and the pupil would not 
dilate any more. I got scared and sent her to an oculist. He 
reported that it was a case of rheumatic iritis. This woman 
had a tonsil that was badly inflamed, and I suspect that that 
was where the trouble started. 

The point I wish to make is that we as general practitioners 
see those cases. I have seen iritis a good many times, and 
some of the cases are perfectly easy to diagnose. In that case 
it was difficult to me. I think there was certainly some in- 
creased tension, and the vision was very much reduced. There 
was that dull look about the cornea, and I thought I could de- 
tect a little greenish reflex such as you see in glaucoma, and the 
pupil would not dilate under atropine. The question in my 
mind was whether it was a proper thing to use the atropine, 
whether I should not have used a miotic, such as eserine. There 
was a lot of trouble in that eye, and she suffered fearfully from 
pain. She had had the trouble before, and she had a five per 
cent solution of dionin which she put in the eye. I was not 
familiar with dionin. That case was kind of a puzzle to me to 
know just what was going on in there. I thought there was 
inflammation back in the ciliary region, probably a case of 
irido-cyclitis. It was a very interesting case, and I would be 
glad to hear a discussion as to how we can tell just when to use 
atropine. 

Dr. Ledbetter: Dr. Hopkins had to leave and asked me to 
close for him. I don't think there is anything else that I want 
to say particularly. 

The doctor spoke of the mydriatic and when to use it. I 
think in all cases of clear cut iritis or cyclitis it is well enough 
to use the mydriatic and push it, but sometimes when we have 



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p. I. HOPKINS. 209 

a very sluggish iris that does not dilate well and we know there 
are deposits on the anterior capsule, we may, in our efforts to 
get results, put it too far, but if you drop it in on the outer side 
of the eye at the outer canthus and put a little compress over 
the inner canthus so as to prevent the tears from carrying the 
atropine into the nose, you can use it for a long time without 
getting the physiological effect on the nose and on the system. 

Sometimes, too, we are called upon to stop the use of a 
mydriatic on account of the tendency to develop glaucoma. I 
do not mean to say that an irido-cyclitis is going to produce a 
glaucoma in a large percentage of cases, but I believe the 
glaucoma is very frequently brought out in old people by this 
inflammatory condition of the ciliary body, which was the pri- 
mary cause of the trouble, and those cases are nearly always 
septic. 

Now, as to the dionin. I did not mention dionin in my dis- 
cussion. But I use it quite a good deal, and get good results 
from it, but, as the doctor states, it produces much edema, red- 
ness and pain for a short while. The physiological effect of 
dionin is to produce that edema. But it is like blood-letting; 
it takes the blood out of the tissues, and with the subsidence 
of the swelling you get some relief. 

Dr. H. S. Ward, Birmingham : I am not a specialist in this 
particular kind of work. This paper on focal infection is cer- 
tainly one of the most important subjects that is going to come 
before this Association, and especially to the men who are doing 
general practice. To my mind there has been no more epoch- 
making work in the last few years than the paper that came out 
by Billings in the Journal of the American Medical Association 
about two years ago. That has almost revolutionized our ideas 
about rheumatism and a great many other forms of infection. 
Up to that time we thought that if we could give large enough 
doses of salicylate of soda we could cure any case of rheuma- 
tism, especially of the acute type. We now find we can give 
them all we want to, but unless we find the focus and remove it 
the patient will continue to have rheumatism. 

Now while the doctor's paper only covered the most common 
causes of infection, we must look further. Personally when I 
see a man with a pain anywhere, without a definite cause, I 
first look at his teeth. If the teeth are clear, then I look at his 

14 M 



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210 IRITIB. 

tonsils, and next find out about his prostate; and if you find 
a chronic appendix, or a chronic gall bladder, any of these will 
act as' a focus, that will invalid the patient for many years. You 
can give him all the drugs you want to and they are not going 
to improve unless the focus of infection is taken care of. 

Whenever I have a patient come in complaining of a neuritis 
and a sallow complexion and I look in the mouth and find a 
beautiful display of dental handiwork, I know at once that it is 
necessary to have a mouth-cleaning. I have in mind a patient 
of that kind, and when the mouth was cleaned up the neuritis 
disappeared. Another patient, I looked at his prostate, found 
nothing; then his tonsils, found nothing. Finally after three 
or four attacks, I found an ingrowing toe nail that was the 
focus of infection. And every time this inflammation flared 
up he had a violent lumbago. As soon as we cured the toe 
there was no more lumbago. So in all these muscular and 
joint affairs and neuritis if you find the focus of infection and 
clear it up you will cure the rheumatism. In all these old 
women who have set up with rheumatism for years it will fre- 
quently be a tooth, though not always ; but if you can locate the 
focus of infection you can stop their drugging, even if you can- 
not cure them entirely, and you will have done these people a 
great service. 



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FOCAL INFECTIONS OF EAR, NOSE AND THROAT 
IN RELATION TO GENERAL DISEASE. 



Paul S. Mebtinb, M. D., Montgomery. 

Your President has asked that I discuss the focal infections 
of the mouth, throat, nose and accessory sinuses in relation 
to general disease. 

The last words of one of the world's greatest poets was an ap- 
peal for more light; the last decade has lifted the diagnostic 
veil from a number of diseased conditions and has thrown light 
where we were in darkness. We are no longer satisfied with a 
diagnosis of a rheumatism, a neuritis, an endocarditis, a uveitis, 
or a myositis. The conditions to which we have given these 
names are often only symptoms or results of a focal infection. 
To discover this focus of infection may require the service of 
the dentist, radiologist, microscopist, urologist, laryngologist, 
or the internist, and even then only after long and careful 
search will it be found. The focus of infection may be easily 
found in many cases while in others a very small abscess at the 
tooth apex may produce symptoms sufficient to wreck the 
whole physical being, and even to result in death. 

The recent lamentable death of one of our greatest surgeons 
with a renal focal infection resulting in aortitis illustrates the 
difficulty often encountered in diagnosis. Dr. Murphy himself 
made the diagnosis of a cryptic infection which he located in 
the kidney, but it was not until autopsy revealed a pus sac in a 
completely destroyed kidney that the diagnosis was confirmed. 

The mouth, throat and accessory sinuses offer abundant op- 
portunities for focal infections. The teeth, from disease of 
often from imperfect dental work or anomalous conditions will 
have foci of pus at their apices. A mouth with many large fill- 
ings and especially crowns should be looked on with greatest 
suspicion. Pain spontaneous or on pressure may be lacking, 
the heat and cold test be negative, and yet the X-Ray may show 
one or more apical abscesses. 



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212 FOCAL INFECTIONS OF EAR, ETC. 

The tonsils composed of masses of lymphoid tissue with 
many glands in its substance, are the most common point of 
focal infection. The hypertrophied tonsil projecting into the 
fauces is less likely to cause trouble than the submerged type 
of tonsil. In making a diagnosis of chronic infected tonsils we 
should make a careful examination. Simple inspection of the 
throat is not sufficient. The following points will be of value 
in determining whether the tonsil is infected. If the tonsil is 
swollen and red, suspect infection. If the anterior pillar is con- 
gested, or there are palpable cervical glands, the tonsils are 
probably infected. To examine the tonsil, the tonsil pillar re- 
tractor or a strabimus hook should be used to retract the ante- 
rior pillar and to explore the crypts. This examination will 
often reveal one or more cheesy masses of Epithelial and mi- 
crobic detritus. Even with this care we may fail in our diag- 
nosis, and only during the tonsillectomy may we find a deep- 
seated focus of infection. 

Chronic infections of the accessory sinuses are common, and 
may give rise to slight or no symptoms to attract attention. If 
the infection is an open one, the diagnosis by rhinoscopy may 
be easy. Where the infection is closed, the diagnosis may be 
made by the symptoms, transillumination, exploratory punc- 
ture, or X-Ray examination. 

Chronic infection of the ear is easy to diagnose. In my 
experience, it is a rare cause of general symptoms except 
where the lateral sinus has been infected, or the adjacent brain 
tissue involved, conditions which in themselves call attention 
to the ear as the primary focus of infection. 

To illustrate the role of focal infections in relation to gen- 
eral disease, I wish to report the following cases : 

Case I. Miss P., nurse; patient of Dr. Mount. — Rheuma- 
tism in feet. Unable to go up steps. Tonsils chronically in- 
fected. Four days after tonsillectomy able to go up steps with- 
out pain. No return of rheumatism. 

Case 2, Mrs. A. — Rheumatism all parts of the body, arms, 
shoulders, back and legs, worse at night. Unable to turn over 
in bed on account of pain. Infected tonsils. Tonsillectomy 
cure. 

Case J. Mrs. H., age thirty-two. — Pain in back following 
acute tonsillitis. Four weeks after tonsillitis, she was still suf- 
fering. She was referred to me by Dr. Wilkerson, tonsils 



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TAVL B. MERTIUB. 218 

chronically infected. The tonsils were enucleated and ten days 
later all her pain had stopped and they had no further trouble. 

These are common histories and the connection between 
rheumatism and focal infections is no longer a theory, but an 
established fact. 

Case 4. Mr. L., a mail-carrier from Conecuh county, re- 
ferred by his family physician. — Chronic iritis, both pupils 
bound down by thick adhesions. Has had frequent attacks of 
rheumatism during the last eight years, vision much impaired. 
Examination of mouth showed many carious teeth, pyorrhoea 
gingivitis. The patient was referred to his home dentist, who 
reported that he had extracted four roots and one crowned 
tooth with an apical fistula. The gums and pyorrhoea were 
treated and the patient given instructions in mouth hygiene. 
The inflammation of eyes cleared up, the vision has improved, 
and the general health and digestion is much better. 

Case 5. Miss T. — ^Three or four attacks of mild iritis fol- 
lowing attack of tonsillitis. The tonsils were enucleated, the 
eyes cleared up and for over a year she had had no trouble. 

Case 6, Mr. C. A., age 46. — Four attacks of tonsillitis rheu- 
matism and iritis during the four or five years he lived in Mont- 
gomery. Each attack confining him to his room for from three 
to five weeks. The patient refused operation from fear of 
ether and possible hemorrhage. 

Case 7. Patient of Dr. C. T. Pollard, child about four years 
of age. — Hypertrophic tonsils, tonsillitis, acute middle ear, 
acute nephritis. The kidney complication cleared up in about 
four weeks. I do not know if tonsils were removed, though 
this was advised. 

Case 8. Mitchel B., age 7, patient of Dr. M. L. Wood.— 
Tonsillitis marked cervical adenitis, temperature 101. No erup- 
tion or strawberry tongue. Acute nephritis. Under general 
treatment by Dr. Wood the kidney complication cleared up in 
about a month. The tonsils were later removed, and now after 
a year the child is in perfect health, is growing rapidly and 
the urine is normal. 

Cases p and 10. Miss G., nurse, and Dr. H. — Both cases 
alike, general depression, headache, tired most of the time. 
Closed empyema of frontal sinus, duration of several years. 
Radical Killian operation relieved both patients. Their gert- 



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214 FOCAL INFECTIONS OF BAR, BTO. 

eral health is much better. The headaches are g6ne, and the 
general depression and tired feeling is a thing of the past. 

Case II. Miss G., age 22. — Neuritis right side fo face and 
region of ear, teeth X-rayed showed several with apical trouble. 
The teeth were extracted, but the neuritis continued. The 
patient was treated as a neurotic. Two months later the patient 
returned with a torticollis in addition to her neuritis. The right 
tonsil was inflamed, the tonsils were removed a few days later 
and now after several months the patient has improved in gen- 
eral health. Her neuritis has cleared up and she has gained 
several pounds in weight. 

Case 12. Any child four to twelve years of age, chronically 
infected tonsils, anaemic, tired at school, undeveloped, frequent 
colds and sore throat, tonsillectomy improvement in general 
vitality, weight, development and health. 

These, gentlemen, are but isolated cases, and in the experi- 
ence of any practitioner could be duplicated many fold. 

The results of focal infection may be serious, involving even 
life itself. The removal of a focus of infection may give most 
brilliant results, but let us use judgment, and not be carried 
away with enthusiasm in advocating surgery or extraction of 
teeth unless the indications are clear and marked. Failure to 
get results will tend to harm your own reputation and bring 
these most valuable operative procedures into disrepute. 

DISCUSSION. 

Dr. S. L. Ledbetter, Birmingham : I do not like to see a 
paper of that kind go by default. The doctor has read us a 
good paper. He gives you something to think about, and after 
all the main point of a paper is to give you something to think 
about, something that you can take home with you, something 
that will give you suggestions as to methods and means of get- 
ting rid of your troubles. 

Of course, I know you all understand that the teaching of 
the present day is that rheumatism itself is not a disease at all ; 
that it is purely symptomatic. We also know that all of the 
authorities are claiming now that rheumatism is the result of 
septic absorption from some focus somewhere or other, gen- 
erally in the tonsil, teeth or intestines. 



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PAUL 8. MBRTIN8. 215 

Now the doctor's cases show what all eye, ear and throat 
men have found, that where you find a septic condition existing 
in the tonsil or in an adenoid and remove it, in a large per- 
centage of the cases you cure your systemic condition. Still 
the thing that I want to speak of here is the other side of the 
question, and I am persuaded to -say what I do, not because I 
disagree with the authorities along that line ; I know that such 
conditions are caused by septic infections, but the question is to 
locate the source of thafinfection before operating. We know 
that the tonsils are not the only things that produce rheuma- 
tism; that there are other focal points of infection; that all 
cases of rheumatism are not due to infection of the tonsils ; and 
that you find it necessary in many cases to advise the family 
physician to the effect that the tonsils are not, the cause of the 
trouble in his case. 

If we find a focus of infection in the tonsil and can find no 
other cause, then I think we should remove the tonsil. But in 
many cases we remove tonsils and do not get results and the 
patients are very much disturbed when they find they have had 
their trouble for nothing; therefore, we should be sure the 
tonsils are bad or that no other source of infection can be found. 
If you find no other source of infection then it is well enough 
to remove the tonsils and see what you get. I think an experi- 
ment in that case is justifiable. In some cases where the ton- 
sils absolutely show no focus of infection I remove the adenoid, 
and get the result that we are looking for. Then I wait for 
further developments. 

I gather from the reading of the literature of the present 
day that some of the leaders in oto-laryng«logy are coming 
back to the idea that it is not always necessary to remove the 
entire tonsil. I think in many cases of mechanical obstruction 
from hypertrophied tonsils such procedure is entirely justifiable. 
I do not think, however, it is ever justified in removing the ton- 
sil, because it seems to be a little larger than it ought to be, 
and yet that is done frequently. I have many parents come to 
me, bringing a big, strong, healthy child who never had any- 
thing but an acute attack of tonsillitis, and they want the ton- 
sils removed immediately. I do not approve of that. The fact 
that the patient has had a sore throat or an attack of tonsillitis 
is not sufficient reason for removing the tonsils. 



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416 FOCAL INFECTIONS OF EAR, ETC. 

Dr. Mertins : In considering the focal infections in relation 
to systemic disease I did not intend to make it an exhaustive 
paper, covering all of the conditions which might follow an 
infection. Very often they claim that high blood pressure fol- 
lows a focal infection. 

Now as to the question of operation on the tonsil. When 
a patient is having frequent attacks of tonsillitis I feel that it is 
a mistake to leave that patient with the tonsils. We know in 
quite a large number of cases of endocarditis that the valvular 
trouble originated from some tonsillar infection, and after the 
valves have once become involved, then it is often — I won't say 
too late to do your tonsil operation, but the damage has already 
been done which the removal of the tonsil would have, in all 
probability, prevented, and it is like shutting the stable door 
after the horse is gone. 

The examination, of course, as Dr. Ledbetter has said, 
should be thorough, and we should be convinced that there is a 
disease of the tonsil, and not simply remove every tonsil which 
comes into the office. The point I made in my paper was that 
we should make a thorough examination; if we find nothing 
in the tonsil we should go to the teeth, or the patient may have 
a chronic appendix or a chronic prostatitis causing the trouble. 
I recall an interesting case in the clinic of Dr. Pusey, in Chi- 
cago. A clergyman twenty-five years before had had an acci- 
dent to his left eye, and some months later he developed an 
iritis in the right eye. In the meantime the other eye had 
been enucleated. A diagnosis of sympathetic ophthalmia was 
made. He was treated. Finally he came to this country. When 
he came to Dr. ftisey's clinic he was put in the hands of Dr. 
Irons, who found a prostatic condition following an old neis- 
serian infection. * This patient was put on vaccines and recov- 
ered. 

I am not inclined to agree with Dr. Ledbetter in doing a 
tonsillotomy instead of a tonsillectomy. I feel that if an in- 
fected tonsil is worth taking out it is worth taking it out en- 
tirely. We are constantly seeing the results of imperfect work 
done ten or twelve years ago. The children are coming back 
with great big stumps of tonsil which are causing trouble. I 
fefel that if you are going to do an)rthing you should clcatn out 
the tonsils from the very bottom, so that patients will not come 



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PAUL 8. MERTIN8. 217 

back and tell you that the tonsil grew back. If you do not do 
a complete operation sooner or later you are going to have 
trouble. You are not going to have trouble in every case; 
some are not going to get proper drainage from crypts; in 
some of them you will get the effects of hidden pus which 
you had not expected. 

The subject of focal infection in my paper was simply lim- 
ited to the eye, nose and throat, and did not include those condi- 
tions which may be found in other parts of the body. 



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SUPRAPUBIC PROSTATECTOMY WITH MECHAN- 
ICAL DRAINAGE. 



Ck)UBTNEY W. Shropshire, M. D. 

and 

Chas. Watterson, M. D., Birmingham. 

It is not the purpose of this paper to discuss the value of the 
various methods of removing the prostate gland, for sufficient 
has been written on that subject, it seems, to show that the 
operations of the suprapubic and perineal prostatectomy are 
entirely different, as far as indications and predilection are 
concerned. The question of necessity for operation will not 
be considered, for abundant statistics are at hand to prove that 
the average catheter life is two years. While an exceptional 
case is reported in which the patient lives in a fairly comfort- 
able manner for a number of years, this does not prove that the 
statistics are incorrect, for a great many patients do not live 
more than a few months, even though the most rigid aseptic 
precautions are taken. 

In all suprapubic operations one, and probably the most ob- 
jectionable feature to be considered, is drainage. 

It is impossible for siphonage to start until the bladder is 
completely filled and sufficient pressure is exerted for the 
column of fluid to rise above the level of the patient's body, and 
it is almost impossible to close a suprapubic wound in such 
manner that lealcage does not occur. 

This leakage causes infection in the perivesical tissue, com- 
posed in great part of fat, and the subsequent toxemia, sep- 
ticemia, or pyemia is often one of the contributory causes of 
death. We have seen, and we are sure that a majority of the 
gentlemen present have seen, severe infection of the prevesical 
tissue extending even into the muscle sheaths following supra- 
pubic cystotomy for drainage, stone, or prostatectomy. 

Without mechanical drainage and where we depend on pres- 
sure to produce siphonage, it is next to impossible to prevent 
leakage around a catheter which is sutured in place in the 
bladder, for the slight pressure necessary to form a siphon is 



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O. W. BHROPBHIRE AND CHA8. WATTER80N, 219 

usually sufficient to force the tirine through a weak point in 
the futures surrounding the catheter, before siphonageis 
started. 

The inevitable result is infection or necrosis of tissue. An- 
other point in favor of mechanical drainage is that the bladdet 
is kept comparatively dry all the time, the tube extending deep 
and the bladder contents being removed every few seconds. 

Numerous attempts have been made to construct an appara* 
tus that would drain the bladder mechanically at stated inter- 
vals, and at the same time not produce sufficient vacuum to 
incite hemorrhage, or cause discomfort to the patient. These 
consist of the hydraulic suction pump of Chetwood which was 
later, because of variation in water pressure, changed to an 
electrically driven pump, and the tipping cup of Bremerman, 
which produces a weak vacuum, but sufficient to cause the 
formation of a siphon which, once started, completely empties 
the bladder; and lastly, the Kells suction pump or the Kells 
constant drainage machine as described by Hume Logan and 
Kells. — The American Journal of Surgery, June, 1916. 

We believe that the success of any bladder drainage lies as 
much in the form of drainage tip to be used in the bladder as 
in the apparatus producing the suction, and to be of value the 
suction tip must be so arranged that sufficient vacuum is pro- 
duced to remove urine, mucous, and blood clots from the blad- 
der, but not strong enough to produce enough vacuum within 
the bladder to cause hemorrhage or pain. 

The pump should be so constructed that it does not run after 
a certain fixed amount of vacuum is produced, for if it did, in 
the event that the suction tube or tip became occluded by blood 
clots or mucous, the amount of vacuum would be continuously 
raised and when it became sufficiently strong to dislodge the 
obstruction within the tube or tip the vacuum might be great 
enough within the bladder to cause severe pain or hemorrhage. 

Another objectionable feature which must be overcome is 
noise. If we place a machine beside a patient's bed which 
produces enough noise to keep him awake, we do more harm 
than go6d, for rest and sleep are essential to recovery. 

The apparatus which we have been using for the past several 
months is the Kells Constant Drainage Machine. This ma- 
chine consists of an electrically driven Kells vacuum pump 
designed for alternating or direct current, a vacuum gage and 



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220 SUPRAPUBIC PROSTATECTOMY. 

two gallon jars, one for receiving the bladder contents and the 
other to be filled with a solution of permanganate of potash 
through which the exhaust from the pump passes, thus pre- 
venting the dissemination in the room of obnoxious odors. The 
intake air of the pump is filtered through cotton and the circuit 
is closed at stated intervals by means of a clock work arrange- 
ment. An emergency switch is provided for the use of the 
physician, nurse or patient. The apparatus is capable of pro- 
ducing twelve inches of vacuum, is noiseless, and reliable in its 
workings. 

Points or tips to be used in the suprapubic opening deserve 
special attention. They are composed of an outer sheath which 
is perforated on the sides and open at both ends. This is 
passed through and fastened to a flat piece of metal. The 
tube therefore forms the perpendicular part of the letter "T," 
while the flat metal forms the top. 

Within this sheath is a second sheath, the inner sheath which 
differs from the outer only in having a closed lower extremity 
with a large opening on either side within the inner sheath in 
the drainage tube proper, composed of a simple piece of metal 
tubing bent at right angles to form the letter "L." This tube 
does not quite reach to the bottom of the inner sheath. This 
drainage tip proper is easily removed for cleaning and steriliza- 
tion as is also the inner sheath, as neither come directly in con- 
tact with the wound proper. The tubes are held in place by 
means of strips of adhesive plaster. 

This tube not only drains the bladder proper, but also that 
part of the wound coming in contact with the tube or influenced 
by whatever vacuum is produced. 

The flat metal forming the upper part of the letter "T" and 
being a part of the outer and inner sheaths may be fashioned 
so as to direct the tip into any part of the bladder cavity. For 
instance, the tip may be directed into the upper part of the 
bladder and the foot of the patient's bed elevated; this will 
assist in keeping the lower part of the bladder dry, but it must 
be remembered when using this or any other apparatus, or any 
drainage apparatus, whether simple or mechanical, siphon or 
suction, that the part of the bladder receiving the tip must be 
made the most dependent part of the cavity. 

The Kells constant drainage machine is supplied with dram- 
age tips of various sizes, the larger one to be used where the 



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C. W. BHROPBHIRE AND CHAB. WATTER80N. 221 

fluid to be aspirated contains a large amount of pus, blood or 
mucous, and the smaller ones to be substituted as soon as the 
character of the fluid permits, to hasten the closing of the 
wound. 

This machine in our hands has proven of the greatest value, 
but we feel that the ideal drainage apparatus will be one which 
does not depend upon a clock work arrangement for automatic 
operation, but is so arranged that when the vacuum falls below 
a certain point, the machine automatically starts and continues 
to run until this vacuum is reestablished. 

The foltowing history will illustrate the manner in which w6 
have used this machine following suprapubic prostatectomy : 

J. L., age 76, colored, male, occupation farmer, married, no 
children. Patient has had trouble in urinating for the past two 
years, and has noticed that he has greater trouble when the 
bladder is full and the desire is urgent than when the desire 
is not so great. Two years ago, during the summer months 
when working in the field, he tried to urinate but was unable 
to do so, and it was necessary to send for a physician to cathe- 
terize him. 

He remained in bed for several days and had no further 
trouble for about six months, when it was again necessary to 
use a catheter, which operation has been repeated on numerous 
occasions since that time. 

When first seen the patient had a very much distended blad- 
der and had not passed his urine for ten hours. He was imme- 
diately catheterized and the specimen of urine examined. This 
proved to be negative, except for the presence of a few hyaline 
casts. 

Cystoscopic examination the following day showed a very 
great enlargement of the lateral lobes together with some en- 
largement of the middle lobe. 

Functional Test: Indigo-carmine-right 11 minutes left 13 
minutes, twenty-four hour specimen of urine quantity 1400 c. c. 
spgr. 1018. Patient was kept under observation for several 
days and another functional test and twenty-four hour exam- 
ination made. The results were practically the same. 

Operation the following day, suprapubic protectomy, gas 
oxygen, anaesthesia. The prostate was very easily removed 
and the subsequent hemorrhage was negligible. In fact' the 
whole operation did not require more than twenty minutes. . i 



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222 SUPRAPUBIC PROSTATECTOMY. 

Following the removal of the prostate, the largest sized drain- 
age tip was placed in the bladder and immediately upon being 
returned to his bed, the machine was connected up. 

For twenty-four hours the urine was colored with blood and 
some clots were withdrawn. The smaller tip was used after 
twenty-four hours. On the third day the patient sat up in bed, 
the drainage apparatus being continued. A few days later he 
was placed in a chair, the apparatus still being used. 

About the tenth day the suprapubic wound became so small 
that it was decided to discontinue the suprapubic drainage. 
The wound was drawn together with adhesive straps and the 
patient was allowed out of bed. Slight leakage resulted for 
about four or five days, then the wound closed. 

A sound passed through the urethra on the seventh day met 
with no obstruction. 

During the whole time that this patient was in bed or we 
might say during his whole convalescence, there was no leak- 
age, no infection, and no bad odor in the room. The wound 
healed by first intention and he was comfortable at all times. 
The nurse was very grateful and said that he was less trouble 
than any patient she had. 

In conclusion we wish to say that : 

1st. Mechanical drainage is of the greatest value in supra- 
pubic operations. 

2nd. That the machine used must have sufficient power to 
remove mucous and blood clots, but it must be so arranged that 
the vacuum does not exceed a certain fixed point. It must be 
noiseless and reliable in its workings. 

3rd. The ideal machine would be one in which the working 
would be governed by vacuum and one in which a certain fixed 
amount of vacuum would be maintained. 

LITERATURE. 

New Apparatus for Complete Drainage of the Bladder Fol- 
lowing Either Suprapubic or Perineal Cystotomy — Lewis Wine 
Bremerman, Jour. A. M. A., Vol. LII, Apr. 24th, 1909, pp. 
1332. 

Drainage of the Bladder Following Suprapubic Operations 
—Charles H. Chetwood, Med. Record, Apr. 4th, 1914, pp. 602- 
603. 



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O. TF. SHROPSHIRE AND CHA8. WATTER80N. 22S 

An Improved Suction Apparatus for Suprapubic Cystotomy 
Operations — ^Hume, Logan & Kells, Am. Jour. Surgery, June, 
1916. 

DISCUSSION. 

Dr. Wilson, Mobile: I enjoyed very much the doctor's 
paper, and while I have not used that apparatus for mechanical 
drainage, I am satisfied from what the doctor said that it is a 
very useful help in suprapubic prostatectomy, because one of 
the disagreeable after effects following suprapubic prostatec- 
tomy, in fact, following any suprapubic operation on the blad- 
der, is the leakage and getting the dressings and bed wet, and 
also the disagreeable odor that is constantly kept in the patient's 
room. The form of drainage that I have always used in those 
cases is a double fenestrated drainage tube. That is, I use 
two tubes. I insert them into the bladder so that the bladder 
can be easily ii*rigated. All of the blood clots can be removed 
and the bladder can be made clean in that way. But with this 
form of drainage it is impossible to keep the dressings and the 
bed dry. So I approve of the method that the doctor suggests. 
I think that he discussed the subject well, and I am glad to 
have heard his paper. 

Dr. Steel, Birmingham: I only heard a part of the paper 
read by Dr. Shropshire, and that part of it was his description 
of his method of drainage. The use of that apparatus, so far 
as I know and so far as I have seen it in use, is very satisfac- 
tory in a hospital or where a man can have complete control of 
his patient, but it costs a good deal of money in proportion to 
what a great many doctors get for doing these operations, and 
there are other means which are just as effective and very much 
simpler and I think more suitable to the general run of cases. 
Of course, where Dr. Shropshire gets five or six hundred dol- 
lars for doing an operation it is all right, but where a lot of us 
do it for very little we have to depend upon some simpler 
means. And one of the most effective methods I have found 
was a simple celluloid powder box with two holes bored in the 
side and a tube put in there and joined to a tube leading to a 
vessel. The edges of that can be treated with adhesive plaster 
and fastened on the belly, so that there will be no leakage, and 



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224 SUPRAPUBIC PROSTATECTOMY. 

the urine will all be drained into a vessel under the bed. That 
is the method that I have used in the few cases which I have 
operated on. I find that very effective, and unless you do use 
something of that kind it is a very disagreeable operation to 
deal with. 

Dr. Scott, Birmingham: I certainly enjoyed Dr. Shrop- 
shire's paper very much, and I hate to disagree with him, be- 
cause he is a most particular friend of mine, but I am absolutely 
opposed to all mechanical drainage. You have got to take 
your mechanical drain out sometime, and when you take it out 
you have still got your leakage. I will also say that I am a 
perineal man, consequently I do not know very much about 
suprapubic prostatectomy. On a recent trip that I took in the 
Northwest I saw a great many suprapubic prostatectomies. The 
one that appeals to me most was the one by Lower in Cleve- 
land; he is Crile's man. Lower does not do it as quickly as 
Squier, but it is very much more efficient, in my mind. He 
puts a catheter in the bladder, makes his suprapubic incision, 
then fills his bladder, and grabs the bladder with two tenacula 
and holds it and lets the water run out. In that way he has 
none of that drainage in the prevesical "space nor the space of 
Retzius. After he does his prostatectomy he puts that catheter 
back in the urethra, takes two gauze drains and packs around 
the capsule of the prostate where it has been enucleated and 
leaves the catheter sticking beyond the capsule just about an 
inch. The next morning he takes the suprapubic drains out, 
and he told us that in three or four days he has absolutely no 
leakage. 

That appealed to me. When I came home I had two cases 
that were waiting for a prostatectomy. I thought I would do 
both of them according to Lower. The first one I did accord- 
ing to Lower. I took the drains out the morning after the 
operation, and he never leaked a drop after that. That sounds 
almost impossible, but it is an actual fact. I got the catheter 
and the drains in the actual position demonstrated by Lower. 
In my next case, which was about a week later, I did not get 
the catheter in the correct position. I got the end of it within 
the capsule. In other words, you do your prostatectomy and 
you have a pouch there where the prostate was, and unless you 
get your catheter through that capsule you are going to have 



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a. W. SHROPSHIRE AND CHA8. WATTERSON. 226 

trouble, because after you close up you cannot shove it further 
in because it lies against the capsule. Now that is just what I 
did in the second case. It has been now about two weeks and 
is still leaking, but he is up and about and ready to leave the 
hospital today. 

I think the whole secret of suprapubic prostatectomy is drain- 
age per urethram. I think you can do better drainage that 
way than you can suprapubically. I think the logical operation 
for prostatectomy is the perineal. 

Dr. Shropshire: I have enjoyed the discussion very much 
indeed. One advantage claimed for mechanical drainage is 
that you do not have so much trouble with blood clots and 
mucous. With this mechanical aspirating of the bladder you 
are not as apt to have the blood form ctots. 

Regarding what Dr. Scott said, in the early part of my paper 
I emphasized the fact that I did not advocate either the supra- 
pubic or the perineal operation to the exclusion of the other. 

He raised the point about having to take out the tube and 
still have an opening in the bladder. You reduce the size of 
the tube down to a No. 16 catheter, and after that is removed 
the edges of the wound are brought together with adhesive, 
and in the majority of cases it holds. And the patient will 
soon pass his urine naturally. 

Regarding the operation as done by Dr. Lower, I had the 
good fortune a few weeks ago to see several prostatectomies 
operated on by Dr. Lower. The difficulty is to get the gauze 
packed within the capsule properly. If the gauze is dislodged 
it is a question whether or not hemorrhage might not occur 
between the capsule and the gauze. If the gauze is packed 
tightly enough it will stay,, but the trouble about the Lower 
operation is the catheter in the urethra. If the patient moves 
in bed he is liable to set up some hemorrhage, and the danger 
of infection and irritation from the catheter in the urethra. 



16 M 



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FRACTURES NEAR THE ELBOW. 



F. L. Chenault, M. D., Albany. 

The elbow is formed by the lower end of the humerus and the 
upper ends of the ulna and radius. Fractures near the elbow 
may be of the adjacent ends of one or more of these bones. 
Further than an occasional reference to fundamental anatomi- 
cal facts, with which we are presumed to be familiar, I shall 
not dwell on the anatomy of the parts. 

These fractures are rather common, especially in children, 
and every doctor is expected to be able to successfully treat 
them. An uncorrected displacement of bony parts resulting 
in deformity and incapacity is not only a reflection on the 
profession, but is a living, walking advertisement, known and 
read of all men, to the chagrin and humiliation of the attendant. 

Fractures of one or more of the bones mentioned may be 
obscured by swelling, beginning on the side of the limb corre- 
sponding to the fracture, but soon becoming general. Ecchy- 
mosis takes the same course. Thus delay on the part of the 
patient in seeking attention renders the examination more 
difficult. 

Injuries about the elbow are always to be regarded seriously. 
Great care should be exercised in making all examinations. 
The bony landmarks to be studied are the external and internal 
condyles of the humerus, the olecranon process of the ulna 
and the head of the radius. Their relations, both in flexion and 
extension, should always be closely observed and compared 
with those of the sound elbow. Observe the character and 
location of any swelling; observe the carrying angle. Rotate 
the head of the radius. Determine possible movements of elbow 
joint. Make measurements. Look for painful line of fracture 
by pressure. 

A correct diagnosis of the nature and extent of the injury to 
the bones in this vicinity and the direction and extent of dis- 
placement may be easy or it may be difficult. Diagnosis is 
a matter of applied anatomy. On a correct diagnosis we 



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F. L, CHENAULT. 227 

should make our prognosis and base our treatment. So the 
diagnosis of these injuries assume a peculiar interest. 

When swelling or pain, or swelling and pain, render exam- 
ination difficult or imsatisfactory, a general anesthetic should 
be given. In children this is rarely contraindicated and avoids 
much pain and nervous excitement as well as relaxing muscu- 
lar contraction materially facilitating examination. 

Many cases which formerly might have been regarded as 
sprains or contusions, are by the X-Ray demonstrated to be 
fractures. So, when examining any injury of the elbow, even 
though it seems to be a sprain or contusion, X-Ray pictures 
of the part should be made. These should show lateral and 
antero-posterior views, and should be compared with similar 
pictures of the sound elbow. Such pictures should be made 
before any attempt at manipulation or replacement and again 
after fixation dressing is applied to determine good or bad 
position of fragments. In difficult cases the X-Ray offers us 
the only positive means of accurate diagnosis. 

Fractures near the elbow have been variously classified by 
different writers. Some have classified them according to the 
direction of the line of fracture ; others as regards involvment 
of the point itself, which is an important prognostic point. Some 
anatomical classification, according to the portion of the bones 
involved, is more satisfactory. Thus we have Supracondyloid 
Fractures; Fractures of the Internal Condyle; Fractures of 
the External Condyle; Fractures of the Internal or External 
Epicondyles ; Supracondyloid Fractures plus Intercondyloid 
Fractures (the so-called Y or T shaped fractures) ; Epiphyseal 
Separation of the Lower End of the Humerus ; Fractures in- 
volving only the Articular surfaces of the Lower End of 
Humerus; Fractures of the Olecranon Process of the Ulna; 
Fractures of the Coronoid Process of the Ulna ; Fractures of 
the Head of the Radius ; Fractures of the Neck of the Radius. 
Here, as elsewhere, fractures may be simple, compound or 
comminuted. They may be single or multiple. They may be 
complicated by dislocations, sprains or contusions. 

In these fractures the usual fracture symptoms obtain. We 
find loss of active motion ; painful passive motion ; motion be- 
tween fragments where normally there should be no motion ; 
crepitation, etc. In the supracondyloid fracture with posterior 
displacement of the lower fragment with the radius and ulna 



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228 FRACTURES ^EAR THE ELBOW. 

we have a condition simulating backward dislocation of the 
humerus. However, in this fracture the normal relations of 
the condyles and olecranon are maintained which would not be 
true in dislocation. In fracture the limb is mobile ; in disloca- 
tion it is rigid. In fracture the deformity is easily reduced and 
easily recurs ; in dislocation, in the absence of fracture of the 
coronoid process of the ulna, the deformity is difficult to reduce 
and does not recur. In fracture there is shortening of the arm 
but not of the forearm ; in dislocation there is shortening of the 
forearm but not of the arm. 

In fractures of the condyles, one or both, singly or connected 
above with a transverse or oblique supracondyloid fracture, the 
joint is usually invaded and a guarded prognosis should be 
given. 

Remember the landmarks — compare with sound elbow — refer 
to X-Ray pictures — thus will the diagnosis of actual displace- 
ments in a given case be figured out. Manipulate the frag- 
ments into their normal anatomical relations and restore normal 
movements of the joint. 

Fractures of either the internal or external epicondyle alone, 
not associated with a dislocation are neither very common nor 
very important. Diagnosis is made with the X-Ray. 

In fractures exclusively through the articular surfaces of the 
lower end of the humerus the diagnosis is made with the 
X-Ray. If function is materially affected an open operation 
should be done and the fragment removed or fastened in place. 

Many good surgeons insist on routine operative procedures 
in the so-called Y and T shaped fractures. This is justified 
in all cases when there is evidence of serious injury to nerves 
or blood vessels not relieved by reposition. In all operations 
avoid entering the joint, if possible. Never allow the finger to 
enter the wound, nor any instrument which has been in contact 
with the skin. A considerable proportion of the failures of 
operative treatment are due to infection. 

For the non-operative treatment of all fractures of the lower 
end of the humerus, the so-called Jones's position or fixation 
in acute flexion is recommended. However, personal equation 
has something to do with it. Some operators prefer other posi- 
tions, such as flexion at right angle, while some advise and 
practice fixation in complete extension. 



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p. L. OHBNAULT. 229 

In ordinary cases of fracture of the olecranon process of the 
ulna an anterior splint with fixation in almost complete exten- 
sion and adhesive straps to maintain the fragments in position 
is satisfactory. If there is much tear in the fibrous attachment 
of the triceps and periosteum and consequent separation of 
the fragments to a considerable extent some operative fixation 
should be done. 

Diagnoses of fractures of the head or neck of the radius are 
best made with the X-Ray, but may be made by loss function 
of the radio-ulnar articulation with other signs of fracture pres- 
ent and the history of the injury. 

In all these fractures the surest way to get a good functional 
result is to seculre a good anatomical result. Methods and 
dressings which secure reposition and fixation of fragments are 
to be adopted — the better the reposition and the more absolute 
the fixation the smaller the callus. Mobilization and massage 
are important adjuncts in the treatment when properly applied 
after some bony union has taken place. 

Practical reduction and fixation of fragments are essential 
to successful treatment, and can be secured in most cases. 

Have and follow a routine system in these examinations. 

In the absence of positive contraindications, unless abso- 
lutely certain as to exact diagnosis, make use of general anes- 
thesia. 

The time is soon coming, if indeed it has not come, when 
the doctor who treats these cases without the aid of the X-Ray 
will be adjudged guilty of negligence. 



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INFECTION OF THE KNEE JOINT, WITH SPECIAL 
REFERENCE TO TREATMENT. 



A. A. Jackson, M. D., Florence. 

The knee joint is more frequently infected than any other 
joint. Because of its extensive articular surface and its dis- 
tance from the trunk between the two longest bones of the 
body, it lends itself very susceptible to wear and to trauma inci- 
dent to walking, and to accidents of various kinds. 

For the convenience of discussion and to expedite the pre- 
sentation of these few remarks, and with the hope that I might 
fully emphasize the vast and urgent importance of early recog- 
nition and classification of knee joint infection, I have divided 
the subject into the tuberculous and the miscellaneous or pyo- 
genic metastatic infections, each class demanding somewhat dif- 
ferent methods of management. 

Knee joint infections, like all other arthritides, are looked 
upon as secondary manifestations or as complications of dis- 
ease of a nidus of infection adjacent to or remote from the 
respective joint involved (barring traumatic infections), so 
that in the treatment of the knee joint for any infection, regard- 
less of its character, it is just as important to attack the origin 
of the infection as it is the metastatic manifestation, and in 
addition, the patient must be systemically treated. 

The tubercular joint is characterized in the beginning by its 
slow onset of symptoms — often a history of trauma, followed 
by moderate pain ; absence of a chill and of high temperature ; 
continued pain, moderate incapacity, and finally complete in- 
capacity at the end of five or six weeks. If the disease is in the 
bone there will be only moderate swelling; if in the synovial 
membrane, the swelling will be intense and will so remain for 
an indefinite time. 

Tuberculosis rarely attacks the synovial membrane in adults 
primarily, but in children the synovial membrane is most often 
first attacked. In children near ten or twelve years old the epi- 
physis usually succumbs first. If the focus of infection is in 



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A. A. JACKSON, 281 

the q)iphysis there will be swelling into the joint owing to the 
close proximity of the irritation to the synovial membrane. 

Tuberculosis of the knee, as in other joint infections, tends 
to incapacitate the joint, but the tubercular process is slow 
and less destructive than the metastatic infections. Our first 
duty in these cases is, at the earliest moment, to institute im- 
mobiliation and defensive measures which, in the end, will 
afford the patient the most serviceable limb. 

If the case is a child, the lesion will probably be in the 
subsynovial vascular membrane, or in the synovial membrane, 
or, if it is in the epiphysis, the synovial cavity will soon be 
invaded, thus establishing a communication between the cavity 
and the tubercular process. This makes the entire diseased 
area more accessible to treatment and affords an opportunity to 
establish connective tissue formation within the joint and en- 
capsulation of the diseased focus. The connective formation is 
best produced by first aspirating the joint, then injecting into 
it two per cent formalin and glycerin, twenty-four hours old, as 
instituted and practiced by the late Dr. Murphy. Formalin is 
the best and safest known stimulant of polymorpholeukocyto- 
sis. Cicatrization is further favored by immobilization of the 
limb by a weight extension. Friction, rotation of the parts, 
and intra-articulac pressure, all to be avoided, are eliminated 
by the weight. Absolute quiet of the limb is imperative if we 
expect to secure the desired encapsulation of the diseased focus. 
If there is no involvement of the synovial membrane and the 
lesion is only in the bone, the injection of any antiseptic into 
the joint cavity will not be productive of results. If an effusion 
exists, however, aspiration is strongly indicated for the relief 
of pain. Aspiration should be practiced in every joint where 
there is intra-articular pressure, great caution being exercised 
not to unduly abrade the articular surface with the needle. 
After the acute processes subside a plaster cast should be put 
on to keep the joint quiet. Ambulatory apparatus for reliev- 
ing intra-articular pressure, and maintaining immobilization 
of the joint, are disappointing and should not be used. It is 
impossible to secure the required amount of rest when the 
patient is allowed to move about or in any way use his leg. 

If the tesion is in the metaphysis, after all evidence of dis- 
ease has subsided, excision of the upper end of the tibial shaft 
should be done, with the implantation of a piece of bone from 



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282 INFECTION OP THE KNEE JOINT, 

the other tibia, using care to cut the bone off above and below 
the diseased area, all the time remaining on the shaft side of 
the epiphyseal line, because destruction of the epiphysis means 
shortening of that limb as the patient grows older. Here 
again, the knee is encased in a plaster cast to favor organiza- 
tion and encapsulation of the tubercular process. 

In the case of an adult, Dr. Murphy says that "once tubercu- 
losis is established in the knee joint, it is practically hopeless 
of repair with any type of expectant or non-operative treat- 
ment. Rest, extension, injection, etc., do not offer sufficient 
hope to justify the expenditure of time and suffering which 
they entail. Primary excision with production of arthrodesis 
of the concavoconvex type within a few months after the onset, 
is the proper line of treatment." 

Systemic measures should be instituted at the outset, con- 
sisting, of the use of a sleeping porch, intensive nourishment, 
the use of tuberculin systematically and persistently after the 
acute process subsides; and irriadiation of the joint with the 
Roentgen-ray, high tension tube, whenever this valuable aid 
is available, to help stimulate the process of encapsulation. 

Tuberculin should be given for about a year. Begin with 
five drops of dilution number three, repeating it every five to 
seven days if the temperature does not exceed 99.6 F. Increase 
the dose two drops each time till twenty drops are given. Then 
two drops of dilution number two are given, increasing the dose 
one drop instead of two. This is continued till twenty drops 
are given, then begin with dilution number one and continue 
as before. Ordinarily by the time number one is given, im- 
munity is established. If the fever rises too high with any 
given dose, the next should be reduced. The fever should not 
exceed 100 degrees F. The doses following should be guided 
by the fever reaction in each case. There is no average dose 
to guide one. The patient's fever reaction is the guide. 

The metastatic pyogenic infections of the knee joint present 
themselves in a materially different manner from the tubercular 
infections. They come on in a fairly uniform time from the 
onset of the infection from which they metastasize. The pneu- 
mococcus, influenza and streptococcus infections metastasize 
with prompt regularity whenever they do involve a joint — the 
streptococcus within forty-eight hours ; the influence and pneu- 
mococcus within fifteen days, and these are very often asso- 



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A, A. JACKSON. 288 

ciated with trauma. The staphylococcus does not appear as 
early as the streptococcus, while the gonorrheal infection oc- 
curs ordinarily within twenty-two days after the appearance of 
the urethral discharge. 

As already observed, tuberculosis is less destructive to the 
joint than the pyogenic infections and is less apt to produce 
ankylosis because of its tendency to heal by encapsulation of 
the infective focus. The metastatic infections, on the other 
hand, heal by the immunization processes brought about by the 
action of the phygocytes and the leukocytes. 

When the metastatic infection is ushered in with a chill, it 
is more than presumptive that there will be one or more stiff 
joints unless prompt and efficient treatment is instituted. The 
chill classifies it as a surgical lesion and is a deciding factor 
between the type of infection that tends to destroy the synovial 
membrane and cartilages and cause a bony ankylosis, and the 
type that repairs without the destruction of these tissues. The 
bacterial emboli lodge in the subsynovial vascular and lym- 
phatic tissues which line the fibrous layer of the joint capsule. 
An attempt to differentiate the type of infection by aspiration 
in the early stages of a given attack might be disappointing 
because the bacteria cannot enter the cavity until the synovia) 
membrane itself is broken down. It thus becomes necessary, 
in order to establish the identity of the infection, to make 
repeated aspirations. This is particularly true with the tuber- 
cular and gonorrhoea! infections. 

When the case is early observed, there should be every degree 
of confidence in expecting and- in obtaining a functionating 
joint. Even if seen rather late there should be every effort 
made to turn our patients out with a straight limb even though 
the knee be ankylosed, and at some future time it will be much 
easier to do an arthroplasty than if the limb be flexed at various 
disfiguring and unsightly angles. 

The plan of treatment best adopted in metastatic infections 
is first NOT to put on a plaster cast, but to put on a good 
weight extension, — ten to fifteen or twenty pounds, to separate 
the articular surfaces of the joint, thus relieving the capsular 
and intra-articular tension and preventing trauma to the articu- 
lar surfaces that would inevitably ensue were the weight left 
off. The intra-articular pressure, owing to the effusion of 
infective matter in the joint, is relieved by aspiration. Through 



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284 INFECTION OF THE KNEE JOINT. 

the same needle the joint contents are made inimical to the 
growth of organisms by the injection of some antiseptic that 
will cofferdam the lymph spaces and establish a chemical in- 
flammatory reaction. This reaction produces a polymorphon- 
uclear leukocytosis which renders the contents of the joint an 
unfavorable culture medium for bacteria. The agent that 
serves this purpose best, as in the tubercular joint, is a solution 
of two per cent, twenty-four-hour-old formalin and glycerin. 
It is imperative that the solution be twenty-four hours old 
because it requires almost that length of time for formalin to 
dissolve in glycerin. Five to fifteen or twenty cc. are first in- 
jected, depending upon the size of the joint. If the tempera- 
ture remains 100.5 F. or more, the joint should be aspirated 
and again in forty-eight hours if much swelling remains. At 
this time there need be no injection unless the temperature is 
high. If much elevated, however, the same amount as at the 
previous injection should be introduced. Ordinarily two injec- 
tions are enough. I have had occasion to inject the third time 
in one case. It may be necessary to aspirate again in seventy- 
two hours and even again if there remains much effusion and 
pain. The aspiration, with the continuous aid of the Buck's 
extension, completely relieves the pain. This plan cures most 
cases in three or four weeks, including gonorrheal joints. It 
does not serve, however, if ankylosis has occurred. It is a plan 
of treatment that can be conducted in any home even in the 
country and does not involve the services of a trained nurse 
for its proper supervision. 

Infections of the knee joint, or of any other joint, should not 
be drained by the introduction of tubes. There is no more 
ideal way of producing ankylosis than by incision and tubal 
drainage. This practice should be condemned as unjustifiable 
in every case. If one is treating a virulent streptococcus infec- 
tion and more drainage is demanded than frequent aspiration 
affords, the soft parts should be freely incised down to the 
capsule, the latter opened, the joint cavity irrigated with normal 
saline solution, and the incision in the capsule sutured. This 
should be followed by frequent aspirations and injections, as 
indicated by the progress of the respective case. 

Owing to laboratory facilities that are now available, in 
every one of these cases, autogenous vaccines should be made 
as an aid to systemic treatment. This particularly applies to 



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A. A, JACKSON, 286 

gonorrheal infections because it is a common observation that 
although the metastatic manifestation. in a given joint be cured, 
it will recur persistently unless the infection be removed from 
the prostate, the seminal vesicles and the urethra. Stock vac- 
cines in my hands have been disappointing. 

The respiratory tract and the oral cavity should receive a 
thorough search in every case where a metastatic infection has 
occurred and any nidus of infection removed as a possible 
source of further trouble. 

In the past, as in the present, the public has pleased -to hold 
the doctor legally responsible for fracture deformities and who 
knows but that in the future we will be held responsible for 
deformities caused by arthritides that could and should be 
prevented? 

DISCUSSION. 

Dr. Mack Rogers, Birmingham: Since the announcement 
of the essayist to the effect that it is criminal to open knee or 
other joints, introduce tubes and irrigate them refutes a paper 
that I propose to present to this Association, I wish to defend 
the proposition that it is not criminal to open the knee joint or 
any other joint when it is full of pus and drain it and irrigate 
it or instill it with the solution I propose to tell you about, and 
that has not yet been tried out to any very great extent in 
America. What I refer to is Dakin's solution. Dakin's solu- 
tion according to the method of Carrel is to my mind, and is 
to the minds of men who have been using it, a revelation. It 
is a benediction. It is the thing in suppuration. It has the 
power to sterilize a wound that is infected and cause it to heal 
as if by first intention. 



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LACERATED PERINEUM AND ITS REPAIR. 



Clarence Hutchinson, M. D., Pensacola, Fla. 

In response to your complimentary invitation to present a 
paper at this meeting, it shall be my pleasure to report for your 
consideration, a selected series of one hundred cases of perineal 
repair, in all of which a standardized technic has been used, and 
to give you the detailed results thereof. 

There has been no attempt to review the literature of this 
subject, nor will there be any comparison or criticism of any 
other technic used in similar instances, and my efforts will be 
confined to a minute presentation of the results of our own 
work, for whatever it may be worth. 

When I speak of a standardized technic, I do not mean one 
of which every step is cut and dried, for any successful technic 
in plastic surgery must be sufficiently elastic to meet wide 
diversions in anatomical changes. 

Of late there has been a considerable effort on the part of 
gynecologists to devise a true anatomical repair in perineal 
lacerations by various methods of suture of the levator ani. 

Our method is simple, if it is anything at all, and we believe 
that it constitutes a true anatomical repair. It is familiarly 
called the single suture operation, because only a single long 
strand of chromic catgut, and one short curved needle is used 
for the entire procedure. 

As a matter of convenient reference we have classified our 
cases into an arbitrary group of four degrees. For instance 
those cases of superficial laceration without any considerable 
involvement of muscular tissue, we call first degree lacerations. 
Those involving a moderate amount of muscular structure, we 
call second degree. Those that show a complete separation 
of the transverse and levator muscles, we specify by the third 
degree, while we choose to designate those cases in which there 
has been a complete destruction of the recto-vaginal septum, 
with loss of bowel control, by the name of fourth degree lacera- 
tions. 



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CLARENCE HUTCHINSON. 287 

Of this series, four were classified as first degree lacerations ; 
thirty-two, second degree ; fifty-three, third degree, and eleven, 
fourth degree. Of the eleven fourth degree cases, five were 
complicated by the presence of recto-vaginal fistulae. In sixty- 
two instances some form of plastic work had previously been 
done. The average age of the patient was 36 years. 87 per 
cent gave history of laceration at first delivery. Of these 87 
per cent, 31 gave history of instrumental delivery producing 
laceration. Eight cases had had previous secondary repair 
operations done. 

Infection occurred in fourteen instances. Twelve infections 
subsided under appropriate treatment and the removal of all 
superficial suture material, and a fair result was obtained by 
secondary granulation. Two failed to heal and required a 
secondary operation; one of these failed entirely of sphincter 
control and had recurrence of recto-vaginal fistula after two 
previous operations elsewhere and two attempts on our part. 
Nisserian infection was definitely demonstrated in this case and 
all our efforts to clear this infection were of no avail. 

We lay much stress on the selection of the time for doing 
this plastic work. We do not assert that it is impossible to do 
a proper repair of the perineum immediately after delivery, but 
we do say that we have not seen a single satisfactory perineal 
repair done immediately after labor. The enormous amount 
of oedema consequent upon the very force that produces the 
laceration, greatly militates against any true anatomical repair. 

The very earliest time that we select for this work is at least 
eight weeks after delivery, and if. a currettage is done at the 
time of operation and the presence of chorium is evident we still 
further defer the repair. 

The preparation of patient begins at least forty-eight hours 
before the selected time of operation. Every effort is exerted 
to rid the ailmentary tract of all solid food material. More 
care is taken to this end in these cases than in the ordinary 
laparotcmiy. Full liquid diet with the exclusion of sweet milk 
is allowed during this period. Many of these cases present the 
problem of acidosis and to them we substitute the gruels from 
cereals, and the drinking of at least one pint of sol. of sod. 
bicarb. 3 vi to water Oi daily. It is in this class of patients 
that we find the most profound neurotics, with gastric mani- 
festations, and the reflex hyper-chloridias, and their prepara- 



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288 LACERATED PERIVEUM^ITS REPAIR, 

tion deserves every consideration. That it would be an unfor- 
tunate mistake to subject some of these patients to the usual 
drastic purgation, is often apparent, and the continued, repeated 
use of enemas is substituted. We use every reasonable effort 
to clear up any suspected gonorrhoeal or syphilitic manifesta- 
tions before operation. The use of bromide and chloral com- 
pounds, and the pre-anesthetic administration of morphine gr. 
J4 and scopolamine 1/150 has proved most satisfactory in our 
hands. 

Preliminary hot tub baths, followed by shaving of the vulva 
and free use of equal parts of alcohol and tinct. iodine, both 
inside and outside the vagina constitutes our surgical prepara- 
tion. 

Technic: The muco-cutaneous margin at the lower end of 
the labia majora on each side is caught up with two pairs of 
small tenaculae. We have abandoned the use of self-retaining 
retractors devised for this purpose because they did not permit 
of the freedom of motion, and the change of tension that we 
required in our dissection. 

The vaginal rim is now put to stretch and by means of a 
small sharp scalpel, a strip about 1/16 inch wide is cut from 
the entire vaginal rim between the points held by the tenaculae. 

A pair of hemostats seizes mucous membrane of the vaginal 
side and dissection upward is begun by use of Mayo scissors, 
care being observed to follow fascial planes if possible. To 
promptly strike the fascial plane is fortunate, for this line of 
dissection will be void of any considerable hemorrhage; the 
hemarrhoidal veins are usually escaped, and there is little 
chance of "button-holing" the vaginal wall. 

We consider this step most important, for a proper dissec- 
tion and clear exposure of the muscular layers portends the 
success of the procedure. A good dissection completes the dif- 
ficulty of this operation. 

For the most part, this dissection is followed up along the 
median line, above the rectum, but often, because of dense scar 
tissue, or the extreme thinness of the re<!:to-vaginal septum, 
we diversify and follow up two parallel planes of dissection, one 
on each side of the rectum, and that portion of the mucous 
membrane so closely adherent to the rectum is finally separated 
by a lateral dissection, from one side to the other, using the 
gloved finger covered with gauze. 



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Clarence hutchinbon. 289 

Greatest care must be taken in this latter plan to prevent 
injury to the rectal wall. The use of force has no place here. 
The result may be a foecal fistula, or perforating infection from 
the rectum when there has been no visible sign of injury to 
the rectal wall. 

The use of clamps to control hemorrhage is rare for the 
bleeding is usually venous and easily controlled by pressure or 
the subsequent suture. 

When our dissection is complete the transverse perineal mus- 
cles are clearly recognized and pushed aside (Illustrations No. 
1 and No. 2). The levators are caught up from each side with 
gentle tenaculae and brought together in the median line. The 
careless use of artery forceps, or other crushing instruments 
to pick up the levators will often result in necrosis of that por- 
tion of the muscle held by the forcep. The needle is now 
passed through both levators with a good bite at two places 
about an inch apart and the sutures tied (Illustration No. 3). 

Any redimdant mucous membrane in the vaginal wall is now 
cut away and the final suturing is begun by inserting the needle 
at the highest point in the resected portion of the vaginal wall, 
and this suture is continued for three or four insertions, ap- 
proximating the vaginal edges in the median line. The suture 
now leaves the vaginal surface and becomes a buried continu- 
ous suture coapting the fascia from each side, and continues 
down the median line until the lowest angle of the perineal 
wound is reached. Here the suture is again brought to the 
surface and with a running baseball stitch includes the skin 
margin and the underlying transversus muscles, upward and 
back to the original starting point in the vaginal membrane. 

In rare instances of extreme lacerations we employ a reten- 
tion or crown suture of a single strand of silk worm gut which 
is deeply inserted through all the perineal tissue by means of a 
large needle, using one finger in the rectum as a guide against 
possible puncture of the rectal wall. 

We have practiced the suggestion of several small puncture 
wounds into the surrounding tissue for the relief of oedema, 
such as is frequently employed after hemarrhoid operations. A 
single vaginal pad constitutes the dressing after a final applica- 
tion of alcohol and iodine. 

It has been our experience that the use of large catgut forms 
an additional burden to the tissue and often causes trouble. We 



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240 LACERATED PERINEUM— ITS REPAIR. 



Fig. 1. — Outlet of a nullipara. Of course this presents quite a 
comparison to tlie outlet we liave to deal with after injury. — {Illus- 
tration from E. Martin.) 



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OLABBNOa HUTOHiySON. 241 

do not remove any of the No. 1 catgut sutures after operation 
unless there is infection. 

After complete reaction from anesthesia the patient is al- 
lowed considerable freedom of motion. We do not indulge in 
the strapping of the patient's knees together, and allow them 
the use of a bade rest after the fourth day. We believe that 
the suture will warn the patient of any undue tension put on it. 

A single strip of iodoform gauze is loosely placed in the vagi- 
nal tract to act as a lamp wick in taking care of moisture. We 
allow these patients to void the urine if possible, and irrigate 
with a }^ per cent Lysol sol. after micturition. The nurse is 
cautioned to dioroug^ly dry the parts with a sterile sponge 
after irrigation. 

We use moqdiine p. r. n. to control pain, and administer % 
gr. before patient Itoves operating room. A long post-anes- 
thetic sleep has resulted in quiet, cahn reactions with us. After 
twenty-four hours tinct opium m x t i. d. suflFices for comfort 
and to control bowels. 

Limited liquiet diet, without sweet milk is allowed and the 
bowels k^ locked for six dsys. The vaginal pack is removed 
the fourth day and a single Lysol douche is given, after which 
the nurse carefully dries out the vagina by means of sterile 
sponges and forceps. We believe that often after douching in 
ihe rectunbent position, much of the fluid is retained in the 
vagina ; that such fluid renders the vagina soggy ; may dissolve 
the sutures prematurely, and often leads to infection. 

The bowels are moved the sixth day by administration of 
castor oil and full feeding is begun. Patient is allowed to sit 
up on the tenth day, but is not permitted to walk until the 
fourteenth day, when she is discharged. 

Some of the most gratifying results that we have ever ob- 
tained in our surgical experience, have been from the success- 
ful, practical, and true anatomical repair of the perineum. 



im 



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!242 



LACERATED PERINEVH^imHEPAIR. 




J?aasi>^.:uj 






S/fhiticti^r ^^t 



Fio. 2. — The transverse perinei here shown is very often mistaken 
for the border of the levator. We are particularly careful to toolate 
these muscles before any suture is begun. — {Illustration from Boeder- 
lein & Kroenig,) 



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Google 



CLARENCE HUTCHi:NSOy, 24« 



Fio. 3.-^Siiowing "Levator Suture." This figure, however, presents 
normal vaginal outlet and no distortion of muscular tissue. T : Trans- 
versus ; R : Rectum ; S :. Sphincter ; G : GJuteus Maximum ; V : Vagi- 
nal orifice; L: Levator ani{ 6: Obturator a.ui.-^ (Illustration from 
Doederlein d Kroenig.) 



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244 LACERATED PERINEVM^IT8 REPAIR. 

DISCUSSION. 

Dr. L. C. Morris, Birmingham : I enjoyed very much hear- 
ing the details of the technic practiced by Dr. Hutchinson in 
this series of a hundred cases, and in the very beginning I want 
to say if there is any procedure which contemplates the use of 
catgut solely that can be made almost invariably successful it 
is a far better procedure than one which contemplates the use 
of non-absorbabk sutures. The chromic gut is ideal for the 
reason that it does not have to be removed. My experience 
with absorbable sutures is that the buried ca^t will stay 
there for a variable period of time, is more likely to become in- 
fected, and that my percentage of failures is definitely larger 
than with the non-absorbable sutures. On the other hand, the 
objection to non-absorbable sutures is the fact that their re- 
moval is exceedingly painful, and occasionally, despite the ut- 
most care, one will be cut off, leaving a loop of silk-wonn gut 
in the perineum, and in one instance in my experience led to an 
infection which was very difficult to dear up. 

I think the technic of the dissection and the anatomical repair 
that the doctor has described is excellent. As a matter of fact, 
we can vary the technic in perineal lacerations, alternating the 
standard operations as I have frequently done in teaching 
students, and if the dissection is made properly and the sutures 
properly introduced, the results are almost uniformly good 
in any of the various operations for repair of the perineum. 

I must say that I want to take issue with Dr. Hutchinson on 
one point, and that is relieving the obstetrician of the burden 
of immediate repair. It is true that following labor the parts 
are traumatized and there is oedema, but either by the sense 
of touch or sight, or by both in the majority of instances, I will 
say almost invariably, a thoroughly successful repair can be 
made immediately, obviating the secondary operation eight 
weeks or more following the laceratbn. I believe that the 
burden of takmg care of these lacerations is upon the obstetri- 
cian, and that it can be done properly, and if it is done properly 
it relieves the woman of the necessity for an anesthetic and a 
secondary operation; no matter how well we may be able to 
operate secondarily the obstetrician should repair these lacera- 
tions at the time. 



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CLARENCE ffUTCHINBON. 24ti 

I think there is some little trick, about introducing the sutures 
in the immediate repair, but it can be done, and the results 
are uniformly good if done properly. 

One other point: Dr. Hutchinson says he does not strap 
the knees together. I think this is unnecessary in the majority 
of instances. There are cases in which when you get through 
there is a good deal of tension upon the sutures. You will find 
when you take the feet out of the stirrups that the whitening 
of the skin and mucous membrane of the perineum caused 
by tension will immediately disappear and the normal color will 
return when the knees are brought together. Those cases in 
their sleep separate their knees, put undue tension on the sutures 
and possibly interfere with the results. My practice has been 
for years in complete lacerations, particularly those cases who 
have been operated on unsuccessfully two or three times before, 
where there are adhesions between the pelvic bones and the soft 
tissues, in order to be able to get approximation in the mid line 
satisfactorily and hold it, to strap the knees together. 

Dr. J. S. Turbeville, Century, Fla. : I wish to state how 
much much I enjoyed the doctor's paper. I wish to speak on 
just two little points. First, in regard to a careful dissection 
of the mucous membrane of the vagina from the tissues be- 
neath. I have had the misfortune to tear the rectum in some 
cases, and I think every man should look carefully after his 
dissection and see that he has not got a tear in the rectum. If 
he has and attends to it properly he will get rid of a great 
many infections. 

Further, I think that most of us are too prone to sew up 
the muco-cutaneous junction too tight. The doctor gets over 
that by the use of the stab wound. 

Dr. W. R. Jackson, Mobile : I must say I enjoyed the paper 
very much indeed, and I approve of every step the doctor takes 
in the operation except the continuous suture, and that is the 
most important thing I think he emphasized. The continuous 
suture has this objection in surgery generally, that when it 
turns loose or tears loose by suppuration or absorption, then 
we have the whole thing turn loose. That is the objection I 
have to the continuous suture. We may think the No. 1 
chromic gut is going to hold it tight, but a hematoma may 



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246 LACERATED PERINEUM— ITS REPAIR. 

form, giving rise to a locus resistentiae minoris and we have 
suppuration and giving way of the suture. 

Second, the doctor says he removes all of the superfluous 
mucosa of the vagina. That is all right and makes a nice job 
when it is all sutured together, but nature put this mucosa here, 
and the majority .of our operators tell us we must save all of 
the vaginal mucosa. There is an art in suturing up all of this 
in the last suture. This is the operation that the Mayos do, and 
I think they do it very well. It is claimed that the little tongue 
of mucous membrane has a certain sensibility and therefore 
lends something to the copulative process. 

Third, catgut on the outside seems to me to be rather inse- 
cure. In addition to the catgut I use silkworm gut, two or 
three deep retention sutures ; if there is a complete laceration 
I use a figure of eight suture and suture the sphincter and 
muscles together. 

Dr. Hutchinson : Dr. Morris has emphasized the main joint 
of my paper better than I could, that is that dissection is the 
keynote. I believe that if a man does an ordinary inguinal 
hernia and thoroughly dissects out that hernia and thoroughly 
dissects out the sack and ties that sack and cuts it off, the hernia 
will get well. I believe that is true in the perineum. I think 
if you will thoroughly dissect these muscles out that nature 
will nearly always do the rest. 

The question of extreme cases and strapping the knees : In 
one or two instances we have not strapi^d the knees but have 
cautioned the nurse about, the position of the patient in bed, 
having a pillow put under the flexed knees, without strapping, 
and in all of these cases we rely upon retention sutures of silk- 
worm gut. 

Dr. Turbeville brought up the point of the tight suture of the 
skin and vagina. We make it a rule to make this suture very 
snug, for this reason : we believe that if the coaptation in the 
median line is snug there is less apt to be infection. In other 
words, we try to make that suture water tight without produc- 
ing necrosis. 

Dr. Jackson brought up the point of the suture breaking. I 
have had them to break. When it does I usually catch the place 
where it has broken and tie a knot where Ae loose point is 
hanging from the vagina. 



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WHY GASTRO-ENTEROSTOMY FAILS TO RELIEVE 



W. R. Jackson, M. D., Mobile. 

The operation of gastro-enterostomy, or gastro-jejunostomy 
is performed for the relief and cure of duodenal ulcer, gastric 
ulcer and cancer, and gastric stenosis. 

The symptoms that demand surgical intervention are those 
usually present in chronic gastric ulcer, duodenal ulcer, and 
gastric carcinoma. The most conspicuous of these are pain, 
nausea, vomiting, indigestion, hyperacidity, hematemesis, ma- 
lena, constipation, and emaciation. 

When posterior gastro-enterostomy for gastric ulcer is done, 
the patient usually manifests marked rapid improvement very 
soon thereafter, gaining from 30 to 40 pounds in two or three 
months. 

After a period of time, varying from six months to two years, 
most of the old symptoms recur. Pain, distress after meals, 
nausea, vomiting, and loss of weight, — all of these symptoms 
indicate that the patient is not cured. 

If we seek the cause by a second operation, we find that the 
ulcer has not healed, or has recurred; that new ulcers have 
formed, or the old ulcer has assumed a malignant aspect. 

In many cases of gastric and duodenal ulcers, where opera- 
tion has failed to give any relief whatsoever, we must seek the 
conditions that will give us the explanation of our failure. 

What are the reasons or causes of failure in these cases? 
When it is recalled that gastric and duodenal ulcers are very 
often produced by metastatic infection from a pre-existent local 
focus of pus, it is no wonder that the ulcers are not cured by 
gastro-enterostomy, especially when the primary or essential 
etiologic factor is allowed to remain undisturbed. 

Recently, it has been shown that these pyogenic foci exist in 
various parts of the body; such as the teeth-alveoli, tonsils, 
prostate and the sinuses of the superior maxilla, frontal, and 
ethmoid ; also in the appendix and gall-bladder, as well as, the 
crypts of the urethra and oviducts. 



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248 GASTRO'ENTEROSTOMY. 

Any pus focus in any part of the body, not necessarily 
chronic, will cause distant metastatic infection. It appears that 
the mucosa of the stomach and duodenum is specially prone 
to infectious infarcts, explained by the frequent irritation of 
these membrances, thus favoring the localization of embolic 
bacteria. The size of the ulcer will depend, of course, upon 
the area of tissue infarcted. 

There are other causes of failure of gastro-enterostomy than 
the failure to remove the pre-existing pus focus. The follow- 
ing conditions have been found to explain some of the failures : 
1, Imperfect anastomosis, as too small a stoma and angulation 
of jejunum; 2, presence of ulcers in the cardiac end of the 
stomach ; 3, jejunal ulcers from sutures ; 4, cicatricial contrac- 
tion of the stoma ; 5, too long a loop, giving rise to a vicious 
circle ; 6, presence of other pathologic conditions, such as galJ 
bladder disease, appendicitis, intestinal stasis, ptosis of intes- 
tines, and bands; 7, herniation of the jejunum through the 
meso-colon; 8, neuratic patient. 

It is conceded that gastro-enterostomy does the greatest good 
when the pylorus is obstructed by cicatricial contraction of the 
ulcers ; thus, it would appear that the operation is one of drain- 
age. If ulcers are located elsewhere than at the pylorus, the 
operation does very little good ; and if any, it results from the 
bile and pancreatic juice entering the stomach and neutralizing 
the hydrochloric acid. 

The consensus of opinion of the best operators today is that 
all chronic ulcers of the stomach and duodenum should be 
excised, and then gastro-enterostomy done. 

The most common site of ulcer of the stomach is at the py- 
lorus, and the most common form is the chronic indurated. 

Chronic indurated ulcer of the stomach near the pylorus 
always demands excision, or pylorectomy; and, if the ulcer 
involves the lesser curvature also, sub-total gastrectomy is in 
order. 

It would appear that the frequent practice of gastro-enteros- 
tomy without resection or excision of the ulcers, benefits the 
patient but very little, and when improvement does result, it is 
of short duration. 

The same rule of excision and resection applies to duodenal 
ulcer also; gastro-enterostomy for duodenal ulcer, without 



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W. R, JACKSOy, 249 

excision of the ulcer, or resection of the pylorus, usually results 
in failure to cure the patient. 

Operation for gastric ulcer is frequently done when no ulcer 
is demonstrable. In such cases, the patient frequently shows 
marked improvement, therefore, it is taken for granted that 
ulcer did exist, and its location problematical. Is gastro-enter- 
ostomy indicated, when the ulcer is not seen or felt? Is gas- 
trotomy and search for the ulcer ever justifiable, when its 
presence can not be shown otherwise ? 

What are the indications to be met to make our operations 
for gastric and duodenal ulcers more satisfactory? 

I would place first and foremost the remotxil of all pre-exist- 
ent local infection; and second, the excision and resection of all 
ulcers. 

Make a large stoma in your anastomosis ; "suture the meso- 
colon opening an inch upon the stomach wall, so that this part 
of the stomach goes down through the mesocolon like a hopper, 
and the freedom of the ends of the jejunum is unhampered." 
Tack with suture the jejunum on each side of the anastomosis 
to prevent angulation of the same. 

Perferom the "no-loop" operation, that is, the loop of the 
jejunum is so short that there is no angulation to cause the 
"vicious circle." 

Use catgut and not linen or silk for the "mucosa-suture," 
thus avoiding the formation of jejunal ulcers, which give rise 
to s)miptoms like that of gastric ulcer. Be sure that the ap- 
pendix is not affected, or if it is, remove it at the same time of 
the main operation. 

Likewise, examine the gall-bladder for infections and stones, 
and if either is present, correct same; intestinal stasis, ptosis, 
and bands should be looked for and corrected if possible. 

It should be remembered that, unless the many foci of infec- 
tion, which may produce the various metastatic lesions, such as 
gastric ulcer, are thoroughly and permanently removed, gastric 
and duodenal ulcers will recur, even if they have been resected 
and excised. 



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2S0 GASTRO'BNTEROSTOMY. 

DISCUSSION. 

Dr. Scale Harris, Birmingham: Dr. Jackson has given us 
a splendid paper on a most important and timely subject. I 
wish that every surgeon and every medical man could have 
the viewpoint of gastro-enterostomy that Dr. Jackson has, and 
if so there would surely be fewer operations of gastro-enteros- 
tomy that would fail to give relief. 

Dr. Jackson stressed the most important points. There is 
one thing that every surgeon should remember in doing a 
gastro-enterostomy and in operating oh an ulcer of the stom- 
ach, and that is that he is not operating upon the cause, like he 
is in appendicitis, that a gastro-enterostomy does not remove 
the cause of the disease, and that it simply relieves the symp- 
toms ; it gives another opening from the stomach through which 
the food may pass and allows the regurgitation of the succus 
entericus into the stomach, thereby giving mucus to coat over 
the stomach and relieving the pain. It is thought that in ulcer 
the mucous lining the stomach is less than normal, and there- 
fore the hyperacidity that is present in the majority of cases 
acts as an irritant to the stomach, thereby causing the pain. 
After the operation or before the surgeon should seek the cause 
of the ulcer and endeavor to remove that. Of course, in a good 
many cases it is a focal infection somewhere in the body, as he 
has brought out — the teeth and tonsils, and, as Dr. Deaver 
stresses, the appendix, and also the gall bladder. 

Now there is one thing that surgeons should remember, 
and that is this, that the appendix is frequently the focal infec- 
tion for ulcer, and that in operating on all cases of chronic ap- 
pendicitis in which there are no acute manifestations of the 
disease it is a mistake to make a small incision and not examine 
the whole abdomen; and there is frequently something also 
besides the appendix, and that if the incision is extended it will 
be frequently found that there is an ulcer also; and while he 
may have removed the cause of it with the appendix, at the 
same time the ulcer still exists. The removal of the appendix 
does frequently cure a gastric ulcer. Of that I am absolutely 
sure. And there are many cases in which the appendix is the 
cause of the ulcer and the removal of the appendix causes the 
cure of the ulcer. 



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W. R: JACKSON. 251 

Another Important reason why gastro-enterestomy in some 
cases fails to relieve — and I may state at this particular time 
that gastro-enterostomy does give relief in the cases in which 
it is indicated, and in such cases the results are the most bril- 
lant of any in surgery — ^is that the patient is sometimes not 
properly dieted after the operation. The patient must be 
taught when he is operated on that he must be careful with his 
diet for a long time afterwards. The diet after gastro-enteros- 
tomy should be much the same as where no operation is per- 
formed! The patient should be given a diet list, and must be 
instructed to follow it for a period, not only of a few weeks, but 
of months or years. 

Another reason for failure of gastro-enterostomy is the lack 
of preparation before for the operation. I think one of the 
greatest contributions to medicine that have been made is the 
work of Fisher on acidosis, and a large number of ulcer cases 
are in a state of acidosis at the time they are operated on. It 
is important to build them up and put them on alkalies for some 
time before the operation and get the patient in good condition 
before the operation is done. 

There is another very important thing in getting good results 
in that operation. It is well enough to remember that there are 
recurrences of the symptoms of gastric ulcer and a recrud- 
escence of the inflammatory process, and that during these 
recrudescences the patient is not in the best condition for the 
operation ; that the thing to do is to tide the patient over that 
recrudescence and they can be tided over practically always — 
and build him up, and then in the interval, when there is a les- 
sened chance of infection, to operate. 

I am glad to have heard Dr. Jackson's paper. I think we 
are fortunate to ha\e had it this morning. 

Dr. L. C. Morris, Birmingham: Dr. Jackson in his paper 
has given us the benefit of his large experience in this work. 
The operation that he describes is the ideal operation for 
gastro-enterostomy. I hope this article of his will be reprinted 
and have a wide distribution, because in my judgment he has 
covered a number of points which I know in the past from 
personal experience have led to trouble and sometimes to dis- 
aster. 



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252 GA8TR0'BNTER08T0M7. 

I believe the most prolific source of failure to relieve symp- 
toms after gastro-enterostomy is what has been touched cm by 
Dr. Jackson, and I simply want to emphasize it — ^that is, the 
cases in which it is done on neurasthenics, men or women with 
ptoses of the stomach, intestines and almost invariably of the 
right kidney, and whose symptcmis will simulate almost exactly 
those of gastric ulcer. The smartest men in the world in pass- 
ing those cases up surgically are the men at Rochester. I 
have known a number of such cases to go to Rochester for a 
gastro-enterostomy, be sent home without it, and I have seen 
them get well, with the proper treatment of the ptoses and 
neurotic condition. I believe that is one of the most prolific 
sources of failure, and I believe we have got to be on the look- 
out for their cause. Sometimes we will come across positive 
symptoms and in our enthusiasm we may consent to operate on 
one of these neurotics, and it will be followed by failure. 

Dr. Clarence Hutchinson, Pensacola, Fla. : I think every 
man here who does any surgery ought to go on record in an- 
swer to the questions which Dr. Jackson has asked. These 
questions are. Is a gastro-enterostomj^ indicated where a dem- 
onstrable lesion is not clearly made out? Is a gastromy jus- 
tifiable in search of a lesion that cannot be palpated from the 
outside ? I say that every man here that does surgery ought to 
record his answer. No ! No ! No ! 



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THE VALUE TO THE GENERAL PRACTITIONER OF 

PROPERLY KEPT RECORDS OF BIRTHS 

AND DEATHS. 



Giles W. Jones, M. D., America. 

Every well organized corporation keeps an accurate inven- 
tory of its liabilities and assets. At the end of each year it can 
be accurately calculated whether or not the business has been 
profitable. Further than that it can be ascertained what de- 
partment, if any, of the organization has been unprofitable, and 
reniedies can be applied. Thus it is with real business, book- 
keeping, accurate book-keeping is the essential safety valve. 
Protection of the public health has now become a real business, 
and the collection of vital statistics is said to be the "book- 
keeping of humanity." 

Vital statistics are the backbone of public health work, with- 
out which it would have a flimsy and uncertain existence. To 
the general practitioner of medicine vital statistics are not only 
the source of much personal gratification but they are guides 
or indicators of his degree of success. Thus a physician in the 
registration area knows from his study of statistics, that for 
every 100.000 people in his territory there will be 46 cases of 
typhoid fever per annum, resulting in about four (4) deaths. 
Of course, this may vary in any one epidemic or in a limited 
number of cases, but it is the result of the accurate recording 
of many thousands of cases. Nothing is more uncertain than 
one human life, yet few things are surer than that 100,000 
people of the same age will have an average of just so many 
years to live. Life insurane companies have made their mil- 
lions by computing rates on these mortality tables. From a 
legal viewpoint vital statistics are of infinite value in all Euro- 
pean countries and are fast becoming of more value in America. 
A recorded birth is legal evidence of citizenship and of inherit- 
ance. The loss or gain of large fortunes from inheritance by 
failing to produce or by producing birth certificates, properly 
recorded are too frequent to countenance examples, but the fact 



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254 RECORDS OF BIRTHS AND DEATHS, 

that these instances are so rapidly increasing is sufficient rea- 
son for the public to demand complete birth registration. Com- 
pulsory education laws, child labor laws and many other indus- 
trial laws are demanding complete birth registration. A death 
certificate, properly recorded, is legal evidence of a man's death. 
Taking for granted that you all agreed with me that the accu- 
rate collection and recording of vital statistics is not only 
worth the cost of labor ancf money, but is absolutely essential 
to human process, I want .to call your attention to some of the 
defects and deficiencies in the present statistics which are given 
us in America. In the miraculous development of this great 
country with its unlimited resources there was :SO much to be 
done that many human problems were forgotten. -Our fore^ 
fathers fought first for freedom and then for self-preservation, 
and little did they know that they were laying the foundation 
of the greatest government that exists. And during these early 
days vital statistics were forgotten and no unified plan for 
their collection was promulgated. Then came our <lual form 
of government and our central government left it as a duty to 
each state to collect and record its own vital statistics. Thus 
chaos began from which we have never fuUy recovered. Very 
few states adopted any such laws for many years, and then 
gradually each state began to work out its own system; everyr 
one a little diflFerent from the other,. until today most of the 
states have some form of law under which vital statistics are 
collected. Some of these laws are excellent. We are con- 
vinced that the laws in our own State for the collection of vital 
statistics, does not get accurate results, but we are more thor- 
oughly convinced, that if each county in the State had a full- 
time health officer and the essential requirements of a burial 
permit our law should get results. But our system is diflFerent 
from that of other states and the results are incomparable and 
often misleading. For example the statistics from Mississippi, 
Alabama, and Massachusetts are incomparable. Each has a 
diflFerent plan and a comparison would be unfair. 

In recent years much have been done to overcome this situa^ 
tion by the adoption of the so-called "Model I<aw" by a great 
many of the states of the Union. However,, many of the states 
have not yet adopted even a modification of this law and the 
statistics that we get from the United States as a whole are 
inaccurate. They are misleading. It appeals to the writer 



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. GILES W. JONES. 256 

that there ought to be a National Bureau for the collection of 
. vital statistics. So accurately does our government record 
. agricultural conditions that wild breaks are caused in Wall 

Street, our financial center, when these reports are published, 

and yet no dependable record of our most value cropi that of 

human beings, is kept 

DISCUSSION. 

Dr. H. G. Perry, Montgomery : I am sorry that Dr. Jones' 
paper did not take another angle. I had hoped that he would 
confine his remarks to the value of vital statistics to the gen- 
eral practitioner. I happen to know that Dr. Jones is one of 
the very few doctors in the State who has felt it necessary that 
he have an elaborate system of records of his births and deaths. 
A year or tWo ago, to my great surprise, I got a letter from a 
doctor that I did not even know, who signed his name "Giles 
W. Jones,'* asking wh^t it would cost to get a register such 
as is used by the county health officers. I wrote him that such 
a register as that would cost him eight or ten dollars and that 
it would last two or three doctors several lifetimes. But he 
said he wanted it and he got one, and I understand he has a 
reliable record of every confinement case he has attended and 
of every death that has occurred in his practice, and I suppose 
he also keeps for his own information a record of the com- 
municable diseases that he attends. I was in hope that he 
would give you these facts in regard to what he was doing, 
so as to stimulate each doctor in this Association to do like- 
wise. 

When I was practicing medicine, before I reformed and 
started doing something else, I used a similar record. I made one 
out of a book that cost me about seventy-five cents, and ruled it 
properly to conform to the requirements of the birth and death 
certificate, and I found not only pleasure but great profit in the 
study of the statistics that I myself compiled. I am sure that 
it is a good habit for a man to get into. It will enable him not 
only to be more certain of what he is doing, but he can, by 
classifying his own cases that he has intimate knowledge of, 
draw very important conclusions that help him in the practice 
of medicine all along the line. 



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S$6 RECORDS OF BIRTHS AND DEATHS. 

All the Statements that the doctor made in his paper I heart- 
ily and thoroughly ag^ee with, except that I hardly agree that 
it is impossible for us to get the statistics of Alabama with the 
laws we have on the statute books at this time. It is hard to 
do it because the individual doctor does not come up to a full 
realization of his duty. But to say it is impossible is not true, 
because I can point here and there to counties where this matter 
has been well worked up, not only in the counties where we 
have full-time health officers, but in the counties where we 
have honest, energetic men serving as part-time health officers. 
I see before me a health officer of a rural county in the State 
who two and a half years ago sent in a report at the end of the 
month with not a single death out of a population of about 
25,000. I ridiculed him so that he wrote me another letter 
and said he could not report them unless they occurred and 
they had not occurred. Thai I told him that I did not believe 
that an imaginary line such as divides one county from an- 
other would have an effect on the death rate, and that the coun- 
ties around him were reporting deaths every day and the aver- 
age deaths reported in those counties came very near to the esti- 
mated average death rate. I told him I thought his doctors 
and he himself were asleep, and asked him to get busy, with 
the result that he is qualifying very closely to our intra-state 
registration area for births and deaths. 

Dr. A. L. Nourse, Sawyerville: I wish to say from the 
standpoint of a country practitioner and one who is able to look 
at it from the standpoint of Dr. Perry today that this proposi- 
tion of reporting statistics is a very, very difficult one. My 
only training until recently has been the training of a physician 
residing in a municipality, where I was compelled to repprt 
them or get into serious trouble. Although I never lost any 
patients, I know a doctor who did lose some. Coming to Hale 
county and locating in the country, I was at different times 
called to difficult cases to properly report. One over here, say 
eight or nine miles, maybe a negro, and I would not hear from 
him again. He had no telephone or anything of that kind. One 
of three things had happened; he had gotten well, changed 
doctors, or else he had become, as the negroes say, "demised" 
But in my efforts to cooperate with the county health officer I 
have taken the time to ask questions in the neighborhood, and 



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GILES W. JONES. 267 

I do not believe that the lack of enforcement of the law in 
regard to selling coffins is entirely responsible, for I am sorry 
to say there is an element of carelessness with our practitioners, 
and not only that, but many a man dies and is buried in a home- 
made coffin, and I do not believe from my experience as a 
country practitioner that it is possible without the closest 
cooperation of all doctors for the county health officers to get 
accurate reports. The proposition is very difficult. 

Not only that, I cannot make a diagnosis off hand of a com- 
municable disease. Neither can any other man, even if he has 
laboratory facilities. Many a time we are called to see a case 
and we make a tentative diagnosis of some one of the com- 
municable diseases, say one of the exanthems. The patient 
gets better or he breaks out and the doctor is not again sum- 
moned. Then there is a center of infection and no cooperation. 
I have no doubt but what men innocently have caused the wide- 
spread of communicable diseases. The same thing applies to 
smallpox. We had it in Hale county a few years ago, and I 
suppose the same thing exists in many parts of the State. So 
it is not always because of carelessness on the part of the physi- 
cian that incomplete statistics exist. 

Really complete statistics will be one of the results of the 
full-time health officers. 

Dr. T. A. Casey, Birmingham: I want to emphasize the 
importance of the paper and to congratulate Dr. Jones on his 
work. He is doing general practice, as I understand it. I do 
think it is a very important subject, and at the same time it is 
hard to write on and it is hard to talk about perhaps. We 
have had it beaten into us ; I had it beaten into me, and could 
not see it. I see it now. 

Another thing that I want to stress is this point : we have had 
literature from the Government and from the State Health 
Officer calling attention to the making out of these reports 
of deaths, and to be accurate and worth anything we have got 
to state the cause of death. What is it? It is a death certifi- 
cate, and gives the cause of death if you can. If the doctor 
doesn't know who does? We say he died from dropsy. Well, 
what is dropsy? Without taking up your time, I just want to 
stress that point. It is very important. I had a case that died 
from typhoid fever ; the patient had a perforation, and I didn't 

17 M 



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268 RECORDS OF BIRTHS AND DEATHS. 

fill out the death certificate, and somebody said he died of gen- 
eral peritonitis. He did have a general peritonitis, but he died 
from typhoid fever. Well, if we say hemorrhage, it might be 
typhoid fever or it might be tuberculosis. We are living in an 
age when we want to prevent these diseases. The Health Offi- 
cer is studying and planning, and if we say hemorrhage and 
peritonitis, he doesn't know what our patient died from. 

Dr. W. H. Moon, Good water: I just want to say a few 
words in reference to the diagnosis of cases and making out a 
case when reports are sent in. I was health officer in our 
county for two years, and I never took more interest in any 
practice I ever did than in trying to work out in our county the 
mortuary and vital statistics, and I think I did a great deal 
towards it. Now as the doctor said, a great many cases are 
reported in which the diagnosis is very indefinite as to the 
cause of death. That is a point that every young doctor ought 
to learn. Some of you probably graduated in Mobile where 
I did, and knew old Dr. Gaines. In his advice to the graduat- 
ing class he used to say: "Gentlemen, when you go to see a 
patient always find out what is the matter with him. If you 
cannot find out the first time, give him a little something that 
won't hurt him and go back and study your books. I once 
went to see an old lady that was dying, and I rolled her over 
and percussed and looked her over until I found out what was 
the matter." Well that means something, but this idea of say- 
ing dropsy — that doesn't mean anything at all, because we 
know that Bright's disease and heart disease and liver disease 
will produce dropsy. The idea with me was to suggest that 
the health oflFicer of every county when he gets such reports 
to let that doctor know that he has not made out his diagnosis 
properly and if possible help him to make it out. Anyhow 
criticise him enough to call his attention to it, and by doing 
that doctors will learn to diagnose cases that they never will 
running along in a loose, slipshod manner. If ever I have a 
boy that takes up the practice of medicine I will tell him to 
keep a record of every case, and keep a record of prescriptions 
that he makes in special cases. I never did it, but I have been 
called on three or four years later for the same thing that I had 
prescribed, and I didn't know any more than they did what it 
was. It will be worth much to the young doctor to be able 



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GILES W. JONES. 259 

to refer back to prescriptions. He may meet up with a case 
that he had treated very successfully three or four years before 
but he has forgotten what remedies he used. I would insist 
that all the young doctors keep a close record of all cases they 
have. Of course, it is not necessary in cases of a minor nature, 
like biliousness, or autointoxication, as it is called today. I just 
want to impress this upon all you doctors who are still in active 
practice ; if I were ten years younger I would keep a record of 
every case of importance, not only for my own benefit, but for 
the benefit of succeeding generations. If every doctor would 
do it we would build up a more thorough and systematic plan 
of practicing medicine. Of course, we have got to learn to 
make our diagnosis. Let's learn that and then see with what 
remedies we get good results and keep r^ecords. 

Dr. B. L. Wyman, Birmingham: I want to endorse what 
has been said in the paper in reference to the great value of 
vital statistics. Of course, I realize that members of the Medi- 
cal Association of Alabama know that this is an important 
question that we are discussing. Many of us, however, do not 
appreciate the importance of the collection of accurate and 
trustworthy statistics. My attention has been quite recently 
called to the very great value of a birth certificate. I have been 
practicing medicine in the city of Birmingham thirty years. 
More than twenty-five years ago I was the family physician of 
a gentleman now living in the city of New York. Two of his 
boys were born in Birmingham, one of them, twenty-six years 
ago. The fkther, while bom in New York state, came of 
German parentage. I received a letter from him a short time 
ago requesting me to furnish him properly certified, birth cer- 
tificates of his two sons, one being twenty-six and the other 
twenty-four years of age. The father stated in his letter that 
I was the attending physician at the time of the birth of the 
sons, that they were both grown and were preparing to go to 
South America, and desired to have proper credentials. I re- 
called at once the birth of the sons, but was not quite sure that 
I had reported them to the Health Department. In those days 
we were rather careless, and sometimes failed in our duty. I 
at once called at the office of the health officer at the city hall, 
where I found our efficient heaUh officer, Dr. Harrington. He 
directed the registrar to look up the record, and much to my 



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260 RECORDS OF BIRTHS AND DEATHS. 

relief, the report of the births of the two sons appeared in the 
record, with the date of each birth and the name of the father 
and mother. The original certificate was not in evidence, and 
the names of these two boys did not appear in the record, — 
this may have been due to an error in copying the certificate, 
or it may have been due to the fact that the mother had not 
named the children at the time I made my report. It was 
still, however, a very valuable record, and my friend was very 
glad indeed to receive the two certificates incomplete as they 
were. In this connection, I am reminded of what Dr. Sanders 
once said to a company of mid-wives in Birmingham, who were 
attending a meeting there, and receiving instruction in mid- 
wifery, and also in reference to filling out birth certificates. 
There were a goodly number of old colored mid-wives present, 
and the doctor was explaining to them, in that methodical way 
of his, the proper method of filling out a birth certificate. He 
said: "Now, the first thing is the name of the baby. Every 
baby should have a name in advance of its birth, and the mother 
should provide one, or have one in readiness." An old colored 
sister sitting over in the corner of the room, whose avoirdupois 
was somewhere between two hundred and fifty and three hun- 
dred pounds, stood up and said : "Dr. Sanders, I want to ask 
you one question, 'How you gwine know whether the baby is 
gwine to be a boy or a girl ?' " The question at first puzzled 
our distinguished health officer, but he soon recovered himself 
and said, "Why, that is easy ; the mother should provide two 
names in advance. One in case the child should prove to be a 
boy, and one in case it was a girl, so that as soon as the baby 
is born the name will be fixed." 

We all appreciate the value of birth certificates, and it is 
becoming more and more important that these certificates 
should be accurate. I am glad to note that we are improving 
every year in Alabama, in the collection of vital and mortuary 
statistics, and I trust that the day is not far distant when Ala- 
bama will be in the registration area. We have been criticised 
frequently, on account of our incomplete statistics, and often 
by men who had no accurate information about what was being 
done. A recent example was a violent attack which was made 
by a man from New York with a German name, before the 
Sociological Congress, which met in Birmingham a short time 
ago. He was especially severe in criticising our vital statistics. 



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GILES W. JONES, 261 

In opening his address, and referring to the South, and his trip 
from Washington to Birmingham, he stated that he saw noth- 
ing from the time he left Washington until he reached Bir- 
mingham but a few cows on the side of the road. These are the 
kind of men who are criticising us, — ^men who are absolutely 
ignorant of the work which is being done in Alabama. It 
remains for the doctors of this State to make our statistics 
complete, and if you gentlemen will do your duty, and report 
your births as soon as they occur, we will soon become one of 
the registration states and there will be no further cause for 
criticism. I believe that there is a need for a standard certifi- 
cate both for births and deaths. The birth certificate used in 
this State is too long and too many facts which are not essential 
have to be given. 

Dr. C. A. Mohr, Mobile: I am sorry I did not hear all of 
the paper, but I wish to say that I am amazed that it is neces- 
sary to draw attention to the importance of doctors reporting 
births. No doctor, no man, no father, no mother has the least 
right to deprive a child of any of its rights, and when the one 
upon whom the duty is imposed of reporting its birth fails in 
this duty, I want to say that the child is robbed of certain civil 
rights that no man has a right to take from it, and it seems 
to me that it is time to stop having to talk to the doctors of 
the State on the importance of this matter. Why, Mr. Presi- 
dent, the birth certificate, the evidence as recorded in the 
Board of Health, may be the only evidence by which a mother 
may be able to prove the legitimacy of the offspring. Now 
what is more cruel than to deny a woman that privilege. The 
reporting of that birth is an act of duty of the doctor who de- 
livers the woman, and if doctors are derelict in that important 
duty, they are liable to civil suits for damage. There is abso- 
lutely no excuse for a doctor failing in this duty. We talk 
about infant mortality; we talk about the uplift work that 
somebody else should do. Mr. President, I say that the doctor 
must be made to do it. 

Dr. Perry: Mr. President, if you will recognize me again, I 
have just received a letter from the truant officer of a district 
in New York City requesting a copy of the birth certificate of 
a child in Montgomery 12 or 14 years ago. 



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2«2 RECORDS OF BIRTHS AND DEATHS, 

What Dr. Mohr has just said there about the value of the 
birth certificate is demonstrated by this inquiry that has just 
come to hand, and such letters come to our office every day 
either in regard to births or deaths. Now this child evidently 
wants to go to school in New York, or to demand some rights 
or privileges that she should have and which can only be 
granted her by a definite statement of her parentage. 

The case that Dr. Wyman spoke of: you all know that the 
foreign governments are calling in all of their citizens in this 
country who are subject to military duty. If these two young 
men could not have proved their American birth in all proba- 
bility they would have been subject to draft by the German 
Government. It is too important a matter for any of us to 
neglect. 

Dr. W. P. McAdory, Birmingham: This is a very impor- 
tant subject, as we all realize when we stop to think about it. 
Doctors are doctors, and some of them are busy. I therefore 
wish to introduce the following resolution : 

Be It Resolved, by this Association, That a proper form of 
certificate be adopted to furnish the family by the health officer 
of the county upon the birth of a child. 

In other words, I may not report a birth, but if somebody 
else has reported the birth, then the family is going to jab me. 
Health officers are rather lenient when we do not report, and I 
move the adoption of this form of certificate to be furnished 
the families. 

Dr. Stone : I want to tell about something that happened to 
me a while back. As for myself, I have kept a record of births 
and deaths ever since I have been practicing. Just a while back 
I got a letter from a young fellow in Texas who wanted to 
join the Woodmen of the World. He wanted to know the 
cause of his father's death, and he had forgotten his father's 
name. Of course, I could just turn to my record and give him 
the information. 

Dr. A. A. Jackson, Florence: It occurs to me, gentlemen, 
that there is one feature about the birth certificate itself that 
is a little deficient, if it could be classed as a deficiency, and 
that is the first line. It asks for the name of the child, whereas 



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GILES W. JONES. 268 

It is probable that about seventy-five per cent of us send in our 
reports before the child is named. If a separate blank were 
furnished that the physician could give the parents to fill in 
as soon as a name is given, and the parents either requested to 
return it to the doctor or to mail it direct to the State Board 
of Health, the records would thereby be made complete. Few 
of us have the time to call on the parents of each child subse- 
quent to the christening, and the result is the name is not sup- 
plied in the majority of cases. 

Dr. E. B. Durrette, Gordo: Suitable blanks are pre- 
pared on which names of parents and child (with 
sex) are furnished each month, by the county health 
oflFicer, to the congressman in the district, who sends 
to each a birth certificate properly filled, a dietary list suitable 
for the child for the first year or more of his life, and other suit- 
able instructions necessary of the care and proper treatment of 
the child. I am sure that each congressman will be glad to do 
this as such literature is furnished by the government and there 
is no pecuniary cost to the congressman, even in sending them 
out, as they are sent out through his government frank. 

Dr. Jones: Dr. Jackson spoke about the certificate going 
in and the name of the child not being given. That can be 
easily overcome. I simply tell the mother that if she does not 
name the child by the first of the month I will name it myself 
and that that name will go on record and stay there as long as 
the record lasts. I tell her she has got to name the baby. I 
haven't had one yet that did not name the baby by the time my 
report went in. 

I did not mean to criticise Dr. Perry when I spoke about this 
State not getting good results. It is not he, but the doctors. 
In my county if a midwife attends a woman I simply go to that 
woman and sign her name to the blank. But in the case of 
deaths it is impossible unless we have a burial permit. 

I thank the gentlemen very much for their discussion. 



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THE RELATION OF THE PUBLIC HEALTH LABORA- 
TORY TO THE HEALTH OFFICER, THE 
PHYSICIAN AND THE PUBLIC. 



B. L. Arms, M. D., State Bacteriologist, Montgomery. 

The laboratory of the State Board of Health of Alabama is 
an institution founded to assist in maintaining the health of 
the citizens and preventing the spread of outbreaks of disease. 

It should be borne in mind that the laboratory belongs to 
the people and the Health Department wishes to make it of the 
greatest possible service to all the citizens of the State. Lest 
someone who is in perfect health may fail to see how he may be 
helped let him bear in mind that whatever affects his neighbor 
affects him also, that every case of preventable disease in his 
community affects him and broadly that every case of prevent- 
able disease in the State affects him. To a group of physicians 
this is of course perfectly plain, but has the general public yet 
reached the point where it can see this ? 

The answer is plainly no, and for proof of the correctness of 
this assertion we have only to look at the appropriation al- 
lotted to the State Board of Health to cover the health work 
of all kinds throughout the State. 

The old adage, "Comparisons are odious," may be true, 
nevertheless it is only by their use that we may judge how far 
we may be from doing our full duty. 

While Alabama ranks as the 16th State in population, it 
ranks 27th in health appropriation, and this is shown more 
strikingly by the per capita expenditure for health purposes 
where it ranks 40th. 

Compare the per capita expenditure of our State, 1.11 cents, 
with the 15.21 cents of Florida, which heads the list, and one 
can readily see that they are in a position to do many things 
that are impossible here; for instance the establishment of 
branch laboratories so that no section of the State is far re- 
moved from one of them, making possible more prompt reports, 
which means so much to the physicians. 



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B, L, ARMS, 265 

Here let me say that each specimen received at the labora- 
tory is reported on as soon as possible and delay of the report 
is caused by the failure of the mails and not by delay at the 
laboratory. Only a short time ago, we received a package on 
the second day after a letter came in regard to it, and the post- 
mark showed that it was mailed to reach us at the same time 
as the letter. The same week we had a package that was, ac- 
cording to the postmark, 5 days coming from an adjacent 
county. Needless to say this matter was taken up with the 
postal authorities and we trust that no repetition will occur, 
but if it does and if your reports do not reach you as early as 
they should, remember that we cannot report on a specimen 
until it reaches us. 

How may the laboratory aid the health officer in the task 
assigned to him in caring for the public health of his territory, 
be it county or city, and we may as well include physicians, for 
each is health officer of the family? There are many ways, 
as for instance when a case of diphtheria occurs the laboratory 
can aid in diagnosis, but do not for an instant think that we 
feel that the laboratory examination is to be waited for when 
the clinical signs point to the diagnosis of diphtheria, nor is a 
negative laboratory diagnosis to be taken as conclusive evidence 
that it is not a case of diphtheria, for it should be considered 
as but one point in the diagnosis. 

Possibly in State work the laboratory can be of greater 
assistance in the release of patients from quarantine after 
diphtheria, for the best test of the time when a convalescent 
is safe to be released is the cultural one and release cultures 
should be taken from both nose and throat, even when the 
lesions have been confined to one alone. It is also well to 
take cultures from those in contact with the case to ascertain 
if possible if there may be some others who may be potential 
spreaders of the disease. 

In typhoid there are many cases in which the laboratory 
can be of aid in diagnosis, but the figures for 1916 show that 
we are called on for only a small percentage of the cases. 
There were but 1,506 specimens submitted for the diagnosis 
of typhoid, while there were 694 deaths from this disease re- 
ported in the State, and on the accepted death rate of 10 per 
cent of the cases, this means nearly 7,000 cases. Consider 
also that but 38 per cent of the bloods gave a positive reaction 



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266 THE PUBLIC HEALTH LABORATORY, 

and it shows that we could be of much greater service if we 
were called on more often. 

This State is in the hookworm area, yet last year but 654 
specimens of feces were received. This seems a small num- 
ber and when you consider that approximately 40 per cent of 
these were sent by the physicians of the city of Montgomery, it 
makes the number extremely small. 

The laboratory can surely assist in control of tuberculosis 
to an extent many times greater than it is called on to do. 
Consideration of the figures f6r 1916 will bear out this state- 
ment, while there were 2,718 deaths reported from this dis- 
ease, 2,526 of which were of the pulmonary type, but 1,477 
sputa were submitted for examination! 

Surely the laboratory cannot be of assistance in the indi- 
vidual case unless you use it. 

Every physician in the State should have outfits on hand in 
which to send specimens and requests for them are filled on 
the day of receipt. 

It might be well here to call attention to the fact that the 
postal regulations forbid the transportation through the mails 
of infectious material unless in proper containers, and it is 
our custom when a specimen is received in such forbidden 
packages to send containers that meet the postal requirements. 

In the examination of water supplies it should be borne in 
mind that the most important examination is the sanitary 
survey of the source, which will show much more clearly than 
will the bacteriological examination if the water is safe. 

Following is a portion of rule 8 which was adopted at a 
meeting of the State Committee of Public Health, July 10th, 
1916: 

"No sample of water will be examined unless collected in 
accordance with instructions, shipped in containers furnished 
by the laboratory, and iced in transit." 

The reason for this action was that many samples of water 
reached us in such condition that the examination would 
show nothing of the true character of the water when taken, 
on account of the increase in the bacterial content after col- 
lection. 

It is surprising to find how many samples are improperly 
sent, even though every box carries printed instructions for 
packing and shipping, and bearing the statement that no 



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B. L, ARMS, 267 

samples will be examined unless iced on receipt. Frequently 
we receive specimens of water from laymen sent by mail and in 
containers that show by inspection that they were not sterile 
and sad to relate, we sometimes have the same thing from 
health officers. 

Another portion of the rule, a part of which was quoted 
above, is as follows : 

"Information by letter must be forwarded regarding sam- 
ples of water to be examined, giving the source of the water 
and its surroundings." Unless this is done, you will readily 
see that we cannot interpret the findings. 

As an illustration of this, let me relate an incident that oc- 
curred in my experience a few years ago in a distant state. 
An outbreak of typhoid was prevalent in a small town some 
80 miles distant and a man — an operator of an ice plant — 
l)rought 6 samples of water to the laboratory for examina- 
tion. He did not wish to say anything about the source of 
the samples, but on being told that no examination would be 
made without it, he did so. Five were from various parts of 
the plant. He still hesitated about the other, but at last he 
said it was distilled water. Further questioning as to the 
method of collection brought out the fact that he lowered the 
bottle well below the surface with his finger over the top of 
the bottle. As he was telling this, he was watching my face, 
and before I had a chance to say a word, he said that he 
saw his mistake and we need not make the examination. 

Now this man might have been justified in feeling that the 
laboratory examination was not carefully done had we gone 
ahead and made the tests without insisting on knowing the 
source and methods employed. As it was he left the labora- 
tory with a friendly feeling towards the institution and a 
willingness to cooperate. 

Rabies is so prevalent in this State that it is a great prob- 
lem and public opinion must be educated to demand safety 
from the dogs and for the dogs. You can help the State 
greatly if you will direct public opinion to demand this safety. 
But few of you come from localities where this is not a vital 
question, for there are but few counties in the State that have 
not had rabid animals and all too few have not sent patients 
to be treated. 



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268 THE PUBLIC HEALTH LABORATORY. 

Until the last legislature met there was no dog license law 
and I venture the assertion that as a consequence there is no 
state with a greater per capita dog population. 

Consider what it costs to feed this great number of dogs, if 
you will, but also consider, aside from this, the economic loss 
caused by rabies. 

In 1916 412 heads of animals were sent from various parts 
of the State for examination for rabies. Of these 193 were 
positive, 193 negative, and 26 were in such condition that no 
examination was possible. In this work you can help us 
greatly, for we frequently receive heads that should never 
have been sent. Remember that the very best negative diag- 
nosis is obtained by keeping the dog alive, and if at the end of 
a week that dog is alive and shows no symptoms, there is no 
danger from the bite. Do not kill the animal unless it is abso- 
lutely necessary as in the case of a stray dog that has the 
furious form of the disease and is making a run about the 
country as they sometimes do; in these cases, it is of course, 
necessary to kill them. 

Only last week we received a head with the statement that 
the dog had never shown any symptoms of rabies, but he bit 
a child and they wanted to be sure. By killing the dog they 
destroyed their best evidence, and this happens all too fre- 
quently. 

When an animal dies of rabies, the diagnosis is usually sim- 
ple, but when an animal is killed in the early stages it is some- 
times necessary for animals to be inoculated, which means 
a delay of some three weeks and in the case of a negative, 
how much more satisfactory to know in a week that there is 
no danger. Unless the bites are about the face there is no 
danger in waiting for the death of the animal, which will 
usually occur within 72 hours. 

Last year 294 patients were given the anti-rabic treatment 
at the laboratory, a great percentage of these were children. 
Do we not owe it to the children of the State that they be 
protected from rabid animals? Reference was made above to 
the economic loss caused by rabies. Following is what one 
dog cost the people of Lamar county. The dog, a worthless 
cur that was given away 3 times one day, bit 20 people, and 
this was the bill : 



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B. L. ARMS, 269 

Railway fare $135.86 

Board and rooms 187.19 

Incidental expenses 9.20 



$332.25 
Loss of time by the wage earners-.^ 217.25 



$549.50 



You will note from the above that the victims of the dog 
paid out $332.25, the balance of the sum being wages lost, but 
as surely a loss as money spent for railway fare. There is also 
one item that cannot be included in terms of dollars and cents. 
I refer to the mental and physical suffering caused by the bites, 
and this is shared not only by the victims of the animals, but 
also by the families of the victims. 

The title of this paper speaks of the relation of the labora- 
tory to the public — every examination we make is for the 
public and it is our desire to serve the public in every possible 
way. Just as soon as sufficient appropriations are available the 
State Board of Health will establish branch laboratories in 
order that more prompt service may be available for the citizens, 
and the time of the establishment of these depends entirely on 
the public. It will be readily seen that it will require an in- 
crease in the appropriation, but is it not worth while? At 
present it is necessary to charge fees for some work that is 
done at the laboratory, but I trust the time will soon come 
when there will be sufficient appropriation that any public 
health test may be done free, and when those tests that have 
to do with individual health alone may not be accepted. Let 
us work together to this goal, and whenever you think the 
laboratory can aid you in any way, remember that we deem it 
a pleasure to be of assistance. 



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A DISCUSSION OF THE WORK OF THE STATE 
BOARD OF HEALTH. 



S. W. Welch, M. D., State Health Officer, Montgomery. 

It would be unnecessary for me to discuss the work of the 
Board prior to the time I took charge of the work in January. 
That is covered by the annual report of the Board which is now 
ready for distribution and is in the Health Office ready for 
any of you who will call for it. It was debated whether or not 
we would send copies of this annual report out by mail, or have 
the gentlemen who are in attendance on the Association call 
and get a copy. We decided that the probabilities were that 
if you came and got these reports you would probably leave 
them in Montgomery. We are very anxious for you to read 
them. So very soon after you reach home you will receive a 
copy of this annual report of the Board, and we commend it to 
your careful consideration. 

Some years ago the International Health Board made a 
proposition to the State Board of Alabama to join with them 
in doing what is known as intensive community work. The 
International Health Board was to contribute an equal amount 
of money as that appropriated by the Alabama Board. The 
Alabama Board did not have money enough to finance its end 
of the proposition. Recently negotiations with the Board have 
been reopened, and it was again found that the Alabama Board 
did not have money enough to finance its end of the proposition. 
I laid the matter before a benevolent lady in Talladega, and 
asked her for a sufficient amount of money to begin this work. 
A day or two after I returned to Montgomery I received a 
check for five hundred dollars from her, which is now in the 
bank, and as soon as the appropriations by the counties can be 
secured we will take up this work. DeKalb county has already 
appropriated a sufficient amount to begin the work there, and 
I would just like the*gentlemen from the northeastern part of 
the State in one of the counties Etowah, Morgan, Marshall, 
Blount, Jackson, or any of those counties contiguous to DeKalb, 



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S.W. WELCH, 271 

immediately to set in motion some sort of movement that will 
secure the appropriation of two hundred and fifty dollars a 
month, so that we can begin the two communities in that section 
of Alabama. The State Board is ready now to begin the work 
if we could get one other county in that section of the State. 
It is very necessary to have two counties contiguous to each 
other, so that the expenses of the State Health Officer in 
looking over this work will not be greatly exaggerated. You 
can readily understand that in looking over this work, which I 
will have to do, that if one community were in North Alabama 
and the other in the extreme southern end of the State that the 
railroad fare and the time taken to inspect the communities 
separately would reach rather large proportions, whereas if the 
two counties were contiguous and the two units working in 
contie^uous territory the expense would not be so large. It 
mieht be well to state here that $500.00 was contributed by Mr. 
W. B. Davis, of Fort Payne, which sum will enable us to begin 
the work in DeKalb county. 

Along this same line the question of the appropriation made 
by the general government was taken up with Surgeon-General 
Blue. When the general appropriation bill passes Congress it 
will carry with it an appropriation for rural sanitation. I im- 
mediately asked Surgeon-General Blue to allow me to share 
in this appropriation as soon as that bill passes. He did not 
say positively that he would do so, but in the diplomatic lan- 
guage of gentlemen in high stations he gave me every assur- 
ance that he would. I am anticipating help from that direction. 
That will be between the counties and the appropriation made 
by the United States Public Health Service, the function of the 
Board in the premises being to secure the United States Public 
Health Service appropriation and surpervise the work when 
taken up. 

Soon after I came to Montgomery I requested the county 
health officers to forward to the congressmen from their respec- 
tive districts a list of the names and addresses of the new 
mothers in their counties. We do not have the means of dis- 
tributing bulletins that would be very useful to the mothers in 
the rural districts, teaching the care of the new baby, but it 
was thought entirely feasible for the congressman to send out 
under his franking privilege the literature from the United 
States Public Health Service and the Child Welfare Bureau in 



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272 WORK OF STATE BOARD OF HEALTH. 

Washington City. I received replies from all the congress- 
men, thanking me for the privilege that this would give them 
of communicating with the new mothers and the new babies 
of their district. 

Efforts are being made to establish all-time health officers in 
about six counties in the State now. We had thought that at 
least three counties would have inaugurated the unified health 
system to be reported at this meeting of the Association, but 
unfortunately those things hang fire, and the commissioners' 
courts have not yet appropriated sufficient money to begin the 
work. We hope, however, to be able to report in the very near 
future six or seven more counties with all-time health officers. 

It has been the effort of the State Board to interest all of the 
welfare movements in the State in the work that we are doing. 
Cordial relations have been cultivated with the Alabama branch 
of the Congress of Mothers. I had the honor to address those 
ladies in this hall a short time ago, and they gave me a very 
courteous and respectful hearing. A good many questions 
were asked along the lines I am discussing with you now, and 
several of them seemed very much enthused over the idea of 
having all-time health officers for their respective counties. I 
was very glad to be so cordially received by this branch of social 
workers, because I know of no people who are doing more 
solid work for the care of the infants of the State than this 
organization. 

The Superintendent of the Anti-Tuberculosis League, Dr. 
Geo. Eaves, has been in constant communication with the de- 
partment for some weeks. He has a plan on foot that was 
authorized by the last legislature to establish a municipal hos- 
pital for tuberculosis in every municipality in the State. He is 
enthusiastically prosecuting this work, and the State Board is 
in hearty sympathy with what he is trying to do. I bespeak 
for him your hearty cooperation when he comes to your respec- 
tive counties, and especially to the towns in which you will 
locate these sanitariums. He has a great deal to say that is 
worth hearing, and the plan which he has to offer you deserves 
your hearty support. 

The work of the Prison Inspector has come under the super- 
vision of the State Board quite recently. Dr. Dinsmore is in 
charge of that work now. You all know the cordial relations 
that have existed between him and the State Board for a num- 



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8, W. WELCH. 278 

ber of years, and he has written all of the county health officers 
and the municipal health officers of the State and the county 
and civil officers of the State apprising them of the fact that 
this office is now under the State Board of Health. I com- 
mend this work to you gentlemen, and hope that when Dr. 
Dinsmore visits your town you will make his work easy for 
him. 

A good many other things have been projected for the 
coming year. I hope that I will be able next year to give you a 
more comprehensive report of the things that have been accom- 
plished that are worth while. We have spent years and years 
in organizing until we have what to my mind is about as per- 
fect an organization as we can formulate. The time has come 
to put the organization into operation and do the things which 
it was organized to accomplish. The original idea in the minds 
of the founders of the Alabama State Medical Association was 
to do public health work. I am here, with the aid and assist- 
ance of the doctors of Alabama, to bring to the highest degree 
of development that idea that was in the minds of the original 
founders of the Association, and so splendidly administered 
and developed by my distinguished predecessor. Now, gentle- 
men, if you will give me your assistance, in a few years we 
will put Alabama on the map on all questions pertaining to 
public health work. (Applause.) * 

I notice that the question of rural sanitation was passed. It 
is one of the most important subjects that can come up for 
discussion before this body, and I suggest that Dr. Harrington, 
the all-time health officer of Jefferson county, be requested to 
address the Association on the subject of rural sanitation. 

Dr. Harrington : Mr. President and Gentlemen : I came to 
Montgomery from Birmingham and Jefferson county to hear a 
paper on rural sanitation, because I am interested in that sub- 
ject and I wanted to learn something of the attitude and frame 
of mind of the State Medical Association and its components 
on the subject of rural sanitation. The State Health Officer 
has put the burden of the communication rather than the hear- 
ing on my shoulders. 

I would like to feel that for a moment we can divest our- 
selves of any idea of municipal, county or State boundary lines 
in talking on the subject of rural sanitation, and then bring 
that subject back home to the State of Alabama, and to the 

18 M 



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274 WORK OF STATE BOARD OF HEALTH. 

counties as it may apply. It is one of the broadest subjects of 
public health, coequal perhaps in importance with the registra- 
tion of vital statistics. We must know the conditions under 
which we live that need curing and then in rural sanitation 
how to cure them. It is a fact that there are few cities of the 
size of the cities of the South that are not part, and sometimes 
as much as fifty per cent., in a rural condition in regard and in 
respect to condition that produce contagious and infectious dis- 
eases. 

I have never yet found or heard a definition that practically 
defines rural sanitation. Sanitation is hygiene in the diction- 
ary, and hygiene is sanitation in the dictionary, and you 
get no farther than that. It has been defined as the science 
of living, or the keeping in place of matter that has been put 
out of place. Now the word filth or dirt has been defined as 
"matter out of place." And with those simple definitions we 
can proceed along a very easy line of instruction in rural sani- 
tation, but it depends upon the individual to carry out those 
instructions. Matter out of place is an insanitary condition. 
For instance, the filth of a stable is not filth if it is where it 
belongs, nor is the filth of a toilet filth if it is where it belongs, 
nor is the dust of the road filth or dirt if it is where it belongs ; 
it is only when this matter^ is out of place that it becomes an 
insanitary condition, and it is those insanitary conditions that 
rural sanitation strives to correct. There is, of course, some 
deviation from this condition when we understand that the 
common house fly may breed in stable manure and still not 
carry that manure out of place, but that fly egg in hatching 
becomes almost a component part of that stable filth, and in 
leaving that stable it is matter out of place. In the carrying 
about on the body and legs of a house fly from the open, 
insanitary toilet of matter that should be and must remain 
therein, that material that is carried about becomes matter out 
of place. 

Now the greatest problem we have in rural sanitation and 
in the rural sections of urban settlements is the prevention of 
diseases that are carried from some substance to the human 
body. Rural sanitation does not deal primarily with the pre- 
vention of diseases that are contracted by direct contact. The 
greatest problem in these United States, front Maine to Flor- 
ida and from the Atlantic to the Pacific, is the proper disposal 



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fif. TT. WELCH. 27B 

of human waste. In our rural districts it becomes a problem 
that falls upon the shoulders of the individual resident or house 
owner or farmer, and in that instant it becomes the duty of the 
physician who is called upon by that family, who has delivered 
the babies in that family, who has carried fliat family through 
sickness after sickness, it becomes a moral duty upon him, 
speaking generally, and it becomes an absolute duty under the 
law in the State of Alabama for every member of the Board 
of Health to carry into effect measures that are necessary to 
improve sanitary conditions in the rural districts. 

It has been my experience that when we go into the country 
and talk to a farmer about the disposal and the dangers of 
material that can be found about his home in a generalized man- 
ner, that we have done absolutely no good. We must become 
specific. We must get down to the most concrete details of 
what we want done before that farmer can grasp for a minute 
what we are talking about. I have experiened that condition in 
some several counties, two of them in this State, in which the 
farmer as a rule is willing to do, wants to do, but does not 
know just exactly what to do. I do not believe it does any 
good to circularize by mail the rural population of any county 
of any State. It is a detail matter that must be brought home 
to him, and in bringing it home to him we must have a concrete, 
matter of fact principle that he can grasp and execute. 

There is still some controversy and there always will be 
some controversy in the minds of sanitarians as to just which 
is the best method of disposal of waste matter from human 
bodies. Studies in England from the disposal plants of their 
sewer system show that the average human adult excretes a 
little over two pounds from the body per day. In some figures 
that I compiled in rural sanitary service, it is shown that the 
average human being of all ages, passed atx)ut four ounces of 
solid matter from the body per day. This shows us that for 
every twenty-eight homes of the average family there is 
deposited one ton of human waste matter on the surface of the 
ground per year, to every square mile. Now that ton of 
human waste scattered about is not over one area of one square 
mile: it is near the home, and that is the most vital point we 
must look after in rural sanitation. 

I am not here to find fault, but I am going to make a report 
that in the seven counties in which I have been employed in 



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276 WORK OF STATE BOARD OF HEALTH. 

rural sanitary work, urging upon the responsible individual to 
consider the problems of rural sanitation and to cure this gross 
insanitary conditions, that the doctors of the community have 
been the last ones to do the work. Now it behooves us, I be- 
lieve, and especially in the State of Alabama, where the best 
doctors, if not all doctors, are members of the State Board of 
Health, and of their local boards of health — ^it behooves us as 
men with legal as well as moral obligations to set an example 
to our neighbors. 

Last year in Tuscaloosa county, where an intensive survey 
was made of two small areas only, the question came up before 
the grancl jury after the survey was completed as to why the 
entire county was not surveyed, and the answer was made, 
"Because the results of the two intensive surveys were so dis- 
couraging that it did not feel really justified in the expendi- 
tures to go further." And it was explained that after visiting 
every home in these two districts and leaving literature and 
explaining to the head of the family what this meant, and going 
back a second, a third, and in some instances a fourth time, that 
we only got a seven per cent, response. The grand jury 
wanted to know what was the matter, and it was shown that 
two of these men's homes had been visited and they had not 
done a thing, and the rest of the grand jury turned to these 
two men and said, "Before we go further you two had better 
start something." They went home and constructed sanitary 
disposal closets. The trouble is that the two classes of people 
that lead a community, the two that are looked to in all kinds 
of trouble, the two closest to the homes and the hearts of the 
people, the doctor and the preacher, those two men are the last, 
as a rule, while they should be the first, to set the example. I 
have found also in homes where they have constructed a sani- 
tary privy that the porch is being repaired and the fences put in 
shape and the house painted and the stables repaired. It is a 
remarkable fact that you could almost pick out a house that 
has been sanitarily improved by passing along the road. 

Do not get discouraged when we tell you that only seven per 
cent, have replied to this urgent appeal, because we know that 
it is a matter of years ; it is a matter of changing conditions 
and habits that have existed for generations, but we must make 
a start sometime. The first home will have to be fixed some- 
time. We will have to show that we can get results, as we 



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8. W, WELCH, 277 

have shown in other communities, in other states, as we have 
shown in two counties in Alabama. We must show the man 
that we can show results in the prevention of sickness by the 
simple expedient of the most important thing in rural sanita- 
tion, and when we get the doctors and the people to understand 
that rural sanitation is really an entity in our lives, then we can 
expect results. 

All of this, however, does not detract from th^ fact that if 
we will protect from spread the contents of the toilet or garden 
house we will protect our water supply, we will protect infec- 
tion of our garden truck, we will prevent fly infection, we will 
protect ourselves from the scattering of filth on the feet of 
chickens, hogs, dogs and cats, we will protect our children and 
will reduce about sixty per cent as a safe venture, the bowel 
diseases of infancy, we will reduce ninety-five per cent the prev- 
alence of typhoid fever, we will increase and have shown that 
we will increase bodily resistance, to the extent of the reduction 
of the total death rate from all causes. Now is that not worth 
while ? 

I might give you, as a matter of interest, figures from Tusca- 
loosa county and the city of Tuscaloosa, where they had a 
reduction of typhoid fever 150 cases in 1915 to only 11 cases 
in 1916, and from 17 deaths to 1 death, and a reduction of 
seventy-five per cent in the infant death rate from bowel trou- 
bles, whereas at the same time the county in the unsurveyed 
section showed an increase in bowel trouble in infants of sev- 
enty-five per cent. That cost the city of Tuscaloosa four thou- 
sand dollars. They have completed a sanitary survey of the 
city and every house within three miles of the city limit, and 
they have installed there an approved method of sanitary dis- 
posal and are scavenging those toilets at a cost of three dollars 
a year each. That is the main item and the prime item of rural 
sanitation. 

We can improve our wells by encasing them with concrete 
tops and pumps, we can keep the chickens from running at 
large, we can keep the hogs in pens, we can clean out the stables 
every day, and we can do all of these things, but we must 
keep in mind that human beings become sick only from the dis- 
charges from human beings and rarely from any extraneous 
matter. So our rural problem is one of preventing the scattera- 
tion of filth so it will not reach the mouths of susceptible per- 
sons. 



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278 WORK OF STATE BOARD OF HEALTH. 

Dr. H. G. Perry, Montgomery : As I recently made up some 
figures for an average county on the question of the necessity 
of rural sanitation as related to all-time health officer work, 
I wish to give you gentlemen here the findings of a county of 
twenty thousand in northwest Alabama. Some time ago I was 
invited to go up to appear before the commissioners' court in 
the interest of getting an appropriation for full-time health 
officer work. The main argument for that work is to stress 
the necessity for rural sanitation. I looked over the records 
in my department for last year and made an estimate as to the 
economic loss in that county for one year because of the want 
of proper sanitation. This is a county where the communicable 
diseases are not fully reported by any means, neither are the 
deaths fully reported. The figures showed a loss of ninety-two 
thousand dollars for the year 1916, whereas by an expenditure 
of three thousand dollars we would have been in shape to begin 
to prevent this great loss and outgo and unnecessary tax upon 
the earning capacity of the people. 

I just wanted to give you the figures in a community of 
twenty thousand people. The meager reports that we had 
showed a loss of nearjy one hundred thousand dollars, and the 
point that I wish to make is that if a portion can be saved by 
intensive sanitary work it certainly behooves us all to get busy 
on that question in our home counties. 

Dr. W. W. Harper, Selma: Gentlemen, the people in the 
rural districts are waking up. I want to repeat to you a story 
told to me by Dr. Palmer, President of the Alabama School for 
Girls, at Montevallo. Said he, "A girl came to this school a 
few years ago whom I knew to be a fine girl, but who struck 
me as being of the 'butterfly type,' and from whom I did not 
expect much. But while here she received an inspiration and 
'heard the call from out yonder.' After graduating she secured 
a rural school in Bibb county. After school hours she visited 
the homes of her patrons. She saw their miserable sanitary 
environment. She saw the loss of the health from poor cook- 
ing and poor housekeeping and she determined to change the 
condition of affairs. Through the United States Public Health 
Service she secured plans for a sanitary toilet and with the 
assistance of Dr. Palmer obtained a working plan for the con- 
struction of this toilet. At the end of a year every farmei in 



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8. W. WELCH, 279 

that community had installed a sanitary toilet. She taught the 
women how to cook and the girls how to sew, and in two years 
time changed the appearance of the whole community and its 
inhabitants/' This was accomplished by a frail girl while we 
strong men sit still and say we can't do anything. Gentlemen, 
let us get an inspiration and go to work, — there is plenty of 
work for us. Let us become electric batteries — not dead bat- 
teries, — for when a battery is charged everybody knows it is 
alive. 

Not long ago I figured up some Dallas county statistics and 
found that the preventable diseases cost the county more money 
than the whole cotton crop brought. Think of that ? Diseases 
that can be prevented costing more money than the entire cot- 
ton crop of the county, to say nothing of the suffering, worry 
and sorrow that are the companions of illness. Senator Rams- 
dell, in his report as Chairman of the Senate Committee on 
Public Health said, "Gentlemen, preventable diseases cost this 
government every year nine hundred million dollars." This 
means nine dollars per capita. President Elliot wrote and said, 
"Let's stop talking hogs and- horses and cows and talk human 
beings." 

Gentlemen, the unsanitary toilet and the house fly spread 
preventable diseases by which death receives such a frightful 
toll of human lives. A sanitary toilet can be installed for five 
dollars and screens for the house cost less than the average 
family's drug store bill. Dr. Harrington tells this story : "You 
can go to a farmer and tell him it will cost five dollars to install 
a sanitary toilet and he refuses to do it. The next day a light- 
ning rod agent comes along and the man spends fifty dollars 
for lightning rods." He does not know that while there are 
only one hundred and fifty persons killed by lightning in one 
year, many thousands are killed by typhoid fever — which was 
spread by unsanitary toilets. In Alabama we have eight thou- 
sand cases of typhoid fever every year and seven hundred 
deaths. We may recover the money loss, but those of you who 
are fathers and who have laid away in yonder cemetery a 
young boy or girl know that there isn't enough money in the 
world to assuage the grief or take the crepe from the hat. The 
best asset a nation has is her children and yet of a hundred 
babies bom into the world, twenty-five of them are in the ceme- 
tery before the end of the first year. Why are they there? 



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280 WORK OF STATE BOARD OF HEALTH. 

Because the fly has infected them with the germs of diarrhoea. 
I said to a legislator, "Look here, we should do something to 
prevent this frightful infant mortality from summer diar- 
rheoeas." His reply was, "That disease only affects negro ba- 
bies." In less than three months time the only child of that 
man was laid in its g^ave — it had become infected from a negro 
baby on his farm. The Lord said unto Cain, "Where is Abel 
thy brother?" The blood of these little infants cry to us and 
we are untrue to ourselves and our profession if we do not 
make an effort to prevent these unnecessary deaths. 

I appeal to you, gentlemen, to enlist the people in the country 
in the fight against these diseases caused by unsanitary toilets 
and the fly. One fly in fifty days will produce five hundred 
pounds of flies. Most of these flies are killed in the fall by a 
fungus disease. Many are killed by cold weather and if we kill 
every fly that enters our homes in the early spring, there would 
be few flies to bother us in the summertime. 

Dr. E. V. Caldwell, Huntsville : I do not know any statistics 
that would have any great bearing on this subject, but I wish 
to express my appreciation of hearing this discussion here this 
evening. It has not been very long since I was one of the rep- 
resentatives of the State Board of Health doing this field work 
in this State, and I have been impressed this evening with one 
idea, and that is the one that Dr. Harrington expressed when 
he said that when they went into a community they found that 
the last man from whom they got a response were the doctors 
and the ministers. My friends, if the Medical Association of 
Alabama could get the vision of the possibilities that there are 
in the rural sanitary work in this State the Association would 
be enthused, and until we get the vision and enthusiasm we 
cannot expect to get cooperation from the masses. (Applause.) 
Furthermore, people all over this State have said to me, "Doc- 
tor, we know everything you say is true; we know that we 
need everything that you suggest, in this community at least in 
some degree, but we cannot get the people to learn. This is 
the greatest mistake that you ever made, and it is a stigma 
on the people of Alabama to say that they are not ready to 
receive a thing that they say and know is a good thing for the 
conservation of life in their State or home. Do you mean to 
tell me that you cannot get the cooperation of the mothers of 



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8, W, WELCH. 281 

your county if you explain to them that they are doing things 
that will take from their home the children that they love 
dearer than their own selves? Did you know if you convince 
a mother that the life of her child is in jeopardy, that there is 
an impending danger over her child, that her soul could not 
rest until it is removed. In my opinion there is a solemn duty 
resting upon the shoulders of this Association to carry enthu- 
siasm back to our homes to aid those who are sent out by the 
State Board of Health or who are paid by the county commis- 
sioners to do their work, because without the hearty coopera- 
tion of the medical profession in the county it cannot be accom- 
plished. We are asking money for a full-time health officer, 
and yet there is dissension enough in our own midst to prevent 
that. This must be righted if we expect to get the money, and 
then we must lend our own cooperation to convince the people 
after we get it. 

Dr. Chapman : This topic of rural sanitation has been most 
interestingly presented. There is only one point I wish to em- 
phasize. The county is a large field for one worker to cover, 
inasmuch as the best results may be accomplished only through 
a house-to-house, or farm-to-farm campaign. This requires 
considerable effort and time. It seems to me that the best way 
of reaching the people is through the community organizations, 
and this usually means the schools. Illustrated lectures for the 
public, talks to pupils and teachers, and making the school a 
sanitary institution, will create an interest in matters of public 
health and sanitation that may produce definite results. Fol- 
lowing up these public exercises, there should be as much indi- 
vidual work as possible. 

Concerning the question of sanitary closets, I believe the 
first place to begin your work is in the schools themselves. I 
have found in Talladega county only two schools removed from 
city sewers, with any approach to sanitary closets. Several 
have two closets each, but many have only one. A few 
have none at all. This I considered my greatest task, and 
therefore discussed the matter with teachers at their institutes, 
the boards of control, and the county school board. It was grat- 
ifying to learn that recently the county board of education 
adopted a resolution, requiring every school in the county to 
install two sanitary closets, according to the specifications of 



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282 WORK OF STATE BOARD OF HEALTH. 

the county health officer, before school could open next Septem- 
ber. This is a good step in the right direction. Pupils can see 
the advantage of sanitary closets, and the patrons will observe 
them, and then I anticipate that many will be installed through- 
out the county on the farms and in communities. 

A strong and effective public health sentiment cannot be 
aroused in a county in a few months. It requires patience, per- 
severance, and lots of hard work. You have got to make the 
people of the rural districts think along the lines of health pro- 
tection, and appeal to them in terms of life and money. The 
fight is worthy of the best efforts of any man interested in 
public welfare. 

Dr. J. P. Stewart, Attalla : This is indeed one of the most 
important questions that this Association could discuss. There 
is no doubt of that in the world, and the indifference of the 
public on this question has infected the doctors of Alabama. I 
was health officer of the little city of Attalla. We had typhoid 
fever there, and I tried to get the municipal authorities to do 
something to keep our town cleaned up, to put it in a better 
sanitary condition. I was elected on the board of aldermen. I 
had a mayor that I had some influence with, and together we 
passed an ordinance to put in a sanitary sewer system. It was 
accomplished, and we provided in that ordinance that every- 
body in the sewer district should connect all closets with the 
sewers. We had no way to enforce that ordinance. That was 
seven years ago, and today there are only four-fifths of the 
closets in the sewered district connected with the sewers, and 
we are informed that there is no law in Alabama that would 
compel those people to connect them. While I was on that 
board we fought for a betterment of our sanitary condition, 
and consequently we have not had any typhoid to amount to 
anything since that time. But after that board passed out the 
condition began to grow worse. Fortunately a few years after 
that I was elected mayor of that town on the sanitary proposi- 
tion — that was my politics. I cleaned that town as clean as 
this floor was before we assembled here. Consequently we had 
no typhoid fever for two solid years in that town — not a single 
case — but we had to do it by strenuous effort and continued 
vigilance. And that is the way we doctors have got to do. As 
I said at the outset, the indifference of the people has infected 



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8. W, WELCH. 288 

the doctors and they are indifferent. You have got to keep 
right after this question constantly and continuously, because 
the people do not pay any attention to it, and if we do not, who 
will ? Somebody has got to do it, and we must ask for legisla- 
tion, and we must ask for appropriations, and we must con- 
tinue to work along this line, gentlemen, if we want to take care 
of our people and bring ourselves up to that high standard of 
cleanliness — cleanliness even — that we should have. If you got 
off at the town of Attalla and walked along the streets and saw 
filth scattered all around you would know that the doctors in 
that town are asleep, because they are the ones who ought to 
look after it. You want to have a good street-cleaning proposi- 
tion ; rural sanitation begins at the outskirts of your city. You 
must keep behind it ; don't let it die ; don't go away from here 
and say, "That was good talk," but go to doing something in 
your own town. What we say here today take home with you 
and say to your people and continue to say it, and work right 
along on this line ; if we want to do something on this line in 
Alabama, and make it what it should be as a sanitary State, 
why we have got to go out and work hard. 

Dr. T. A. Casey, Birmingham : There is one point I would 
be glad if Dr. Harrington would bring out in closing. Dr. Har- 
rington is competent to advise us on these matters, and it cer- 
tainly is an important matter. We have a great many doctors 
here from different parts of Alabama. You have heard some 
mighty fine talk. 

Now, these sanitary toilets — a great many of the industrial 
companies around Birmingham have fallen into line, and they 
are tearing down the old toilets and building new toilets with 
galvanized tubs, with solutions to disinfect and deodorize, and 
they carry that off and pay for doing it. There is no odor and 
no filth. In the cities we have a sanitary system. In the 
smaller towns they can "hire it done. In the rural districts we 
have a different proposition. I would like Dr. Harrington to 
explain what would be the best way to dispose of the accumula* 
tions in these closets. 

Dr. H. G. Perry, Montgomery: I want to make just one 
suggestion. The best way to teach is by example and not by 
precept. I have had the good fortune in the last few years to 



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284 WORK OF STATE BOARD OF HEALTH. 

visit the homes and the offices probably of more of the rural 
doctors than any other doctor in the State, and two things have 
impressed me very much. First, that the ordinary busy coun- 
try practitioner is usually too busy to pay that attention to the 
office that he ought to pay to keep it clean and sanitary, as a 
place to have his patients go, and that has grieved me very 
much, and with one exception I have yet to see a sanitary privy 
in the home of any doctor in Alabama who does not live in a 
town with a sewer system. I spent quite a while in the hook- 
worm work. I preached the question of sanitation. I went 
around and help clinics in various counties; I went from doc- 
tor's house to doctor's house, and we preached and preached 
about these things. I built my own sanitary closet before I left 
home, I will tell you that. There was only one doctor that 
responded to the efforts that we made in that respect, and until 
we can clear our skirts and come up here at the next meeting 
and say "that I have built and I maintain a sanitary toilet on 
my place," I do not think we have got much right to say any- 
thing. 

Dr. Paul P. Salter, Montgomery: This is such an impor- 
tant subject that I cannot pass it up. I am reminded, first, of 
an incident that happened when I first got out of school. One 
of the first cases I was ever called to see was an old man who 
was related to me, and we called him Uncle John. I had a 
hurry call from him one afternoon to come to see him. When 
I got there he said, "Oh, doctor, doctor, I am in pain." I said, 
"Uncle John, what is the matter." And he said : "You know 
I have a goat which will dispute the right-away." I said, "Yes." 
"Well, yesterday he and I met, and as a result you see me in 
this predicament." I said :, "I am so sorry." "But think, doc- 
tor, that I went four long years through the Civil War and 
wasn't injured, and then to come home and be butted by a billy 
goat and thus killed." 

The point is this: In the present crisis I will assert that 
there will not be as many lives lost in one year from the bullets 
as are killed in the United States each year from the unsanitary 
closets and the flies. Thus we return from the war only to die 
of avoidable diseases. We have all conceded that the one thing 
to be accomplished to get rid of this appalling loss of life is to 
get rid of the source of these preventable diseases, and we can 



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8. W. WELCH. 286 

get rid of the source of these diseases by putting in sanitary 
closets. I did not get up to discuss the sanitary closet, because 
we have all concluded that it is the one thing that rural Ala- 
bama now needs more than any other. 

I simply got up to tell you what the State Board of Health is 
trying to do in the way of rural sanitation. We have so far 
two prime objects which we are trying to carry out. The first 
is this : in those counties which are able, to establish and main- 
tain an all-time county health officer or a unified system, we 
are endeavoring to show those in authority that this is the best 
asset that any county can have. In one of the counties, just 
for illustration, where we have an all-time health officer, I 
was talking to the probate judge of that county, and I said to 
him, "Judge, what do the people really think of their unified 
health system." He replied thus: "Doctor, if the vote were 
put to the people whether we should do away with the probate 
judge or the all-time health officer the probate judge would be 
without a position. The five men in Alabama today who are 
doing more towards public health than any other five men in 
the State are Drs. Grote, of Walker ; Chapman, of Talladega ; 
Durrett, of Tuscaloosa ; Harrington, of Jefferson, and Justice, 
of Elmore. 

Now there is one other alternative the Board has, and that is 
if a county is unable to appropriate a sufficient amount to put 
on an all-time health officer, we have a second proposition 
which we wish to put before any county which will meet us 
half way. That is this: through the untiring efforts of the 
new State Health Officer, Dr. Welch, the International Health 
Board has been induced to come to Alabama and help us in our 
sanitation. It is my purpose to tell you of this agreement, hop- 
ing some of you will write me to come and help you begin this 
survey in your county. The proposition is this : for every dol- 
lar that any county will spend the Rockefeller Commission will 
spend one dollar or the State Board of Health will spend one 
dollar. In other words, for every dollar spent there will be 
one other spent for the improvement of the sanitation in your 
county. It will be impossible for the State Board to do this 
work covering the entire area of the 67 counties. So we have 
taken this plan : we are to select from each county one, two or 
three communities, making twenty-five square miles each and 
consisting of 700 to 1,000 population. For each community 



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286 WORK OF STATE BOARD OF HEALTH, 

surveyed an appropriation of $250 will be the county's share. 
It will require one month to complete the sanitation of each 
community. Thus for an appropriation of $250 by the county 
the State Board of Health or the Rockefeller International 
Commission will spend a like sum, making in all $500.00 spent 
in each community. What better proposition have I, through 
the Board, to offer you today ? At a recent visit to one of the 
northeastern counties — DeKalb— I received an appropriation 
to begin this work there, and I hope that some of the adjoining 
counties, such as Etowah or Cherokee, will make a like appro- 
priation. If any of the gentlemen from the above-named coun- 
ties happen to be here, will go home and take it up with the 
commissioners, and if you are of the opinion that the subject, 
meets with favor, notify the Board, and we will send a man 
to go before the commissioners and explain the plan in detail. 
The idea is that these centers will act as examples for the rest 
of the county and that the sanitation will spread. It acts in 
another way. We hope to follow up this intensive work with 
efforts directed towards establishing all-time health officers, 
and if that had been done following the Rockefeller work on 
the hookworm there would be in the State not less than fifty 
all-time health officers. It is our intention to follow in close 
succession, the intensive rural sanitation and put on all-time 
health officers in that county. In each county in this State 
there occur about 270 deaths annually that are absolutely avoid- 
able. Some of the men who have talked here today have given 
you a rough estimate of just what a life is worth. The lowest 
estimate is $1,700. Now that is a small sum, but if you con- 
sider it in this light: suppose that were my son or my child? 
Is his life not worth more than $1,700 to you? And each of 
the five all-time health officers today is saving more than eighty 
per cent of those 270 avoidable deaths. 

Now I want to ask you to help us in carrying out this work. 
And I, as field director of the State Board of Health, am at 
your service, and anytime you see fit to call upon the Board for 
aid we will appreciate it and will give the call an early response. 

Dr. W. H. Oates, Mobile : It is with the greatest of pleas- 
ure that I have listened to this discussion this afternoon. It is 
the first time since I have been in this organization that I have 
seen absolute symptoms of the organization waking up. I 



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H. W. WELCH, 287 

have heard, year after year, of the beautiful organization, lik- 
ened many times unto the mogul engine standing at the siding 
and doing nothing, and I have been convinced, having heard it 
so frequently, that it has done nothing, and I have in my hands 
Chapin's report showing statistics from the American Medical 
Association placing us eighth from the bottom in the United 
States in efficiency. I have heard symptoms galore this after- 
noon, but I have heard no treatment discussed. It was my 
pleasure for the last six years to travel throughout this State 
in the capacity of State Factory and Prison Inspector and 
visit all the counties of your State, and I can corroborate the 
remarks as to the insanitary conditions throughout the whole 
State as far as the disposal of sewage is concerned. It is our 
one great disgrace. It was evidenced a few weeks ago in the 
examination of the cavalry regiment where fifty per cent, of 
them and more had hookworm, and we are responsible for it. 
We know the cause, we know the cure, we know the preventive 
measures necessary to stop it, but we are sitting idly on the 
siding doing nothing. As surgeon in the United States Army 
for four years I had sanitation drilled into my head. I had 
power and authority there to enforce modem sanitation. In 
the army you command and you are obeyed. A nuisance is 
abated at your command. Garbage around the kitchen must 
be removed at your command. The army surgeons are respon- 
sible for the health of his troops, and should be held respon- 
sible for it because he has the power. But, gentlemen, unfor- 
tunately the health officers of our State haven't that power. 
They have the intellect, they have the education, they have the 
ability, but they are really void of power. Another potent 
whip which we need is money. The perfection which this As- 
sociation has exhibited in lobbying in the legislature has led 
me to come to the conclusion that it is nearly perfect as a 
machine, but cannot we use it to get more money to save the 
lives of the people in Alabama than they are paying or paid at 
the last legislature for hogs ? The last legislature spent $25,000 
for the hog serum plant at Auburn, and they spent $25,000 for 
public health in Alabama, so we are on a parity with the hog. 
"Unless we do something I predict that this organization is 
going down, but under its present head I predict it is going up. 
Can't we get together and organize a full lobby if necessary. 



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288 WORK OF STATE BOARD OF HEALTH, 

go to any honorable means to conserve the lives of the people 
in this State? 

Chapin, the man sent out by the American Medical Associa- 
tion to make a survey of the various boards of health in the 
United States, classes Alabama 105 out of a possible 1,000, 
which would be perfect. New York gets 760 odd, and Massa- 
chusetts leads the United States with 775. We get 105. Seven 
other states, Arizona, South Carolina, Oklahoma and several 
others, are lower in the scale than we are. Now, I disagree 
with the man on some of his estimates of our efficiency and 
inefficiency. He is lower in vital and mortuary statistics than 
I know we should be, knowing Dr. Perry and his good work. 
But we are way down yonder. It makes we think of Bobby 
Burns' lines — 

"O, wad some power the gifte gi'e us 
To see ourselves as ithers see us! 
'Twould from many a blunder free us 
And foolish notion." 

We have got to get the notion out of our heads that we are 
doing anything. We are not doing anything. Tuscaloosa, yes ; 
Talladega, yes ; Walker, yes ; Birmingham, starting. But what 
are four out of sixty-seven. 

I want to leave one idea with you to take back home on dis- 
ease prevention. Get the cooperation, aid and assistance of the 
women of your communities. You will find organizations in 
your communities, women's clubs of various kinds. If you will 
go to those women and lecture to them on disease causation 
and disease prevention and get their cooperation, you cannot 
stop short of a landslide on the prevention of diseases, which is 
necessary in this State. 



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VALUE AND LIMITATIONS OF BLOOD EXAMINA- 
TIONS. 



John A. Lanfobd, M. D., New Orleans, La. 

A discussion of this subject must necessarily be brief be- 
cause of its extensiveness and the many kinds of blood exami- 
nations and if I slight certain phases of it, the explanation is 
that in a fifteen minutes talk something must be neglected. 

I can well say without fear of contradiction that the advance 
of medicine has followed the information obtained from blood 
examinations and at the present time a vast majority of the 
diseases of mankind produce some characteristic change which 
is recognized either as an important symptom or a positive 
diagnostic sign. 

A study of the condition of the blood gives us more valu- 
able and varied information than can be obtained by an exami- 
nation of any other tissue or fluid of the body and should be 
made a routine in all cases of fever whether or not associated 
with pain, as well as in all chronic conditions with vague and 
indefinite objective and subjective symptoms. 

Examinations of the blood will give us diagnostic and prog- 
nostic information which certainly has an important bearing 
on treatment. For the purpose of this paper I shall consider 
the subject chiefly from the standpoint of diagnosis and will 
divide it into three divisions : First, a study of the cellular ele- 
ments of the blood, which include variations in their number, 
their proportion to each other, and their content. Second, a 
study of the serum content of the blood with reference to cer- 
tain biological properties, as immune bodies, and changes from 
the normal in its chemical composition. Third, a consideration 
of parasitic invasion of the blood. 

Cellular Elements : A study of the cellular elements of the 
blood will include an enumeration of the total number of red 
and white cells and their variation from the normal and the 
information thus obtained enables us to draw certain definite 
conclusions. 

19 M 



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290 BLOOD EXAMINATIONS. 

A variation from the normal number or erythrocytes to- 
gether with changes in their structure and color content, sug- 
gests at once a pathological state of the circulation per se or 
of the generating center of the haemopoetic system. When 
there is a great diminution in the number of red cells and 
marked variation in size, shape and staining reaction together 
with numbers of normoblasts with high haemoglobin content, 
the picture suggests primary anemia, while a similar picture 
with a low color index is noted secondary to many pathological 
conditions in the body other than those referable to grave bone 
marrow changes, for example hemorrhage, carcinoma, intesti- 
nal parasites, etc. On the other hand, chlorosis with its rela- 
tively large number of erythoc)^es and their low haemoglobin 
content, distinguishes this condition from those above men- 
tioned. 

The information derived from the study of the white cells 
is more valuable clinically for the reason that there is scarcely 
any pathological condition of the body as a whole which does 
not affect in some way these important elements of circulation. 

An enumeration of the white cells together with their relative 
percentage is probably the most common form of blood exami- 
nation and is especially useful in the diagnosis of acute sup- 
purative processes, for example, in cases with pain in the abdo- 
men, whether in the inguinal region or elsewhere, if there is 
an increase in the number above 10,000, together with a high 
neutrophile count (80 per cent or more), it is evidence of active 
inflammatory reaction and surgical interference is indicated. 
Such a picture of the blood is obtained in appendicitis, otitis 
media, meningitis, pyelitis, cholecystitis and all conditions asso- 
ciated with local or general pyogenic infections. In a study of 
an acute illness associated with fever and a high leucocytic 
count, it is important that the surgeon search for the focus of 
infection. This may be found in the kidneys or the prostate 
or even in the lungs, without the manifestation of any local 
pain and is a constant finding in acute ulcerative endocarditis 
and pneumonia. A comparison of the cell count with the clini- 
cal findings, enables him to determine whether an operation 
is urgent or not. 

In patients suffering with chronic diseases of the heart, lungs 
or kidneys, who are regarded as bad surgical risks and should 
they be so unfortunate as to develop a localized internal acute 



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JOHV A. LANFORD. 291 

inflammatory process, a study of the white cells often enables 
us to determine the prognosis if operation is postponed. In 
such cases it is a fact that where there is a total number of 
cells above 15,000 together with a differential neutrophile per- 
centage of 86, we can with assurance inform them that their 
body forces are capable of caring for the infection. However, 
the blood should be studied at intervals of six or eight hours 
to note any change in the white cell count and should a lessen- 
ing either in the number or percentage of the neutrophiles be 
noted, it is evidence of a decline of the body forces and the 
prognosis becomes more unfavorable. 

There are two conditions characterized by an increased num- 
ber of white cells, in neither of which is fever an important 
symptom. I refer here to lymphatic and spleno-myelogenous 
leukemia. One is characterized by a large number of small 
white cells (lymphocytes), there being at times as many as 
100,000 per cubic m. m., and the other by a large number of 
embryonal leucocytes or myelocytes, they reaching sometimes 
as many as 1,500,000 per cubic m. m. These diseases are posi- 
tively diagnosed by the blood findings. In the absence of any 
proven etiology, it is the concensus of opinion among patholo- 
gists that these two grave conditions are probably neoplasms ; 
one, namely, lymphatic leukemia, being primary in the lymph- 
adenomatous tissue, and the other myeloid leukemia, being pri- 
mary in the bone marrow, and both metastasizing to the blood 
stream. 

Certain writers place considerable stress upon an increased 
percentage of the lymphocytes of the blood and claim diagnostic 
importance for them in suspected syphilis and tuberculosis, but 
it is not universally held that these findings justify such conclu- 
sions. It is a fact, however, that in whooping cough and influ- 
enzal infections, there is an increase both in the total and per- 
centage of the l)rmphocytes, but blood cell findings do not serve 
to differentiate these two conditions. 

While considering the variations from the normal in the total 
white cell count of the blood, it is important to bear in mind 
that a few diseases show a diminution in the number of white 
cells. Chief among these are malaria and typhoid fever. It is 
practically impossible to draw conclusions from the blood in 
these conditions, although when associated with a proportionate 
increase in the endothelial leucocytes, it is very suggestive of 



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292 BLOOD EXAMINATIONS, 

malaria. There is one disease, namely, splenic anemia, which 
is characterized by a marked diminution of the white blood 
cells ; they sometimes being as low as 1,000 per cubic m. m., the 
red cells show a similar decrease. 

When studying blood smears, if a large percentage of eosi- 
nophils (above 4 per cent) is noted, it is suggestive evidence 
of irritation of some of the epithelial structures of the body, 
especially, the skin and alimentary tract, and entitles the patient 
to an examination of the stools for intestinal parasites, espe- 
cially hookworms, and the skin for some form of dermatitis. 
Bronchial asthma and trichiniasis are also associated with an 
eosinophilia. I have recently seen a case with 60 per cent of 
these cells which was negative for all the above conditions and 
it was our opinion that some proteid substance was undergoing 
puterefaction changes in the intestines, which stimulated an 
excessive eosinophile production. 

Before dismissing the discussion of the cellular elements 
of the blood, it might be well to say something of the blood 
platelets. These little structures are so fragile and difficult of 
examination, that at the present time we have been unable to 
obtain any information of diagnostic importance. However, 
it is a fact that they are increased in conditions associated with 
suppuration and the anemias of the secondary variety, while 
they are decreased in diseases primarily involving the bone 
marrow. It is probable that some time in the future workers 
will discover changes which are diagnostic. 

Serum Examinations : Within recent years, examination of 
the blood serum has been very rapidly developed and at the 
present time a large number of diseases are diagnosed by this 
means. These examinations are of two distinct types, one in 
which a search is made for certain immune substances, such as 
agglutinins, complement binding bodies, etc., and the other, 
in which the chemical composition of the serum is determined, 
as in blood sugar and blood urea. 

Among the immune substances which are produced in the 
human body as a result of an infectious process, there are three 
distinct types recognized, all of which are utilized to a greater 
or less extent in the diagnosis of infections. Immune bodies 
of the first order are those which combining directly with the 
toxin of the infecting agent neutralizes it; examples of these 
are diphtheria and tetanus antitoxins. The Schick cutaneous 



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JOny A, LANFQRD. 298 

reaction is based on the presence of this type of immune sub- 
stances and in practice is used to determine the presence or ab- 
sence of immunity to the diphtheria bacillus. Immune bodies 
of the second order possess an action resembling those of a 
ferment and in addition acts on the invading organism through 
its combining property, as the agglutinins, precipitins, opsonins. 
Immune bodies of the third order have two combining groups ; 
one for anchoring the substance instrumental in their produc- 
tion, as bacterial cells, corpuscles, etc., and the other for an- 
choring the real destroying agent, namely, complement, which 
is normally present in the blood, and through this substance 
causes a destruction of the invading bacteria or foreign proteid 
material. Such immune bodies are lytic substances and are 
spoken of as bacteriolysins, hymolysins, etc. Members of these 
three groups are utilized to determine the presence or absence 
of pathological conditions, and it may be stated that of all blood 
examinations, they are by far the most important since they 
are specific. 

The more commonly used serum tests are those for detecting 
agglutinins and complement binding substances. The aggluti- 
nin test is applied at the present time to detect the presence of 
special varieties of organisms, but its first period of usefulness 
was shortly following the description of the test as applied by 
Widal in the diagnosis of typhoid fever and is to this day 
spoken of as the Widal reaction. By means of this test, we are 
able to distinguish typhoid fever from similar types of fever, 
as para-typhoid (alpha and beta) and other intestinal infections. 
However, it is useful in the diagnosis of typhoid fever only 
after the seventh day of illness, because before that time the 
body has not produced demonstrable immune substances and 
the test is therefore more of corroborative value than diagnostic 
importance. It should be made with a suspension of typhoid 
bacilli which are living, as only in this way do we get an abso- 
lutely reliable result. The use of a heavy suspension of dead 
t)rphoid bacilli which is to be poured on a blood smear and the 
resulting clumping of the bacteria noted, as advocated by some 
of the recent writers, should not be considered as a substitute 
for the test made with living organisms and at best if positive 
is only suggestive evidence of infection. The principle of the 
agglutination test has been applied to the diagnosis of tuber- 
culosis and influenza, and while the information gained is at 



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294 BLOOD EXAMINATIONS, 

times valuable, it is also at times disappointing, and these tests 
have never come into general use. This test, however, finds a 
useful field in the diagnosis of bacillary dysentery in children 
and is quite an important aid in separating this condition from 
others assoicated with a troublesome diarrhoea. 

Hemagglutinins : This test is of great value in determining 
the suitability of bloods for transfusion purposes and only those 
bloods should be used for this purpose which show no clumping 
or dissolution of the cells, either of the recipient or the donor, 
by the other serum. 

The complement fixation test is the most generally used of 
all the serum tests. The principle of this test was discovered 
by Bordet and Gengou, who determined that complement when 
mixed with an antigen in the presence of its specific antibody 
will be fixed, and sensitized red blood cells added as an indi- 
cator, would remain unchanged. It was applied by Wasser- 
mann and others to the diagnosis of syphilis and for this con- 
dition is known as the Wassermann Test. There are numerous 
modifications which are in many instances more valuable than 
the original technic as described by Wassermann. The prin- 
ciple of this test has been applied to the diagnosis of gonorrheal 
infections, whooping cough and quite recently tuberculosis, and 
it may be stated that it can be applied for the detection of any 
infectious disease where the etiology is known. The only dif- 
ference being the use of the specific antigen, the technic being 
similar. 

The Wassermann test for syphilis is looked upon as very 
reliable evidence of infection with treponema pallida. A posi- 
tive reaction obtained by a reliable serologist to my mind is 
diagnostic evidence of syphilic infection, even though the pati- 
ent denies all knowledge of an initial lesion. Unfortunately, a 
negative Wassermann reaction does not warrant us in dismiss- 
ing syphilis from a suspected case, and this result like negative 
results in other conditions, should not be considered proof of 
the absence of infection. It is important, however, to obtain a 
negative Wassermann reaction in patients who are known to 
have been infected and who have been under vigorous treat- 
ment. It is well in these cases that the test be repeated at fre- 
quent intervals over a period of several years and after pro- 
vocative administration of potassium idodide or a small dose of 
salvarsan. 



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JOHy A, LANFQRD, 296 

The complement fixation test in its application to Neisserian 
infection, has not met with general use, probably because of 
the ease with which these infections are usually diagnosed. 
However, there are cases of suspected gonorrheal -arthritis or 
endocarditis when a complement fixation test is of great im- 
portance, and a positive result indicates a focus of living gon- 
ococci. It should be applied to all cases of posterior urethritis 
and a negative result obtained before a patient is pronounced 
cured. 

Within the past few years, this test has been applied to the 
diagnosis of whooping cough and it has proven a very valuable 
aid to the earlier diagnosis of this condition. It gives positive 
information before the clinical evidence is diagnostic. This is 
a very important fact, as it enables the physician to execute 
treatment at an early date, and also to isolate the case. 

In the past eighteen months laboratory workers have shown 
that the application of this test in the diagnosis of tuberculous 
infections oflFers positive information and in the active and 
incipient cases and also the early latent cases a positive fixation 
result is obtained in over 90 per cent examined. This informa- 
tion oflFers an early dia^niosis to those deep-seated and incipient 
cases in which the clinical findings are not absolutely certain 
and enable the physician to institute proper hygienic and thera- 
peutic measures early. 

It is an unfortunate fact that many very important condi- 
tions are not associated with a characteristic change in the 
blood either in the cell proportion or the serum content which 
enables us to arrive at a definite diagnosis. The principal dis- 
eases of this group are the malignant tumors, carcinomata, sar- 
comata, non-bacterial diseases of the nervous system, as demen- 
tia precox and pregnancy. The eflfort of Abderhalden was 
along this line and although he devised a test which was her- 
alded as a positive aid in the diagnosis of pregnancy either 
intra or extra uterine, his results have not been confirmed by 
the best workers and the test has not generally been accepted. 
The principle of the Abderhalden test is theoretically sound, but 
its present application is faulty ; however, it is probably only a 
question of time before his test will be made of value. 

Chemical Composition : For many years physiologists have 
been able to determine the variation from the normal of the 
chemical content of the blood serum, but only recently have 



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296 BLOOD EXAMINATIONS. 

these tests been simplified so that their performance could be 
carried out in the small clinical laboratory, and at the present 
time it is fairly easy to determine the functionating capacity 
of the kidneys by estimating the amount of urea in the blood 
and the amount of non-coagulable nitrogen in the same fluid. 
The information thus obtained is of vast importance in the 
study of diseases of the kidney and determining the functional 
capacity of those organs in cases of nephritis. • 

The study of the chemical composition of the blood serum 
has advanced quite rapidly within the last few years and at the 
present time we have tests available for the determination of 
the various products of metabolism, such as uric acid, urea, 
crenatinin and other purin bodies, as well as the sugar content 
of the blood. Most of these are rather too complicated for the 
clinical laboratory, but the determination of the blood urea and 
total non proteid nitrogen of the serum is sufficiently simple 
to be carried out in the ordinary laboratory. 

The estimation of the blood sugar content is a common study 
in diabetic patients and offers great information as to effect 
of the diet treatment of this disease. 

Workers at the present time are studying the carbon-dioxide 
tension of the blood in conjunction with that of the expired air 
in certain diseases. Their findings have a bearing on the prog- 
nosis of conditions, but offer little information from a diagnos- 
tic standpoint. 

This brings us to a study of the blood from the standpoint 
of hematogenous micro-organisms. These examinations are 
made in two ways by smear and culture, both of which are very 
important and offer valuable information. First, is an exami- 
nation of stained blood smears. By this means we are able to 
recognize certain infectious organisms protozoan in type, such 
as malaria, filaria and trypanosomiasis. The examination for 
malaria infection is by far the most common and in the major- 
ity of instances shows the presence of these protozoan organ- 
isms attached to the red blood cells. Occasionally these bodies 
are present in large numbers and are therefore easily founds 
but at times in chronic infections and some cases of estivo- 
autumnal types, it is very difficult to find them in the ordinary 
way. We then resort to the use of a thick film and sometimes 
to the centrifuging of the blood. The finding of these organ- 
isms is positive diagnosis of infection, although a negative re- 



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JOHy A. LANFORD. 297 

suit is not evidence of the absence of these parasites from the 
circulating blood. 

The second method of examining blood for invading organ- 
isms is that of culture by which we are able to demonstrate the 
presence of bacteria in the circulation. This method is appli- 
cable to all cases associated with a bacteriaemia whether pro- 
duced by the ordinary pyogenic organisms or those associated 
with a peculiar type of fever. The principal types of speti- 
caemia are those produced by the staphylococcus, strepococcus, 
pneumococcus, B. coli and gonococcus. Among the other 
types of diseases are typhus and typhoid fevers. 

The finding of the specific organisms enables us to make 
a definite diagnosis of these diseases. Typhoid fever can be 
diagnosed much earlier by means of a blood culture than in any 
other way. In a large proportion of cases within the first week 
of the disease, the typhoid bacilli are detected by culture in 
the circulation. As the body produces immune substances the 
proportion of positive cultures becomes less and in the second 
and subsequent weeks this procedure does not offer as much 
diagnostic aid as does the demonstration of the immune sub- 
stances by means of the agglutination test or Widal reaction. 

While it is not within the domain of practice, it may not be 
amiss to mention the fact that blood examinations are at 
times of vast importance in certain medico-legal cases where 
the nature and type of blood stains are in question. By means 
of the precipitin test we are able to determine positively from 
what animal a given stain is derived. 

I realize that the above is only a resume of the subject and 
I have only lightly taken up the various divisions. However, 
it is possible that I have shown that the examinations of the 
blood are becoming more common as our knowledge increases 
and the limitations will not be reached until man has lost his 
energy and his desire to help his fellowman. 

I would like to impress upon the profession the importance 
of blood examinations and I would also like to add that while 
in many cases the blood findings are absolutely diagnostic, still 
it must not be supposed that they can take the place of clinical 
examinations and findings, as only by the closest corroboration 
between the clinician and the laboratory worker will the bene- 
fits to the patient be of the highest type. 



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298 BLOOD EXAMINATIONS. 

BLOOD EXAMINATION. 

1. Cellular: 

Erythrocytes 
Total number 

Percentage of coloring matter 
Variation in size, shape and staining reaction 
Primary anemia 
Secondary anemia 
Chlorosis 
White Cells (Leucocytes and Lymphocytes) 
Total number 
Differential count 
Neutrophilic increase 
Lymphocytic increase 
Lymphatic leukemia 
Whooping cough 
Influenza 
Syphilis 
Tuberculosis 
Eosinophile increase 
Intestinal parasites 
Asthma 
Skin diseases 
Intestinal toxemia 
Mononuclear (endothelial cells) increase 
Malaria 
Typhoid 
Myelocytes 

Myelogenous leukemia 

2. Serum: 

Immune substances 
Agglutinins 

Typhoid and allied organisms 
Dysentery and allied organisms 
Influenza 
Tuberculosis 
Complement Fixation Substances 
Syphilis 
Gonorrhea 



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JOHy A. LANFORD. 299 

Tuberculosis 

Whooping cough 
Chemical Composition 
Blood sugar 
Protein nitrogen 
Non protein nitrogen 

3. Extraneous Invaders : 
Protozoa 

Malaria 

Filaria 

Trypanosomes 
Bacteria 

Typhosus 

Coli 

Streptococci 

Pneumococci 

Gonococci 

Treponema Pallida 

Staphylococci 

DISCUSSION. 

Dr. J. S. Turbeville, Century, Fla. : I hesitate to even try 
to discuss this paper. However, I am going to discuss it strict- 
ly from the standpoint of the general practitioner, and try to 
emphasize some of the things the doctor brought out. I wish 
to express my appreciation of the paper. 

The blood examination is at times worth everything. That 
is particularly true in febrile conditions. I would like to em- 
phasize that, because in the country where you have a lot of 
fevers to my mind the blood examination for the presence of 
malaria, carefully conducted, will eliminate malaria in a febrile 
condition — understand, gentlemen, I am not talking about 
chronic malaria ; I am talking about acute febrile malaria. What 
does that mean ? That puts us on our guard right there against 
one of the worst infections we have, and that is typhoid fever. 
I think in the first stage of any febrile condition if a man will 
make a careful blood examination for malaria and eliminate 
malaria, that puts him on his guard, and he can begin imme- 
diately his prophylaxis for typhoid fever. If we did but just 



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SOO BLOOD BXAMINATIOyS. 

that one thing in general practice we would do the greatest 
good to our community we can think of. If you begin the first 
days your prophylactic measures against the spread of typhoid 
fever you will not need much vaccination, though this is not a 
talk against vaccination. This will prevent typhoid getting 
into the whole family. It has been my rule for a number of 
years in the practice of medicine, that if I cannot find malarial 
organisms, I tell my people that I cannot tell what it is yet, but 
I begin protection of the family right here. That is a practical 
point for that particular phase. 

Now there is one point where we are often handicapped in 
blood examinations for malaria. The people have gotten in the 
habit of taking quinine, and a good dosing with quinine before 
you get your blood makes it very difficult to find malarial or- 
ganisms, and you frequently cannot find them where they are 
present. Of course, the doctor has mentioned cases where you 
cannot find them anyway. That is especially true in cases that 
have taken quinine. In these cases I would not advocate that 
a man wait very long to give his quinine because his patient 
might suffer as a consequence of waiting, but I certainly would 
try to make the diagnosis if possible. 

The doctor has called attention to septic infectioa You can 
conduct your malaria examination and the examination for 
septic infection at the same time. You can make a differential 
blood count while you are looking for your malarial organisms. 
Remember that malarial and septic infections present an oppo- 
site picture. In malaria you have a relatively high l)rmphocyte 
count and in septic infections a relatively high pol)rmorphonu- 
clear count. 

The doctor spoke about the serum reactions. I have had 
very little experience with the serum reactions, because the 
country practitioner cannot do them, but I use the laboratory 
on all these cases. Seven to ten days after I get a febrile pati- 
ent I submit specimens of the blood for a Widal reaction. 

I will just touch on the hemoglobin, and that is practical to 
all of us. But I wish to state that there are some pitfalls in 
the hemoglobin estimation. I once had a patient with cancer 
of the stomach, and it was so diagnosed, and I had a consultant 
who said it probably was not cancer of the stomach because of 
the high hemogloblin. The patient had never had a hemor- 
rhage, had never had pain, never much indigestion, conse- 



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JOHN A. LANFORD, 801 

quently he had had nothing to produce anemia. So we had no 
r?ght to draw that conclusion. 

Now, pernicious anemia — I think a man who does much 
blood work will b^n to suspect pernicious anemia from an 
ordinary blood smear. From any of the malaria stains you 
can get a suspicion of pernicious malaria. Remember, gentle- 
men, it takes more careful study to work it out, 

I would warn against sending a blood smear to the labora- 
tory and saying nothing about it. Let the doctor know what 
you wish, and he will make a more careful examination along 
that line. I do not believe that the average routine blood exam- 
ination is worth nearly as much as to make a specific examina- 
tion for something you have in mind. 

Leukomias — of course, those are all cytologic diagnoses. 

I have spoken of some of the limitations in examinations for 
malaria. When, investigating deep pus infections, there is 
something right here. I remember doing a foolish thing. I 
spent an hour once examining a man's blood whom I suspected 
of appendicitis and I carefully worked out my blood picture, and 
when I got through I told the doctor. I says, "Well, we have 
done a foolish thing. You see that boil on the man's lip." He 
had a furuncle on his lip. So, right there, if we had noticed 
that we could have saved ourselves some work. The man did 
have appendicitis, but we could not have told anything about 
it so far as the blood picture went. 

The doctor spoke of influenza having a lymphocytosis. I 
just wish to point out something you can gather right here as 
regards complications. Most pneumonias have a polymor- 
phonuclear leucocytosis ; so in your cases of influenza if you 
have a polymorphonuclear leucocytosis, why it is time to suspect 
a complication, whether it is tangible or not, it is time to suspect 
it and begin to look for it. 

Now, I would warn against negative findings. I know men 
all over your State and all over every state that take most any 
negative laboratory finding as negating the presence of that 
particular disease. That is especially true of sputum examina- 
tions for tubercle bacilli. You have no idea the doctors who 
think that a negative finding negatives the presence of that 
disease. Those examinations should be repeated, and, of 
course, constant repetition with negative results means some- 
thing. 



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802 BLOOD EXAMINATIONS. 

Now the interpretations of laboratory findings — I believe 
that I have a little quarrel with the laboratory men about the 
interpretation of their findings. I believe it is their duty to 
interpret their findings to the average man, because there are 
a lot of us who do not know what certain things mean. I have 
had to ask questions myself, and I have had other people ask 
me questions about the reports they got. So I would ask the 
laboratory men to give us some idea of what it means. Of 
course, the clinician's first duty is to submit a skeleton of the 
clinical history of the case to the laboratory man. 

Dr. W. W. Harper, Selma: Dr. Lanford's paper is very 
valuable. A practical point that struck me is this: The im- 
portance of blood examination in fevers with obscure causes. 
The clinical symptoms of typhoid in the early stage are so 
similar to those of other fevers that it is very hard sometimes 
to make a diagnosis. A Widal is, of course, useless until about 
the 8th day of the disease, and as the most dangerous period 
of typhoid is in the beginning, it behooves us to use every 
means of identifying the disease as early as possible. A smear 
will in most cases give you an idea of what you are dealing 
with. It will indicate a leucocytosis or a leucopenia. If there 
is an apparent leucocytosis, typhoid and malaria may be ruled 
out, and one may feel certain that "there is pus somewhere." 
If the smear shows a decrease in leucocytes, look out for ty- 
phoid or malaria. A differential gives valuable information. 
If it shows an absence of eosinophils, — this with a decrease in 
leucocytes, would suggest the wisdom of "typhoid precautions.'' 
In cases of malaria a smear would show a leucopenia, an in- 
crease in endothelials, stippling and polychromatophilia. These 
findings would make you strongly suspect malaria even after 
quinine has been administered, which, of course, drives the 
parasites out of peripheral circulation. 

In cases of infection caused by a pus producing organism a 
total leucocyte count and differential give a point on prognosis,^ 
— which is this: An increase of neutrophiles — say about 90 
per cent, and a total leucocyte count of 8,000 or 10,000, means 
a severe infection and poor resistance. Of course a similar 
picture may be found during the first few hours of illness in 
those cases of severe, virulent infection before the leucoc)rtes 



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JOHV A, LANFORD, 803 

have had time to respond to the call. A later examination will, 
in favorable cases, show a marked increase in white cells. A 
high percentage of neutrophiles and a low total leucocyte count 
in infections of some standing usually mean a funeral. If a 
patient comes in with evidence of some acute abdcMninal condi- 
tion and the blood examination shows an increase of neutro- 
philes — say 90 per cent, and a low leucocyte count — say 6,000 
or 8,000, do not operate, — ^the patient is probably going to die, 
and the case would be one against surgery. If possible, tide 
him over and then operate later after he gets over the acute 
attack. If, on the other hand, the patient shows « large in- 
crease in leucoc)rtes with a mild increase in neutrophiles, he 
has good resistance with mild infection, — ^the patient would 
probably make a quick recovery after an operation. In other 
words, the neutrophiles are an index to the virulence of the 
infection, and the patient would probably make a quick recov- 
ery after an operation. In other words, the neutrophiles are 
an index to the virulence of the infection, and the leucocytes 

are an index to the resistance. 

- -i 

Dr. W. A. Sellers, Montgomery: I consider that the per- 
sonal equation is of the greatest importance in determining the 
value of blood examinations. In the hands of one man it might 
be worth everything, in another it might not be worth any- 
thing. There is one point, however, I wish to call attention to. 
In the presence of a virulent infection in some cases you find 
practically no leucocytosis in the peripheral blood. You have 
a chemotaxis, all of the leucocytes having gone to the seat of 
involvement. 

Dr. W. R. Jackson, Mobile : I have a question bearing on 
surgery I would like to ask our hematologists. Suppose a man 
had his leg crushed and the next morning he had an acute pain 
in his appendiceal region, and our hematologists make a blood 
count and find a leucocytosis, a polymorphonuclear or neutro- 
phil, am I supposed to operate for the appendicitis, or would 
he think the appendicitis problematic and the crushing trauma 
the cause? In other words, will trauma, will fright, will ex- 
citement, will an operation, will anesthesia cause as much leuco- 
cytosis as a pyogenic focus ? That is what I want to know. 



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804 BLOOD EXAMINATIONS. 

Dr. Lanford : I wish to thank the gentlemen for the interest 
they have taken in this paper and for the discussion of the 
paper. There are just two points I wish to mention, hardly 
within the domain of my paper, so that I could not mention 
them at that time. A great many of you are not equipped to 
do your own laboratory work. You send it to the men you 
have confidence in, some of you send it to the State Bacteriolo- 
gist. I want to say that when you make your blood smears for 
examination do not put a drop of blood on the end of the slide 
and expect the laboratory worker to tell you whether it is 
malaria or not. Everybody can make some sort of a blood 
smear on a slide. There are various methods. You might use 
another slide to smear it over, you might use a toothpick or a 
piece of cigarette paper. But do not leave a small drop of 
blood on the end of a slide. The results are bound to be nega- 
tive if you do. If you want the Widal reaction made, the 
laboratory worker can make that from a smear as well as from 
a drop of blood. Discontinue putting a drop of blood on the 
end of a slide. Smear it over. Do not send just one smear 
to make one test, but send several. 

With reference to the question which Dr. Jackson asked, I 
will say that I do not consider that either anesthesia or trauma 
can give you as high a leucocytosis as a pyogenic infection. I 
do not think the laboratory worker alone, with the facts that 
he has, in every case can tell whether the leucocytosis is due 
to a pyogenic infection or some of the other conditions men- 
tioned, but that the clinician will have to follow up his clinical 
findings and then compare them with the laboratory findings 
and draw his conclusions, because they will not be the same in 
every case. 



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CHLOROSIS. 



IBBY C. Bates, M. D., Taylor. 

Chlorosis may be defined as a form of anemia in which there 
is an excessive reduction of the amount of hemoglobin over 
that of the reduction of the blood corpuscles ; usually occurring 
in girls about the age of puberty, and often associated with im- 
perfect development of the genitalia, and sometimes of the 
heart and blood-vessels. 

Etiology.-^The causes of chlorosis are not definitely known, 
but among those most generally accepted may b6 mentioned the 
following: faulty hygiene, tight lacing, overwork, mental anx- 
iety, improper food, constipation, and family predisposition, 
indoor work and lack of sunlight. It seems to be more preva- 
lent in those who have recently changed from a warm to a 
colder climate. The majority of cases occur between the ages 
of fourteen and twenty-one. The association of gastro-intesti- 
nal derangement gives rise to the opinion of some that it is an 
auto-intoxication. Handmann believes that the association of 
chlorosis and thyroid enlargement in twenty-five out of forty- 
four of his cases cannot be a coincidence. 

Pathology. — ^There is a hypoplasia of the aorta and arteries, 
and a defective development of the uterus and ovaries has been 
found in many cases. The heart is often in a condition of 
hypertrophy with dilatation. 

Blood-findings. — The color index is low. The hemoglobin 
running from 12 to 75 per cent, its average being about 45 
per cent. The red blood corpuscles are not proportionately 
decreased, often being nearly normal in number. Their aver- 
age size is a little smaller than normal. The red blood cor- 
puscles show a great loss in coloring matter. The leukocytes 
are not increased. The specific gravity of the blood is de- 
creased. 

Symptoms.^-The subjects presents a characteristic pallor, 
which in some cases assume a transparent waxy, greenish hue. 
They are usually well nourished. There is no loss of flesh and 
these subjects often appear somewhat stout. 

20 M 



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806 CHLOROSIS. 

There is marked dyspnoea on exertion. In severe cases there 
is slight cardiac dilatation, soft, full pulse, venous stasis and 
sometimes slight edema of the lower extremities. 

Menstruation is usually very scant, of a pinkish color, and 
irregular. There may be complete amenorrhea. May be dys- 
menorrhea. Digestive disturbances are common. 

There may be palpitation of the heart and pulsation of the 
peripheral veins. 

Emotional and nervous symptoms are common. The sub- 
jects often become morose and despondent, hysterical or melan- 
cholic. 

Attacks of gastralgia are frequent and gastric ulcer or 
phthisis may occur as complications. 

Functional cardiac murmurs may be detected. Headaches 
and neuralgia may be present. 

Diagnosis. — An examination of the blood, showing the 
marked disproportion between the hemoglobin per cent and the 
number of red blood corpuscles usually makes the diagnosis 
easy. 

Prognosis. — Death from chlorosis is rare but the condition 
has a tendency to become chronic and relapses are frequent. 

Treatment. — The treatment of chlorosis consists of the ad- 
ministration of iron and arsenic with the proper hygienic and 
dietetic measures. 

In beginning the treatment it is best to put the patient to 
bed for at least a week. Open the bowels well with castor oil 
or preferably fractional doses of calomel. 

Give them a light diet rich in iron-containing foods — ^vege- 
tables, eggs, fish, meats, milk, cream, etc. 

Have them take a cool bath once or twice a day. 

Give these patients plenty of fresh air and sunshine, but do 
not allow over-exertion. See that they have intervals of rest 
and plenty of sleep. 

If the condition occurs in school girls it is best to take them 
out of school for some time. 

Almost any form of iron may be given, but probably the 
best is Basham's Mixture in doses of two drams three times a 
day. 

Arsenic may be given in the form of Fowler's solution or 
in the form of sodium cacodylate. 



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IRBY C. BATES. 307 

DISCUSSION. 

Dr. William C. Maples, Scottsboro : The last speaker men- 
tioned bad hygiene and bad habits as causes of chlorosis. 
In that statement I do not think he is borne out at all, 
the fact being that chlorosis occurs rather more fre- 
quently among the better class of people than among those 
with bad hygiene. I have to take issue with him on that. I 
have done a lot of practice among very poor people, and chloro- 
sis is not common among them at all. The treatment is all right. 
Iron is the great remedy for chlorosis. It is almost a specific. 
The preparation I like is reduced iron. 



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THE DIFFERENTIAL DIAGNOSIS AND TREATMENT 
OF THE LEUKEMIAS. 



Chilton Thobington, M. D., Montgomery. 

The terms leukemia and leucocythemia were proposed by 
rival claimants for priority of discovery. Virchow proposed 
the term leukemia, while Hughes-Bennett used the term leuco- 
cythemia. From an etymological standpoint leucocythemia is 
more descriptive of the blood findings, meaning white-cell 
blood ; while leukemia simply means white blood. 

Von Leube designates leukemia as a disease characterized 
by an increase in the number of white cells in the blood, as the 
result of morbid activity of the blood forming organs, and in 
which the blood alteration forms the essenial feature of the 
progressive and pernicious course of the disease. 

Two classes of leukemia are described, the myelogenous, 
and lymphatic. Either class may become chronic or acute, and 
by some investigators it is claimed that they have different etio- 
logic factors; however, this would seem to be improbable, 
inasmuch as chronic leukemia may have an acute onset as well 
as an acute termination. 

Although leukemia is more common in middle life, and in 
males, cases occur in quite young infants, and in the aged. It 
usually runs its course in three or four years ; however, it may 
prove fatal within a few weeks, or continue its pernicious 
course for a number of years. 

It is said of leukemia that it is the only disease affecting 
alike man and the lower animals, such as the ox, sheep, dog, 
hog, cat, and chicken. 

The early symptoms of myeloid leukemia are those of other 
anemias, viz : indigestion, anorexia, headache, weakness, short- 
ness of breath — amounting to dyspnea on exertion — palpita- 
tion, faintness, and, as claimed by some authorities, priapism. 
These symptoms are insidous in onset, and are followed by 
emaciation, fever, and splenic enlargement, possibly lymphatic 
enlargement ; however, Cabot states that he has never detected 
lymphatic enlargement in the myeloid type of. leukemia. Hem- 
orrhages are the most unfailing symptom, and may be the first 



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CHILTON THORINGTON. 809 

cause of real alarm to patient, or the impelling influence caus- 
ing him to seek medical aid. They may take place from any of 
the mucous membranes, especially the stomach, or into the skin 
forming large pupuric spots. When occurring into the brain 
hemiphlegia may result or, indeed, sudden death. Dropsical 
swelling appears as a late symptom. The urine contains albu- 
min, casts, and an excess of uric acid. 

The blood picture of myeloid leukemia is characteristic, dis- 
tinguishing it from all other diseases. In recent cases its gross 
appearance may not differ from the normal, but in extensive 
cases it is pink, and more opaque. In some cases it may be 
quite dark, even cholocate color. Coagulation is slow, or may 
be absent altogether. The red cells are diminished in number. 
Osier's average count being 2,800,000, however, it may be as 
low as 500,000. Poikilocytes, marcrocytes, and microcytes, are 
rare, but normoblasts may be found in large numbers, and ac- 
cording to Emerson, are best studied here. Hemoglobin is re- 
duced, giving rise to a low color index — usually about .5. 

A hyperleucocytosis of 500,000, or more, is not an unusual 
finding in leukemia, however in a few cases, and just before 
death, a leucopenia may be observed. Neutrophilic myelocytes 
predominate, and may constitute 30 to per cent of the white 
cells, while basophilic myeloc3rtes are next in importance in 
diagnostic significance, being 5 to 10 per cent. Eosinophilic 
myelocytes are also found, but never as many as the above. The 
neutrophiles, while increased in number, are relatively dimin- 
ished, rarely exceeding 40 per cent. L)miphocytes, both large 
and small, are found. Indeed it is the polymorphorous state 
of the blood that impresses us. 

Acute lymphatic leukemia, as described by Ebstein and 
Fraenkel, is charatcerized by suddenness of onset, by its febrile 
course, and its resemblance to that of a severe acute, infectious 
disease. The onset is not accompanied by enlargement of 
spleen or glands — at least not noticeably so — ^but the most prom- 
inent clinical feature is a hemorrhagic tendency of the disease ; 
it has the appearance of hemorrhagic purpura, and. may be 
confounded with this, especially as the hemorrhages may occur 
before the characteristic blood picture is formed. 

Stomatitis and tonsillitis are early concomitants of the dis- 
ease. 

The following case of acute lymphatic leukemia was instruc- 
tive as my first diagnosis was typhoid fever. 



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810 TREATMENT OF THE LEVKEMIAB, 

Patient, negro, male; age 19. — History negative, except ty- 
phoid fever two years previous. Denies ever having had 
syphilis, or malarial fever. 

Symptoms : Onset sudden, first noticed by headache, fever, 
and prostration. It was not until the advent of hemorrhages 
from the stomach and bowels that he applied for medical ad- 
vice. 

Physical Examination : Tonsillitis but no stomatitis. Tem- 
perature range from 100 to 103. No splenic or glandular en- 
largement. To obtain sufficient blood for a Widal, white cell 
count, and smears, some six or seven deep stabs had to be made 
into the finger tips, and even then only a few drops could be 
obtained. Widal was weak positive. Leucocyte count could 
not be made, however there was an enormous number of Xyvci- 
phocytes, most of them were the small variety. The positive 
Widal may have resulted from the antecedent typhoid fever, or, 
as we some time find, from other processes not understood. 

Chronic lymphatic leukemia is charatcerized by its protracted 
course, by painless enlargement of the lymph glands, and prob- 
ably some enlargement of the spleen. Pallor and emaciation 
are manifest. Continued hemorrhages provoke anemia which, 
in turn, causes viceral changes, especially in that of the heart 
giving rise to myocardial insufficiency. 

The blood shows a hyperlymphocytosis, especially the small 
lymohocytes, which may represent 90 per cent of all the white 
cells. Limbeck considers that the blood picture in this form 
of leukemia is not sufficient for a diagnosis, since in some cases 
of lymphosarcoma the blood findings may be similar. 

In a few cases of lymphosarcoma in which I examined the 
blood the lymphocytes were increased, but not to the extent 
found in lymphatic leukemia. A case of lymphosarcoma re- 
cently referred to me for blood examination showed nothing 
unusual, however, he had just returned from Johns Hopkins 
where he had been treated with radium. 

In making a differential diagnosis of leukemia from other 
diseases, we must rely largely upon the blood findings in leuke- 
mia, as in no other disease is the blood formation similar. 

The anemias are to be differentiated by process of exclusion 
and inclusion. The pernicious type, which at first sight may 
be considered leukemia, will fail to show glandular and splenic 
enlargement, and the blood picture is quite different. The most 
striking thing about the blood of pernicious anemia is the great 



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CHILTON THORINOTON, 311 

reduction of red cells, with a relative increase of the hemo- 
globin. The color index is always above unity, and quite fre- 
quently as high as 1.8. Poikilocytes and megalocytes are numer- 
ous, and it has occurred to me that inasmuch as the red cells 
are so greatly reduced in number, the megalocytes are but red 
cells considerably distended by reason of the additional hemo- 
globin — (which may be as much as 25 per cent to 75 per cent) 
— crowded into them, which finally rupture, giving rise to the 
irregularly shaped poikilocytes. Polychromatophilic degenera- 
tion is extensive in pernicious anemia. The megaloblasts should 
outnumber the normoblasts, otherwise, according to some au- 
thorities, a diagnosis of pernicious anemia is not justifiable. The 
leucocytes are not increased, and the lymphocytes may equal, 
or exceed the neutrophils in number. 

Splenic anemia, from a clinical standpoint, may have many 
symptoms in common with leukemia, especially myeloid leuke- 
mia. The patient shows unusual pallor, or may actually be 
lemon color. He presents symptoms found in the anemias with 
the additional symptoms of hemorrhages, and enlarged spleen. 
At times the spleen is greatly enlarged, extending to the median 
line, and occupying much of the left side of the adbominal cav- 
ity, displacing part of the vicera. The heart may be pushed 
upward until its apex beat is found in the fourth intercostal 
space. 

The blood picture in splenic anemia is nothing like that in 
leukemia. The red cells and hemoglobin are reduced, but a 
leucocyte and differential count will determine that this is not 
a leukemia, inasmuch as the leucocytes are reduced in number, 
and there is nothing unusual regarding the white cells. 

Hogkin's Disease, or pseudo-leukemia, may resemble the 
leukemic state because of the enlarged lymph glands, and the 
anemic course of the disease, but here again will the blood 
examination assist us in differentiating the two diseases. Be- 
yond a moderate anemia there is nothing extraordinary regard- 
ing the blood of Hogkin's Disease. A microscopical examina- 
tion of one of the excised glands should settle all doubt. 

Tubercular lymph glands are more localized, and more irreg- 
ular in shape than is found in lymphatic leukemia. The blood 
presents nothing unusual, therefore a diagnosis must be made 
by exclusion, or by microscopical examination of one of the 
excised glands. Tuberculin injections will be followed by tem- 
perature reaction if the process is tubercular. 



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812 TREATMENT OF THE LEUKEMTA8. 

Syphilitic glandular enlargement may have to be excluded 
before considering the patient leukemic. The blood is negative 
in so far as resembling leukemic blood ; however, it should give 
a positive Wasserman ; failing in this one of the glands should 
be punctured with a hyperdermic needle and some of the sub- 
stance of the gland placed under a darkfield condenser, and 
search be made for the treponema pallida. 

Simple leucocytosis is to be differentiated from leukemia by 
the transiency of the former, and by the preponderance of the 
neutrophiles. 

Causal treatment in leukemia is impossible, as the etiology 
of the disease is yet to be discovered. Arsenic for many years 
was the drug most used. It was given in the form of Fowler's 
solution, but more recently the newer forms of arsenic are 
used, such as atoxyl, soamin, and sodium cacodylate. Louis 
Mix advocates the treatment of these cases with neosalvarsan, 
given intravenously ; he adopts this treatment on the hypothesis 
that leukemia is due to a form of spirochete. Glandular and 
splenic enlargement is reduced by X-ray treatment, but other- 
wise the disease continued uninfluenced. According to letters 
received from Hot Springs, Ark., the radio-baths are not help- 
ful. Dr. Martin states that any improvement these patients 
receive is attributed to X-ray. 

Benzol has received critical study by leading therapeutists, 
as relates its action upon the leucocytes in leukemia — which 
would appear to be selective — inhibiting cell proliferation in 
leukopoietic tissues, resulting in a more normal quantitative, 
and qualitative leucocyte count. It is claimed that benzol is 
more potent in the chronic type of leukemia, and less potent, 
or actually dangerous, in the acute type. The dose of benzol 
recommended is from one to two drachms daily. It is best 
administered in capsules with equal parts of olive oil. 

Should white -cell proliferation be due to over-activity of 
some ductless gland located within the brain which presides 
over the lymphatic glands, it would not be unreasonable to ex- 
pect a cure of leukemia with properly selected endocrins. 

No matter what plan of treatment is adopted in the leuke- 
mias, many organic proprietary preparations are exploited for 
the associated anemia; but after all too much reliance cannot 
be placed in these highly organized products, inasmuch as these 
beautiful — though frail — structures may become reduced to 
their original elements by the iconoclastic action of the gastric 
juices. 



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HEMOPHILIA. 



F. W. WiLKEBSON, M. D., Montgomery. 

Hemophilia is a "hereditary constitutional anomaly charac- 
terized by severe, often uncontrollable, bleedings." The hemor- 
rhage is usually from trivial cuts or bruises, or it may be spon- 
taneous. 

The first American article on this subject was written by Dr. 
John C. Otto, and the first American bleeder, whose detailed 
record was given, was Oliver Appleton, of Ipswich, Mass., 
early in the eighteenth century. 

Etiology : The disease is almost always congenital, though 
cases of apparently spontaneous origin do occur ; usually there 
are a large number of cases in one family, and the tendency of 
the disease is to skip one generation and appear in the next. 
Males are more frequently affected, but it seems to be trans* 
mitted by females. In other words, if a man belonging to a 
hemophilic family marry a healthy female there will be no 
hemophilic children ; but if a female of a bleeder. family, though 
herself healthy, marry a healthy man, there are very likely to 
be hemophilic children. That the disease does not always skip 
a generation is proven by the case of a friend of mine — a man 
in my class in medical college. This man's father and himself 
were both bleeders, the father finally dying from a severe, un- 
controllable nosebleed. In this case, the transmission was not 
through the mother, for she came of healthy stock. Night 
blindness and color blindness are somewhat similar to hemo- 
philia in that males are usually affected, and the disease usually 
spread by females. The disease seems to be more common in 
Northern climates than Southern, and usually occurs in the 
earlier years of life. It is exceedingly rare for the onset to 
occur after the twenty-second year. If a hemophilic live to 
adult life, the tendency is for the trouble to improve, though 
this is not always the case, as is shown by the instance just 
mentioned of the man dying from the nosebleed, which occur- 
red about his sixtieth year. Blondes seem to be affected more 



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814 HEMOPHILIA. 

than brunettes. Many cases of hemorrhage occurring in new 
bom infants are due to sepsis, and should not be mistaken for 
true hemophilia. 

Pathology: Formerly it was thought that hemophilia was 
due to great fragility of the blood vessel walls, but this idea has 
been discarded and the most commonly accepted theory today 
is that it is due to failure of the blood to clot. The normal 
method of blood clotting is the formation of fibrin, from fibri- 
nogen, which is previously present in the circulating blood. 
This does not occur spontaneously, but only when the fibri- 
nogen is acted upon by thrombin. Thrombin is not normally 
present in the circulating blood, but is formed after the blood 
has been shed from three other substances; prothrombin, cal- 
cium salts And thrombokinase. Pro-thrombin and calcium salts 
are present in the circulating blood, and thrombokinase is pres- 
ent in the formed elements of the blood and tissues generally. 
There is much belief, too, that the blood platelets in some way 
aid in the formation of thrombin. To summarize — ^thrombin 
is formed from the interaction of pro-thrombin, calcium salts 
and thrombokinase, and fibrin from the interaction of thrombin 
and fibrinogen. 

There are many ways in which the phenomena of hemophilia 
are explained, and one of the most convincing theories is that 
of Addis. He. considers that the delay in coagulation is due 
to the slow formation of thrombin rather than to lack of inter- 
action between thrombin and fibrinogen after the thrombin has 
been formed, and he considers further that the slow formation 
of thrombin is the result of an inherited anomaly in the blood 
which causes an abnormally long time for the formation of 
prothrombin. The addition of calcium salts to the blood does 
not hasten the coagulation time in any way. 

There are many other theories as to the delayed coagulation 
time, none of which are more than theoretical, but this one of 
Addis' is to me the most convincing yet offered. 

Symptoms: Occasionally prodromal symptoms precede the 
onset of bleeding, such as headache, plethora, palpitation, a 
feeling of tightness, etc. These, however, are rare. The char- 
acteristic symptoms of the disease are severe bleeding following 
very slight trauma, or occurring spontaneously. The hemor- 
rhage may be classified according to location, as external, in- 
ternal and synovial. Of these, the most common are the ex- 



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F. W. WILKER80N. 816 

temal with epistaxis, occurring much more frequently than any 
other. Next in order of frequency, come hemorrhage from the 
gums, stomach, intestines, urethra and lungs. Fatal hemor- 
rhages may follow the extraction of a tooth, a slight nasal 
operation or a tonsillectomy. The bleeding in this disease 
usually lasts for hours, and some time ago I saw a man whose 
gums had oozed constantly for four days following removal of 
a tooth. One injection of horse serum stopped it, after all 
local applications had failed. In female bleeders, menstruation 
and parturition do not seem to be attended by any ill effects, 
and the flow is apparently no greater than in normal women. 
Internal hemorrhages are not so common as external, though 
large hematomata may occur as a result of muscular action. 

Synovial or joint hemorrhages are quite frequent, the knee, 
ankle, wrist, elbow, hip, being involved in order of frequency. 
The joint may fluctuate and there may be a rise of tempera- 
ture, causing the condition to be mistaken for a septic joint. 
The blood may be absorbed in a short time, or may remain, 
become organized and ankylosis be the final result. 

There is usually no change in the blood, except the delayed 
coagulation time, until after there has been numerous hemor- 
rhages or one severe one, when the blood picture will be that 
of a secondary anemia. 

Diagnosis: The family history is the most important point 
in the diagnosis of this disease. No single hemorrhage, no mat- 
ter how bad, warrants the diagnosis. The hemorrhage of the 
new bom is usually septic in nature, and should not be re- 
garded as being due to hemophilia. 

Purpura may be difficult to distinguish from hemophilia, 
but in purpura the coagulation time of the blood is not delayed 
as it is in bleeding. In purpura, the blood platelets are consid- 
erably reduced in number, which is not true of hemophilia. In 
hemophilia the hemorrhage is usually from one site, but in pur- 
pura the hemorrhages are multiple and not associated with any 
trauma, as is usually true of hemophilia. 

As already mentioned, there is possibility of mistaking a 
hemophilic joint for a septic joint, and the possibility of hemo- 
philin should be borne in mind in all acute joint conditions. 

Prognosis : This is always bad, but if the patient survive the 
adolescent period, the tendency to severe hemorrhage often 
ceases. In many cases, however, as already stated, the hemor- 



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816 RBMOPHILIA. 

rhagic diathesis still persists, and fatal hemorrhages may occur 
late in life. 

Treatment — Prophylaxis: Hemophilics should not marry, 
especially the females of hemophilic families. All children of 
hemophilic families, during their childhood, should be care- 
fully protected, and every endeavor should be made to keep 
them from even slight injury. Surgeons should not undertake 
the slightest operation without first ascertaining the patient's 
family history in regard to bleeding. Failure to do this has on 
more than one occasion resulted in the death of the patient 
from hemorrhage, and in damage to the surgeon's reputation. 
Hemophilics of all ages should lead lives of comparative quiet, 
with careful regulation of diet, bowels, and all that pertains to 
personal hygiene. Every effort should be made to keep in 
the best possible condition. 

Local Treatment: The usual measures for the relief of 
hemorrhage should be applied to the bleeding spot : firm pres- 
sure, the usual styptics, and, if necessary, application of throm- 
bokinase in the form of an extract of lymph gland, thymus, or 
testis. The part should be kept at rest, and any loose clots 
removed, as these sometimes interfere considerably with the 
cessation of the bleeding. 

Medical Treatment: Some years ago the calcium salts 
were extensively used on the theory that a deficiency of calcium 
was responsible for the delayed coagulation time. With the 
more recent work done in this connection this has been shown 
to have been an erroneous conception, and clinically it was 
found that these preparations were of little value. Their use 
has now practically been abandoned. Many other drugs which 
were supposed to have a styptic effect have been employed, but 
apparently without benefit. 

Serum Treatment : The trial of blood serum in these cases 
was first introduced by Weil, and this has proven to be by far 
the most efficacious treatment yet discovered. Fresh human 
serum is the best that can be used, but serum, already prepared, 
as anti-diphtheritic serum, or other animal serum, can be used 
if necessary. It is better to employ this intravenously than 
hypodermically, because a hematoma is apt to form when a 
hypodermic is given to a hemophilic. The dose is 20-30 c. c. 
hypodermically, and 10-20 c. c. intravenously. This treatment 
can be given for emergency use, and it also can be given be- 



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F. W. WILKER80N. 817 

tween hemorrhages as a prophylactic, injections being given at 
intervals of several days for a more or less indefinite period, 
depending on the response. The son already mentioned in this 
article would take a series of injections of human serum upon 
the appearance of even a slight epistaxis. Then he would have 
a long period of quiescence, resorting again to the serum on the 
occasion of the first sign of blood. The serum always stopped 
the bleeding, and kept him free much longer than any other 
treatment. 

In the last few years transfusion has been employed with 
success in a great many instances, especially when the hemor- 
rhage has been sufficient in extent to endanger the life of the 
patient. 

DISCUSSION. 

Dr. W. W. Harper, Selma: I had hoped to show a very 
interesting case and had arranged for the case to be present, 
but after our program became disarranged, I telephoned him 
not to come. This case was a little boy, a hemophiliac. This 
child came under my care some two years ago for a slight bleed- 
ing from the gums, having fallen and broken a tooth. We 
recognized that he was a hemophiliac and gave him, first, anti- 
toxin,— ^the only serum we had being some diphtheria anti- 
toxin. That helped the condition. Later on, after giving sev- 
eral doses, I gave him coagulose. This seemed to improve 
him for a while. When he ceased to improve, we gave him 
serum from his mother's blood. The child did well for a while, 
and then I lost sight of him for several months. The last of 
February the child was brought in with the history of having 
had a general convulsion. When I saw the boy he could not 
stand on account of paralysis of the left leg, he was having 
tonic contractions of the left forearm and his face was drawn 
to the left side, — showing a left-sided hemiparesis. The symp- 
toms indicated cortical hemorrhage over the right motor area. 
I began giving the boy serum from the father. This was Tues- 
day. I gave him 20 c. c. of his father's serum as soon as I 
could prepare it. This was repeated Wednesday. On Thurs- 
day I was called about 2 a. m. to see the child, who was in a 
general convulsion. I suppose it took me fifteen minutes to 
reach the hospital, and the convulsion lasted five minutes after 



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318 HEMOPRILIA. 

I reached the hospital. At 6 o'clock he had another convulsion. 
The child then had complete paralysis of the arm and I con- 
cluded that there had been further increase of the hemorrhage. 
I at once injected into the boy's thigh 20 c. c. of whole blood 
from the father. In twenty-four hours the child began to im- 
prove. I repeated the injection every day for several days and 
then every other day ; then once a week until the present time. 
There was very little pain. The boy began to improve at once, 
had no more general convulsions, and today he hasn't a sign 
of paralysis anywhere. The whole thing has cleared up. For 
the first time in the boy's life he is eating as a normal child 
should, his color is good and he is rapidly gaining in weight. 

I want to advise the use of whole blood instead of blood 
serum. Take the father's blood, not the mother's. It is a 
peculiar thing that this disease always skips a generation. The 
mother inherits this tendency, does not transmit it to her 
daughter, but does transmit it to her son ; but when her daugh- 
ter marries, she transmits it to her son and not to her daughter. 
Therefore, do not use the mother's blood because it seems to be 
deficient in the thing that causes coagulation. 

You know, of course, that we should use only the blood of 
relatives in transfusion. This spring we stumbled on a point 
which I believe is very important for the pediatrician and for 
the surgeon. A few months ago some one stole the sheep 
which we kept for Wassermann purposes and we had to go 
out into the country for sheep blood. A lamb was caught and 
in attempting to draw blood from the heart the needle was in- 
serted several times, — securing only a very little blood. As the 
lamb was very young, we thought it best not to stick it too 
many times so another sheep was used and the blood from the 
two animals put into the same container. When I reached the 
laboratory there was not a single red cell in the container, — 
the blood of one sheep had hemolysed that of the other. Had 
one of them been the mother of the other, the chances are that 
hemolysis would not have occurred. ' On another occasion I 
had to go to a flock of sheep in the country for blood and after 
the sheep were driven about a mile I procured blood from one 
of them and, as usual, put it into sodium citrate. When I 
reached the laboratory this, to, was hemolysed, — there was not 
a single red cell. The explanation, I believe, is this: When 
the blood was drawn the animal was very tired and hot — and 



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F. W, WILKER80N. 819 

this, in some way, produced hemolysis. The point is this : Do 
not use the blood for transfusion from a man or woman who is 
worn out from a day's work or who is very warm, — for the 
the same thing may happen that occurred with the sheep, — ^the 
blood of the patient may be hemolysed by that of the donor, — 
and there will be a funeraL We do not know that this would 
happen, but we are not going to try it. 

In giving blood to hemophyliacs, two points should be kept 
in mind : Use the blood of the father, — the whole blood, not 
just the serum, and see that the father is not tired or hot. 

Remember that hemophilia skips one generation, — the daugh- • 
ters do not have it, — a wise provision because if they did the 
chances are that the mothers would all die during parturition. 

Dr. T. B. Hubbard, Montgomery: I have had two cases 
of hemophilia that have taught me a great deal. The first case 
I had was a baby two weeks old with bleeding from the um- 
bilicus. The parents were healthy, neither one of them specific, 
and the child before that had been a healthy child. I was called 
in to see him when he had been bleeding for several hours. At 
first I did not think it was a hemophiliac. So I simply, there in 
the home with the doctor, took a piece of silk and ran around 
the imibilicus and drew it tight. That stopped the bleeding and 
I left it alone. That was midday. At six o'clock that after- 
noon we went back again and it was oozing. We took it to the 
hospital, and gave it some coagulose. It kept on oozing, and I 
thought I would see if I could not tie it tighter. I put in some 
deep sutures and tied them over a roll of gauze. Gave him some 
more coaguolse. About midnight it was still bleeding. I opened 
it up with, and included the umbilical stump and the wound in 
figure of eight sutures of heavy linen. It stopped bleeding and 
I thought it was going to be all right. The child started to 
oozing again and bled to death. The point I want to make is 
that there is no use wasting time trying to stop the bleeding 
point ; we must get at the hemophiliac condition. 

In another case that I have had just recently I was a good 
deal more successful. I saw a child, a healthy child, one week 
old, that had bleeding from the umbilicus. I did not do any- 
thing locally except to take a little coagulose and apply it lo- 
cally. Then I gave it a dose of coagulose, and immediately 
drew some of the father's blood and gave four ounces of the 



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320 HEMOPHILIA. 

father's serum, and the baby never bled after that. The whole 
treatrtient in this case was directed to the child's serum and 
not to the local condition. So I think we should not waste any 
time in bothering with the local condition. And, as Dr. Harper 
has brought out, there is no particular use in stopping to let 
corpuscles settle before we take the serum. It is just as well 
to use the corpuscles and the serum, as the corpuscles are not 
in the least toxic. All we have to do is to draw the blood off 
and inject it into the child immediately, and I believe that is as 
efficient as transfusion and it wastes no time, and is far more 
•simple in technic. 

Dr. H. S. Ward, Birmingham: One little practical point 
about hemopilias is that you are liable to mistake a hemorrhagic 
diathesis in which you have an acute hemorrhage from a hemo- 
philiac patient. As I view a hemophiliac patient it is one who 
has hemorrhages at all times. That is a familial disease ; they 
were bom with it and they will die with it. No familial disease 
can be permanently cured. In the case of all of the familial 
diseases, such as progressive muscular atrophy, there is no cure 
for them. That is an inherited thing, and we get it like we get 
the color of our hair and eyes and our general features. Now 
in the case of many of these babies that have these acute hemor- 
rhages it is a blood dyscrasia. Of course, the treatment is the 
same, you give them this serum, the whole blood, or blood trans- 
fusion. That cures them for the time. The same thing is true 
in typhoid hemorrhage; typhoid hemorrhage does not mean 
that it is a hemophilia. You give them the serum and they get 
well. In these children who have had hemorrhage you treat 
them like any other hemorrhage, but as years go by and they 
get another injury they will bleed just as badly as they ever did. 
Apparently this blood from the father to the child will cure 
them for a certain length of time. Until thbse bodies, whatever 
they may be — which apparently no one has definitely made out 
— gotten from the father and given to the child, when they are 
all used up, the child is back in the same stage it was when it 
was born, still a hemophiliac, and, as I say, any one who is 
born a hemophiliac will die a hemophiliac. Take Dr. Harper's 
case ; his case will have to be watched the rest of his life. They 
must prevent in this child all types of injuries as far as possible. 
When the injuries do come you treat them as suggested. As 



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F. W. WILKER80N, 321 

soon as it uses up the coagulant bodies secured from the father 
it will then be a bleeder. Now a blood dyscrasia and a hemo- 
philia are entirely different things. In these infants where you 
do not get a history, it is usually a dyscrasia. Whole blood is 
better than serum, but the serum alone will stop it. If it is an 
oozing horse serum will stop it, but if the bleeding is from a 
large vessel it will not do any good. If it is a large vessel you 
must tie the vessel if you expect any results. 

Dr. H. L. Castleman, Sylacauga: I had not expected to 
discuss this paper. I do not expect to add anything particu- 
larly to the splendid paper of Dr. Wilkerson, but since Dr. 
Ward has spoken I thought that I might report a case that I 
had of hemophilia. I was suprised and put out not to be able 
to find anything on this subject in the texts at hand. I watched 
the case. I delivered the mother. I was called the second day 
to stop a hemorrhage from the umbilicus. I thought it was 
because it had been handled roughly. I succeeded in stopping 
the hemorrhage, and in the course of time the child was brought 
to my office almost exsanguinated from a little nick on the 
side of the thumb. I saw the child from time to time and made 
the diagnosis of a bleeder. Dr. Ward tells us that there is no 
cure for it. That is why I am reporting this case. I saw that 
child, as I say, from time to time, and I have seen it all cov- 
ered with hemorrhagic spots, hematomas under the skin; I 
have seen it covered from its head to its feet; one large one 
over its right eye which suppurated and caused a great deal of 
trouble. Finally it stopped bleeding and healed with an im- 
mense scar. 

There was one thing that I noticed in treating that child, and 
the only thing that I could find in the literature that was ad- 
vised, and that was the use of aromatic sulphuric acid. I gave 
it all the armoatic sulphuric acid I could get the people to ad- 
minister, and as long as they were giving it the spots would all 
clear up, but in the course of time would return. So, if there 
is no cure and if you know you have a bleeder, in my mind, 
from the experience I had with that case, you will find that aro- 
matic sulphuric acid will do about as much good as anything 
else. I saw the child in a number of bleeding spells, but the 
last trouble it had it stumped its toe, which caused it to bite the 
side of its tongue. That happened at five o'clock in the after- 

21 M 



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822 HEMOPHILIA, 

noon, and there had been an attempt before I saw the child to 
close the cut with a suture. When I saw the child it was 
about two or three o'clock in the morning. The child was 
almost exsanguinated. I gave it horse serum, emetine, in 
fact I ran the gauntlet of usual remedies, but, as I say, the 
child was almost exsanguinated, and died about nine o'clock 
in the morning. My reason for reporting the case was my 
experience with aromatic sulphuric acid when the child would 
be covered with hemorrhagic spots and hematomas, which so 
long as continued seemed to benefit temporarily, at any rate 
cleared up the hematomas. 

Dr. Minehiner: I would like to report three cases in one 
family, apparently a healthy woman, no history of bleeders or 
of syphilis in the family, two males and the last a female. They 
all had hemorrhages come on about the fifteenth day and they 
all died. We used horse serum. The hemorrhages were in 
the form of hematomas under the skin and also from the umbil- 
icus after it had apparently healed. We used mattress sutures 
in the first case, and even the suture holes bled. In the last 
case the mother refused to allow any treatment, for which I 
didn't blame her. 

Dr. Thorington : I won't take up any more time. Describ- 
ing the disease is the most we can do for it. We haven't yet 
found a cure, and the patients get worse and worse until they 
finally die. 

Dr. Wilkerson : I appreciate the discussion very much, and 
I was especially interested in the work of Dr. Harper. The 
work he did on hemolysis is very interesting, and it will be in- 
teresting to hear what it may lead to. He said that invariably 
the disease skips a generation. That is not always so, as 
proven by the case I mentioned of father and son. That could 
not have possibly been transmitted through the mother, because 
there was no history on her side. 

I think that these cases of hemorrhage in the new bom that 
get well, I do not care what you give them, are not true hemo- 
philiacs. As Dr. Ward so well said, they have some blood 
dyscrasia, a good many are septic, and they may bleed from 
other causes, things we do not know anything about. They 



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F. W. WILKER80N. 323 

are not true hemophiliacs unless they have the tendency to bleed 
as long as they live. Sometimes as they get very old they seem 
to be free and have no further hemorrhages, but if the hemor- 
rhagic tendency persists then you can be sure that you are deal- 
ing with a true hemophiliac. The most important point in the 
diagnosis of hemophilia is the family history. No single hemor- 
rhage, no matter how severe, is sufficient to warrant the diag- 
nosis of hemophilia. 

The most efficacious treatment is serum, but if they get well 
and stay well they haven't true hemophilia. 

Dr. Griffin: I am mighty glad to have heard the doctor 
read his paper on pituitrin. I have been using the drug ever 
since it first came out, and the more I use it the better I like it. 
I feel that it has shortened labor in every instance where I have 
ever given it, and it has saved the physician a great deal of 
time, and it is perfectly safe if used with proper precautions 
and if not given too early. I just want to thank the doctor for 
his paper and I wanted to ask him the size dose that he admin- 
istered. He failed to mention the size dose he gave. I gen- 
erally give about ten minims every five or ten minutes. I think 
you can get excellent results when administered that way. 



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CAESAREAN SECTION. 



TucKEE H. Frazeb, M. D., Mobile. 

In presenting this paper to this distinguished body, I make 
no apology for its brevity or for its freedom from the classical 
review of the literature upon the subject. I deem it more im- 
portant rather, at this time, to endeavor to magnify the opera- 
tion as a life saving one, and to direct the thought of every one 
present to the basic principles that have placed the operation 
upon such a high and safe plane. 

Do we approach the operation known as Caesarean section 
with fear and misgivings, or with almost absolute certainty of 
success? The many intervening years from the time of the 
first authentic operation by Trautman to the time of Sanger, 
witnessed the gradual evolution and perfection of the princi- 
ples as embodied in the operation under discussion include two 
things, viz., a thorough architectural knowledge of the female 
pelvis and the parturient canal, and a thorough grounding in 
antiseptic surgery. Our modern teaching embraces both, and 
I go so far as to say that no one should dare to enter upon 
obstetric practice who is lacking in knowledge of either. 

When we stop to consider the frightful fetal mortality and 
maternal morbidity that have been demanded as toll for ignor- 
ance in this field of practice, w^e can not be too grateful for 
the advent of antiseptic surgery and the marvellous victory that 
it has achieved in placing Caesarean section in the category of 
other abdominal operations ; and besides the surgeon, familiar 
with laparotomies for other, and, oftentimes, more serious con- 
ditions, has been emboldened to perform lapora-hysterotomy 
as a choice of election, and has been rewarded by a success that 
challenges the admiration of the entire profession. 

My aim is to make clear to the members of the Association 
that the operation is now one of safety, and whether the indi- 
cation for the operation be absolute or relative, it can be done 
without fear or trepidation. In any given case the obstetrician 



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TUCKER H, FRAZER. 326 

wishes to save mother and child, and in the procedure he has. 
the satisfaction of knowing that no harm can result to the fetus 
and that the mother escapes with a minimum amount of trauma. 
When one reflects upon the statistics of the morbidity, to say 
nothing of the loss of maternal and fetal life accompanying 
other operative procedures, he can only marvel that the profes- 
sion has been so slow to adopt the section as a method of re- 
lief. May I be so bold as to declare that with the proper 
technic, the mortality should be nil, and if I can indicate to you 
the things that enhance good technic, I may be able to stimu- 
late a desire to seize the opportunity to substitute Caesarean 
section for other operations. Defeat is more often than not of 
one's own choosing. And that disregard of the two basic prin- 
ciples will negative the most careful operative technic. 

In pointing out the indications for what is termed conserva- 
tive Caesarean section, I shall make clear the reasons that 
guided me in the cases that I have had. In some the indica- 
tions were absolute and in others relative. In explanation of 
the two terms, "absolute" and "relative," I would say that 
Caesarean section is absolutely indicated when the dystocia, 
either maternal or fetal, is so great that it is impossible to re- 
move the fetus even by mutilation, such conditions as tumors, 
neoplasms, and exostoses, can produce such narrowing as to 
necessitate the operation. If discovered before gestation is far 
advanced, these may be removed, or danger anticipated by do- 
ing a therapeutic abortion. Of course, if allowed to remain 
until labor, the obstetrician has but the one recourse — opera- 
tion, — to save the mother. A true conjugate of 6 cm. or 6J/4 
cm. with a dead fetus would give an absolute indication, and 
when mother and child are to be saved, a true conjugate of 
6.5 cm. to 9 cm. would give an absolute indication. A wider 
range is embraced by the term ^'relative/' When I decide, for 
instance, that the section will give better results as to mother 
and child, than embriotomy, pubiotomy or symphysiotomy, or 
even at times, forceps, I place the case in the relative category. 
However, there are cases coming under this head, and because 
of conditions surrounding them cannot be classed as fit sub- 
jects for section. To illustrate : cases of prolonged labor, fre- 
quent and questionable manipulations, futile attempts at for- 
ceps delivery. In the face of such conditions, choice should 
be between that of mutilation and a laparo-hysterectomy. 



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326 CAE8AREAN SECTION, 

More than a quarter of a century ago, an authority declared 
that embryotomy in case of a greatly contracted pelvis was as 
dangerous to the mother as Caesarean section, and that since 
the former operation always sacrificed the child, we should not 
wait too long before resorting to the latter when other means 
of delivery fail. As a rule, I should say, that, placenta praevia 
is not a relative indication, yet it has been made one by some 
operators. The risk to the mother should always be consid- 
ered in case of placenta praevia, and the demand for an effort 
to save the fetus should be urgent. I include also as a relative 
indication, an unyielding cervix and undilatable external os. T 
have, in my statistics, a case of this kind, and so fortunate was 
the outcome that I am almost persuaded to agree with Newell 
that Caesarean section offers more to the mother than does 
instrumental interference, followed by nervous shock, pros- 
tration and morbidity. In the light of present day surgery, the 
operation should be done more often and with the supreme 
idea of saving mother and child, and with the additional idea, 
in suitable cases, of protecting the mother against subsequent 
pregnancy, by sterilization, as accomplished by section and 
burying of the oviducts. 

Before taking up the consideration of the conditions to be 
met in doing the operation, I desire to recapitulate. If the 
fetus, even after mutilation, cannot be delivered, the indica- 
tion is positive. If mutilation of a dead fetus can be done 
without too great risk to the mother, the operation is relative. 
If the fetus be living, and embryotomy can be done without 
risk to the mother, the operation is relative. If the conjugate 
vera is 7.62 cm., and the fetus be alive, or if the conjugate 
vera is 7 cm., and the fetus dead, the indication is positive. A 
generally contracted pelvis, in the presence of a normal size 
fetus, is always a menace to the mother if embryotomy is at- 
tempted, and it is here that Caesarean section offers most. 

Reliable statistics show that Caesarean section is rapidly be- 
coming one of the safe operations. My own record of ten 
cases, covering several varieties as they relate to the etiology, 
show a negative mortality for the ten mothers and eleven 
babies. My own success is due to three things: mother and 
fetus in good condition, well equipped operating rooms, and 
competent assistants. 



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TUCKER E. FRAZER. 827 

Every operator realizes that certain conditions must be met. 
This rule does not apply to the "absolute" indication, because 
here the fetus can be removed in no other way, and whether the 
woman has been infected or not by preceding treatment, it 
must be removed. For relative indication the mother should 
be a fit subject and the fetus be viable. I should not, in the 
presence of a relative indication, proceed if the fetus were a 
monster. As pointed out by the precedins: speaker, the X-ray 
is now a valuable aid in clearing: up this question. The woman 
should be in no daneer from the anesthetic, or from shock be- 
cause of kidnev or he^rt disease. Gonorrheal infection would 
be a bar to a relative Caesarean section. It is also desirable that 
the cervix be patulous and that labor has begun. Herein is 
the danger of operating for placenta praevia; viz., hemor- 
rhasre on account of badly contracting uterus. Many operators 
prefer to anticipate labor, claiming many advantages from 
careful and unhurried preparations for the operation. 

If the case is one of election, no pains should be spared to 
place the patient in the best condition possible for the opera- 
tion. If one of emergency, no detail shrould be omitted from 
the beginning to the end of the operation. I am now to empha- 
size the point that every case of Caesarean section should be 
one of election, and not of emergency, barring, of course, the 
infrequent cases of eclampsia and placenta praevia. The pro- 
fession should now be able to properly diagnose the condition 
demanding surgical interference, and I should be bold to advise 
the procedure. All doubt as to whether the case is one of abso- 
lute or relative indication should be promptly settled. 

A thorough working knowledge of pelvimetry should be the 
claim of every doctor who offers to practice the obstetric art. 
And the application of this knowledge should keep pace with 
the application of the principles of modem surgery. When 
the obstetrician engages to care for his patient during the 
period of gestation and to conduct her safely through the 
period of labor, he should at once fortify himself with knowl- 
edge as nearly complete as possible concerning the size and 
shape of the pelvis of his patient. If a primipara, this knowl- 
edge should be so exact as to reveal whether or not a normal 
sized fetus can pass through, and whether the physician be long 
or early from the school room, he should be thoroughly familiar 
with the method of obtaining this knowledge. If I can stim- 



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328 CAE8AREAN SECTION. 

ulate thought and arouse a spirit of determination in regard 
to a more honest relation between physician and patient in 
this field of practice, I shall not have spoken in vain today. 
Many physicians, otherwise excellent surgeons, hesitate to ex- 
tend relief here because of the fear of failure, and on the other 
hand, many physicians invite failure by a careless disregard of 
the essential of success. The well equipped hospital enables 
the physician to approach the operation with absolute certainty 
as to the details of technic, and this leads me to speak of the 
technic of this operation. 

If possible, the patient should be in the hospital several days 
before the expected date of the operation. If this cannot be 
done, the patient should have the best possible care, as to gen- 
eral health, in the home. All pathologic conditions should be 
treated, and strict attention should be paid to all of the emunc- 
tory organs. The bowels should receive special attention in the 
way of laxatives and enemata. The immediate preparation of 
the patient is that for other laparotomies, and, if deemed ad- 
visable, the additional safeguard exercised by having the vagina 
carefully cleansed before the operation. 

You have discovered that no allusion has, thus far, been 
made to extra-peritoneal Caesarean section and vaginal Caesar- 
ean section, and therefore for the purpose of this paper, I shall 
omit any description of these methods of operating, and shall 
not indicate the technic of either. 

I deem it of much importance that the operator have a clear 
knowledge of the position of the fetus, and also of the loca- 
tion of the placenta even before the patient is placed on the 
operating table. This knowledge is obtained by careful palpa- 
tion and auscultation. Success depends upon scrupulous regard 
to details in every step of the operation. 

The operator needs few instruments, the outlay as compared 
to that for other operations is indeed modest. Two knives, 
two pairs of scissors, one-half dozen artery clamps, two pairs 
of tissue forceps, eight curved needles, two needle holders, No. 
2 and No. 1 chromicized 20-day cat gut, silk worm gut, plain 
No. 2 cat gut ; and if there is probability of a Porro operation 
to be done, there should be ready for use 2 or 3 retractors, one 
dozen pedicle clamps, vulsellum forceps and angular clamps. 

I employ five assistants, in addition to the anesthetist, — one 
to assist me directly in supporting the abdominal tumor and 



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TUCKER H, FRAZER. 829 

subsequently to wall off the peritoneal cavity and compress the 
uterus after it has been delivered from the cavity ; one to han- 
dle instruments ; one to handle sponges, and one to receive and 
care for the infant. I emphasize the importance of having a 
level-headed assistant for the duties first mentioned. The pati- 
ent is catheterized after being placed on the operating table, 
and before the final sterilization of the abdomen. Assuming 
that from 20 to 30 minutes will be consumed in anesthetizing 
the patient, I have an assistant give 30 minims of ergotole 
hypodermatically just as the anesthetist begins his duties. When 
the anesthetist announces that the patient is almost ready, the 
skin of the abdomen is iodinized, and the occlusive sheets placed 
over the patient. Now when I am ready to make the adbomi- 
nal incision, I have the assistant give 1 c. c. pituitrin hypo- 
dermically. 

The first step in the operation is the abdominal incision, 
which is made in the median line extending from 3 or 3J4 
inches above the umbilicus to the same distance below, and to 
the side of the umbilicus. Care is to be observed because of the 
thin wall, the scalpel coming quickly upon the uterine wall, and 
there is danger of incising the wall too early. I prefer to com- 
plete the incision through the abdominal wall with the scissors. 
At this step, after the needed number of artery forceps have 
been applied, the cavity is carefully protected by means of 
towels placed between the uterus and the abdominal walls, 
pressure on the sides of the abdominal tumor being made by 
the chief assistant, which forces the uterus firmly into the open- 
ing made by the incision. Inspection of the uterus to ascer- 
tain the degree of rotation, if any, is now made. If the uterus 
is found to be rotated on its axis, the incision now to be made 
will not correspond with that through the abdominal wall, but 
must be made midway between the comua. The uterine inci- 
sion is not quite as long as the skin incision, and my rule is to 
make this incision before delivering the uterus from the abdom- 
inal cavity, but if indications pointed to a Porro operation, I 
should deliver the uterus before making the incision. Incision 
into and through the uterine wall results in hemorrhage, which 
may appear formidable. You cannot now regard hemorrhage, 
but must proceed to enlarge the opening to the full extent. The 
placenta may be implanted on the anterior wall of the uterus, 
if so it must be pushed aside or be bored through by the hand 



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830 CAE8AREAN SECTION. 

of the operator. As a rule the membranes are ruptured or 
cut on opening the uterus. The amniotic fluid, although it 
floods the field of operation, can not enter the abdominal cavity, 
because the first assistant is making pressure. On thrusting 
the hand into the uterine cavity, an effort is made to seize a 
foot by which the fetus is extracted. Sometimes the head, if 
not engaged, is the first part of the fetal elipse to be seized. 
Extraction should not be hurriedly done, but the hand first 
introduced should not be removed from the uterine cavity un- 
til this is accomplished. The fourth assistant now receives the 
infant, the cord is clamped by two forceps and cut between the 
clamps. The placenta is now removed, as well as all of the 
membranes, care being taken to go over the inner wall of the 
uterus with a gauze sponge. Now observe if the os is patu- 
lous, because good drainage must be assured. At this step, I 
place a good sized gauze sponge into the uterine cavity, and 
then lift the uterus out of the abdominal cavity, my first assist- 
ant simultaneously placing a towel under the uterus, thereby 
protecting the abdominal cavity from blood contamination. 
Hemorrhage is still going on, but it can be controlled as soon 
as the uterine sutures are placed and ligated. 

I proceed now to place three rows of sutures, using for the 
first row No. 2 chromic 20-day cat gut, and for the other two 
rows No. 1 chromic cat gut. In placing the first row, I intro- 
duce the needle into the outer surface, J4 inch from the margin 
of the wall, and bring it out in the wall, barely missing the edge 
of the inner wall — it is re-introduced into the opposite side 
of the cut, barely missing the inner wall and coming out on the 
external surface % inch from the margin — this row of sutures 
are placed yi inch apart, and are not tied until the next row 
has been placed. Now with No. 1 chromic cat gut, on a full 
curved needle of proper size, I place the second row of sutures 
between the sutures of the first row. The needle is introduced 
into the muscle of the walls of the uterus, avoiding the serous 
covering, and brought out in the same side }i inch from the 
endometrium, re-introduced into the opposite wall, J/g inch from 
the endometrium and brought out just free of the serous coat. 
Having placed the second row, I proceed to tie the sutures of 
both, first tieing the first deep suture and the first muscle su- 
ture, then the second deep suture, and so on until all are tied 
and cut very close. As the sutures are tied the gauze in the 



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TUCKER H. FRAZER, 881 

Uterus IS gradually removed. Now with No. 1 chromic, I place 
a continuous suture through the serous coat, which coapts the 
edges of this coat, and completely hides the row of interrupted 
deep sutures >4 inch apart. The uterus is now returned to 
the abdominal cavity, the intestines drawn up out of the 
pelvic cavity, and the omentum placed behind the uterus. The 
abdominal wall is now closed after the approved methods em- 
ployed in other laparotomies. 

In the way of after treatment, I advise immediate cathe- 
terization of the bladder; morphine, if needed, for pain for 
first 24 hours ; one-half drachm doses of ergot is given every 
6 hours for three days. The child is put to the breast within 
24 hours, and on the morning of the third day, the bowels are 
moved by castol oil. I remove the silk worm gut abdominal 
sutures on the eighth day. I allow the patient to sit up at the 
end of the fourteenth day, and begin to walk at the expiration 
of 21 days. 

I ask your indulgence in being allowed to describe four cases 
that seemed to me to be typical cases, illustrating the different 
features of the operation. 



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MORBIDITY FOLLOWING CONFINEMENT. 



W. F. Betts, M. D., Evergreen. 

In the introduction to his text book on the Principles and 
Practices of Obstetrics Joseph B. DeLee makes the assertion 
that labor in woman should be, but is not a normal function ; 
that it is safe to state that 20,000 women die every year in the 
United States from the direct or indirect effects of labor and 
that 50 per cent of women who have had children bear the 
marks of injury and will sooner or later suffer from them. He 
concluded with "Can a function so perilous that in spite of the 
best care it kills thousands of women every year, that leaves 
at least a quarter of the women more or less invalided, and a 
majority with permanent anatomic changes of structure, that 
is always attended by severe pain and tearing of tissue, and that 
kills 3 to 5 per cent of children, can such a function be called 
normal ? 

In the opinion that labor is not a normal function he is sup- 
ported by many authors of wide experience and observation. 
Whether or not we take this view we all recognize the fact 
that even under the most favorable environments the morbidity 
attending and following labor is great. Our chief concern, 
therefore, is to so look after our patients before, during and 
after labor as to reduce the injury done to a minimum, for 
prevent it entirely we can not. The lack of the laity in recog- 
nizing the seriousness of labor and its sequalae together with 
the lack of preparedness upon the part of the average attending 
physician accounts for the invalidism of many women. Twen- 
ty-five years ago when I was graduated from one of the leading 
medical colleges of the South I had never been present at a 
case of labor and my first experience along this line was any- 
thing but gratifying, as the mother of the young woman in 
labor became very much excited when the patient began to 
scream as the head came down and accused me of killing her 
daughter, (I had just given a vaginal douche against the moth- 
er's wishes) and as she had seen more cases of labor than I had 
I did not know but what she was correct Fortunately the 



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W, F. BETT8. 338 

case terminated favorably for the Gods were kind. Schools of 
today recognize the necessity of instruction along this line and 
I am sure that the more recent graduates are better prepared 
than older ones were and often still are to give the pregnant 
woman the proper attention. The title of the paper suggested 
to me by your honored president and my boyhood school-mate 
and friend, Dr. Henry Green, of Dothan, and which I agreed 
to prepare was Chronic Pathological Conditions Following 
Confinement — How to Prevent. From this text my article was 
prepared and this paper is only intended to deal with the pre- 
vention and not treatment of the diseases. This resolves itself 
into treatment and instruction of the patient before, during and 
after confinement. Where the physician is consulted early in- 
structions as to diet, exercise, clothing and the adoption of 
means and habits to prevent constipation as far as possible 
prove to be of benefit. Especial care should be taken in looking 
after the kidneys as they are generally recognized to be the or- 
gans that bear the strain of pregnancy the worst and frequent 
urinalyses for the detection of albumin and casts with the cut- 
ting down of nitrogenous elements of food to the minimum and 
the stimulation of the emunctory organs when the above condi- 
tions are found, help us to ward off convulsions at labor and 
chronic nephritis afterwards. The correction of mal-presenta- 
tions whenever possible and mensuration of the pelvis so that 
in disproportion of the foetus and outlet operative procedures 
may be resorted to before or at the time of delivering should 
be resorted to whenever practicable. However, the great ma- 
jority of women confined in the country are first seen by the 
attending physician when they are in labor and 'often the call 
to the labor case is the first intimation that the physician has 
that he is expected to deliver the woman. Even if notified 
earlier economic reasons and distance from the physician's of- 
fice precludes any instruction or treatment until labor actually 
sets in. Under these conditions the woman's welfare depends 
upon the treatment she receives during labor. DeLee places 
the confinement of a woman among the major surgical opera- 
tions and prepares for it as for any other major operation. 
However, the lack of asepsis here is not so fatal as it would be 
in abdominal surgery else practically all of the women deliv- 
ered by midwives would die and over one-half of those deliv- 
ered by physicians would meet the same fate. 



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884 MORBIDITY FOLLOWING CONFINEMENT, 

After labor many patients suffer from either celulitis, ovari- 
tis, cystitis, pyelitis, caused from infection, cystocele, rectocele, 
foecal incontinuence, from laceration of the pelvic floor, or a 
combination of several of these, together with a train of nervous 
symptoms making life miserable for themselves and all those 
about them. The prevention of these pathological conditions 
depend upon proper preparation of the patient, aseptic conduct 
of the confinement, judgment as to the length of the time the 
patient should be allowed to remain in labor without operative 
procedure, the use of anesthetics when indicated, repair of in- 
juries incurred during labor, the proper care of the lying in 
woman and the correction of malpositions of the uterus after 
the patient is up. The ideal place for confinement is a well- 
equipped hospital where the accoucheur has trained assistants 
and everything at his disposal. Here asepsis is easy to attain 
and the patient prepared according to the judgment of the phy- 
sician in charge, operations performed and injuries repaired 
under the most favorable conditions. In actual practice in the 
small towns and country the conditions vary from first-class 
to those that are anything but ideal. Occasionally with one 
wash pan for his hands and to wash the baby, no towels or 
soiled ones, a poor light, untrained assistants, if any at all, he 
is expected to bring the mother safely through labor with a 
living child and have them get along alright afterwards, and 
they usually do so in spite of adverse circumstances. Even 
under these conditions patient can be fairly well prepared. The 
vulva and adjacent parts should be well washed with an anti- 
septic soap and hot water with absorbent cotton. If old cloths 
only are available these can be made sterile by soaking in a 
bichloride of mercury solution and the thighs and legs wrapped 
in them. The bowels should be emptied by an enema and the 
patient is ready for her ordeal. Usually the conditions are bet- 
ter than those enumerated above and clean towels in abundance 
with pans and bowels are available. The physician should wear 
sterile rubber gloves if he has any cause to suspect that his 
hands are infected, otherwise hot water and soap with some 
antiseptic solution will render his hands safe. If any faeces 
escape during labor they should be caught on sterile cotton or 
gauze pads and carried away from the vulva. No vaginal 
douches should be given during labor as experience has found 
them to be worse than useless. No woman need te infected 



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W, F. BETTS. 386 

by the attending physician if the above precautions are ob- 
served. Laceration of the pelvic floor, of the support of the 
uterus, bladder and vagina occur in every labor "according to 
DeLee and he states that he has never seen a woman as anat- 
omically correct after labor as she was before. These lacera- 
tions convert the soft parts into an open wound favorable to the 
entrance of pathogenic germs and infections of the adjacent 
organs. Celulitis may then develop and under favorable con- 
ditions general septicaemia; if the perineum is badly torn pro- 
lapse or retroversion of the uterus occur later in life and if the 
sphincter ani is involved foecal incontinence occurs. Cys- 
tocele and rectocele follow a decent of the uterus and chronic 
catarrh of the cervix and the vagina may occur from infection 
caused by exposure from the open vagina. Precipitate labor 
is most often the cause of deep vaginal and perineal lacerations. 
Pituitrin is of benefit in uterine inertia and cases of tedious 
labor, but has to be used cautiously under normal conditions, 
as it has invariably, in my experience, caused considerable 
laceration of the perineum in all my primipara cases when used 
in full doses. Forceps delivery show 54 to 85 per cent of tears 
(DeLee). Unwillingness to wait for the completion of a nor- 
mal labor or the increased fee attached to forceps delivery some- 
times, not often perhaps, but sometimes are responsible for 
the use of forceps and injuries to the soft parts. When for- 
ceps are used, delivery should be done slowly and with care. 
Where the presenting parts are in contact with a rigid peri- 
neum chloroform or ether pushed almost to the point of surgi- 
cal anesthesia may allow the perineum time to dilate and save 
a severe perineal laceration. If lacerations occur to any but a 
slight extent they should be repaired as soon as the placenta is 
delivered, unless the condition of the patient or circumstances 
forbid. 

Immediate repair is generally followed by primary union and 
if the operation is not a success it does not interfere with an 
operation several months later. Many women date their ill 
health from an unrepaired perineum. Care should be taken 
to remove the placenta intact, either by expression Crede's 
method, or manually. If aseptic precautions are observed I do 
not believe that any harm results from the manual removal 
of the placenta, although this is not usually necessary. Re- 
tained portions of the placenta are conducive to infection and 



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886 MORBIDITY FOLLOWING CONFINEMENT. 

hemorrhage. The vulva should be dressed as an open wound 
with antiseptic or aseptic pads of cotton and gauze which 
should be changed as often as soiled. After each urination an 
antiseptic solution should be poured over the vulva. Cathe- 
terization should not be resorted to unless other means fail. 
Massage of the urethra, pouring hot water over the vulva, and 
hot applications over the bladder often cause the patient to void 
the urine when a catheter would otherwise be required. If once 
urine can be voided after labor catheterization is seldom re- 
quired, but if a catheter is once used it often is necessary to 
continue its use several days with the consequent danger of in-, 
fection of the bladder. If its use becomes necessary strict asep- 
tic precaution should be observed and urine rendered antiseptic 
by the internal administration of hexamethylene-tetramine. Be- 
fore leaving the patient the uterus should be examined exter- 
nally to see that it is well contracted and in position. The pati- 
ent should ordinarily be kept in bed nine or ten days and the 
position changed from the back to the sides and stomach to 
prevent uterine retroversion. No heavy work should be done 
until time has elapsed for the uterine supports to regain their 
strength and involution has taken place. After the patient has 
been up three or four weeks a vaginal examination should be 
made and if any misplacement found a well fitting pessary in- 
troduced to correct it. A pessary may usually be worn four 
or five months or longer without injury to the patient. It has 
been suggested that a pessary be introduced a couple of weeks 
after labor and worn as a preventive against uterine prolapse 
or misplacement. In view of the many misplacements follow- 
ing labor the idea appeals to me as being a good one. A good 
tonic to hasten convalescence should be given several weeks 
after the patient is up. 

SUMMARY. 

1st. Instruction of the patient from conception to confine- 
ment. 

2nd. Proper preparation of the patient for confinement. 

3rd. Cleanliness on the part of physician and septic conduct 
of the labor. 

4th. The prevention of lacerations to as great an extent as 
possible. 



I 



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TT. F. BETTS. 8t<7 

5th. Immediate repair of laceration, if possible, otherwise 
an operation later. 

6th. Intelligent after-treatment of the patient. 

These are, I believe, the cardinal points in the successful pre- 
vention of the common pathological conditions following con- 
finement. 

DISCUSSION. 

Dr. T. B. Hubbard, Montgomery : In the papers that I have 
heard here on obstetrics there is one thing that has impressed 
me very greatly, as far as the prevention of a lot of these mal- 
adies is concerned, and that is the question of hurry. Dr. Britt 
spoke of it this morning on the subject of oxytocics. Dr. Bates 
speaks of it now in the prevention of a lot of these troubles such 
as lacerations and infections. It is a question of hurry. I 
believe that the main cause of morbidity in obstetrics is the 
inability and the indisposition on the part of the busy practi- 
tioner to give a sufficient amount of time to the care of a labor 
case. It is not all the fault of the doctor. I do not know what 
you get around in the country for attending a labor case, but I 
do know that in most cases in the city if we get anything at all 
the fee ranges around twenty-five dollars. In other words, the 
people do not realize the importance of a case of labor and they 
are not willing to pay a doctor for sufficient and efficient at- 
tention. A man cannot give his time and attention suitably for 
a small fee in labor cases. Here in Montgomery I believe more 
and more cases are taken to the hospital and more and more 
attention is being paid to the proper care of cases of labor. In 
the prevention of morbidity in labor it is more important than 
anything else, to convince our patients that labor is not a phy- 
siological process like defecation. It may be in nine cases out 
of ten, but in that tenth case when you have to apply forceps, 
it is far from a physiological process, and it is a time when a 
man has to give his time and all his wisdom, and he needs all 
the assistance that he can possibly get. You cannot always "^et 
them to a hospital in the country, because you haven't always 
got a hospital, but if we can get them in a hospital they can be 
looked after better. We can keep them from havinir kidney 
complications, so that it will not be necessary to terminate the 
labor quickly with forceps and have these lacerations. So that 

22 M 



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888 MORBIDITY FOLLOWING CONFINEMENT. 

if we can get people to understand that we have to spend more 
time and therefore charge larger fees if necessary for labor 
cases we can greatly lower the morbidity and mortality. We 
cannot be aseptic if we are called in late and rush in just before 
the baby is born. 

Another thing about the repair of the perineum. Dr. Hutch- 
inson said yesterday that he did not believe a man ought to re- 
pair the perineum right after labor. That to my mind is not the 
case at all, and I do not think that most people believe that. It 
seems to me it is easier when the wound is fresh, when the 
muscles are relaxed ; just as we have relaxation of the sphincter 
ani in a hemorrhoidal operation, we have relaxation of the leva- 
tor ani muscle after labor. They are not going to retract ; you 
can catch them and sew them up without any trouble, and most 
of them are going to heal up, I believe, whereas, if you leave 
these cases alone it will not be a simple suturing, the uterus is 
going to sag, and we are going to have a complication of af- 
fairs. 

Then one other thing following Dr. Britt's paper of this 
morning. I did not hear much discussion of it and I did not 
have an opportunity to discuss it myself. The use of oxy- 
tocics in labor is a thing that has been carried to extreme. It 
takes time to dilate a cervix, it takes time to dilate the muscles 
of the perineum, and it takes time to soften up the structures so 
a child's head can be born, and we are meddling trying to 
terminate a labor in three or four hours where nature takes 
twelve or fifteen hours. 

Dr. T. J. Brothers, Anniston: One of the most frequent 
complications following delivery is, as we all know, infection. 
My experience has been that almost all those cases follow some 
operative interference or follow a long drawn out first stage of 
labor, and the way to avoid these complications is to avoid these 
two things if possible. It is practically impossible to avoid a 
long first stage in some cases. Of course, a woman who is 
thoroughly exhausted is much more liable to infection than one 
who is in good condition. How to avoid that I do not know. 
That is something that is mighty hard to do, but, as the doctor 
suggested, the question of hurrying to terminate the labor can 
be avoided, and in that way in a great many cases we can avoid 
operative interferencfe. As I say, the great majority of cases 



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W. F. BETT8. 889 

of infection have followed one of those two things, the cases 
where the cervix is a long time being dilated and the woman 
is almost exhausted before the second stage starts. And I think 
in that kind of a case we are justified in using forceps very 
much sooner than we would be where the first stage was short, 
because I think the danger from a long continued labor is 
greater than the danger of infection following the use of for- 
ceps. 

Another thing I have not heard mentioned in connection with 
the repair of the lacerated perineum. As the doctor just said, 
in any other field of surgery if you have a fresh wound the 
sooner you treat that wound and repair it and bring the surfaces 
together the better chance you have of getting union by first 
intention. And of course that is true of repair of the perineum. 
There is one thing in connection with it that I have not heard 
mentioned, and that is the suture material used. If you use 
cat gut you will get failure in a large percentage of cases, and 
if you use silk you will get failure in a large percentage of 
cases, because the silk acts like a wick and carries infection 
down into the tissues. The proper material is silkworm gut, 
and if that is used and the suturing is done immediately you 
will get a good result in almost every case. 

Dr. L. A. Jenkins, Birmingham: I would like to say one 
word in regard to these hurried up labor cases. I have been 
practicing medicine for about twenty-five or thirty years, and 
I do not think it is the time to hurry up. I have waited on as 
many as three or four women in one night, and I was not wor- 
ried ; I never got in a hurry ; and my experience is that if you 
sit around women they get in a hurry and make the doctor get 
in a hurry. I think if you go there and find you are going 
to save a slow, tedious case of labor, the patient is suffering 
and the women want you to do something, give her a hypo- 
dermic of morphine, and if you are satisfied that everything 
is all right — which you ought to be — give them plenty of time 
for that first stage; give them eight or nine hours; drop by 
and see if she is all right ; and in that way you will get up to 
your second stage of labor and you will find the parts very soft 
and pliable, and then get in a hurry if you want to; give her 
then the pituitrin, and in fifteen or twenty minutes your case 
will be over with and then you can go on to your others. I 
have done that a good many times and continue to do it. 



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840 MORBIDITY FOLLOWING CONFINEMENT. 

As far as lacerations are concerned, there is no doubt in the 
minds of a great many of us, and I say repair as soon as you 
have lacerations. Your woman has given birth and you have 
delivered the placenta. Th^ best ligature is silkworm gut. That 
has been my experience in some fourteen or fifteen hundred 
women I have delivered in my life. 

Dr. L. R. Stone, Taff : Some you need to hurry, and some 
need to be let alone. One rule will not work in all cases. You 
have to be the judge. Some it will do to give oxytocics to, and 
some to let alone. 

Dr. J. L. Snow, Montgomery: This is quite an interesting 
subject, and it seems from the discussion that every man has 
an experience of his own. Some get up and tell us that labor 
is not a physiological process. I do not understand how they 
could arrive at a conclusion like that. Every man that has 
ever been in the world, so far as I have ever been able to find 
out, except one, has come through that route, and I think that 
meddlesome midwifery is perhaps the cause of more trouble 
than almost anything else so far as labor is concerned, and a 
great many times no doubt the doctor does get in too big a 
hurry and does not give the patient long enough time for dila- 
tation to take place, but I do look upon it as being a physiologi- 
cal process, whether it is slow or whether it is rapid, and there 
are perhaps less lacerated pefineums than there are rectal ab- 
scesses, fissures and fistulas, and these are perhaps due to phy- 
siological processes also. 

As to repairing the perineum, I think it depends entirely on 
the individual case. If you have a slow, tedious labor, with 
considerable edema of the vulva, perhaps a repair would be a 
failure at that time. Tf the labor is not attended by edema and 
the discharge is not great, my experience is that a repair is suc- 
cessful at that time. Now I have had one case recently where 
I had considerable laceration, a primipara with a tedious labor 
had to be delivered with considerable force, and in this case 
repair would have been impossible owing to the amount of 
edema and would certainly have been an absolute failure. I 
think that these repairs should be attended to as soon as the 
adema subsides, and the results, it seems to be, would be suc- 
cessful. The other cases should be repaired at the time. 



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TT. F, BETTB. 841 

Dr. W. F. Betts, Evergreen : In regard to the use of oxy- 
tocics, I stated that with full doses of pituitrin in primipara 
almost invariably I had a laceration. I used to give one c. c. 
and sometimes repeated that, but in the last year or two I only 
give about five minims and generally find I get sufficient effect 
from a small dose and that there is not so much liability to 
lacerations as from the larger doses. 

Now oftentimes we have trouble from prolonged labor, and 
I think that forceps delivery is indicated rather than to have 
the head press against the perineum too long. I remember one 
case in which the pressure was so great that there was gan- 
grene of the perineum ; later there was an opening there which 
required an operation afterwards. So we can err on either 
side, leaving the woman too long in labor or hurrying her 
through too quickly. You are liable to get infection from the 
colon bacillus too if you allow the head to press too long and 
the parts become contused. 

In regard to the repair of a laceration, I said that ordinarily 
I believed that immediate repair was the thing to do, because 
at that time the patient's parts are so benumbed that the pati- 
ent is not so susceptible to the pain They do suffer. The man 
that tells you that he can repair a laceration without chloroform 
or ether and not cause pain is telling an untruth. However, if 
you have used chloroform or ether during the labor you can 
have your assistant give just a little more and you can put in 
the sutures without much pain. Of course, if you have got post 
partum hemorrhage to contend with or the woman is much 
weakened from any cause or if you have puerperal convulsions, 
then tmder those circumstances I do not think you would be 
justified in repairing the perineum then, or if the lights are 
too poor or the conditions such that you cannot get asepsis, 
you can wait a day or so and you can get your union just as 
well as if you had done it at once. Some time back I repaired 
a perineum two weeks after labor. This woman was having 
some fever and a good bit of discharge. It was not my case. 
I gave her a curettage under morphine and hyoscine and irri- 
gated the uterus, and rubbed oflf the granulations where it was 
necessary, denuded the perineum, passed a crown suture 
through, whipped the tear together with a cat gut suture, put 
two or three silkworm sutures on the outside and the parts 
healed perfectly. Oftentimes these lacerations extend up into 



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842 MORBIDITY FOLLOWING CONFINEMENT. 

the vagina, and if we go up as high as necessary, take a ten-day 
chromic gut and whip these muscles together and the floor of 
the vagina, going right on down to the perineum as far as the 
laceration goes, and afterwards put about three silkworm gut 
sutures, we have closed up all pur dead spaces, and we haven't 
the same danger of infection as if we just put in the outside 
sutures. If you repair the perineum at once it will cost the 
husband but a little bit more; and he would rather pay you 
five or ten dollars more to have it over with so that when the 
woman gets up she will be able to go about her duties. If 
you wait eight months or a year afterwards until the organs 
drop down, she has got to go to the hospital and stay from 
one to four weeks, and so it makes a great deal of difference 
to the patient, not only so far as suffering is concerned, but so 
far as the financial end of the proposition is concerned. 



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THE USE AND ABUSE OF OXYTOCICS IN LABOR. 



Walter S. Britt, A. B., M. D., Eofaula. 

It is the duty of the physician to see that nothing is done to, 
or administered to, a parturient woman which will in any way 
jeopardize her safety or her life or that of her offspring. It 
is also his duty to alleviate her suffering as much as possible 
and hasten delivery within the bounds of safety to mother and 
child. 

The time was when quinine was considered a most valuable 
aid in exciting effectual labor pains, but it is now very rarely 
used and there is room for serious doubt as to its value. 

Strychnine is quite often administered, and probably very 
effectually, to the mother who is weak and worn out with "nag- 
ging pains." Morphia may be classed as an indirect ox)rtocic 
and proves of very great value. It relaxes cervical spasm; 
first inhibits and then (as its effect wears off) regulates irregu- 
lar and ineffective pains; and overcomes fatigue and exhaus- 
tion, by affording a few hours of rest. If a patient be in labor 
for hours, has ineffective "nagging pains," becomes restless 
and excited and shows no adequate dilatation and advance, a 
single dose of one- fourth grain should be injected subcutan- 
eously, provided there is no absolute dystocia. Ergot is strictly 
contra-indicated before the placenta has been expelled, but 
should then be exhibited. If the patient be conscious one to 
one and one-half drachms should be administered orally, if un- 
conscious — twenty minims of ergotole subcutaneously. Rush- 
more states that adrenalin is the most powerful and prompt 
oxytocic that we have, but that it is contra-indicated during 
labor because it produces tetanic contractions ; but for the post- 
partum hemorrhage it is prompt and efficacious, though tem- 
porary. He injects ten minims of a one to one thousand solu- 
tion into the wall of the uterus as high as may be reached on 
pulling down the cervix. 

The greatest discovery and the greatest boon in obstetrics, 
in recent years, is pituitary extract or pituitrin. At first, like 



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844 OXYTOCICS IN LABOR, 

all new things, it was pooh-poohed and reviled by those who 
having eyes see not and having ears hear not. It has done 
more to reduce the morbidity of obstetrics than any one agent 
now in use. By shortening labor it has almost done away 
with forceps delivery. One must not think that pituitrin takes 
the place for forceps, but by shortening the time of labor in 
normal cases the accoucheur who has more work than he can 
decently attend to is not tempted to apply forceps unnecessarily, 
in order to get away and save lives which he thinks no one else 
can save. Thus we have less infection, fewer torn perinea, 
fewer invalid women, fewer deformed children and fewer 
deaths. The action of pituitrin is almost human. You would 
think it knew how much damage the meddling accoucheur was 
producing by repeatedly introducing his fingers into the vagina 
of the parturient. So it crowds the head down upon the peri- 
neum in the shortest possible time ^nd thus actually prevents 
him from putting his fingers into the vagina so often or for so 
long periods. Thus is sepsis forestalled. 

Pituitrin must be used with brains. It may be just as dan- 
gerous as it is useful. 

It is a most effective drug but must be employed with great 
caution. It intensifies labor pains for one-half to three-fourths 
hour without, as a rule, producing tonic contractions if em- 
ployed in the proper manner. 

In the first stage its use is usually contra-indicated. It may 
sometimes be given in small doses near the end of this stage if 
the cervix be dilatable. 

In the second stage the value of this drug can not be over- 
estimated. It should not be employed to overcome serious 
mechanical dystocia. Its application is found mainly in the 
stimulation of weak, irregular or infrequent pains, where, here- 
tofore, forceps delivery was indicated. 

Conditions and contra-indications — ^The following accidents 
have been reported: (1) Tetanus and strictura uteri with in- 
carceration of the foetus and death; (2) too prolonged uterine 
contractions with fatal foetal asphyxia; (3) rupture uteri; (4) 
pressure necrosis; (5) atony of the uterus post-partum and 
hemorrhage; (6) deep cervical and perineal lacerations; (7) 
eclampsia; (8) toxic convulsions in the infant. 

Pituitrin should not be given where there is any danger of 
rupture of the uterus, i e., in contracted pelvis, malpresenta- 



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WALTER 8, BRITT, 845 

tions and malpositions, tumors blocking the passage, fibroids, 
diseased uteri, e. g., scars from previous operations. It may 
not be used early in labor or when the cervix is closed or undil- 
atable. 

If the head is not engaged it may 'be exhibited only after the 
attendant is convinced that feebleness of the pains is the sole 
cause of the head remaining high. 

Heart disease and the dangers of a sudden increase in blood- 
pressure are contra-indications. 

REFERENCES. 

DeLee, second edition. 

American of Surgery, November 1916. 

Operative Therapeusis- Johnson, Vol. V. 

DISCUSSION. 

Dr. William C. Maples, Scottsboro: I think that attention 
ought to be called to the danger of pituitrin. It is a very pow- 
erful drug, and it is one you are going to get results from every 
time you give it. In this rushing age when time counts so much 
there is a strong tendency for the doctor to hurry up and give 
a good dose of pituitrin, but if we do not watch we will get in 
trouble. By using it cautiously, in suitable cases, it is a very 
valuable drug. I saw one case where an awful lot of damage 
was done, I think, by giving pituitrin. This was in a primipara. 
A young physician gave her a big dose of pituitrin and the 
result was about the worst laceration of the perineum I have 
ever had to contend with. This is a drug that is very useful 
in certain cases, but it won't do to give it in all cases. Lots of 
cases do not need anything at all. There are other cases in 
which the pains are feeble in which it is a very valuable drug. 
But if you give it only where you want to hurry up labor, you 
are liable to do a lot of damage. I think it should very 
rarely be given in a primipara. If you have a patient in whom 
you know there is nothing in the way and you have feeble 
pains it is a most valuable drug. I usually get it in the ampules 
containing one c. c, and I usually give about half of one of 
those, never more, wait a while, and then give the rest of it if 
necessary. Given in that way you get very nice results in suit- 



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846 OXYTOCICS IN LABOR. 

able cases, but do not go to giving pituitrin to all women in 
labor. 

Dr. Britt : I wish to thank the gentlemen for the discussion 
of the paper. The doctor asked what size doses I usually gave. 
That depends entirely upon the patient. If it is a multipara 
with full dilatation and the head pretty low down, I do not hesi- 
tate to get my chloroform ready and give a full dose. There 
is no danger in a full dose if you use chloroform freely, but I 
do advocate the very free use of chloroform and the holding of 
the head back with the hand to prevent too rapid expulsion and 
laceration. 

I do not know whether T understand the doctor about giving 
it to primipara. I do not hesitate giving it to a primipara, but 
you certainly must use it very cautiously. I never give a primi- 
para a full dose as the initial dose. Usually about one-third of 
one c. c. ampule will give very effectual pains. This will last 
twenty-five or thirty minutes, and then it can be repeated as 
indicated. I think it is very unwise to give a primipara a full 
c. c. at one dose, because it is apt to produce contractions that 
are very undesirable and apt to cause disturbances of the nerv- 
ous system. I have had only one death that I could attribute to 
pituitrin, one child born dead which I am quite sure could be 
attributed to the pituitrin on account of the premature expul- 
sion of the placenta. The placenta came immediately behind 
the child, and I do not think there is any doubt that the pitui- 
trin was the cause of it. 

Another point: we are cautioned in the text-books about 
giving pituitrin when you fear the appearance of convulsions. 
I have had more than one case that had considerable albumin 
in the urine, a rather high blood pressure, with some of the 
symptoms of approaching convulsions in a multipara in whom 
I was in a hurry to make a rapid delivery, and have given the 
pituitrin before the dilatation was advanced very far, although 
the cervix was dilatable, with good results. I believe we should 
make all efforts to expel the child as soon as possible, and after 
labor has set in I am quite sure pituitrin is the most effective 
measure we can use. 



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PUERPERAL ECLAMPSIA. 



W. A. Gbesham, M. D., RussellvUle. 

I am very glad and appreciative of the privilege of addressing 
the Alabama State Medical Association upon a subject today 
that is of much* interest to me, and I dare say to many of you. 

We are living in the age of preventive medicine, and the 
conservation of human life is no doubt the greatest and highest 
privilege with which mankind is intrusted. While our army 
and navy are fighting for our national honor, and we as a pro- 
fession stand ready to respond to our country's call when 
needed, yet for the most part, ours is a peaceful mission. There 
is nothing of more importance to the welfare of the nation than 
the saving of the lives of our women and babies, and after all, 
there is no one who has a greater patriotism, or a deeper love 
of humanity than the every-day country practitioner. For him 
there is no bugle call, but only the telephone bell. No bands 
playing, flags flying or comrades to keep step to the music. With 
his carefully packed obstetrical bag, (for he must be ready for 
all emergencies) he starts on his long drive to some humble 
cabin home, and by the fitful light of a kerosene lamp ushers 
into the world a new-bom American citizen. The successful 
eflforts of the profession in preventing various diseases, and the 
wonderful cures of great surgeons have overshadowed the trials 
and tribulations in the life of the family physician in his daily 
and nightly task of delivering poor women who are carrying 
out the biblical injunction of multiplying and replenishing the 
earth. 

Puerperal eclampsia is the result of some pathological condi- 
tion occurring during the latter months of pregnancy, the diag- 
nosis of which is rarely confused with hysteria. The attacks 
usually occur after the woman has been in labor for several 
hours. As to more complete points in the diagnosis, there is 
hardly a place to mistake the condition. During labor the 
patient will be progressing as nicely as one could wish, when 
she will suddenly begin to complain of blindness, or severe 
headache. This, in my opinion, is one of the most prominent 
warning symptoms for the physician to realize that his patient 
is about to go to pieces. The face is at first pale, later changing 



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348 PUERPERAL ECLAMPSIA. 

quickly to that of extreme cyanosis. There is a twitching of 
the muscles of the face which extends rapidly to all the muscles 
of the body. The tongue is always bitten unless protected. A 
more horrible sight cannot be imagined than a puerperal con- 
vulsion, so horrible it is that we frequently have all her friends 
desert her, the picture being more than they can stand. The 
attacks recur at varying intervals, and the experience can never 
be forgotten. 

The cause of eclampsia remains almost as obscure today as it 
did some decades ago, while persistent and faithful workers 
eminent in our profession have sought for it. Renal insuffi- 
ciency and autointoxication no doubt bear a heavy suspicion. 
The severe strains of labor produce cerebral congestion. Zan- 
gerneister has written much concerning the cause and pre- 
vention of eclampsia. His arguments sustain the assumption 
that hydrops of pregnancy is responsible for the attacks by in- 
volving the brain by pressure produced during severe labor 
pains. The early symptoms are those of cerebral pressure. The 
clinical symptoms of eclampsia lead us to think that pressure 
or congestion of the brain plays an important part in the prin- 
cipal cause. The preventive treatment we give is that of re- 
lieving congestion, and by such treatment we are often able to 
ward off convulsion, by watching for and combatting hydrops 
gravidarum. The various remedies resorted to all tend to 
reduce edema and cerebral irritation. 

Inasmuch as we are of the opinion that eclampsia is caused 
by autointoxication, defective metabolism, failure of elimina- 
tion and inactive emunctories, associated with renal insuffi- 
ciency, it behooves us as responsible and intelligent practition- 
ers to see that every expectant mother coming under our care 
has as much instruction as is consistent with circumstances. I 
take it that eighty per cent of all obstetrical cases are attended 
by the general practitioner. The kidney, as we all know, is the 
principal organ we should watch. Frequent urine analysis 
should be done. Unfortunately there are many women who are 
totally ignorant of the fact that these conditions should be 
watched. If we are to do better and more intelligent work we 
should educate them, and take the necessary time to do so. The 
digestive system is taxed* and should not be overburdened, for 
the appetite is frequently abnormal at such a time, and the 
woman takes more food into her stomach than she can properly 
assimilate. I notice that recent reports from German maternity 



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TT. A. 0RE8HAM. 349 

hospitals state that owing to the scarcity of meats and fats, 
these are necessarily eliminated from the patients' diet, causing 
a great reduction in the number of cases of eclampsia. 

In the early part of my medical career, unfortunately for 
myself as well as the patients, when confronted with this con- 
dition, having been taught the value of veratrum and the pois- 
onous effect of the drug, I gave it in doses of six to eight drops 
as advised by most text-books, but to my disappointment the 
patient would continue to have just as hard and frequent con- 
vulsions. There is little in text-books concerning the use of 
this remedy, although it has long been used as a reliable and 
powerful cardiac sedative. Most authors give five to seven 
drops as a dose, but this falls far short of the effects we are 
looking for in this most urgent need. Nothing short of twenty 
to twenty-five drops given hypodermatically is to be considered 
in a case of eclampsia. It reduces arterial tension and cerebral 
congestion. It lessens in a marked degree both the force and 
rate of the cardiac pulsations. The lowering of arterial tension 
is due to depression of the vasomotor centers. Should the con- 
vulsions continue, repeat this dose within twenty or thirty min- 
utes until the pulse falls to sixty or sixty-five. Venesection is 
advised by many, but is often difficult owing to the plethoric 
condition. I often find it near impossible, without a good deal 
of mutilation, as the arm of these patients will be so rounded 
out with subcutaneous fat, it is a difficult matter to cut down 
on a vein with precision. During convulsions protect the 
tongue with cloth rolled around any convenient instrument, and 
place between the molars. This is decidedly better than the 
uncovered instrument. As quickly as possible give a large dose 
of calomel and sodium bicarbonate, later followed by salts. 
One-fourth of a grain of morphine should be given to assist in 
quieting the restlessness of the patient. As quick delivering is 
necessary to save the life of the child, we wish to empty the 
uterus as early as possible. The patient should be watched for 
several days. Some surgeons are in my opinion rather hasty 
in resorting to Caesarean section. While this operation is some- 
times necessary and can be successfully done in a well-equipped 
hospital, however, it is a perilous undertaking when resorted 
to in an isolated farm house. 

In Norwood's tinct. of veratnim given hypodermatically in 
doses of 20 to 30 drops, repeated often as indicated, we have a 
most effective remedy. 



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THE CAUSE AND MANAGEMENT OF PUERPERAL 
ECLAMPSIA. 



R. S. Hnx, M. D., Montgomery. 

I am today the victim of a violent cold, and I do not know 
whether I will be able to say the things touching this subject 
that I have in mind. I shall beg your indulence in my effort 
to do so. 

Noting my position on the program, being the last on the 
program, of the symposium of obstetrics, I purposely refrained 
from preparing a paper, thinking that if I read a paper, I would 
in all probability repeat much of what had been said by those 
who preceded me. In other words, I decided I would act the 
part of what the old negro calls an exhorter. He was asked 
to tell the difference between an exhorter and a preacher. "The 
preacher is a man," said he, "who takes his text in the seven 
stars and there he stands ; the exhorter is a man who takes his 
text in the seven stars and travels through the elements." But 
I find on account of the absence of several of the essayists the 
program has been changed, and consequently my plans are in 
a measure disarranged. 

There is, gentlemen, so much that might be said on this im- 
portant subject that I shall not dare undertake more than a 
brief reference to some things that appeal to me as of particu- 
lar interest. Many theories have been advanced to explain the 
cause of eclampsia, which simply means that no one of these 
theories has proven entirely satisfactory. To my mind it seems 
clear that the light of present day, advanced medicine reveals 
distinctly the general, underlying cause of this condition to be 
defective reserve force in the woman, a subnormality of the 
potential energy that is required or that is called for by the 
pregnant state. Every system in its every part, yes, its every 
cell, has a reserve force, has a potential energy that is called 
forward to meet the frequently and intermittingly increased 
demands that are made upon it in the life that we live. 

To illustrate, the muscles of our legs have a reserve force, 
they have a power to meet an emergency that requires unusual 



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R, 8. HILL. 351 

speed, such as to catch a moving street car or to run away 
from a man with a pistol. Now, if our muscles did not possess 
a reserve force, then they could do no more than a certain, 
specific, accurately regulated amount of work each day, and 
that amount of work would be measured exactly by what they 
are accustomed to doing daily. And so with the function of the 
organs concerned in digestion. If our digestive forces could 
take care of only a specific amount of food which must be ex- 
actly the same taken each day, then our digestive organs would 
not be able to take care of an extra large meal that we might 
eat, and consequently we would probably suffer severely as a 
result of taking this increased quantity of food. We know, as 
a matter of practical experience, that even with a good diges- 
tive reserve force, if we tax our digestion too far, we suflFer, 
which means simply that the digestive reserve force has failed 
to meet the demands made upon it. We might recall many 
other experiences in life to show the necessity of every part of 
the individual having a reserve power, having an emergency 
force, as it were, but for our present purpose it is unnecessary 
for us to do so. 

Now what happens in the pregnant state? What do we find? 
We find the mother called upon to do what? Not only to take 
care of the metabolism of her own body, but to safeguard the 
metabolism of the developing child. We know that in the 
process of metabolism, in the chemical changes that take place 
in our body, that there are many toxins formed, that some of 
these toxins are converted into inert substances through the 
activity of certain organs, that others are eliminated by the 
kidney, by the skin, etc. The mother's organs must dispose of 
not only the toxins of her own metabolism, but many of those 
of the developing child, and there is no tissue more active, there 
is no tissue in which there are greater physiologico-chemical 
changes than embryonic tissue. In short, we may say the de- 
veloping child requires of its mother not only an abundant, but 
an increasing amount of properly prepared food to sustain the 
increasing physiologico-chemical changes that are taking place 
in its tissue, and also makes an increasing demand upon. the 
organs of her body to dispose of the resulting, increasing toxins 
generated by the changes in its growing tissues. The vital 
functions of the mother's organs are taxed by pregnancy more 
than by any other condition. 



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862 PUERPERAL ECLAMPSIA, 

The speaker just preceding me referred to the increased ap- 
petite of pregnant women. This is a provision of nature that 
the mother might take more food than her own tissues require 
to meet the increasing demands for nourishment of the grow- 
ing child. 

Now if the mother's digestion is incapable of taking care of 
its increased food-stuff, if she has not the digestive reserve 
force to meet the demands that are made upon her to nourish 
herself and her developing child, she may become reduced in 
flesh and strength, and have born to her a child of subnormal 
vitality, or worse, she may be made sick by the absorption of 
poisonous products, overpowering to her agents of protection, 
from the intestinal tract resulting from chemical changes in the 
imperfectly digested food. 

Now what is true of the organs of digestion is true of other 
organs belonging to the mother. Her organs must take care 
of not only the increased toxins resulting from the increase of 
the chemical changes of the tissues of her own body but toxins 
coming into her circulation from tissues of the developing child. 
The thyroid, the adrenals, and other structures are possibly 
gravely concerned in the protection of the mother, but the or- 
gans that stand out prominently in our minds as chiefly con- 
cerned in this work are the liver and kidneys. This is prob- 
ably because the pathological changes afe most markedly mani- 
fested in their structure. The liver changes certain toxic mate- 
rials into inert products and prepares others for elimination by 
the excretory organs, chiefly the kidneys. 

Now then, if the liver is unable to meet the increased de- 
mand, if it lacks sufficient reserve force, these toxins pass on 
to the excretory organs, chiefly the kidneys, in increased and 
perhaps overpowering quantity. They accumulate in the sys- 
tem and produce pathological changes in the tissues of the 
body, in the structures of the very organs, liver and kidneys, 
which are chiefly charged with their destruction and elimina- 
tion. The pathological changes in the liver are not the pri- 
mary condition, the cause of the eclampsia; the pathological 
chanties in the kidney are not the primary condition, the cause 
of the eclampsia. The primary cause, gentlemen, is simply a 
defective reserve force, a lack of potential energy, in the 
mother to meet the increasing physiologico-chemical demands 
of pregnancy. 



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/?. 5?. HILL, 858 

Now what of our clinical observations ? Do they support the 
theory we are trying to present? I think so. Why? Because 
we find that puerperal eclampsia is more common in the primi- 
para, in the woman whose reserve forces have never been put 
to the test. After a woman's reserve power has been tested, 
and it has proven equal to the demands of pregnancy we are 
warranted in looking with increased assurance to her passing 
safely through future pregnancies. Again, a woman, as a primi- 
para having eclampsia, is less liable to have it in subsequent 
pregnancies than she was in the first. Why? Because the 
reserve force has been built up by the first pregnancy. We 
know, as a general proposition, that our capacity to do a thing 
is increased by the doing of the thing; and, therefore, when 
the first pregnancy takes place the woman's reserve force is 
built up and is better able to meet and overcome the demands 
made upon her in subsequent, like experiences. Of course, the 
probability is that better care will be taken of a woman after 
one experience with eclampsia, and this will contribute towards 
lessening the risk of another such experience. 

We find further that if the child simply dies, not be deliv- 
ered, but dies in the uterus, that the chances of the mother's 
recovery are increased. Why? Because the toxins that are 
formed by the metabolism of the child's tissues cease with the 
death of the child, and then the mother only has to take care 
of her own toxins and those accumulated before the death of 
the child. Of course it is most desirable to have the child de- 
livered. 

Again we find that puerperal eclampsia is decidedly more 
common in a twin pregnancy than a single pregnancy ? Why ? 
Because there you have the toxins of two children entering into 
the circulation of the mother to overcome the reserve forces of 
the mother. I repeat, gentlemen, it is quite plain to my mind 
that the primary cause of eclampsia is not to be found in the 
placenta, is not a diseased condition of the kidney— of course, 
if a kidney is diseased it more readily breaks down under the 
strain — it is not a diseased condition of the liver, but is in gen- 
eral terms a lack of reserve force in the woman to meet the 
increased demands of pregnancy. 

If our contention as to the cause of eclampsia is correct, then 
the management of the condition is quite clear. In the first 
place, when we have a pregnant patient we should do that 

2SM 



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364 PUERPERAL ECLAMPSIA. 

which we are repeatedly asserting should be done and which 
we are not doing. That is, we should take charge of the woman 
from as early a date as possible and watch her throughout her 
pregnancy. I do not mean to criticise the profession severely 
for not doing this. The people are in a large measure respon- 
sible for their failure in this regard. They do not think they 
need a doctor to prevent disease, but only to cure disease. If 
they would only wake up to the fact that they need a doctor 
more to prevent disease than to cure disease, our work would 
be more satisfactory, their health better, and their deaths fewer. 
If we could keep in touch with the pregnant woman from the 
beginning, the great majority of cases of eclampsia could and 
would be prevented. 

In pregnancy the woman's digestion should be safeguarded 
as far as possible, not by starvation, but by giving her the kind 
of food that can be easily assimilated, that kind, of food from 
which she can get the greatest amount of nutriment at the least 
expense to or tax on her digestive forces. Chief among the 
articles of diet is milk. Milk is the only diet we know of that 
will sustain life almost indefinitely. In passing I can not stress 
too much the importance of drinking water freely and of keep- 
ing the bowels active. 

We come now to the curative treatment of eclampsia. What 
should we do? There have been a thousand and one prepara- 
tions used to control the convulsions. I need not go into their 
discussion. The woman's system is saturated, as it were, with 
toxins, and the indication is clearly to bring about their elimi- 
nation as speedily as possible. If convulsions begin or con- 
tinue, notwithstanding the use of sedatives and the elimination 
treatment, then what? Interruption of the pregnancy. How 
should the pregnancy be interrupted ? This is a great field for 
discussion. But I have already detained you beyond the time 
allotted an essayist. 

The motion was made and carried that Dr. Hill continue the 
discussion. 

Dr. Hill, continuing: This is very kind of you, gentlemen, 
and I thank you very much. 

In the multipara I quite agree with the advocates of delivery 
by the obstetrical forceps. In multipara, particularly where the 



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R. 8, HILL. 366 

cervix is dilated, delivery with forceps is beyond question the 
best thing. But eclampsia is more frequent in primipara. In 
a case that recently came under my observation as a consultant 
there was no dilatation, no uterine pains, no beginning labor, 
and what were we to do? This brings up the question of 
Caesarean section, a most important question. I do not advo- 
cate the reckless resort to Caesarean section. I recognize that 
in the home where most of these cases will be managed Caesar- 
ean section is out of place. However, let me stress the impor- 
tance of taking advantage of the facilities of a well-regulated 
hospital, if available. I rather feel that in the home the interest 
of a primipara with an unobliterated and even undilated cervix 
is best subserved by bleeding and the use of medicinal agents. 

To deliver a primipara before the cervix is dilated is a very 
difficult and dangerous thing. We should be slow to undertake 
it. Vaginal Caesarean section does not appeal to me. In my 
hands — and I have had quite a few cases brought to the hos- 
pital — before a vaginal examination was made I found abdomi- 
nal Caesarean section very satisfactory. It is quite an easy 
operation. Hemorrhage ordinarily need give no concern; in- 
deed, more than usual loss of blood may prove beneficial in get- 
ting toxins out of the woman. This seemingly was true in two 
of my cases, Caesarean section, however, will have a high 
mortality if repeated vaginal examinations have preceded the 
operation. These examinations carry germs of infection to or 
into the opening of the .cervix from where they more readily 
find their way to the fertile field furnished by the operation. 
The germs may be picked up by even a gloved examining finger 
as it enters the vagina, for the difficulty of sterilizing the vulva 
and vaginal outlet is very great. Caesarean section, therefore, 
must not be an operation of last resort, but an operation of 
election. 

There is one question that comes up in my mind, and my 
experience has not been sufficiently long for me to answer it to 
my own satisfaction. That question as to the scar in the womb 
giving trouble in subsequent pregnancies. Years ago we ex- 
perienced a great deal of trouble in the union of our abdominal 
incisions. We had hernia after hernia following our abdomi- 
nal operations. We do not have those things now because we 
know better how to close our abdominal incisions. But do we 
know how to sew up the uterine incision so as to insure against 



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856 PUERPERAL ECLAMPSIA, 

rupture in subsequent pregnancies, and if sewed up properly, is 
the condition of the uterine tissue such as to make an imperfect 
union? In other words, the woman's tissues are, as it were, 
water-soaked, and unhealthy from the effect of the accumulated 
toxins. Does the uterine structure share in the unhealthy 
state? If so, what effect will it have on the healing of the 
uterine incision? Those are the questions that come into my 
mind, and my personal experience has not covered a sufficient 
number of years to enable me to form a positive opinion re- 
garding them. 

Then there is the quetsion as to whether the diseased condi- 
tion of the wall of the womb, which corresponds to the diseased 
condition of the other tissues of the body, will form a fertile 
field for infection after a Caesarean section by germs that are 
in the vagina and vulva. I dare say it will. I venture to assert 
that a woman is less liable to resist infection after Caesarean 
section for puerperal eclampsia than after Caesarean section 
for obstruction to the passage of the child. To my mind this 
is another element of danger attending Caesarean section in 
eclampsia. 

Now as to what shall be the future treatment of women who 
have had Caesarean section. Does one Caesarean section spell 
Caesarean section for each subsequent pregnancy? I do not 
believe as a rule it does. I would be inclined to rely on the 
forces of nature, unless the personal history of the patient was 
such following her first Caesarean section as to cause a suspi- 
cion that there was an infection which probably interfered 
with the proper union of the wound through the uterine wall. 
This infection may be so mild as not to threaten the life of the 
woman. In other words, if I should do a Caesarean section on 
an eclampsia patient and that woman should develop a slow 
fever with a retarded recovery that could not otherwise be ex- 
plained, I would feel that something had gone wrong in the 
healing of the uterus and that a good, firm and positive union 
would not be secured; and, therefore, in subsequent pregnan- 
cies I would be inclined to more readily subject her to a Ceasar- 
ean section than I would had her convalescence after the first 
Caesarean section been smooth and unsuspicious. 



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R, 8. HILL, 867 

DISCUSSION. 

Dr. W. R. Jackson, Mobile : I consider this subject a surgi- 
cal subject as well as a medical one. You know it is conceded 
now that there are certain organs of the body that are motor ; 
they are the driving organs — ^the brain, the thyroid gland, the 
suprarenal glands, the liver, the pituitary and the muscles are 
considered motor organs; they are the driving organs of the 
body machinery. Now in this condition of uremic intoxication 
— we used to call it ; we call it the toxemia of pregnancy now — 
I say in this condition we have an abnormal toxin, a motor 
toxin ; it is a toxin that excites the motor neurones, and if we 
get more stimulation of the motor neurones than the physical 
resistance can stand it explodes immediately. We have uncon- 
trollable convulsions. We do not know the nature of this toxin ; 
we call it a multi-toxin, the result of incomplete destruction in 
the liver, and if it fails to destroy this toxin it excites the motor 
neurones of the brain and we have a convulsion. We often 
have these convulsions in primipara and in plural pregnancies, 
and therefore it is important not to use pituitrin. Hyper- 
excitability would contraindicate the use of any of these motor 
stimulants. 

Dr. M. C. Thomas, Blocton: I have most thoroughly en- 
joyed the essays. I think the question of puerperal eclampsia 
is one that has not received the attention of the medical pro- 
fession that it should have. To epitomize, it seems to me that 
the question once and for all is a matter of education of the 
physician as well as the patient. Dr. Hill beautifully illustrated 
the fact that it is a question of potential energy in the individual 
patient. That being true, if we had that patient in the begin- 
ning of the pregnancy and watched her carefully, and, as he 
well said, at or just preceding confinement, I do not know of 
an)rthing else better than a time properly selected and when 
other remedies fail, do a Caesarean section. This is indicated, 
if at all, certainly before the patient has been subjected to in- 
numerable vaginal examinations and when it can be done under 
proper aseptic conditions, otherwise or if after repeated vaginal 
examinations and the membrances have ruptured it will be a 
serious proposition. 



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858 PUERPERAL ECLAMPSIA. 

Dr. L. C. Morris, Birmingham : I have been immensely in- 
terested in these valuable contributions to this subject, and I 
simply want to mention one thing that was not clearly brought 
out in either the discussion or the papers, and that is the ques- 
tion of a differential diagnosis between what we have consid- 
ered as a true toxemia of pregnancy and a simple puerperal 
eclampsia. Our conception of a true toxemia of pregnancy has 
been that form of toxemia which leads to autolysis or fatty 
degeneration of the liver, and which we believe is invariably 
fatal unless the pregnancy is interrupted. A woman with 
eclampsia or the pre-eclamptic state under proper treatment 
frequently goes on to full term and normal deliver)' without in- 
terference. It is as impossible I believe to make an absolutely 
positive early differential diagnosis between the pre-eclamptic 
state and the true toxemia in all cases as it is to determine in 
cases of uterine infection which ones are going to be lethal re- 
quiring early hysterectomy to save life, and which ones by 
ordinary treatment we may be able to relieve. I believe that 
unless a certain percentage of cases of pregnancy are inter- 
rupted before you can be absolutely sure that it is a really true 
toxemia, you will lose a certain number of cases which you 
had hoped were ordinary eclampsia. 

Another question which comes up and which I think of 
paramount importance is at what stage should interference be 
done in those cases ? Have we got any group of symptoms or 
any standard conditions which justify interference? I do not 
believe so. I think the point brought out by Dr. Thomas and 
by Dr. Hill of the careful watching of those cases during preg- 
nancy is most important. I believe we have got to make more 
frequent urinalyses than we have been doing in the past. I 
believe the obstetrician who makes a urinalysis during the first 
six months only once a month may overlook the condition until 
serious symptoms have ensued. I have seen cases absolutely 
free of albumin ten days before they had eclamptic convulsions. 
The only way we can catch those cases in time to carry out the 
preventive treatment is by frequent examinations and the early 
detection of albumin in the urine, which is the first sign. 

Another most valuable thing which was mentioned by the 
essayist is the question of blood pressure. I believe that is a 
valuable aid in determining which cases shall be terminated 
and which ones we shall try to tide over and treat symptomat- 



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R, S, HILL, 859 

ically. We do know that when a woman reaches the point 
where the manifestations of toxemia are so great that it pro- 
duces a convulsion the chances for the child as well as the 
mother are definitely less by any operative procedure for deliv- 
ery than they would have been had we done this prior to the 
convulsive state. 

Another question is : having determined, either by the pres- 
ence of a convulsion or by the existence of certain symptoms 
that interference is necessary, what shall we do? Gentlemen, 
that is simply a question to be determined in each individual 
case. There are primiparae in whom I feel sure delivery per 
vias naturales is more dangerous to mother and child than 
delivery by Caesarean section. There are other cases, particu- 
larly those cases in which there is a marked edema of the lower 
abdomen where delivery through the vagina should be done. I 
saw a case a few days ago, a multipara with marked edema, 
with a dilatable cervix and enormous amount af albumin. The 
preferable way in her case was delivery per vias naturales. 
There are others in which delivery by the natural channel is 
more serious both for the mother and the child. 

Dr. Hill brought out a very interesting point in the question 
whether the existence of this toxemia has led to a lowered re- 
sistance on the part of the patient and whether she is more 
likely to have an infection following a Caesarean section than 
if she had a mechanical obstruction. My experience has been 
that there is no more liability to infection ; judging from my 
series of six cases. In one of the six cases of eclampsia or the 
pre-eclamptic state which I have operated on has there been 
any evidence of infection. 

I do not believe there is any question in the world that one 
Caesarean section, no matter how thoroughly we may close the 
uterine wall, does predispose to rupture of the uterus at a sub- 
sequent pregnancy. That has been shown by Dr. Davis, of 
New York, who reported a series of cases in which rupture has 
followed Caesarean section. I have had two cases that have 
been subsequently delivered by the natural channel without rup- 
ture of the uterus. 

Dr. Hill : I have nothing further to add except to refer to 
the matter of whether the condition of the tissues in puerperal 
eclampsia makes a patient more prone to infection than in a 



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860 PUERPERAL ECLAMPSIA, 

normal case. I, too, might say that I have not observed that 
that was true in the experience that I have had with the opera- 
tion, yet from the natural condition that we find in these pati- 
ents it seemed to me we should be led to believe that there 
would be an increased liability to infection, and I have often 
wondered in those cases that have been reported of subsequent 
rupture whether there was not an imperfect union of the 
wound, not because of any faulty work on the part of the oper- 
ator, but as a result of a mild form of infection that took place 
in the line of the wound that hindered a proper union. As I 
say, in my private work, as has been the experience of Dr. Mor- 
ris, I have not observed that this was true, but I have just felt 
that maybe I have been fortunate. 



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THE LACTATING WOMAN— HER CARE, DIET AND 

HYGIENE. 



Harris P. Dawson, B. S., M. D., Montgomery. 
Visiting Pediatrician to St. Margaret's Hospital. 

On account of the great improvement in the last few years 
in artificial feeding, there are many women and a few physi- 
cians who seem to have lost sight of breast feeding. Until the 
eighteenth (18th) century, babies were breast-fed by the moth- 
er or a wet-nurse. Up to the end of the fifteenth (15th) cen- 
tury suckling was continued for two (2) to three (3) years. 
By the end of the seventeenth (17th) century the duration of 
the suckling was reduced to eighteen (18) months to twenty- 
four (24) months, the child being weaned when all the teeth 
were cut. Shortly afterwards, weaning was advised at eight- 
een (18) to twenty (20) months, and since then the period of 
nursing has been gradually reduced, until at the present day it 
is rarely continued under medical advice, beyond nine (9) 
months. If a woman is healthy and secretes milk, there can be 
no doubt that she should nurse her baby, especially during the 
first three (3) months of life. 

It is generally recognized that the natural food for a baby is 
human milk, that breast-fed babies are more likely to live than 
are artificially-fed, and that, as a class, they are healthier, more 
vigorous and more resistant. There is a much greater mortal- 
ity in the artificially-fed than in the breast-fed. There are a 
great many statistics to prove this, but I shall mention but a 
few. 

In Berlin, where the character of the feeding of all living 
children is determined by the census, during the five (5) years, 
nineteen hundred (1900) to nineteen hundred and four (1904), 
only nine per cent (9%) of the infantile deaths were in breast- 
fed babies.* The Department of Health of New York City 
estimates over eighty-five per cent (SB^c) of all infantile deaths 
are in those artificially fed. 

Of one-thousand (1,000) fatal cases of diarrheal disease in- 
vestigated by the Health Department of the City of New York, 



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362 THE LACTATING WOMAN, 

in nineteen hundred and eight (1908), only ninety (90) had 
previously been entirely breast-fed.^ 

Now in order to bring about this breast-feeding, it is the 
duty of the physician to do all in his power to encourage ma- 
ternal nursing and to promote its success. To do this he has to 
pay especial attention to the Care, Diet and Hygiene of the 
Lactating Woman. She should be impressed with the impor- 
tance of breast-feeding, and told that fully four-fifths (4/5) of 
the deaths under one (1) year are in infants who are artificially 
fed. The expectant mother's health should be looked into, to 
see that she is free from genereal disease, tuberculosis, neph- 
ritis, or any infectious disease. Before her confinement she 
should be impressed with the importance of sleep, rest, fresh 
air, exercise, proper diet, the dangers of constipation, and of 
not drinking enough water. 

The lactating woman, should be encouraged to eat a regular 
normal diet, which should be selected principally from cereals 
with milk, corn meal muffins and gruels, red meats, eggs, vege- 
tables, stewed and raw fruits, and some milk. I wish, to here 
emphasize, the fact that women should not be filled up on milk, 
tea, coffee, malt preparations, or beer. These interfere with 
digestion and do not make the best milk for our babies. From 
one (1) to two (2) pints of milk a day, with plenty of water is 
sufficient liquid for most lactating women. 

From the day a prospective mother places herself in the 
hands of a physician, it is his duty to forcibly impress her with 
the importance of maternal nursing and her ability to accom- 
plish the act. The two main things which bring about breast- 
feeding, are regularity in nursing and the psychic elements. 
Phychic phenomena, doubt and fear ; especially, that the milk- 
supply is insufficient in quality or quantity or both, are often 
responsible for the suspension of the flow. Such a case re- 
cently came under my care, and by persistent persuasion it was 
possible to carry the mother along for seven (7) months, the 
baby gaining from one-fourth (34) to one-half (J4) pound 
each week. This mother was seen when the baby was six (6) 
weeks old, and she came to me for a milk formula, as she 
wanted to wean the baby, on account of not having sufficient 
milk. During the seven (7) months of breast-feeding, there 
was not a week that she did not ask for a formula. Finally at 
the end of the seventh (7) month, when I wanted to start sup- 



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HARRIS P. DAWSON, 868 

plemental artificial feedings, she said no, that she had plenty of 
breast-milk. 

It is a grave error, too often committed, to discontinue the 
breast at the first sign of indigestion in the new bom, — an oc- 
currence, so common, that it may almost be regarded as nor- 
mal. 

Shock, fright, or sudden joy may temporarily, but rarely per- 
manently, impair the flow. Insufficient rest, a continuous round 
. of social pleasures, excessive indulgence in alcohol, too much 
physical work and too little food, together with poverty, espe- 
cially when the mother must go out to assist in earning her 
living, — all, by interfering with the proper metabolism of the 
maternal organism, inhibit or prevent the mammory secretion. 
Then again, the lactating woman can be helped, by giving 
proper attention to the breasts and nipples both before the birth 
of the baby, and during the first (1st) few weeks of its life. 

In conclusion, I wish to say that if we wish to reduce our 
infant mortality, we must stop so much artificial feeding, and 
pay more attention to the Care, Diet, and Hygiene of the Lac- 
tating Woman, in order that she may be able to breast-feed her 
offspring. 

1. Graham : Journal A. M. A., 1908, LI, 1045. 

2. Holt: Journal A. M. A., 1910, LIV, 682. 

DISCUSSION. 

Dr. W. W. Harper, Selma : In regard to the paper of Dr. 
Dawson, which I think is a most timely one, Truby King, of 
New Zealand, in his experiments with guinea pigs discovered 
that unless he could give his guinea pigs one maternal nursing 
he could not raise them. They had to have one maternal nurs- 
ing. This discovery of King has thrown much light on infant 
immunity. What did King find? He found that there were 
antibodies in milk which gave an immunity to the young and 
the sucklings could obtain this antibody only from its own 
mother and not from another mammal. This was a matter of 
tremendous importance because it proves the value of breast 
milk. If the mother is only able to nurse her baby once a day, 
let it have that one nursing. It is extremely rare, as Dr. Daw- 
son has said, that it is necessary to stop maternal nursing. Fre- 
quently we stop it on too trivial a pretext — something has gone 



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864 THE LAOTATING WOMAN. 

wrong, the baby probably simply vomits the milk. I recall a 
case in which the baby was vomiting its milk. The mother was 
healthy and had nursed her two other infants. The physician 
discontinued the breast because the baby vomited, — ^vomited 
malted milk, Mellens food, modified cows milk. There was 
nothing wrong with the breast milk but the baby had pyloro- 
spasm and the vomiting ceased when the pylorospasm was re- 
lieved. I recall another case (both of these cases were in the 
hands of good men, — they had discontinued the breast because 
they said the baby threw up what it nursed). This other baby 
ran the gamut of every form of feeding and still continued to 
vomit. At the end of three months it did not weight any more 
than it did when it was born. This was another case of pyloro- 
spasm. We gave big doses of belladonna and sodium citrate 
and the baby has gained from four to eight ounces a week. Do 
not stop the maternal nursing until you find the cause of the 
vomiting. 

I am sorry I was unavoidably detained from the hall during 
the reading of Dr. Fellow's paper because it deals with one of 
the most important subjects now before the profession. Every 
summer there are numbers of cases of acidosis and when you 
get a well-marked case of acidosis, nothing saves the patient. 
I was talking to Dr. John Rowland, of Johns Hopkins a year 
ago. I said, "What do you do for acidosis?" He said, "We 
have never been able to save a case — a true case of acidosis — 
in this hospital." In a recent paper, Dr. Rowland reports sev- 
eral cases of acidosis — all fatal, — some dying two or three days 
after acetone had disappeared from the urine. He says that 
something happens to the brain cells which makes death inevit- 
able even after an apparent recovery from acidosis. The con- 
dition is probably akin to ether narcosis in which Crile has 
shown that the lipoids of the brain cells are dissolved. If this 
pathology becomes rooted and grounded in your being, you 
will bend your energies to the prevention rather than to the 
cure of acidosis. Remember in every case of bowel trouble to 
start at once the bicarbonate of soda and do not be afraid to 
give it. Do not fool around with five grains, but give the baby 
from twenty to sixty grains every hour until the urine is alka- 
line. If it vomits, give it more soda. It will continue to vomit 
until the urine is thoroughly alkaline. 



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HARRIS P. DAWSON. 865 

What are the symptoms? Cherry-red lips, lilac colored cheeks 
and the odor of new mown hay on the breath, acetone in 
urine and, later, hyperpnoea. The breathing becomes more 
labored, the child rolls its head from side to side and throws 
one arm and then the other up 'and down like a semiphone. 
"Look out, danger ahead." Now examine the urine. If the 
child is a boy, the specimen is easy to obtain. Simply attach 
the tip end of a finger cot to a test tube with adhesive plaster 
and slip the other end over the penis. An infant generally 
urinates when it is nursing and a specimen can be obtained 
from a girl by sitting it over a shallow vessel while it is nurs- 
ing. The test for acetone is quite simple. Some of you may 
not know the test. Take a test tube and put into it a few grains 
of sodium nitroprusside, then put into the tube two or three 
c. c. of urine and shake ; now drop into it five or six drops of 
glacial acetic acid and slowly run in some aqua ammonia; if 
acetone is present there will be a lilac ring at the juncture of 
the two fluids. 

My experience has been that you have acidosis much more 
commonly in cases of intestinal toxemia than you do in ordi- 
nary bacillary dysentery. My observation has been that where 
you have a good deal of blood in the bowel movement, you. are 
not going to have as much acidosis as when you have the spin- 
ach stool. In those cases of mucous stools, the infection is in 
the ileum where absorption is most active and where the toxics 
are rapidly absorbed ; these patients usually die from acidosis 
unless they are promptly soaked with bicarbonate of soda. They 
will probably stop vomiting after a while. If you cannot give 
the soda by mouth, give it to them by proctoclysis. If they 
cannot retain the proctoclysis, give the soda subcutaneously. 
Remember that when you heat a solution of bicarbonate of 
soda, you convert it into a carbonate of soda which is irritating 
and if you inject such a solution under the skin, you will cause 
sloughing. My experience has been that if you get Merck's 
or Squibb's bicarbonate of soda and use from a fresh can with 
a sterile spoon the solution will be sterile. 

In acidosis there is a disturbance of the carbohydrate metab- 
olism and I always give these patients a five per cent glucose 
solution with the soda. The glucose being the only form of 
sugar which can be absorbed from the intestinal canal and being 



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866 THE LACTATING WOMAN, 

the form which circulates in the blood, it is the only prepara- 
tion of sugar that can be used. 

In infants before the fontabelle is closed you can give the 
glucose and soda solution in the longitudinal sinus. Four to 
six ounces given in this way brings to life apparently mori- 
bund cases. After the fontanelle closes give the glucose and 
soda solution subcutaneously, intramuscularly or intraperiton- 
eally. At Johns Hopkins the solution is given intraperitoneally, 
— about eight or twelve ounces. 

These patients must have water, more water and yet more 
water. A child will stand food starvation but not water starva- 
tion. We starve these patients for twelve hours, but do not 
stop the water for a minute. If you will soak these patients 
with water, with glucose and with bicarbonate of soda, you will 
save many a funeral bill. 

Dr. J. L. Bowman, Union Springs: I want to say a few 
words about Dr. Dawson's paper. It is on a subject that I 
have mentioned before this Association several times before. 
Our text-books on the care and treatment of diseases of chil- 
dren take up a great many pages on the subject of artificial feed- 
ing, but it is rare to find more than a page, if we find that, on 
the maternal nursing. And yet in my location the only reason 
why we ever have any artificial feeding is because we fail to 
secure the quantity of milk necessary for the baby or on ac- 
count of the quality of the milk. 

Dr. Dawson mentioned fear, and it seems to me and has 
seemed to me in the past year or a little more than fear on the 
part of the mother has been responsible more frequently for the 
mother failing to give the proper quality and quantity of milk 
to the baby than any other one thing. I recall now a patient 
of mine who, after I had failed, came to Dr. Dawson, and I 
think he found maternal nursing an equally difficult proposi- 
tion, because he finally put the baby on artificial feeding. That 
mother was actually scared to death all the time she was nurs- 
ing the baby, and I will state without exaggeration that when 
he gave that mother milk formulas and told her how to sterilize 
that food she worked twenty hours out of the twenty-four ster- 
ilizing the food. That is just the way she lived, and it was a 
day and night proposition with her, up at four o'clock in the 
morning and to bed at ten o'clock and afterwards. 



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HARRIS P. DAWSON. 367 

And so with these mothers with the first baby we find them 
frightened, afraid something is going to happen to that baby 
every time that baby cries, and as long as that fear is present 
that mother's milk is going to disagree with the baby. 

However, outside of those cases, I find mothers whose milk 
contains too much fat, and I have found in some of them, with 
all the dieting that I could do, I never was able to reduce that 
fat so that the baby did not pass the greenish stools with 
saponified cream in them, as shown by the fact that these lumps 
were dissolved by ether. I have found others that with all I 
could do it was curd — casein — instead of fat. I have found 
others where I thought it was too much sugar. I was not chem- 
ist enough to test all the milk to find out just what was the 
cause. But I found this, that all I can do in the way of diet 
and care of the mothers I fail to secure results, and our litera- 
ture at this time is very much wanting in information along 
this line, and I wish and have wished for a number of years 
now that the next man who writes a text-book on babies would 
put in three or four pages on the diet and care of the mother in 
case of certain conditions of the milk that disagree with the 
baby. 

Dr. J. H. Fellows, Pensacola, Fla. : I would like to say just 
a word regarding Dr. Dawson's paper. I heartily agree with 
what he said about nursing infants. I do not think they should 
be weaned too early, but I do not think we should go to the 
other extreme and nurse them too long, because it keeps them 
from getting the food they need, and if they should have an ill- 
ness they haven't sufficient vitality. I do not nurse them longer 
than fifteen months if I can avoid it, and never that long unless 
it is summer. 

Regarding the diet, I do not think that the doctor should go 
in the home and prescribe ai certain diet that the mother pos- 
sibly has never been used to and that will upset her digestion 
and the baby's digestion, by laying down certain fixed rules. 
But I would give this mother what she has been accustomed to, 
except a little bit more of it, but I believe if you go there and 
prescribe certain cereals and various meats that she has not 
been accustomed to eating you will upset her digestion and she 
will have trouble with the baby. 



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368 THE LACTATINO WOMAN. 

Dr. Reid, Birmingham : I would like to ask in regard to the 
cases where the mother is nursing a child and becomes preg- 
nant again. That happens occasionally. What is his advice 
and his procedure where that happens in four, six, eight or ten 
months ? 

Dr. Fellows: There is one thing I would suggest. I cer- 
tainly would not push the soda after the urine is alkaline. That 
is very important. I usually do not give it quite so frequently ; 
every four to six hours is enough; a drachm to the glass is 
about all he will be able to take care of, and when the urine 
becomes alkaline leave off for a half day, and when it becomes 
acid start again. 

Dr. Dawson : I regret very much that I was detained and 
was not able to hear Dr. Fellows' paper, and I enjoyed what 
Dr. Harper had to say in regard to our infantile diarrhoeas of 
the various types and also about acidosis. There is one thing 
he did not bring out strongly enough. That is, at this season 
of the year when we are having our infantile diarrhoeas, of all 
types — fermentative, infections or what not — ^that these children 
undoubtedly die from acidosis. Death is not due to the condi- 
tion of the diarrheoa or the particular organism that you wish 
to try to isolate, but it is due to the acidosis. 

Now there is one thing that I wish to condemn, and that is 
when you see a baby going through the symptoms which he de- 
scribed of becoming red-lipped, a pinched expression around 
the eyes, slightly cyanotic, with tossing of the head and a little 
nausea, to think you are going to give calomel and stop the con- 
dition. Numbers of you have tried it; you say, "Give some 
small doses of calomel." Nothing is going to help except giv- 
ing bicarbonate of soda to the point of alkalinizing the urine, 
just as Dr. Fellows has said. I do not believe in giving it too 
long; examine the urine and if it is alkaline, stop the soda. 

Then in regard to what Dr. Fellows said about the prolonged 
period of nursing infants. I think probably he misunderstood 
part of the paper in which I said it was usually the custom to 
begin supplemental feeding with breast-fed babies about nine 
months, and it was not the intention to breast-feed these babies 
eighteen months or two years. We try to give some form of 
artificial feeding in the seventh to ninth month providing it 



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HARRIS P. DAWSON. 869 

does not come'in the months of July, August, or September. 

Now in regard to what Dr. Bowman said about fear. There 
is no doubt that fear, with irregularity of nursing, has a great 
deal to do with the mother not giving her baby the proper 
anwunt of maternal milk. The case which he just cited is very 
clear to my mind, and if that woman had worked equally as 
hard to keep her breast milk and not been so frightened that 
she probably was not going to be able to nurse the baby, I be- 
lieve she would have been able to nurse the baby longer than 
she did. 

In regard to the question of pregnancy occurring while the 
mother is nursing her infant, I think it is generally accepted 
that as soon as we are pretty positively sure the mother is preg- 
nant the baby should be weaned. And you will find when you 
are trying to find out whether the mother is pregnant and the 
baby has nursed three or four months and the baby is having 
green stools, is fretful and not gaining properly, then probably 
it would be a good idea to supplement one or two feedings of 
some artificial formula of cow's milk. By doing that you are 
putting the baby in a position where you will not have to take 
the breast milk away from it at once. You will probably be 
able to give it three artificial feedings of cow's milk and three 
feedings of breast milk. 

In conclusion, I wish to say that the question of continually 
encouraging the mother is absolutely one of the most impor- 
tant things about the question of breast feeding. If you keep 
telling her the baby is going to gain, keep on hammering, each 
week getting her up to where it is taking a little bit of breast 
milk, you are likely to succeed. I think that is a very impor- 
tant point. 

In regard -to the fats and sugars of breast milk, you can pro- 
ject around one way or another with them, but do not jump off 
of the breast. Keep on with the breast milk, and you will save 
the baby at the end of a year if you will continue with the breast 
feeding. 



24 M 



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ACIDOSIS IN INFANTS AND CHILDREN. 



James H. Fellows, M. D., Pensacola, Fla. 

Morbid physiology rather than morbid anatomy seems to be 
occupying the minds of medical men today. This means that 
clinical facts which were not known before are being revealed. 

A disturbance of respiration does not necessarily mean that 
there is a disease of the pulmonary structure. It has been dem- 
onstrated that the respiratory center is stimulated by an excess 
of carbondioxide in the blood. The blood as we know is nor- 
mally slightly alkaline ; carbon dioxide is an acid. Hence if we 
have an excess of carbon dioxide circulating in the blood we 
would expect some change in reaction. Any other substance of 
acid nature would produce a similar change. 

Incomplete combustion of the products of metabolism with 
the accumulation of carbon dioxide in the blood will tend to 
bring about an increased pulmonary ventilation. This increased 
pulmonary ventilation is one of the first clinical evidences of 
an acidosis, and was so clearly marked in a case I recently saw 
that the mother asked the explanation of the "panting." To 
be sure it is better and more scientific if we call in the labora- 
tory apparatus to help confirm our opinion, but I believe that 
this is no more essential than the clinical thermometer to tell 
that a patient has an elevation of temperature. The apparatus 
I use is the one described by Marriott. It is simple, inexpen- 
sive and is sufficiently accurate for practical purposes. It is far 
easier to handle than is the Van Slyke apparatus, though not 
quite so accurate. It requires no special skill and can be used 
by any one in general practice as easily as can the Faught or 
Tycos Sphigmomometer. It is described by Marriott about as 
follows : An ordinary hygeia nursing nipple with a sheet of 
rubber tissue about 8 by 10 fastened over the lower rim by 
means of rubber cement and adhesive plaster. The tip of the 
nipple is cut off and a short glass tube about three-eighths 
of an inch in diameter is inserted in its place. In making a col- 
lection of alvolear air a rubber bag of at least 600 c. c. capacity 



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JAMES H. FELLOWS, 871 

is connected with the mask and partially filled with air by 
means of an aspirator bulb. The neck of the bag is closed off 
with a pinch cock or with the fingers, the mask is placed over 
the nose and mouth of the infant preferably at the end of ex- 
piration, the rubber tissue is closely drawn around the face so 
as to prevent the escape of air. Respirations are allowed to 
continued for twenty-eight or thirty seconds. At the end of 
expiration the mask is removed from the face and the air an- 
alyzed immediately. 

The acidosis with which I think we come in contact with most 
frequently in infants and childen is that accompanying the in- 
testinal disturbance such as the diarrhoeal disease and the so- 
called intestinal poisoning in which there is often obstinate con- 
stipation. Acidosis should no more be regarded a clinical 
entity than an elevation of temperature. It may be described 
as an acid intoxication of the body ; is accompanied by a reduc- 
tion of the carbon dioxide tension of the alveolar air, an in- 
crease of the hydrogen iron concentration of the blood, e. g., a 
shifting of reaction toward acidity, and the visible air hunger 
or hyperpnea (Rowland & Marriott). 

In acidosis accompanying the diarrhoeal disease oxybutyric 
and diacetic acid are not found in any greater excess than they 
are sometimes in normal urine, possibly due to the diminished 
activity of the kidneys which fail to take these substances' from 
the blood. The urine is often very scant, especially in the two 
intestinal conditions mentioned above. This was very clearly 
demonstrated in a case of intestinal poisoning accompanied by 
an acidosis that I had in February of this year: Isabel C, a 
six and one-half year old girl had been ill two days with nausea, 
vomiting and obstinate constipation. This was all the mother 
had noticed. Patient complained of no pain, temperature was 
99 F. Physical examination was negative, other than the toxic 
appearance of the patient such as staring of eyes and pinched 
expression with air hunger or forced rapid breathing. I asked 
for a specimen of urine and it took forty-eight hours to get 
four or five ounces. 

As to the cause of acidosis much has been said and but little 
is known. It is probably the result of a perverted metabolism 
(whatever this may mean) and is liable to occur in many dis- 
eases. Rowland and Marriott say it may result when abnormal 
acids are formed in excess in the body and when the acids nor- 



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372 ACIDOSIS IN INFANTS AND CHILDREN. 

mally produced are not excreted by the kidneys. In the 
diarrhoea! disease the loss of bones play a part. Many other 
causes are advanced but these seem most tenable in intestinal 
conditions accompanied by an acidosis. 

Probably the simplest method of diagnosing an acidosis at 
present is to determine the carbon dioxide tension of the alveo- 
lar air (Marriott Method) and this should be done where prac- 
ticable, but if not, I believe one should not hesitate to use means 
to combat an acidosis where there is evidence similar to the 
following: Nausea and vomiting usually at the beginning of 
the attack, which are sometimes quite persistent, marked pros- 
tration, often staring of the eyes and rolling up of the eyeballs, 
the lips look pinched and the child appears toxic and often in a 
semi-comatosed condition. The temperature usually ranges 
from subnormal to 101 F. or may go higher. The skin is 
clammy and the tissues have a doughy feeling; hands are 
usually cold and have a cyanotic or purplish tinge. The acces- 
sory muscles of respiration are brought into play amounting to 
what has been called '^Hyperpnea," or air hunger and this 
latter is practically always present in the more severe cases. 
Tympanities was absent in the cases I have seen and there is 
usually found the boggy or doughy condition of the abdomen. 
The urine is diminished, and there is usually an increase in the 
leucocytes. 

Prognosis : In cases I have observed where the alveolar air 
was around or below fifteen m. m. (scale of Heynson, Westcott 
& Co.) the outlook is exceedingly grave, and have never seen 
a case recover where the alveolar was below 15. 

Treatment : This is simple and should be vigorous and con- 
tinued until we are sure we are safe. As a preventive meas- 
ure I use soda bicarbonate in any condition in which I think an 
acidosis is liable to occur, using a drachm to a glass of water 
and letting patient drink freely. This I continue until the urine 
is alkaline. If acidosis is present and there is marked prostra- 
tion I do not hesitate especially in infants to use a three per 
cent soda bicarbonate solution subcutaneously and in extreme 
cases have given a 5 per cent solution into the superior longi- 
tudinal sinus with excellent results. One should surely be care- 
ful after sterilizing the solution to pass a little carbonic acid 
gas (which can easily be obtained at the ordinary soda fount) 
through the cold solution to remove the carbonates or .other- 



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JAMES H. FELLOWS. 373 

wise you may get a slough when giving it subcutaneously. 
When all of the carbonates are removed a little phenothalin 
will not give a color reaction. 

I usually use not less than a hundred c. c. every four to six 
hours until urine is alkaline. 

I wish to say in conclusion that while I can not stress too 
heavily the prevention of an acidosis or its vigorous treatment 
should it occur, we should not forget that there is an under- 
lying condition which demands our attention also. I feel sure 
that I am having better success in the management of summer 
diarrhoeas and cases of intestinal poisoning since I have begun 
the use of alkalies early. 



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WEANING AND DIET IN SECOND YEAR. 



Alfred A. Walker, M. D., Birmingham. 

This is a subject of the utmost importance, especially that 
which has to do with the diet of children in the second year. 
Parents and, unfortunately, physicians are too prone to adopt 
an attitude of false security once a baby is weaned from the 
breast, and consequently we have as a large part of our prac- 
tice at this time of life, patients whose illness is directly caused 
by faulty feeding. This faulty feeding, whether due to ignor- 
ance or to carelessness, gives rise to the dread which parents 
have for the second summer, especially here in the South. 

There are several common errors usually made in the feeding 
of children during the second year. First, there are errors of 
overfeeding, and especially too frequent feeding. This is re- 
sponsible for very much of the chronic indigestion seen in 
childhood. The practice of allowing children to eat any and 
everything at any time of day, with absolutely no regularity, is 
indeed pernicious. I am personally of the opinion that the en- 
deavor should always be to feed three meals a day allowing at 
most between meals a glass of milk with a piece of cracker or 
zweiback. 

Another quite common error is underfeeding at this time of 
life. How often we see small, undernourished and anaemic 
babies, perhaps eighteen months old, who are still getting most 
of their nourishment from the breast, with a taste, perhaps, of 
everything the mother eats. We have all had experiences with 
this type of patient, and know how often it is that difficulties 
are met with when we try to take these babies oflf the breast 
and make them take a well balanced diet which is compatible 
with their caloric needs. 

In this connection, I want to say that the caloric needs of 
infants cannot be met by exclusive breast feeding after the 
twelfth month, and it is my experience among the better class 
of women, especially in the cities, that this caloric need is rarely 
met after the eighth month when reliance is placed on exclusive 
breast feeding. 



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ALFRED A. WALKER. 876 

Now, the above are what we might call errors of quantity 
and method, and while they are responsible for many of the 
ills of early childhood, they do not cause the fearful infant 
mortality which is always with us, and which is largely pre- 
ventable. This annual slaughter of the innocents is due, for 
the most part, to that ever present foe to mankind, namely, 
germ infection. 

I am firmly of the opinion that we have at our disposal a 
preventive remedy for fully 75 per cent of the deaths occurring 
in the second summer, and that remedy is to allow no milk 
which has not been rendered sterile by thorough boiling. We 
are all familiar with the battle which has been waging between 
the pediatricians of the country on this subject of boiled milk. 
Many have been the objections raised by the anti-boilers, the 
most common objections being that boiled milk is responsible 
for scurvy. This objection is met by the other side with the 
admission that boiled milk does cause scurvy occasionally, but 
this more or less theoretical bugbear can be avoided by the 
giving of a daily ration of some fresh fruit juice. "But," say 
the anti-boilers, "boiled milk causes constipation." This is also 
admitted, but instead of being a valid objection to its use, it is a 
distinct advantage over what is liable to be the result of raw 
and infected milk feeding. 

How many times have we prayed for constipation in our 
patients who are the victims of infectious diarrheoa caused by 
feeding raw milk. In other words, as long as such simple 
remedies as milk of magnesia, glycerine suppositories or plain 
warm water and a syringe are obtainable, we can overcome 
constipation, troublesome though it may be. 

It is my opinion, and my experience has borne me out in this 
opinion, that the article of diet which causes the great majority 
of infant deaths, due to what the laity calls "summer com- 
plaints," is sweet milk which necessarily forms the greatest 
part of the dietary in the second year of life. This is not to be 
wondered at when we realize that sweet milk is one of the best 
culture media we have for the growth of pathogenic bacteria. 

We all know that it is next to impossible to obtain a sterile 
milk, or a milk which even approaches sterility, and, if there 
happens to be pathogenic bacteria present, they multiply to pro- 
digious proportions in a very short while, especially in hot 
weather. The rules of various Boards of Health for the issu- 



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MS WEANINO AND DIET IN SECOND YEAR, 

ing of a certificate to a dairyman who wishes to supply certified 
milk emphasizes this fact. Our Board of Health in Birming- 
ham allows a bacterial count of 15,000 in winter, and 20,000 
in summer, and I am informed that even with this liberal allow- 
ance, it is almost impossible for a dairyman to live up to the 
conditions day in and day out. This is true especially in the 
South, and I wish to say here, that my remarks are applicable 
especially to conditions here in the South. 

There is yet another way to avoid this dangerous pathogenic 
milk infection which I wish to speak of, and that is to allow 
no sweet milk whatever in the dietary, and in its stead use but- 
termilk. 

I have been using this method of feeding for several years 
now, and I don't recall that I have ever seen a case of infectious 
diarrheoa in a child who was being fed in -this way. We all 
know that pathogenic bacteria do not survive in milk which 
has been treated with lactic acid producing bacilli. 

The way I am in the habit of using this lactic acid milk in 
Birmingham, where the patient has more or less trouble in 
getting good buttermilk commercially, is to use as a starter 
the Hquid culture of the Bulgarian bacillus and have my pati- 
ent plant two quarts of milk every day. It is not necessary to 
use a new culture every day, but a little of the milk of the 
previous day can be used. In my hands, this buttermilk feed- 
ing has not only proven to be good in a prophylactic way, but 
is perhaps the best treatment for the great majority of the 
cases of infectious diarrhoea. I hope, in some future paper, to 
give my experience with buttermilk in this connection. 

Referring now to weaning. As I have said in an earlier por- 
tion of this paper, practically no infant will thrive satisfactorily 
on exclusive breast feeding after the twelfth month, and a 
large proportion of our modern babies must have their feed- 
ings supplemented at about the eighth month. In weaning a 
normal baby, several things must be considered. First, the 
weaning must or should be, if possible, gradual. Second, a 
formula comparatively weak for the age of the infant should 
be given for a short time, and if well T>orne, it can be rapidly 
strengthened until straight milk is given. Third, it is advisable 
to start weaning in the cold months of the year so as to get the 
infant thoroughly adapted to the artificial feeding before hot 
weather sets in. . . ' 



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ALFRED A. WALKER. 877 

Speaking generally, the method to be followed in weaning a 
normal infant at from 9 to 12 months of age is to begin with a 
feeding once a day of a simple dilution of two-thirds whole 
milk and one-third water, to which has been added a small 
amount of sugar, the whole mixture to be boiled. This daily 
feeding should preferably be given from a cup and the child 
taught to drink. If all goes well, after one week another breast 
feeding can be dispensed with and the feeding from the cup 
substituted. It is well at this time to strengthen your formula 
to three-fourths milk and one-fourth water. If the child has 
as many as four or six teeth, it is my habit now to allow it to 
have a piece of toast or Zwieback with its feeding. 

The third week of weaning, another nursing should be dis- 
pensed with, and in its place some well cooked cereal should be 
varied from day to day so that the child will become accustomed 
to the taste of different foods. Cream of wheat, oat meal gruel, 
rice, etc., are examples of what can be used. 

Instead of the milk formula mentioned above, it is prac- 
ticable to use undiluted buttermilk. If weaning on but- 
termilk is done at six to eight months of age, very 
little trouble is experienced in making the baby take the 
food. Occasionally when an attempt is made to make an in- 
fant from twelve to fifteen months old take buttermilk, you en- 
counter great difficulty on account of the taste. However, if 
the indication is strong enough for the use of this food, this 
difficulty can usually be overcome by a period of starvation. 

A baby who has been properly weaned should within five 
or six weeks be entirely on artificial food with the exception 
of perhaps one feeding from the breast at night. When this 
time comes, say at twelve months, when you desire to stop this 
night feeding, it is necessary for the mother to sleep in another 
room and turn the baby over to a nurse. If this is firmly done, 
the habit of night nursing will be broken within a few days, 
especially if the child is getting the proper amount of food 
during the day. 

We now have our baby on some such schedule as thi3 : 

7 A. M. — Eight ounces of boiled milk, toast or Zwieback and 
some cereal. 

9 A. M. — ^Juice of half an orange. 

10 :30 A. M. — Milk 8 ounces, with a cracker or Zwieback. 



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878 WEANING AND DIET IN SECOND YEAR. 

2 P. M. — Boiled milk or buttermilk, a cereal. After 1 year, 
a baked potato with butter. After 14 months, an egg, or in- 
stead of cereal, chicken or beef broth with rice. 

6 P. M. — Milk 8 ounces, milk toast, dry toast. 

10 P. M. — If the baby has been in the habit of waking at 
10 o'clock to nurse, it will be necessary to allow another milk 
feeding at this time. 

The above would be a proper schedule for a child from 
twelve to fifteen months of age. At fourteen or fifteen months, 
meat in the form of scraped beef should be given once a day. 
Fresh cooked fruits, such as prunes, or baked apple, can now 
be given and are especially valuable if there is a tendency to 
constipation. 

Green vegetables are indicated soon after the fifteenth month, 
but it must be understood that these vegetables must be tlior- 
oughly cooked. It has been my experience that the Southern 
cooks do not cook their green vegetables enough. 

Desserts are allowed children after the eighteenth month. 
These desserts should be simple and should not contain an ex- 
clusive amount of sugar. Good examples are gelatine and baked 
custard. 

I am convinced that it is much better to have young children 
eat apart from the family, inasmuch as the temptation to give it 
a little of everything on the table is usually very great. 

The above outline is, of course, meant for entirely normal 
babies, and it is my firm conviction that if it is carried out with 
the same care usually given to artificial feeding of young in- 
fants, these babies will remain normal, and the dread second 
summer will lose most of its terrors and will not be any more 
dreaded than any other summer. We also will not see so much 
of the trouble which the laity is so fond of ascribing to teeth- 
ing. 

Very rarely one finds a baby that is so constituted that it can 
not take cow's milk or any derivative thereof, even in the 
smallest amounts. In this connection, I am reminded of an 
exceptionally well nourished infant, eight months of age, whom 
it was thought necessary to wean on account of the mother. An 
attempt was made to give this baby a very weak cow's milk 
formula. The child absolutely refused the proffered formula, 
and after several days of effort a total of about two ounces of 
the mixture was forced. In thirty minutes, this baby had quite 



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ALFRED A. WALKER. 379 

a violent attack of angioneurotic edema, with the eyes nearly 
closely, the hands and feet greatly swollen, and several large 
patches of giant urticaria on the body. This subsided within 
twenty-four hours, and several days later an effort was made 
to give it a formula of Mammala for a three months old baby. 
The same difficulty was experienced and when, at last, the 
child really swallowed a small amount of the mixture, the same 
anaphylactic phenomena appeared. 

This baby cannot take cow's milk protein in any form, and 
it is being fed with cereal decoctions, broths, olive oil, etc. It 
is probable that its tolerance for cow's milk can be increased 
by starting with minute quantities of milk and gradually in- 
creasing it. 

In conclusion, I want to particularly impress the importance 
of boiled sweet milk, beginning in the early spring and con- 
tinuing throughout the summer. 



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INTUSSUSCEPTION IN CHILDREN; WITH A RE- 
PORT OF THREE CASES OPERATED ON. 



Oastoit Tosrence, M. D., Birmingham. 

To quote Kimpton — Intussusception is essentially a disease 
of childhood. The diagnosis of intussusception is the mother's 
story, practically every time. In hardly any disease is this so 
often true. Usually the mother will say that the baby was per- 
fectly well when suddenly he began screaming, turned pale and 
vomited, but got better very quickly. After that the baby was 
fussy, cried, and apparently had pain at intervals, with strain- 
ing. Soon after first sharp pains the bowels may have moved. 
Usually within the first twelve hours the mother notices blood 
in the stools and sends for the doctor, and it is very important 
that he should make his diagnosis on his first visit. 

Diagnosis: Colitis is about the only thing to be ruled out. 
In colitis there is usually a temperature and frequent move- 
ments mixed with fecal matter and bloody mucous. 

Usually an abdominal tumor can be felt, but sometimes this 
can not be made out on account of straining. Kimpton says : 
"The tumor felt by rectum could well be omitted, for it would 
seem just to say that many early cases have slipped by because 
of not finding a mass on rectal examination. So often is this 
error made that certainly lives are lost. A rectal mass has 
little to do with the diagnosis of intussusception in the majority 
of cases, at the time the diagnosis should be made." 

Snow reports three cases in which the diagnosis was con- 
firmed by the use of X-ray and bismuth injection. 

Halahan (Beunos Aires) reports a case of appendicitis sim- 
ulating intussusception — a transverse mass could be felt, there 
were bloody mucous stools — ^no fever and great pain. An enor- 
mous appendix, 14 centimeters long, was found and removed. 

Butzner reports a case of spastic ileus simulating intussus- 
ception. A perfectly healthy child eight months old was sud- 
denly seized with sharp pains which came at intervals of about 
five minutes, a mass could be made out in the upper abdomen, 
subnormal temperature, bloody mucous stools. At operation, 



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GASTON TORRENOB. ^g) 

a dilated gut was found which ended at a joint as abruptly as 
if clamped off. Abdomen closed ; patient recovered. 

Etiology: Cubbins says that the long mesentery (2j/i to 
3J4 in.) of terminal ileum and the fact that the cecum in these 
cases had a distinct mesentery has attracted his attention. 

Ladd says intussusception occurs more frequently in healthy 
and well nourished babies than in those that are poorly devel- 
oped and nourished. Forty-nine of the sixty-three cases he 
reported were under one year of age. 

Depping reports two cases as a sequel to whooping cough. 

McGlannon reports a case caused by round worms. Two 
intussusceptions were found, one in the terminal ileum and one 
in the jejunum, the bowel was opened and the worms removed. 
The child died 16 hours later. 

In most of Starr's forty-six cases there was a history of 
intestinal disturbance, either marked constipation or diarrheoa. 

Treatment : No other means of treatment except operation 
should be considered after the diagnosis is made, and every 
case should be operated on within the first twelve hours from 
onset. 

The incision should be made through the right rectus muscle 
and should be closed with through and through silkworm gut 
to prevent the wound from opening up or the formation of a 
hernia, which frequently has happened from the child crying or 
straining. 

Great care should be used in "milking out" the intussuscep- 
tion and very little traction should be used. Reduction is suc- 
cessful in from 80 to 90 per cent of cases. 

Tilton advises giving salt solution by rectum or hypoder- 
moclysis, and thinks it advisable for the mother to resume 
nursing the baby at an early date so as not to disturb it more 
than necessary. He thinks a dose of castor oil the best means 
of carr)ang off the accumulated fecal contents and blood. 

Operation : Cubbins suggests suturing the head of the ce- 
cum to the pelvic peritoneum and the ileum to the ascending 
colon with four or five sutures, bringing them parallel to each 
other and thereby preventing an intussusception from reform- 
ing. 

Tilton thinks that any operation to. anchor the gut after re- 
duction is useless and only prolongs the operation and tends 
to lessen the Kttle patient's chances of recovery. 



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882 INTUSSUSCEPTION IN CHILDREN. 

Lord operated on a child of eight months that had been re- 
lieved by hydrostatic pressure and inversion, the third time 
within five and a half months, a large edamatous appendix was 
removed and the mesenteries of the cecum and ileum were 
reefed with silk sutures, complete recovery and no return. 

Mr. Turner says, "Taking all the circumstances into consider- 
ation, I do not think it is necessary to take any special means 
to anticipate recurrence.'* 

Mr. Gray says, "I do not believe there is any need to fix the 
cecum as a preventive measure. Also, in these cases no more 
should be done than is absolutely necessary." 

Resection: Mr. Gerald S. Hughes (London Lancet, Sept. 
28, 1912, page 878) reports the case of a child six months old 
from the York County Hospital which was operated on 48 
hours or longer after onset (ilio-cecal variety) extending down 
into descending colon, 15 inches of the cut were resected with 
complete recovery. 

Charles N. Dowd reports an intussusception in an infant five 
days old which was operated on 37 hours from the onset of the 
trouble, more than one-third of the colon from above the mid- 
dle of the transverse colon down to the upper portion of the 
sigmoid was excised with recovery. 

C. Leonard Isaac (Swansea, England, London Lancet, Feb- 
ruary 1, 1913, page 318), reports a child two years old — ^with 
irreducsible ilio-cecal intussusception in which he resected the 
cecum and did an anastomosis between the ileum and ascend- 
ing colon with recovery. 

Gallie reports 45 cases from The Toronto Children's Hospi- 
tal in which 17 resections were done ; all died. 

Mr. Gauntlett reports a child ten months of age in which he 
did a resection 24 hours after onset with recovery. 

Eisendrath reports the case of a three-months-old child seen- 
on third day of intussusception — complete resection with anas- 
tomosis of ileum to sigmoid with recovery — on seventh day 
during crying spell there was a complete evisceration. Intes- 
tines put back and wound resutured. He says recovery after 
resection is rare and that the mortality is close to 100 per cent. 

Elliott reports case of intussusception in boy 7 years in smalF 
gut due to a Meckel's diverticulum. Resection was done with 
complete recovery. No blood was shown in stools which is thet 
rule rather than the exception above the ilio-cecal valve. 



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GASTON TORRENOE. 388 

Fraser reports two cases of intussusception above ilio-cecal 
valve, (J4 and 10 years) resection was done in both cases with 
recovery. No blood in stools of either child. 

Recurrence: Mr. Edw. M. Mahon recently reported in 
Guy's Hospital Gazette (London Lancet, December 20, 1913, 
page 1785) a boy three years old who was admitted to Guy's 
Hospital November, 1910, and was operated by Mr. C. H. 
Fagge for ilio-cecal intussusception. He was perfectly well 
until July 15, 1913, when he had a severe pain, blood, etc., and 
was removed to the hospital and was operated on 11 J4 hours 
after onset, the condition was found to be an exact duplicate 
of his previous trouble, and he again made a complete recovery. 

Mr. Chas. P. B. Clubbe in his "Diagnosis and Treatment of 
Intussusception," says that it is very rare that any trouble fol- 
lows complete reduction after operation, and did not occur in 
any of his 144 cases, extending over a period of 13 years. He 
has operated on two children for recurrence coming on two 
and six months after operation. 

Adams and Cassidy in "Acute Abdominal Diseases" record 
only one recurrence in 100 cases, and this occurred five weeks 
after operation. 

Mr. Thos. H. Kellock (London Lancet, July 20, 1912, page 
154) reports the case of a child that apparently had had five 
attacks and was relieved three times by enemas and twice by 
operation. 

Mr. G. Grey Turner (Newcastle-Upon-Tyne) reports the 
case of a child 8 months of age operated on June, 1907, again 
in October same year, and in May, 1908, for the same type of 
intussusception. At the second operation he sutured the ileum 
to the cecum for four inches, the sutures were found at the 
third operation to have held "firmly," "though there were long 
flimsy adhesions between the two:" The child was in perfect 
health in 1913. 

Mr. Turner reports another case operated on in 1910 at 
seven months of age, the following year he had a recurrence of 
the condition and the physician found a mass protruding from 
the rectum. When he was admitted to the hospital this could 
be felt up in the rectum, but when the abdomen was opened 
the intussusception had been relieved. 

Mr. Tywell Gray reports a case operated on three times for 
intussusception with recovery. At the second operation a mo- 
bile cecum was fixed. 



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884 INTUSSVaCBPTJON IN CHILDREN. 

F. O. Allen reports a case that was operated on and did well 
for four days, and then recurred and was operated on again. 

Mortality: C. L. Starr's (Can^d. J. M. & S., Vol XL, 133 
— 1916), paper was based on 46 cases with 31 deaths and 15 
recoveries admitted from three hours to eight days from onset. 
Average in fatal cases 74 hours, and 32 hours in cases that re- 
covered. 

In GalHe's 45 cases, of which 16 recovered, 12 were operated 
on in 24 hours from onset. 

Parmenter reports 53 cases operated upon by "a considerable 
number of Buffalo surgeons,*' 23 were operated on in from 3 
to 24 hours with only one death. The remaining 30 cases were 
operated on from two to iour days, with 9 recoveries and 21 
deaths. 

Abott reported at a meeting of The Western Surgical Asso- 
ciation (1916) 12 cases with four deaths and eight recoveries. 

McMurtry reports four cases. Only one case was operated, 
two cases recovered. 

Results: Dowd reports (1915) two cases, nine months and 
three years old seen 20 and 28 hours after onset with recov- 
ery. He thinks that by the use of bismuth and X-ray and the 
usual symptoms that no case should escape an early diagnosis. 

Kimpton says that prior to 1908 the mortality was 80 per 
cent in The Infants and Children's Hospital. He quotes 
Clubbe's Statistics. In the first 50 of 124 cases the mortality 
was 50 per cent. In the second 50, 25 per cent, and in the next 
24, 12y2 per cent. 

Ladd says that prior to 1908 there were 10 cases operated 
on at the Massachusetts General Hospital with one recovery, 
— and eight cases at The Infants' Hospital with one recovery. 
Since 1908 there have been 63 cases operated with 32 recov- 
eries and 31 deaths (mortality 49 per cent). Of the last 19 
cases operated on only 4 have died (mortality 21 per cent). 
Four of these 63 cases were operated in 12 hours with no 
deaths ; 18 cases at 24 hours with three deaths, a mortality of 
16.66 per cent; 13 cases at the end of 36 hours with 54 per 
cent mortality, and 17 cases at 60 hours or more, a mortality 
of 88 per cent. 

Peterson reports 19 personal cases (ages six days to thirteen 
months) with eight deaths. All were seen within twenty- four 
hours. 



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GASTON TORRENCE, 886 

Vance reports seven cases with three early diagnoses that 
recovered and four late diagnoses and all died. 

Abbott reports twelve cases with eight recoveries. 

Snow reports four cases (early diagnoses) diagnosed 2-13-52 
and 80 hours with two deaths. 

F. W. Wilkerson reports a successful case of a child one year 
old operated oa seven hours after onset. 

Case Reports: No. 1. — Breast-fed child 7 months of age. 
Was in perfect health and was suddenly taken with sharp, 
cramp-like pains, became quieter, but was uncomfortable and 
irritable. Bloody stools, and mass could be felt on left side of 
upper abdomen. At operation 12 hours after onset an ilio-cecal 
intussusception involving the transverse colon was found and 
was easily reduced. There was considerable thickening of the 
head of the cecum. No fixation. Child died 36 hours later. 

No. 2. — (Operation by Dr. Gewin.) Breast-fed male child 
5 months old. Was suddenly seized with pain. Was well and 
strong prior to this. Was sent to the infirmary for observa- 
tion. Blood in stools. Mass in upper abdomen. Operation 8 
hours after onset. Ilio-cecal type, acutely inflamed appendix. 
Reduction easily accomplished; appendix removed and abdo- 
men drained. The child made an uneventful recovery. 

No. 3. — ^A perfectly normal breast-fed little girl of 9 months 
was suddenly seized with pain. An inexperienced colored 
nurse had taken the child out in the woods a few hours before 
and told the mother that the baby had swallowed some leaves 
from some small plant. She grew more quiet and was brought 
into the city the following morning, about 18 hours after onset, 
and was operated on within 2 hours. She had bloody mucous 
stools, and a mass could be felt in the epigastrium. Nothing 
felt by rectum. Ilio-cecal variety passing beyond the hepatic 
flexure of the colon. A small drain passed down below the 
cecum. Complete recovery. Soda proctocylsis was given in all 
these cases. 

REFERENCES. 

D. N. Eisendrath. Surg. Gny. & Obs., May, 1915, p. 621. 
Wm. R. Cubbins. Surg. Gyn. & Obs., Feb., 1915, p. 177. 
Ellsworth Elliott. Annals of Surgery, April, 1915, p. 476. 
Charles N. Dowd. Annals of Surgery, Sept., 1915, p. 852. 
A. R. Kimpton. Boston M. & S. Jour., Feb. 3, 1910, p. 131. 

26 M 



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386 INTUSSUSCEPTIOy IN CHILDREN. 

J. Fraser. Edinburgh Med. Jour., 1916, XVI, 275. 

Wm. E. Ladd. Boston Med. & Surg. Jour., Dec. 9, 1915, p. 
879. 

W. E. Gallic. Canad. J. M. & S., Vol. 40, p. 58, 1916. 

Benj. T. Tilton. New York Medical Jour., Oct. 7, 1916, p. 
681. 

E. W. Peterson. Medical Record, 1915, LXXXVII, p. 218. 
J. P. Lord. Trans. West. Surg. Asso. (Denver), Dec. 1914. 
J. Vance. New Mex. M. J., 1914, XIII, p. 45. 

A. W. Abbott. Trans. West. Surg. Ass. (Des Moines), 
Dec, 1915. 

F. J. Parmenter. J. A. M. A., Jan. 22, 1916, p. 304. 

C. W. Depping. U. S. Naval Med. Bull., April, 1916, Vol. 
X, p. 2. 

Irving M. Snow. J. A. M. A., Oct. 30, 1915, p. 1524. 

G. G. Turner. London Lancet, Jan. 17, 1914, p. 169. 

H. Tyrrell Gray. London Lancet, March 14, 1914, p. 746. 
Robt. E. Holohan. London Lancet, June 6, 1916, p. 1608. 
Alexius McGlannon. So. Med. Jour., Nov., 1916, p. 977. 
F. W. Wilkerson. So. Med. Jour., Oct., 1914. 
J. D. Butzner. J. A. M. A., Oct. 17, 1914, p. 1391. 

E. G. Gauntlett. London Lancet, Feb. 14, 1914, p. 456. 
Lewis S. McMurtry. Transactions So. Surg. Ass., 1915. 

F. O. Allen. Annals of Surgery, Feb., 1914, p. 262. 
Charles N. Dowd. Annals of Surgery, May, 1913, p. 713. 
Charles P. B. Clubbe. The Diagnosis and Treatment of In- 
tussusception — Edinburgh, 1907. 



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CRIPPLED KIDNEYS. 



J. P. Stewart, M. D., Attalla. 

The kidneys are very important organs and their function is 
of vital necessity to life and continued good health. 

So important are they, that the least impairment of their 
function disturbs at once the very life blood of the body, and 
shows its effect, sometimes immediately, sometimes remotely, 
in some clinical picture, that is usually recognizable by those 
who are familiar with the signs and symptoms of these affec- 
tions. 

In their normal condition the function of the kidneys is to 
purify the blood, by a system of drainage or filtration peculiarly 
arranged, so as to withdraw from the circulation, certain dele- 
terious substances that have accumulated from the general me- 
tabolism of the body, substances that if left in the blood would 
soon poison the body and destroy life. 

These are well-known facts, and are only mentioned here to 
impress upon you, at the beginning of this paper, the very great 
importance of the kidneys. 

Post mortem examinations have revealed the fact that few 
kidneys go through the entire length of an average life with- 
out some impairment. This is a grave and serious statement, 
yet it is true. So many diseases, even of childhood, leave their 
impression on the kidneys, and often cripple them permanently. 
Take, for instance, scarlet fever, measles, roseola, diphtheria, 
chicken-pox, meningitis, erysipelas, intestinal-catarrh, cholera 
infantum, malaria, extensive bums, etc. 

The kidneys of young childreo, like their other organs, are 
very impressionable, and in all those diseases which we know 
there is the slightest danger of impairment we should use the 
greatest care in their protection. A slight injury in childhood 
could, and often does, lead to grave trouble in after life. 

Of course there are also immediate and often fatal condi- 
tions as sequelae of some of these diseases of childhood, more 
especially of measles, scarlet fever, and extensive burns. 



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888 CRIPPLED KIDNB78. 

In older persons, whose kidneys have escaped the ills and 
misfortunes of childhood, come a number of causes and diseases 
that mark and cripple the kidneys. They are: changes in the 
blood pressure, from heart troubles, causing a lowering or rais- 
ing of the circulation ; from diseases of the arteries, especially, 
arterio-sclerosis, alcoholism; injuries, especially injuries about 
the head; exposure, especially exposure to cold; rheumatism; 
chronic skin troubles; typhoid fever; malaria; septic fever; 
syphilis ; tuberculosis ; gout ; pregnancy, especially the toxemia 
of pregnancy ; and sometimes pneumonia, especially if the kid- 
neys have been affected in childhood. 

There are also some potent drugs that sometimes cause im- 
pairment of the kidneys and often lead to permanent injury. 
These we should keep in mind so as to avoid large doses or 
continued use of them. They are cantharides, copaiba, cubebs, 
squills, chlorate of potash, petroleum, turpentine, pyrogalic acid, 
chrysarobin, carbolic acid. 

In diseases of the kidneys, such as Brights in its various 
forms, pyelitis, hydronephrosis, nephrolithiasis, etc., with our 
present methods of chemical urinalysis, the centifuge, the 
microscope, together with the history of the case, and the clini- 
cal picture, we are enabled to diagnose with a great deal of 
accuracy. 

But there are certain conditions, such as acidosis and uremic 
manifestations due to a crippled condition of the kidneys with 
impairment of their function, that seem to baffle our most care- 
ful and painstaking methods. We have the symptoms and 
clinical picture of uremic poison, convulsions and coma, etc., 
yet an examination of the urine fails to account for the trouble. 
Still we feel sure after careful elimination of other causes that 
we must have a case of uremia. 

I am persuaded to the belief, that at sometime, from some 
cause, that peculiar and complex system of drainage in the 
kidneys has been disturbed functionally or crippled perma- 
nently, so as to allow certain toxic elements of the urine to 
escape, or remain in the blood, causing a train of symptoms 
that heretofore has been ascribed to the liver, such as vertigo, 
headaches, blind-spells, "that tired feeling,'* neuralgia, rheuma- 
tisms, swelling of the hands and feet of a morning, puffiness 
under the eyes, heavy feet and les^s — **hook wormy." My 
opinion is that fifty per cent of these cases are of the kidneys. 



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J. p. STEWART, 389 

There are other cases where the urine fails to register the 
kidneys at fault, and for which I fully believe they are respon- 
sible. They are those peculiar nervous conditions known as 
hypochondria, melancholia and monomania. Not that I believe 
that all neurotic or hysterical conditions should be attributed 
to failure of perfect function of the kidneys, but I do believe, 
and after careful study and treatment of some of these cases, 
that there is a toxemia of the system that has its origin in this 
way. 

Of course we all know that often we have nervous conditions, 
arising from a thyroiditis, or an affected ovary, or some uterine 
trouble. Also in the male some disturbance of the sexual or- 
gans. But when by elimination we find that our symptoms can 
not be attributed to these conditions, then where are we going 
to place them ? 

Post mortem examinations in the cases fail to find any lesions 
elsewhere except in the kidneys and even. there the pathological 
conditions are very slight. But be it ever so slight, knowing 
the very great importance of their function could it not be pos- 
sible that the slightest impairment of their highly necessary 
function might cause the train of symptoms found in hypo- 
chondria for instance. 

I know we are often lead to believe that they are simply 
psychological — imaginary as it were. Granted, but could not 
this toxemia produce the psychopathy. 

I have no doubt that many of our so-called "brain storms" 
are caused by the functional derangement of a crippled kidney, 
allowing certain toxines to poison the blood and through it 
affecting the brain. 

Kidneys crippled in childhood, by some eruptive fever, or 
otherwise, not noticeable at the time, followed later in life by 
some great exposure or prostrating disease, that otherwise, pos- 
sibly, would not affect them, had their resistance been normal, 
lose their functional ability to eliminate properly and become 
a menace to health and even sanity. 

There are also certain cases of acidosis due to a crippled 
condition of the kidneys. Alkalinity means life, acidity, death. 
We must keep the body chemically embalanced by proper elimi- 
nation through the functions of the liver, kidneys, skin and 
bowels, so that the blood stream and cells of the tissues may 
maintain their normal alkalinity, for on this depends the very 



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390 CRIPPLED KIDNEYS. 

life of the body. In acidosis this alkalinity is neutralized by 
the acids of metabolism, which should in part be eliminated by 
the kidneys, thus poisoning the system and endangering life. 

Too many of these cases heretofore have been attributed to 
a torpid liver, to indigestion, to obstipation, etc., when the 
kidneys have been largely at fault. 

Feeling that the importance of the functional work of the 
kidneys has been overlooked in many of the case herein enum- 
erated and believing that greater attention should be given 
them, and that their care and treatment should ever be borne 
in mind, I offer as an apology, if one is necessary, fpr this 
paper. 

The treatment of these cases is symptomatic and varied. 

Of course you must consider the cause, the history and the 
idiosyncrasies in each case. Making careful study of every 
apparently insignificant detail, overlooking nothing, if you wish 
to effect a cure. And be sure to examine the urine every week 
and every day in the week, minutely and painstakingly, for 
there nine times out of ten you will get some light on the 
nature of the trouble. 

DISCUSSION. 

Dr. T. A. Casey, Birmingham: I do not want to allow a 
paper like this to pass and not talk about it a little bit. Dr. 
Stewart has presented a very important subject and a good 
paper. I was impressed with this point, that the idea of any 
one who wanted to maintain health has a great deal to do with 
the action of the kidneys. You take rich food, a whole lot of 
it, and it might be said to be a harmless proposition, but it will 
influence the kidneys in a very unfavorable way. I have had 
some personal experience in practice, and have had to advise 
some old men that might have gone to doctors for prostatic 
trouble, and after regulating their diet the trouble would pass 
off. Of course, no examination was made for enlarged pros- 
tate, but merely the clinical picture. I merely want to empha- 
size the point that the diet as well as what you drink has a whole 
lot to do with it. 

Then take the pregnant woman, and we have a serious im- 
pairment, a toxemia and a great many symptoms. I have seen 
some of those patients that were in a very deplorable condition. 



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J, p. STEWART. 391 

perhaps permanently impaired mentally. We name these things 
a great many times when we do not know exactly what they are. 
Dr. Stewart impressed me as having the thing in hand. It is 
a good thing when a man reads a paper to see that he has 
thought about the subject and has it well in hand. 

Dr. H. S. Ward, Birmingham: Dr. Stewart's paper was 
certainly a very timely and entertaining paper. But I do feel 
that Dr. Stewart is a little enthusiastic on the subject of at- 
tributing too much to the kidneys. Just like at the present time 
we are very liable to attribute too much to focal infections. An- 
other thing, since the Wassermann and salvarsan have come so 
much into prominence we are attributing a great deal to syph- 
ilis, though I do not think we are attributing too much, inas- 
much as it is pretty definitely settled that one in five men is 
infected with syphilis. While the kidney plays an important 
part in the body, Fisher's recent work shows that we can get 
along with a very small amount of kidney. He has done a lot 
of work on rabbits, in which it has been shown that we can get 
along in perfect health where we have only one-eighth of our 
kidney function, showing us what an extraordinary thing na- 
ture is. For instance, at the post mortem table we find men 
who have lived to old age with these little contracted kidneys, 
little things not over an inch and a half long. You look at them 
and wonder how a man could have lived, and yet he has lived 
a long and useful life, and you know that those kidneys have 
been many, many years in coming to that size. I remember 
seeing a post mortem on a negro man not long ago who had 
been leading a pretty useful, active life, and at post mortem he 
had only one kidney, and that a very small one, showing that 
we can live with a small amount of active kidney substance. I 
do not mean, in the least, to minimize the importance of the 
kidney, but I do think we must not attribute melancholia, hypo- 
chondriasis, neurasthenia and all the things we do not know 
what they are to the kidney function, especially when the indi- 
vidual is putting out a normal amount of urine and nothing is 
found on examination. 

So I feel that while the paper is an important one, and I do 
not want in any way to minimize the value of everybody look- 
ing to the kidney and its function. Yet, at the same time, we 
are liable to get just a little bit lazy. Somebody comes along 



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392 CRIPPLED KIDNEYf^. 

with a hypochondriasis and we will say the kidney is not work- 
ing well, just like the old notion that the liver was not working 
well. The doctor hides behind this instead of finding out just 
what the trouble is. I do not believe Dr. Stewart means us to 
think the kidney is doing all the work. But that is the infer- 
ence that could be drawn if we are inclined to be too enthusi- 
astic on the kidney function. 

Dr. C. W. Shropshire, Birmingham: Kidney functional 
tests have done more, I think, in the last few years to bring to 
light the true and the false condition of the kidney. Through 
the monumental work of Drs. Geraghty and Rountree, of Johns 
Hopkins, on phenolsulphenophthalein. Dr. Marshall on urea 
estimation, and the use of the cystoscope and the X-ray, we 
are in a position to make a definite, clear-cut diagnosis. It is 
no more a question of going in the dark and finding out on the 
post mortem table whether we have a unilateral or a bilateral 
tubercular infection of the kidney. With modem instruments, 
as the cystoscope, urethral catheter, X-ray functional tests and 
the blood estimation and your urinalysis, which is very impor- 
tant, you can tell which kidney is involved and the extent of it. 

Recently I had the good fortune of spending several days in 
Cincinnati with Dr. Fisher, who is physiological chemist at the 
University Hospital there, and he showed me some of these 
rabbits and dogs on which he had lectured to us physicians in 
Birmingham. First, he took a wedge out of one kidney and 
traced the kidney function. Then he removed the other kid- 
ney. And as Dr. Ward just remarked he kept on until he had 
only one-sixth or one-eighth of a kidney, and these animals 
have been living for four or five years, and they have bred and 
inbred, raising different breeds of rabbits and dogs, and there 
has been no deterioration in the size or function of the animals 
produced. He showed me the various functional tests, and he 
is doing a great deal of work on kidney function. 

Dr. Stewart's paper is very timely, but the trouble and the 
trend of opinion today is that we are too apt to jump to con- 
clusions and not to work quietly and conservatively and make 
the diagnosis of what it is and what caused it. 

Dr. William C. Maples, Scottsboro: I am glad the doctor 
brought out something about Dr. Fisher. I heard him deliver 
that lecture. Fisher is a great enthusiast. If I remember cor- 



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/. p. STEWART. 398 

rectly, he considers that there is only one kind of inflammation 
of the kidney, and that is what we used to call the interstitial. 
The other is really not an inflammation, but due to diminished 
alkalinity of the blood. His theory is that this edema that we 
call Bright's disease is due to conditions of the blood. Ido not 
think his theories have been thoroughly accepted, but according 
to Fisher we have very few kidney diseases that start in the 
kidney, but they start in the blood, due to diminished alkalinity 
of the blood. Probably these various disturbances of metabo- 
lism may have something to do with it. He has demonstrated 
that we do not need much kidney to get along with. It is a 
universal law that we have a superabundance of tissue, a great 
deal more than we need. If that were not so we would be very 
liable to die from slight disturbances. We have got a big 
reserve. 

Dr. Walter F. Scott, Birmingham : I am awfully sorry Dr. 
Geraghty is not with us today, because I believe that Dr. Ger- 
aghty knows more about the kidney function than anybody in 
this country. I fortunately was with Dr. Geraghty at the time 
that he and Rountree were working up their phenolsuphoneph- 
thalein test. That sounds like a big name, but it is such a simple 
thing to do that I feel that every member of this Association 
ought to adopt it. We can absolutely tell the condition of the 
kidneys by that test. I won't say absolutely, but almost abso- 
lutely. It is very true, as Dr. Shropshire has said, in surgical 
conditions of the kidney it is very important to find out which 
kidney is the good one and which is the bad one with the aid 
of the cystoscope and your functional tests, but in the ordinary 
medical cases it is not necessary to use the cystoscope. It has 
been proven by experiments by Geraghty and Rountree that six 
milligrams of the phthalein injected subcutaneously, that the 
kidneys will throw out within an hour, allowing ten minutes 
for the time of appearance, say an hour and ten minutes after 
the time of your injection — will throw out anywhere from 
twenty to forty per cent., between thirty and forty being nor- 
mal. With an ordinary case, say, of measles or of scarlet fever 
if you are in doubt about the kidneys you can inject your six 
milligrams, which is put up in ampules by Hynson & West- 
cott, and in an hour and ten minutes have your patient void. It 
is merely a color test. You have your standard solution, which 
is six milligrams to one thousand c. c. of water. You collect 



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2U CRIPPLED KIDNEYS. 

the urine in an hour and ten minutes, dilute to one thousand 
c. c, adding sodium hydroxide to make it alkaline, which in- 
tensifies the color, and then compare the two by a colorimeter, 
which is a very simple thing. You have the standard solution 
in one and your colored urine in the other and you just co^n- 
pare the solutions according to a scale, and you can actually 
find out the condition of your kidneys. 

As Dr. Stewart has very truly said, the condition of the kid- 
neys is not truly shown by the urine always. At the time when 
I was with Geraghty I remember a case which illustrates that 
very forcibly. There was quite a prominent man at Hopkins 
whom Thayer and Barker were treating at that time, and 
Geraghty asked permission to give this man a functional kid- 
ney test. To Geraghty's surprise this man only threw out 
twelve or fourteen per cent. Geraghty went to Thayer and 
told him his patient was going to die inside of two weeks if 
something was not done. Thayer said it was impossible, 
that there was absolutely nothing wrong with the man's kid- 
neys, no albumin, no casts, or anything else. Geraghty said he 
didn't care, that he believed the man was going to die. Thayer 
laughed at him, but just the same the man died in ten days. So 
you cannot always tell by the urinalysis. I think the phthalein 
test is the simplest and easiest test that can be used, and it 
ought to be used not only in surgical but in medical conditions 
as well. 

Dr. Paul P. Salter, Montgomery: The first question that 
arises in my mind when I think of the subject of the crippled 
kidney is, What do we consider a crippled kidney? One doc- 
tor has said that parenchymatous nephritis is a thing of the 
past and we do not have it, that an interstitial nephritis is the 
only nephritis that we recognize. I would like to ask him if 
this is so, what irritations or what diseases give rise to inter- 
stitial nephritis. If interstitial nephritis is a primary affection 
what infections lead to it? Doesn't a parenchymatous nephritis 
always precede an interstitial nephritis. In cases examined and 
found to have swelling and other evidences of parenchymatous 
nephritis? I have never examined a slide from any patient 
whatsoever, young or old, which did not show some nephritis, 
usually parenchymatous, and at the same time, with it, a little 
interstitial nephritis. But pathologically, parenchymatous de- 
generation always precedes the interstitial changes. The point 



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J. P, STEWART, 896 

I wish to bring out is this, that we may have a parenchymatous 
or an interstitial nephritis, and one or the other may predomi- 
nate at the time of examination, but the parenchymatous stage 
preceded. The parenchymatous and interstitial may be either 
acute or chronic in form. Now let us consider the first ques- 
tion, what is a crippled kidney? Not all pathological kidneys 
are clinically crippled, e. g., a man having both limbs removed, 
say below the knee, and has artificial limbs, his function may so 
approximate perfection that you can hardly tell he was shy of 
his lower extremities. 

He was crippled, pathologically, but so far as securing and 
prosecuting the functions he was not crippled, clinically. Some 
of the doctors said that it had been , demonstrated that one- 
eighth of a kidney was sufficient to carry on life. Then if we 
have that one-eighth, it makes no difference what pathological 
condition we have, if that one-eighth is capable of sustaining 
life, so far as we are concerned that is not a clinically crippled 
kidrLey, while from a pathological standpoint the kidney is 
greatly impaired. 

I want to disagree with Dr. Scott on the functional test. It 
is the best thing which we have today, but it is not one hundred 
per cent perfect ; it can mislead as well as the urine examina- 
tion. It happened to be my luck while in the hospital to see a 
case with a blood pressure of 220. On making a functional test 
the excretion for two hours and ten minutes was fifteen per 
cent, and that case is still living. However, I will agree that 
the average case does not meet with such a happy end. Why 
this one did not die I will not attempt to explain. So far as 
we know today, the functional test is the best aid to a correct 
diagnosis at our disposal, and I hope that every physician, espe- 
cially the practicing physicians, will take up this simple test and 
not rely absolutely on whether or not heat and acid will show 
albumin, or whether the microscope will show casts, because 
these will not always show the condition of the kidneys. On 
the other hand we may have a crippled kidney and the func- 
tional tests will not show it. We are striving and working in 
the right direction, and each day we are climbing to higher 
heights, and I hope some day we will have an absolute test. 
But I am not yet as firmly convinced as are Drs. Shropshire 
and Scott, that the phenolsulphophthalein test is 100 per cent 
correct. Nor do I think that the time is yet ripe for us to say 
that by this test we should know absolutely the condition of the 



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39« CRIPPLED KIDNEYS. 

kidney. So far as I am aware the originator of the test did not 
claim that the findings would give you the differential diagnosis 
of the pathological condition in the kidney. 

This test, coupled with the urine findings, a careful history, 
examination, the X-ray, cystoscope and sphygmomanometer 
will lead the average physician to a very clear insight into the 
kidney condition. 

Dr. Stewart : We know so little about the kidneys that this 
subject is a hard one to discuss. What I mean is this, we know 
that even the functional test has fallen down on the true condi- 
tion of the kidney. We know that the chemical test, the mi- 
croscopical tests, that all of the other tests that have been 
spoken of here have failed to reveal the fact that the kidney is 
crippled and that it does not do its functional work. What I 
mean by that is not the quantity of urine, and not quality as far 
as the examination goes, but we have symptoms in our subject 
that reveal the fact that there is a toxemia producing the symp- 
toms, that we cannot attribute to any other cause except some 
disturbed function of that kidney. 

Dr. Ward says we can get along on a small amount of kid- 
ney. That may be true ; it may be possible and is possible, and 
no doubt he is right, and I believe he is from what I have read 
and thought and seen ; but, at the same time, we may have two 
good-sized kidneys and those kidneys not doing their func- 
tional work, and we may have one little kidney and it is doing 
all the work and doing it perfectly. A man may be perfectly 
healthy apparently, and the warm blood of life flowing through 
his veins, with a very small kidney, and only one at that. But 
there may be another man who has two very large kidneys, and 
those kidneys failing. Although they do the work, as far as 
quantity of urine is concerned, and yet that man have a train 
of symptoms that puzzle us. 

Dr. Shropshire says that we can make a perfect diagnosis by 
X-ray, cystoscopy, functional tests and one thing and another. 
I would love to see any man who can make a perfect diagnosis 
of a kidney. I would love to go to school to him for about 
ten days or two weeks if I had the time to do it. 

In answer to what Dr. Ward said, I want to say that he is 
correct. I do not attribute everything to crippled kidneys, but 
I do believe that the crippled condition of the kidneys is largely 
responsible for a gjeat many of these cases. 



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Knpwiea^e oi mis laci nas neipea lo expiam many seemine^iy 
strange phenomena connected with headache. It is needless at 
this time to enter into a discussion as to how the location of the 
seat of pain was found to be as described above. 

It is extremely difficult to get a satisfactory classification of 
the various types of headaches, for the different forms overlap 
each other so much. The majority of all headaches may be. 
embraced under the two classes: (1) headache of intracranial 
origin, and (2) headache of extracranial origin. This classifi- 
cation is not satisfactory for relatively so few headaches has its 



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398 HEADACHE. 

origin within the cranium. I have attempted to classify it as 
given below, the classification being based on anatomy, etiology, 
pathology, and to a slight degree on some special symptomatol- 
ogy. The types that I am about to discuss are taken from a 
combined grouping by several authorities, and embraces all the 
more important forms of the malady. 

(1) Migrainous. — I am heading the list with this type for it 
is the most frequent chronic headache seen by the general 
practitioner. It occurs in early life ; more frequent in women ; 
has some indefinite relation to the menstrual cycle ; the pupils 
are contracted during the attack; usually history of heredity; 
vomiting usually follows with more or less relief ; is unilateral 
in about two-thirds of the cases ; and the pain is intermittent. 

(2) Indurative or Rheumatic. — This is almost as frequent as 
the migrainous type. These two types forming about four- 
fifths of the chronic headaches seen in general practice. It oc- 
curs later in life; the pain is practically continuous; usually 
begins in the occipital region and spreads, so to speak, over the 
entire head. In this type we often have small nodules forming 
in the muscles of the head and neck, and these nodules are ex- 
tremely sensitive — even slight irritation or trauma bringing on 
a severe attack. 

(3) Toxemic. — Which may be subdivided into two types 
as, (a) those caused from exogenous poisons, as alcohol, lead, 
arsenic, nitroglycerine, ether, amyl nitrate, etc.; (b) those 
caused from endogenous poisons, as typhoid fever, influenza, 
small-pox, chronic Bright*s disease, portal cirrhosis, diabetes, 
hyperthyroidism, chronic gastritis, starvation, cerebral syphilis, 
fatigue, bad air, constipation especially with putrifaction, and 
other diseases due to alimentary disturbances. This is a very 
common type of headache but is usually very amenable to 
treatment. 

(4) Infectious Diseases — (Onset) — As malaria, scarlitina, 
measles, yellow fever, dengue, tonsillitis, etc. This group is of 
minor importance from a headache standpoint. 

(5) Anaemia. — Either primary or secondary — is often ac- 
companied by a low grade headache. 

(6) Syphilis. — This form might easily be included in one of 
the above classes, but because of its importance and frequency 
I have put it in a class to itself. Always be suspicious of syph- 
ilis in a periodic nocturnal type of headache. I once heard a 



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FRANK W. YOUNG. 399 

good man say, "A periodic diurnal headache, in our Southern 
States, is usually caused from malaria ; and a periodic nocturnal 
headache is usually caused from syphilis." My experience has 
been the same. I believe the formerly so-called "Sun Pain" 
is due to malaria. 

(7) Brain Tumors. — This type presents the very character- 
istic general and focal symptoms. 

(8) Diseases of the eye, ear, nose, and throat. — As eye 
strain, otitis media, tonsillitis, hypertrophied turbinate bodies, 
etc. This class belongs more to the specialists on these 
branches. 

(9) Neurotic type. — As seen in hysteria, neurasthenia, etc. 

(10) Nephritis. — In the chronic types of nephritis the ac- 
companying arteriosclorosis is usually the cause of the pain, if 
we except the headache of uraemia, and I question if "Arteri- 
osclorosis" would not be a better term for this class. 

(11) Insolation. — With or without actual sun stroke. It is 
often a question to be determined as to whether these cases 
are real or should be called hysteria or neurasthenia. How- 
ever, there are enough real cases of headache caused from in- 
solation to entitle it to a class here. 

(12) Traumatic. — Many injuries to the skull, and especially 
to the accessory sinuses, are responsible for headache, and 
oftimes of the very severest type. 

(13) Inflammations within the skull. — As meningitis, cere- 
bral arteritis, etc. 

(14) Reflex Causes. — As seen in various menstrual disturb- 
ances, lacerated cervix, malpositions of the uterus, diseases of 
the bladder, etc. 

(15) Habit Headache. — This type perhaps is but a branch 
of the neurotic type, but for apparent reasons there are many 
classes that we cannot put in that class. 

(16) Lymphatic. — This is a very important and frequent 
type of "occasional headache." It is made worse on exercise, 
attacks last from one to six hours, the pain is dull and heavy 
unless it occurs in the frontal or the temporal regions then it is 
throbbing, it may occur in any part of the head, and is asso- 
ciated with a deficient coagulability of the blood. 

(17) Idiophathic. — We always dislike to have an "Idiopa- 
thic" type of a disease, for it is a more or less an acknowledg- 
ment of our "shortcoming," but there are some cases of head- 



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400 HEADACHE. 

ache whose origin, pathology, etc., cannot be definitely ascer- 
tained — hence this class. 

This classification includes all the more important head- 
aches, and it will be readily seen, as stated above, that no class 
is clearly a type of itself, but they intermingle one with the 
other. So much for the classification of headache. 

There has been much written, and many diagrams drawn, in 
an attempt to show the importance of the so-called "Head 
Zones" and the postures the sufferers assume in the various 
types of headache. I am forced to confess that my experience 
has been rather disappointing in following these diagrams, etc., 
towards a diagnosis. Naturally we usually look first for trou- 
ble at the point designated by the patient, and in only a few 
cases will this point of pain look toward the seat of the trouble 
if the trouble has referred the pain. 

Just a few words concerning the diagnosis of headache, or 
perhaps I had better say concerning the importance of careful 
diagnosis of headache. This is such a common complaint that 
we have long since ceased to treat it with its due importance. I 
wish to register here a most earnest plea for a more systematic 
study of our cases of headache, especially on the part of the 
general practitioner. Few of us cannot recall a case that we 
would rather forget, because of the fact that we treated it too 
lightly. Aside from the usual examination of the case the fol- 
lowing special tests should be made in all puzzling cases of 
headache : 

"(1) Thorough examination of the eyes (including retinos- 
copy), the pupils, and testing of intraocular pressure or ten- 
sion (Glaucoma?). 

(2) Temperature records (Infections?). 

(3) Blood pressure measurements (nephritis? tumor?). 

(4) Urinalysis (albumin? sugar? acetone? etc.). 

(5) Palpation of the insertion of the nape muscles at the oc- 
ciput. 

(6) Examination of the nose and its accessory sinuses. 
And in the history under special points we should ascertain if 

the headache is of paroxysmal occurrence and fixed duration, 
disturbances of vision, great prostration (migraine?), history 
of psychoneurosis, and is the pain periodic." 

In conclusion I wish to devote just a few words under the 
head of treatment. The old principle, "Find the underlying 



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FRANK TT. YOU NO, 401 

cause and treat that," applies here better than in almost any 
ailment we have to deal with. Diagnose your case ; then you 
will be in a position to offer a scientific and rational relief, or 
if there is no relief then you can so inform your patient and 
thus save considerable disappointment on both parties con- 
cerned. The best drugs to apply for temporary relief, while 
we are striving to remove the cause, will also vary with the 
diagnosis, or perhaps I had better say with the cause of the 
trouble. A combination of aceto-salicylic acid with codein will 
relieve in more cases than any other one remedy — morphine 
excepted, of course. The bromides, and in some cases the coal 
tar products are good. Right here permit me to pause long 
enough to condemn the use of opiates in any chronic headache 
because of its habit-forming tendency, and other deleterious 
effects. Codein is the least harmful of all the opiates in this 
particular trouble. There is no specific for the temporary re- 
lief and each case must be a case unto itself. 

There is perhaps no complaint for which more patent or 
proprietary remedies are offered to the public than for head- 
ache. This class of remedies cannot be too strongly con- 
demned. They are dangerous. They are oftimes habit-form- 
ing. They oftimes mask, so to speak, conditions that other- 
wise might have been treated successfully if taken in time. Let 
the profession stand united as one in condemning this self- 
administered form of treatment. 

The well-known Chas. L. Dana, M. D., of New York, has 
recently presented a paper (A. M. A. Journal for April 7, 1917, 
page 1017) on what he terms "Puncture Headache" — a head- 
ache resulting from lumbar puncture. This type will no doubt 
eventually take its place as another class of headache. 

REFERENCES. 

"Pain," by Richard J. Behan. 

"Differential Diagnosis," Vol. I, by Richard C. Cabot. 

Tyson's Practice of Medicine. 

Kelly's Practice of Medicine, Etc. 

DISCUSSION. 

Dr. H. S. Ward, Birmingham : This is indeed an extremely 
important subject. I do not know that there is any specialty 

26 M 



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402 HEADACHE. 

that does not have to deal with headaches. Any man who does 
anything apparently in the domain of medicine or surgery, his 
patients are going to complain of headache. I cannot add any- 
thing to the different types and classification given, because it 
seems to me the classification is perfect. The essayist has cov- 
ered the ground thoroughly. 

Speaking of this lumbar puncture headache, I might remark 
that I have just had the same experience that he gave of that 
kind. I did a lumbar puncture on a young girl of sixteen who 
has had an extremely obscure condition, to have the spinal fluid 
examined. She remained in bed only a few hours, and they 
were also making some X-ray tests on her stomach at the same 
time. She was only going to spend a couple of days in the 
hospital purely for diagnostic purposes. So she got up and 
went home on a street car. I told her to go to bed immediately 
on getting home. About the second or third day her headache 
came on, and it was extremely violent every time she would try 
to leave the bed, and she also had considerable vomiting. I 
feel perfectly sure that that was the delayed lumbar puncture 
headache that has recently been reported in the Journal. It 
was the first case I had seen, and if it had not been that I had 
just seen that article a few days before, I do not think I would 
have recognized it as this type of headache, because headache 
had not been one of her characteristic symptoms that she was 
brought to make a diagnosis of. By keeping her in bed the 
headache all passed away, and she is in good condition. But I 
feel perfectly sure that this headache was entirely due to that. 
Most of the cases of lumbar puncture headache which we see 
come on within a few hours and the headache soon passes 
away. I believe that the practice of doing lumbar puncture in 
your office and allowing the patient to get-up and go home is a 
rather hazardous practice. But even this case was in a hori- 
zontal position for about six hours after I did the lumber punc- 
ture. 

In most headaches, if you will put in sufficient time on them, 
you can make out the cause. I think one of the types of head- 
ache that the doctor mentioned has been called malarial head- 
aches or sun pains. Our nose and throat specialists have dem- 
onstrated that a great many of these headaches, instead of being 
due to malaria, are due to a frontal sinus condition. In the old 
sun pain the patients got up with it and when the sun reached 



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FRANK W. YOUNG, 403 

a certain point in the heavens it passed away. That, I believe 
nose and throat people tell us, is due to pus in the frontal 
sinus. When that is operated on the pain is relieved. Of 
course, we used to think that large doses of quinine relieved 
these cases, but I do not believe quinine has any effect. 

Another type of headache that is very common is the head- 
ache that comes on with chronic nephritis. I think we are apt 
to overlook a number of these cases in people who have high 
blood pressure and come down with severe and .violent head- 
aches. Frequently there will be no definite urinary findings 
that would point to the kidneys. As a rule, however, if you 
observe them long enough you will find that there will be 
traces of albumin, the urine is of a low specific gravity and pale 
in color. 

The headaches of intracranial tumors are perhaps one of the 
most alarming and the most difficult to do anything for. The 
headache is of the most intense type, a headache that extends 
through the head on a straight axis from the occiput to the 
front, with vomiting in the early morning, should be further 
examined for an intracranial growth or for something that has 
produced an internal hydrocephalus, usually due to stopping up 
of the drainage between the sinuses and the outlet, so that you 
get a headache due to a damming up of the cerebrospinal fluid. 

Another type of headache that is extremely difficult to make 
out is a headache that comes on and is extremely violent and 
you have the eyes examined and find no trouble, and the ears 
and urine and blood pressure and everything are apparently 
normal, and you send her to some good man and he looks up 
into the nose and finds a pressure upon one or the other of the 
turbinates. That is a very common cause of a very trouble- 
some type of headache, and apparently the only thing that is of 
any value to them is to have this turbinate bone removed so as 
to relieve that pressure. 

Of course, in the headache of hysteria, the most common type 
is the clavis or the boring of a nail in the top of the head ; we 
all see more or less of that. But we are all getting more and 
more away from calling headaches nervous headaches. The 
more we look and the more thorough examinations we make 
and have made by the specialists, the more we make out the 
cause and cease to think of its being a nervous headache. Most 
of you might just as well make up your minds that when a 



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404 HEADACHE. 

patient comes to see the doctor, especially if you are not doing 
contract work, there is something the matter, and it is an insult 
to them to tell them, "Oh, there is nothing the matter with you ; 
go and do not think about yourself and you will be all right." 
There is something the matter, and if you will keep looking 
you may find it. If you do not find it why somebody else most 
likely will. So I say, I believe in practically all headaches, if 
you will look long enough and examine long enough, you will 
be able to make out the cause. Of course, after you make out 
the case you are not always able to remove the cause, you will 
have to tell the patient you cannot remove the cause and they 
will have to submit to it. 

Of course, there are headaches in people who are not quite 
able to endure the ordinary strain or stress of life. You recog- 
nize those as strain or stress headaches, and the thing to do is 
to try to relieve the strain and stress. 

Another type of headache is the migraine, which is a very 
interesting type of headache. That is another familiar disease, 
and apparently there is no cure for it. It is. a disease very 
closely allied to epilepsy. They have all the aura, — flashes of 
light and aphasis preceding an attack of headache. Instead of 
having a convulsion they will have a violent pain in the head, 
and it comes on at frequent intervals, and may or may not be 
due to some mistake in diet. These, of course, come and go. 
The best thing you can do for them is to give them something 
to regulate their habits. If we regulate their diet and habits we 
can decrease the number, but if it is an inherited headache, 
like all inherited diseases it lasts a certain number of years 
and at a certain period of life they cease to have them, and that 
is about all the hope you can give them. There are various 
forms of treatment that will be palliative, but there is nothing 
I know of that will be specific. 

I enjoyed the doctor's paper very much. 

Dr. Scale Harris, Birmingham: I think that Dr. Young 
brought out the most important point in the discussion of head- 
aches, and that is, when possible, to find the cause, and I may 
say it is not always possible to discover the cause of head- 
aches. I think that one of the frequent causes of headaches, 
however, after the patient has been thoroughly examined for 
everything else, is in the gastrointestinal tract. Some fifteen 



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FRANK W. YOUNO. 406 

years ago Bouchard, in studying the periodic types of head- 
ache, discovered that there was in each case that he studied an 
acute dilatation of the stomach that would come on and last for 
a period of two or three days, and then the stomach would go 
back more or less to its normal size. In some of the cases I 
have observed I have been able to make out that point. Cer- 
tain headaches are very often associated with dilatation of the 
stomach and with gastroptosis, but of course gastroposis is 
also attended with neurasthenia and you could not say it was 
due absolutely to the condition of the stomach. But I think one 
of the most frequent causes of headaches is that due to intesti- 
nal toxemia, and to a toxemia that comes from the excessive 
use of meats. The work of Allen Eustis and a number of 
others along these lines shows that headaches frequently occur 
in excessive meat eaters, and that with the cutting out of pro- 
teins, and purins particularly, that the headaches will subside or 
be very much benefited. I have observed a number of these 
cases myself in which there would be a history of taking meats 
three times a day, and these headaches would be more or less 
periodic, but not the type of migraine that Dr. Ward spoke of 
associated with headaches and vomiting. If the urine is exam- 
ined it will show an excessive amount of indican, a tract of albu- 
min, and a few granular and hyaline casts. Cutting out the 
meats and using colonic irrigations and keeping the intestinal 
tract thoroughly cleansed, the headaches will subside. But 
those patients should be kept on an almost meat free diet for a 
long time. As I said before, I think a great many headaches 
are due to the gastrointestinal tract. 

Dr. C. S. Chenault, Albany: I would like to ask Dr. Har- 
ris to discuss the so-called trench headaches of the soldiers in 
Europe. 

Dr. Harris: I must admit that I do not know anything 
about that particular headache. The probabilities are that the 
concussion might have something to do with it. Certainly from 
the use of the very heavy guns deafness comes on in a great 
many of those cases, and in many of the cases the soldiers ac- 
tually go insane. There has been a very great increase in in- 
sanity among the soldiers in the trenches. Of course, that is a 
nervous manifestation, and if there is any tendency towards 



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406 HEADACHE. 

headaches I should think that the very strenuous life that they 
lead in the trenches and also the high explosives might have 
something to do with it, the irregular habits, the stress, and all 
those things. But I believe it is probably an excited, nervous 
system more than anything else. 

Dr. Thorington, Montgomery : Intestinal toxemia is a very 
common cause of headache. The test for this is so simple that 
I think all physicians ought to be prepared to make it, because 
they could eliminate that source very easily. You can take a 
test tube and put about a couple of inches of urine in it, equal 
parts of hyprochloric acid and permanganate of potash and 
chloroform. If the chloroform comes down dark blue you know 
you have an excess of indican. That is so simple that I believe 
every practitioner can use it, and it will show intestinal putre- 
faction. 

Dr. Young: I do not know of anything that I can add to 
what has already been said. I appreciate the discussion of the 
paper. 

In regard to this trench headache I should think that the 
nitroglycerine in the explosives perhaps would be one of the 
causes. 

Another thing that I wish to bring out is the question of the 
pain that we .have in these nervous headaches. It is usually 
more of a sense of pressure than it is of pain, or it varies from 
a sense of pressure up to a pain. 

Another type of headache not mentioned is that of preg- 
nancy. Of course, that would come under the toxemic type. 



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REMARKS ON THE EARLY DIAGNOSIS OF ULCERS 
OF THE STOMACH AND DUODENUM. 



Seale Habbis, M. D., Birmingham. 

When our President, Dr. Green, invited me to read a paper 
on the subpect of "The Diagnosis of the Commoner Gastric 
Disorders from Clinical Symptoms," it seemed to me to be a 
splendid subject, and I started out with the idea of writing a 
paper on that subject, but I found that in order to cover the 
subject adequately it would be necessary to write a book, so 
that I thought it best to consider the phases of just simply 
one condition, and the subject of my paper is* "The Early Diag- 
nosis of Ulcers of the Stomach and Duodenum." 

The Mayos in their statistics say that the cases that have 
come to them have existed over a period of an average of nine 
years. Finney states that the cases that have come to him 
have existed over a period of ten years. And most gastro- 
enterologists and others who have studied those conditions par- 
► ticularly say that the ulcer has existed for quite a number of 
years before they get to them or before a diagnosis is made. 
For some time I have been making the effort in getting the 
histories of patients, to go back over a period of years and find 
out just the symptoms that those patients held before the diag- 
nosis of ulcer was made, and I think that the principal reason 
for the failure of the diagnosis of ulcer of the stomach and also 
of the duodenum is the teaching of the text-books on the sub- 
ject, that all of us consider the trial of symptoms, of plain, 
vomiting and hematemesis, when in reality all three of these 
are late symptoms. The gastric ulcer usually has existed for a 
number of years before any one of these symptoms appears. Do 
not misunderstand me as saying that pain, which is the most 
frequent and the most characteristic symptom of ulcer in the 
late stages, is not sometimes present in the early stages, be- 
cause it is present frequently observed as one of the early symp- 
toms, but in a great many* cases the ulcer has existed for a long 
time before the pain is present. Please do not understand me 



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408 EARLY DIAGNOSIS OF ULCERS. 

as saying that hemorrhage is not an early symptom sometimes, 
because I have seen two or three cases in which the hemor- 
rhage was one of the first symptoms that the patient has had ; 
and vomiting may be an early symptom ; but as a rule the pain 
and vomiting and hematemesis are late symptoms of gastric 
ulcer. 

It is a very important thing to make the diagnosis of ulcer 
of the stomach early for many reasons. In the first place, you 
then look for the focus of infection, that is, a focal infection, 
and you then remove the cause, and in the earlier years of gas- 
tric and duodenal ulcers, with the removal of the cause in the 
great majority of cases the patients will get well without any- 
thing else being done for them 

Another reason, of course, is that when the ulcer has existed 
for a long time you get the complications, the organic stonosis, 
the perforations and the hemorrhages, and in making the diag- 
nosis early you can relieve those patients before any of these 
complications come on. 

Another reason for making an early diagnosis is that those 
patients can as a rule be cured without the necessity of pro- 
longed treatment ; that is, where the focal infection is removed. 
Many cases get well spontaneously, and many are cured with- 
out the necessity of having to go to bed, simply with a proper . 
diet and with the proper care of their health and with the gen- 
eral treatment. 

It might be well at this particular time to discuss the fre- 
quency of gastric ulcer. Gastric ulcer is without any question 
very much more frequent than is generally supposed. Grun- 
feld states that twenty per cent of the autopsies that he has 
performed have shown evidences of gastric or duodenal ulcer. 
Other authorities put it at one in every two hundred autopsies. 
Still others put it at less. 

The early symptoms of gastric ulcer are very much those that 
are usually described under hyperacidity or hyperchlorhydria. 
For a number of years, as a rule — not in all cases — ^before pain, 
vomiting or hematemesis come on, the patient will complain of 
discomfort ordinarily twenty to thirty minutes to one or two 
hours after eating. This discomfort persists over a period of 
two or three hours, and then is relieved by the food passing 
into the intestine, or the patient has learned to take a little soda 
or sometimes to take food that relieves the pain. The patient 



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8EALE HARRIS, 409 

sometimes in the early stages will vomit acid fluid. They will 
sometimes eructate acid fluid sometimes before vomiting occurs 
and get relief from that. 

Another symptom that is prominent is a burning sensation in 
the epigastrium. The patient will complain of heartburn that 
passes off after the height of digestion is over. Then there is 
ordinarily a tender spot that is constantly present over the site 
of the ulcer. That, by the way, is a very variable position, de- 
pending upon the location of the pyloric end of the stomach. If 
there is gastroptosis the tender spot is low down, and I think a 
great number of those cases have been operated on for chronic 
appendicitis where the ulcer has been low down and sometimes 
to the right. Then this discomfort frequently comes on at 
night, in duodenal ulcer. The patient awakens and is uncom- 
fortable, lies awake, and does not realize what it is. Later on 
the hunger pain is present, but for sometime that hunger pain 
or pain of any kind is not present. 

The diagnosis of gastric ulcer: In a patient who has had 
chronic indigestion, persistent examination of the feces will in 
many cases disclose occult blood. I think that is one of the 
most important tests, though it is not present in all cases. Of 
course, the patient should be instructed not to>eat meats for 
several days before these tests are made. 

The examination of the stomach contents, I think, is of con- 
siderable importance in the early diagnosis of gastric ulcer. I 
think a great deal of harm has been done by the idea that the 
examination of the stomach contents is not of any value in 
gastric ulcer, and the statistics of our distinguished friend who 
is here (the best statistics that we have on that subject) show- 
ing that subacidity is about as frequent as hyperacidity in gas- 
tric ulcer, and those statistics are, of course, correct. I believe 
in my cases in which I have been able to make the diagnosis 
early hyperacidity has been an almost constant symptom, except 
in those cases with arteriosclerosis. In arterioslerotic cases 
there is a subacidity. But after the ulcer has existed for a 
number of years a dilatation of the stomach takes place and 
you have a retention of food, and in those cases you get a 
chronic gastritis with a lowering of the degree of acidity. 

Of course, in the late stages too there is another reason for 
the early diagnosis — there are a number of cases of ulcer that 
do develop cancer, and for a period of some time before the de- 



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410 EARLY DIAGNOSIS OF ULCERS, 

velopment of the carcinoma at the site of the ulcer the amount 
of hydrochloric acid is reduced. That is not a sudden change. 
It takes time for that to be done. So that in the early diagnosis 
of gastric and duodenal ulcers hyperacidity, I think, is a matter 
of considerable importance. 

Of most importance in the diagnosis of practically all gastro- 
intestinal conditions — and of conditions in the abdomen and 
chest — is the X-ray. It is well enough to remember that the 
X-ray is not infallible, that a negative X-ray report does not 
mean that the patient has not a gastric ulcer, and that a positive 
report, the filling defects or other signs that are considered as 
characteristic of gastric ulcer, that if those filling defects are 
not present constantly over a period of examinations that does 
not always mean that the patient has ulcer. There should be 
repeated examinations, and then, with the filling defect and with 
the retention of food after a barium meal after a period of five 
or six hours the diagnosis, in the majority of cases, can be made 
with the X-ray. 

Now there is another very important thing in the early diag- 
nosis of gastric and duodenal ulcers — and I hope that the sur- 
geons and everybody will remember this. The surgeon by mak- 
ing a long incision and examining everything in the abdomen 
when he operates for appendicitis will find that a great many 
cases of chronic appendicitis are associated with gastric ulcer. 
I haven't the statistics, but I really believe that fifteen or twenty 
per cent of the gastric ulcers that come to me have had an oper- 
ation for chronic appendicitis and it has not given them relief 
from the symptoms. A long incision does not add anything to 
the danger from hernia, because surgeons inform me that her- 
nia is from infection more than anything else and that the 
whole abdomen might as well be explored at one time. So that 
if surgeons will make a large incision they will frequently find 
gastric ulcer when they suspected the gall bladder or the ap- 
pendix. 

Another thing in making the early diagnosis, if the patient 
does not get better — the symptoms, as I say are vague and not 
characteristic of ulcer in the early stages — if he does not get 
better after thorough and systematic treatment and after the 
case has been studied thoroughly, then an exploratory opera- 
tion sometimes will reveal the presence of ulcer. 



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REMARKS ON THE TREATMENT OF DRUG HABITS. 



W. D. Pabtlow, M. D., Tuscaloosa. 

As to the extent of this serious evil, I might state that within 
the past four years in the Bryce Hospital at Tuscaloosa where 
we receive only those extreme cases who are sufficiently ex- 
treme to be committed to the hospital as insane, we have treated 
213 cases. Within the past fifteen years I have observed under 
treatment about 750 cases. From the figures from the 
Pure Food Commissioner of the State of Tennessee — 2,340 
drug habitues, I believe, are the figures — and from the 
fact that the regulations and restrictions thrown about the ad- 
ministering and dispending of opiates in Tennessee, and condi- 
tions in Alabama being fairly similar otherwise, I feel certain 
a conservative estimate of the number of cases in Alabama is 
2,000 to 2,500 drug addicts. The estimates of the number of 
cases in the United States now vary. I believe the Public 
Health Department estimates the number at 118,000, and the 
estimates run on up to two per cent of the entire population, 
which certainly, I think, is too high. 

One of the indices to the extent of this evil is to be gotten 
from the quantities imported into the country. In going over 
the figures recently I find that there has been imported — entered 
regularly for consumption, — into the United States about an 
average of 500,000 pounds of powdered opium, crude opium 
and the various alkaloids of opium — 500,000 pounds per an- 
num of all combined. When we think that in a pound of opium 
there are about 11,000 doses, and in a pound of morphine there 
are about 23,000 or 24,000 doses, then we can get some idea of 
the immense quantity regularly imported for consumption, not 
allowing anything for those quantities we are supposed to re- 
ceive through Mexico and the Mexican side of the country. 
From this we judge that a very large per cent of the opium 
entered into the country is consumed illegitimately and a very 
small per cent is used legitimately in medicine. 



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412 TREATMENT OF DRUG HABITS. 

In running over an estimate of the past four years, I find 
that about forty per cent of the cases we have treated are neu- 
rotics before they began the drug, and we class the entire num- 
ber of cases as those in whom the habit is a symptom and those 
in whom the habit is the cause of a psychosis or neurosis. In 
the first division we find the moral imbecile, the immoral per- 
vert and the highly nervous individual. In the latter class we 
find those who are normal when the drug is eliminated and who 
have been put on the drug by taking it for some acquired con- 
dition. It is alarming to learn that fifty-four per cent of the 
total number of cases can be attributed to doctors' prescriptions. 
Dr. Terry, City Health Officer of Jacksonville, has done some 
very interesting study along this line, and the gist of it all is 
that some of the profession prescribe sedatives and anodynes, 
including the opiates, too freely and too generally. 

As to what the habit does for the individual : In those in 
whom the habit is merely a symptom of depravity it 
merely aggravates and increases their depravity. In many who 
were normal before the habit was contracted I have found the 
extreme cases, using large quantities, that went to the very 
depth of degradation. I have observed ministers of irreproach- 
able character preceding the habit who from the use of the drug 
have become utterly unreliable as to their word and their honor. 

I might report here briefly a case that comes to my memory, 
of a rather elderly gentlemen who had filled some of the most 
important stations. He had got into the habit of using opiates 
by some one advising the use of laudanum for hemorrhoids. 
He soon found that to take the laudanum by mouth would give 
him more relief. He soon found he could not do with lauda- 
num; then he took morphine, and was using about a drachm 
per day when he came to the hospital. He came in separated, 
as we thought, from all his effects. He was placed in bed, 
given the usual cathartic and no sedative of any description. At 
the end of twenty-four hours he was entirely comfortable. We 
began to grow a little suspicious then. At the end of forty- 
eight hours he was still comfortable. He vigorously and re- 
peatedly denied that he had any opiates. I sat down beside the 
bed, had the nurse go out of the room, and I said, "You needn't 
deny having an opiate, I know you have." The pupils were 
somewhat contracted, and he was in a good humor. After 



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W. D. PARTLOW. 418 

<lenying it repeatedly, he said : "I see you know I have had it, 
and I have." I asked him how he had been getting it, and he 
pulled from his rectum some toilet paper in which was wrapped 
plenty of the drug. 

In private practice, or outside of a public institution, probably 
complete discontinuance of the drug immediately is imprac- 
ticable, but from trying the gradual reduction methods, we 
have found that there is less detriment and less shock from dis- 
continuing all of the drug, watching the pulse, and if the pulse 
gets very slow give a small quantity, a quarter or an eighth, 
and usually the cases gets no sedative, no opium, after admis- 
sion. We give strychnine, but no sedative. Often they do not 
sleep the second night; by the third night often they begin 
sleeping. Within three or four weeks they have gained ten 
pounds, or in four weeks often as much as twenty-five pounds. 

In our gradual reduction method it would take three or four 
weeks to get them entirely from the drug. At the end of that 
three or four weeks they would be considerably exhausted, and 
discontinuing the last eighth would be almost as bad as stopping 
the entire amount. So the gradual method of substituting any 
other anodyne or sedative I regard as not the best treatment. 
With caffeine and strychnine, daily warm baths and free elimi- 
nation by taking quantities of water and good purgation, I 
have never seen one die, and only in the old and the feeble do 
we find it necessary to give even a quarter of a grain for two 
or three days following admission. 

As I view the question, the matter of stopping the individual 
cases is a very small and a very insignificant part of the whole 
question of the drug traffic and drug habit in the country. 
The main question we want to consider as physicians of the 
State is that of prevention. We know that the Harrison law 
being efficiently enforced has a good effect, but it does not go 
far enough, and it was not the intention of the Harrison law to 
cover the entire question of drug traffic. The Harrison law is 
primarily a revenue law. Its second function is that of requir- 
ing registration. It is not the intention of the law to prohibit 
drug sale or drug administration or to limit it materially. En- 
forced it does limit it to some extent. But the real object, out- 
side of revenue gathering, of the Harrison law is to require 
registration in order that each State may regulate the matter. 
It requires registration with the internal revenue collectors, and 



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414 TREATMENT OF DRUG HABITS. 

these records are open to every officer of the law or anyone else 
legally authorized so that State officials can enforce any statute. 
What we want is enforcement of our statutes, and this can 
easily be done under the Harrison act if it is efficiently en- 
forced. 

In my opinion, more depends upon three classes of men doing 
their duty conscientiously, and viewing this important question 
as it is to make effective the intention that drug traffic shall be 
discontinued. These three classes are, first, the officers of the 
law; second, the doctors; third, the druggists. We should 
expect, first, from the officers of the law that the government 
Harrison anti-narcotic law be enforced ; and second, that from 
our local county and State officials that the statutes regulating 
pharmacy be effectively enforced. We should expect from our 
druggists that no one betrays a trust if not a violation of law to 
administer or to fill a prescription except it be in accordance 
with the usual rules of dosage. Then the doctors can do the 
rest. I believe if there is any one thing in which modem medi- 
cine could be criticised it is in this one matter and this one 
suggestion that less time and attention be given to the uses and 
therapeutics of opiates and other anodynes and sedatives and 
that more space and time be given to the dangers of these 
drugs. The legislators, both National and State, have indeed 
been liberal in their consideration of the medical profession as 
regards their legislation on these prohibited poisons. We so 
frequently see the phraseology, "Provided, This act is not to be 
construed to include drugs administered by a regularly licensed 
physician," that makes an exception and leaves the doctors to 
fill the exception. 

Then, with no intention of arraigning the medical profession 
of Alabama, yet, knowing that drugs are being gotten to hab- 
itues in drachm doses and in quarts of paregoric in some way, 
then it certainly is a conscientious duty of ours to see how that 
is done. Drug habitues in the State should not be permitted to 
obtain opiates in the large quantities mentioned. 

DISCUSSION. 

Dr. Rogan : I quite agree with Dr. Partlow that the method 
of treatment is a matter of secondary importance, and the more 
experience I have had with these patients the more firmly I am 



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W, D. PARTLOW, 416 

convinced of that fact. In institutional work I fully agree with 
him that withdrawing the drug at once is the best way to handle 
the patient, but in private practice it is not always possible to do 
that. I also heartily agree with the doctor in what he said 
about the prescribing of opiates, that the real indications for 
the prescribing of opiates are very few indeed. The practice 
of prescribing codeine for headaches and such things as that, 
which all of us probably have been guilty of at times, is cer- 
tainly a bad practice, and a thing we ought not to be guilty of. 



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BLOOD PRESSURE. 



p. P. Salter, M. D., Montgomery. 

About one hundred years ago auscultation began to be sys- 
tematically employed in the examination of the heart. With 
that injudicious enthusiasm, which at all times has heralded a 
new method of observation, fabulous qualities and quantities 
were at first attributed to the stethoscope. People were found 
to have murmurs before their death and long before the cause 
of murmurs was known or their significance realized. The 
statement went forth with all the weight of the highest au- 
thorities that these signs betoken previous heart trouble. To- 
day, notwithstanding the enormous amount of attention that has 
been given to the subject, the whole profession suffers from this 
untrustworthy observation. Realizing that the determination 
of blood pressure is but one score years of age, yet even at this 
early date we see some observers, without ground to back 
them, state that a correct estimation of blood pressure is our 
one means of reaching a prognosis in heart affection, while 
others will state that it is an absolutelv true guide for a definite 
line of treatment. Our state of development doesn't warrant 
such extreme assertions. An endeavor will be made to uphold 
this statement. 

In 1886, in Flint's "Practice of Medicine," there is a passage 
referring to increase of blood pressure in cases of small granu- 
lar kidney and in cases of apoplexy. A little later, Delafield, 
in this connection, spoke of cases of arterial narrowing, with 
increased intravascular tension, but no measurements of pres- 
sure were referred to. In 1889, Stengel read a paper on ath- 
letics * * * with no mention of blood pressure. In 1903, 
Cabot presented observations of blood pressure in man, and in 
1904, there was a second paper by Cabot on observation of 
blood pressure by means of the phymomanometer. Since that 
date we have developed an easily available method by which 
any physician can gain by measurement essentially accurate in- 
formation concerning systolic and diastolic pressure in the 



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p. p. SALTER, 417 

arteries. It has made a clinical entity of the essential hyper- 
tension of cardio-vascular disease. It has disclosed the high 
pressure of the eclamptic state, and the low pressure of a my- 
loid kidney. 

The pioneers in the field of cardio-renal-vascular disease 
early appreciated the great advantage they possessed by this 
means of graphically measuring arterial tension over the old 
method of estimating tension by the finger, for the accuracy of 
tactile estimation of blood pressure was notoriously uncertain, 
so that errors of 10-80 mm. were common. 

Such have been the character and the value of the information 
the findings have furnished. Sphygmomanometers now con- 
stitute a part of the armamentarium of almost every physician 
as a result of the valuable data that they furnish. In the opin- 
ion of so eminent a physiologist as Ludwig, the discovery of 
blood pressure by Stephen Hales was more important than that 
of the circulation by Harvey. The clinical study of pressure 
although a little over a decade old, has developed from a proce- 
dure of uncertain and doubtful value to one of precision, 
equalled by few of the many other methods of daily use by the 
physician. 

Recognizing that the science of medicine is so broad, its 
ramifications so extensive, and its literature so voluminous that 
few physicians, if any, are able to accurately follow and intelli- 
gently grasp the almost daily advances in all branches of medi- 
cine, serves as an ample apology for this brief paper. I have 
no new thoughts for you who have been so fortunate as to 
keep abreast with the procession, but to you who have been so 
busy, since the year 1904, that you were robbed of this oppor- 
tunity I submit this discussion on blood pressure, its determina- 
tion, physiology and the interpretation of pressure readings. 

Physiology : The maintenance of a normal circulation is es- 
sential to good health. Abnormalities in the circulation are 
either the result of, or result in, disease. A normal circulation 
physiologically distributes the blood to every part of the body, 
whereby the normal interchange of nourishment and waste is 
sustained in all the organs and tissues. 

The human blood pressure system comprises essentially, the 
heart ; blood vessels ; and the vaso-motor regulating mechanism. 
The three are intimately associated ap that disturbance of any 
one is followed by derangement of the balance existing among 

27 M 



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418 BLOOD PRESSURE. 

them. So far as the heart and blood vessels are concerned, 
blood pressure depends largely upon the energy of the heart; 
the peripheral resistance ; and the volume of the blood. The last 
has but a theoretical bearing. It is essentially then the activity 
of the heart and the nervous control of the vaso-motor system 
over blood vessel walls that the difference in the blood pressure 
of the arteries and the veins is maintained. 

In general, other things remaining equal, we may state that 
an increase in the heart rate raises blood-pressure and a slow- 
ered rate diminishes pressure, e. g., a slow heart rate, due to 
vagi stimulation, gives a fall in pressure, while cutting the vagi 
shows that with an increase in blood pressure we get an in- 
crease in the pulse rate. Clinically some . observations do not 
corroborate this otherwise simple postulate, for sometimes high' 
pressure is associated with a relatively slow heart and vice 
versa. This is easily understood when we take into account, 
that pressure depends, in addition to heart rate, upon the 
amount of blood leaving the heart in a unit of time. A sIqw 
heart with a long systole may discharge a quantity of blood 
that would counteract the pressure-lowering effect of the slow 
heart. On the other hand, clinically a rapid heart may accom- 
pany a low pressure, for the increased cardiac rate may not al- 
low of sufficient time for filling of the ventricles with blood and 
thus less blood is put into the circulation per unit of time and 
thereby the blood-raising tendency of the fast heart is offset by 
the pressure-lowering tendency of the incomplete output. 

The third factor in blood pressure maintenance is peripheral 
resistance. Without resistance there could be no pressure. 
Therefore, the greater the resistance the higher the pressure, 
other things remaining equal. This peripheral resistance, for 
our purpose, may be taken to include, changes in the size of 
the blood vessels, whereby their lumen is increased or de- 
creased, thus diminishing or increasing resistance respectively. 
In the interpretation of all pressure readings we must settle 
in our minds which of the three factors is the cause of the hy- 
pertension, e. g., in nephritis, it is the increased peripheral re- 
sistance, due to the diminished size of the vessels in the kidney 
that produces the hypertension or is the pressure accounted for 
by the increased action of the heart, stimulated to the over- 
work by toxic substances that would filter through the tubules 
and glomeruli of a normal kidney ? Such should be the nature 



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p. p. SALTER. 419 

of the questions that naturally arise after obtaining an abnormal 
pressure. 

After this brief and incomplete discussion of the physiology 
of blood pressure we shall consider the methods of its determi- 
nation. As early as 1733 Stephen Hales published an account 
of his method of estimation of pressure in his Statical Essays. 
The instrument used was of necessity crude and results were 
not accurate, but from that as a basis we now have through the 
efforts of von Basch, Ludwig, Magendie, Hurthle and others 
our modern, accurate, and indispensible manometers for all 
clinical purposes. 

The instruments in general use today are of two types. The 
one a mercury instrument, typified in those of the Nicholson 
manometer or von Gartner's tonometer; the other a spring 
or diapragm instrument, e. g., the Roger's Tycos manometer 
and Faught's manometer. For the general practitioner I be- 
lieve the last named type of instrument is mort suitable, easier 
of application, and very accurate. In the technic of estimation 
given I refer to the spring or diaphragm instruments. 

Determination : The patient should be in a comfortable posi- 
tion, either sitting or reclining, and completely relaxed. All 
subsequent estimations should be taken under exactly the same 
circumstances. That part of the sleeve containing the rubber 
bag is placed well on the inside of the bare arm, above the el- 
bow, and the remainder of the sleeve wrapped around pre- 
cisely as a bandage would be applied, the last few inches being 
tucked under the preceding fold. The manometer is then at- 
tached to either one of the two rubber tubes leading from the 
sleeve. The inflating bulb and valve are attached to the second 
rubber tube. This arrangement forms a continuous closed 
pneumatic system. When pressure is thus raised in the arm- 
band by the pump, the amount of force exerted is indicated by 
the swing of the pointer on the dial, the figures indicating mm. 
of Hg. 

Clinical experience and experimental research have demon- 
strated that the auditory or auscultatory method of estimating 
pressure to be easier of interpretation, less often aflfected by 
abnormal conditions and vastly superior to the older and less 
accurate methods of palpation and oscillation. For the above 
reasons I will discuss only this method of estimation. The arm- 
let is distended until the artery is obliterated. On listening with 



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420 BLOOD PRESSURE, 

the stethoscope at the bend of the elbow, medial to the biceps 
tendon, when the pressure in the bag is gradually released, the 
returning blood-wave in the artery under the stethoscope indi- 
cates its presence by sounds that vary from an upper to a lower 
limit as the external pressure is released. These sounds owe 
their origin to vibrations of the arterial wall when the normal 
circular form of the artery is, in the compression area, more 
or less distorted by the external pressure. 

Between the upper and lower limits of sound production 
marked variations in character and intensity are recognizable. 
These variations can be described in five district phases : 

1. A clear, sharp sound — the index of systolic pressure. 

2. A murmur, loud, rough, stenotic, and of variable dura- 
tion. 

3. A distinct change to a clear, loud, snappy sound replacing 
the murmur. 

4. A transformation (usually sudden, at other times grad- 
ual) of the clear sound into a dull, muted, altered sound — ^the 
index of diastolic pressure. 

5. The disappearance of all sounds. 

Criteria : The beginning of a clear sharp tone on lowering 
the external pressure from above the obliteration point, reading 
the figures on the dial indicated by the point of the hand at the 
distance the sound is heard, marks the reading point for systolic 
pressure. 

The lowest point of the excursion of the hand on the dial, 
taken at the instance a transition of sounds from a clear, loud 
tone to an appreciably dull tone marks the diastolic pressure. 

Thus we have obtained systolic pressure, which is the maxi- 
mum pressure exerted on the vessel walls during the cardiac 
cycle. This maximum pressure represents the total energy of 
the heart. 

Diastolic pressure, which represents the tension in the artery 
due to its own constriction (systole of the artery) during the 
diastolic phase of the heart. It is then an estimation of the 
entire load of pressure borne by the whole arterial system 
during diastole. The diflference between the readings of sys- 
tolic and diastolic pressure represents pulse pressure. This 
represents the eflficient work of the heart and* indicates the 
extent to which it overcomes peripheral resistance. The deter- 
mination of pulse pressure is of greatest importance in the 



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p. p. SALTER, 421 

study of diseased conditions, particularly in estimating cardiac 
muscular efficiency and in determining the prognosis in cer- 
tain valvular and blood vessel diseases. 

Just what figures can be taken to represent the normal blood 
pressure, a very essential element to know when trying to de- 
termine whether a reading is abnormal, will vary with each 
individual and his peculiarities. The generally adopted fig- 
ures are as follows: The normal systolic blood pressure in 
adult males ranges from 105-145 mm. Hg. In children over 
two years of age 85-110 mm. In females the pressure is about 
10 mm. lower than in males. The normal diastolic pressure 
ranges from 25-50 mm. less than the systolic pressure. The 
pulse-pressure varying from 25-50 mm. of Hg. 

The normal blood pressure varies at different times of the 
day, and is affected by position, exercise, excitement, baths, di- 
gestion, heat, cold, sleep, alcohol, tobacco, altitude and many 
other things. But as these are all transitory factors, repeated 
examinations will soon lead to their elimination. 

So far we have considered the physiological side of blood- 
pressure and have left untouched the fundamental fact that a 
patient consults a physician because he is conscious there is 
something wrong with him. The doctor, in his examination, 
may find some sign or sensation which he recognizes as a 
departure from the normal. He may even recognize the me- 
chanism by which the symptoms are produced and be interested 
in it from the physiological and pathological standpoint of 
view; but these are not the points that are essential to the 
proper performance of his duties, although they may be con- 
tributory to that performance. He must view the matter from 
the patient's standpoint, and, apart from the question of imme- 
diate relief the patient's standpoint may be summed up in this 
question, "What bearing has the cause of this symptom upon 
my life and future?" 

If by chance it should happen that the abnormal manifesta- 
tions indicated that the trouble was from an abnormal blood 
pressure, it is up to the observer to determine what is the un- 
derlying cause or causes and what bearing the finding has upon 
the patient and not the fact that he or she has an abnormal 
pressure. Keeping this in mind we will discuss the findings 
in some of the commonest diseases. 



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422 BLOOD PREB8URB. 

So far very little significance is attached to a low pressure 
finding, yet low pressures are almost constant in all of the 
acute diseases except epidemic cerebro-spinal meningitis. It 
is a frequent accompaniment of anemic states, chlorosis, chol- 
era, hemorrhage, rheumatoid arthritis, starvation, diarrheal dis- 
eases, shock, collapse, pulmonary tuberculosis, etc. 

The value of the test as an aid to an early diagnosis of pul- 
monary tuberculosis will be more apparent when the general 
practitioner begins the universal use of the mancwneter in all of 
his cases, for it is on him that the profession will greatly de- 
pend in the future. Those who have used the test routinely in 
their diagnostic work have found a uniformly subnormal pres- 
sure in pulmonary tuberculosis. Bunton believes that hypo- 
tension may be a guiding sign before any physical phenomenon 
is present in the lungs. Cook makes the following statement : 
"When low blood-pressure is persistently found in an individual 
or in families, it should put us on our guard for tuberculosis." 
And I believe that the test is of such significance that it will 
warrant the statement that when a low pressure is persistently 
found in an individual pulmonary tuberculosis should be ex- 
cluded, not diagnosed. In a series of experiments carried on 
by Schnitt in early cases of tuberculosis 48 per cent showed a 
marked lowering of pressure, 37 per cent moderate lowering, 
7 per cent tension of 123, and 8 per cent normal pressure. He 
found that a pulse pressure of 25 mm. or under was especially 
significant. The test serves us as a prognostic sign to deter- 
mine the amount of exercise to be safely permitted in cases of 
tuberculosis. 

The low blood pressure found in cases of typhoid fever from 
the first week is of utmost importance, as it indicates myocardial 
degeneration. Briggs and Cook claim that there is no patho- 
logical condition apart from shock in which blood pressure 
readings are of more significance. The estimation should be 
recorded as often as temperature, respiration, and pulse rate. 
It will be found that there is a gradual and progressive fall in 
pressure as the case progresses. In case of hemorrhage, there 
is a sharp, sudden fall, while on the other hand perforation will 
be accompanied by a sharp and sudden rise of the pressure. The 
sharp rise may and often does occur hours before the perfora- 
tion. It is in just such cases that a change of the management 
of the case may mean the saving of life. 



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p. p. SALTER. 423 

In cases of moderate severity of pneumonia the pressure is 
but little changed. In severe cases it is usually subnormal. 
When we realize that 43 per cent of the fatal cases of pneu- 
monia die from vaso-motor paralysis and the remainder die 
from heart failure it is evident that the test should become 
universal. A drop of 15-20 nmi. is perfectly safe, but a pro- 
gressive fall indicates the need of stimulation. A sudden drop 
is rarely seen except just before death. A slow, gradual fall 
of 20 mm. means cardio-vascular asthenia, and calls for an 
increase in the stimulation. Gibson and Gordon gave us a very 
safe rule to follow in cases of pneumonia before the age of 60. 
"When systolic pressure expressed in mm. of Hg. does not fall 
below the pulse rate expressed in beats per minute the fact 
is of good augury and the converse is likewise true." This 
rule is too dogmatic and incapable of flexibility for we have all 
seen cases that did not conform to the rule and yet had a favor- 
able outcome. But no rule is infallible. It simply gives us a 
guide that aids us to make a fairly safe prognosis. 

In cases of scarlet fever, diphtheria, variola and other acute 
infectious diseases the test is only of a theoretical value until 
the stage of convalescence sets in. At this time, in diphtheria, 
it may serve as an indicator for the institution of certain treat- 
ments in order to avoid heart failure, so often the cause of 
death, while during the convalescent stage of scarlet fever, a 
sudden increase in the reading may mean nephritis. The hyper- 
tension due to such a cause is evidenced by the increase of the 
pressure even before alubumin appears in the urine. 

In considering hypertension it has been found that the cases 
can be divided into three groups: First, simple high tension 
without signs of arterial or renal disease ; what Clifford Allbut 
terms "Simple Hjrperpyesis," and James Mackenzie calls "Phy- 
siological Hypertension ;" second the cases of high tension as- 
sociated with an arterio-sclerosis with consecutive cardiac and 
renal involvement ; third a group of high tension cases second- 
ary to forms of chronic nephritis in association with cardio- 
vascular disease. From a careful study of the groups it appears 
to me that most of our cases of high-tension are preventable. 
I believe the physician should be as energetic in teaching the 
prevention of arterial hypertension as he is in preventing con- 
tagion. This is an age of prevention and as infectious diseases 
are reduced in frequency more patients live to die of degener- 



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424 BLOOD PRESSURE. 

ative diseases later in life and diseases of hypertension are on 
the increase. 

The etiology of nephritis, arterio-sclerosis, cardiac, and vas- 
cular diseases giving rise to hypertension is a long list of ex- 
cessive stimulations and extreme mental depressions; a story 
of great risks taken and great losses borne ; of heavy burdens 
carried and long strains endured ; of excessive dissipation ; of 
auto-intoxication ; leutic and other infections. It is essentially 
a history of the modem world ; of progress and power and suc- 
cess ; of liberty, luxury and their antitheses. The bucolic Swede, 
the wandering Scotch bard, probably never knew arterio- 
sclerosis except as an accompaniment of ripe old age. Now 
the Chinese Coolie, the Japanese rickashaw man, the Western 
athlete, the emotional American, the excitable Jew and all races 
are subject to hypertension and thus their days are shortened, 
by the early hardening of their arteries, the criterion that marks 
our days and numbers our steps upon this earthly pilgrimage. 

Well-developed cases of hypertension are incurable, unless 
the underlying cause happens to be lues. In such cases specific 
treatment often yields very happy results. We have no single 
drug that will permanently lower the pressure in cases of hyper- 
tension, and in so far as the writer is aware, we have not yet 
found a method of treatment that is attended with stable re- 
sults. It is urgent, therefore, to emphasize that the blood pres- 
sure test should be used more frequently in routine examina- 
tions, so that we will henceforth get these cases in the early 
stages before any great damage is done and permanent hyptr- 
tension may be avoided. 

Trischer found in 550 patients, with permanent high pres- 
sure, above 140 mm., 62J/2 per cent had definite signs of neph- 
ritis, 14>4 per cent had signs of probable nephritis, and in the 
majority of the remainder cardiac, arterial, or liver abnormali- 
ties were predominant. Janeway found that in his cases 15 
per cent of the hypertension patients showed cardiac hyper- 
trophy and arterial changes. It is evident that the diseases giv- 
ing rise to hypertension are incurable, hence I wish to empha- 
size my point again, that we must in the future lay more stress 
on prevention of hypertension and a routine blood pressure 
test in all cases. This will give you valuable information, ob- 
tainable in no other way. 



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p. p. SALTER. 425 

The test is indispensable if you have the care of pregnant 
women. Evans, of Montreal, studied 38 cases who had 
eclampsia, toxic vomiting and albuminuria, and found the sys- 
tolic pressure to vary from 140-200. Newell, of Boston, studied 
the pressure in 450 pregnant women, and concluded that when 
the systolic pressure was below 100 the patient was below par, 
and her condition required attention so she could stand the 
strain of parturition. He believes a persistent systolic pres- 
sure above 130 should be carefully watched, and that blood 
pressure of 150 is the danger line. Fifty cases of the 450 
showed albumin at some time in the nine months. Of these 
50 cases, 39 had no high pressure and never developed any bad 
symptoms. He thus concluded that a slight amount of albu- 
min in the absence of high blood pressure is of no significance. 
He did find that a rise of blood pressure followed by the ap- 
pearance of albumin, is a combination shown to be a definite 
sign of the development of toxemia. It is not always the high 
blood pressure that is significant, but of more importance as 
shown by Newell, Hirst, Evans and others, is the fact that a 
continuously high pressure is not as indicative of toxemia as 
when a pressure has been low and later suddenly rises. 

The management of cases of hypertension can well be cov- 
ered by a few rules which are worthy of attention : 

1. Do not tell your patient who has a moderate hypertension, 
few symptoms, and whose kidneys are functioning well to stop 
eating meat and to starve. Remember, that aside from danger 
of cerebral hemorrhage, oedema of the lungs, etc., that if the 
heart is well compensated as evidenced by being normal in size, 
with no abnormal action, and which responds favorably to ef- 
fort, the individual is often less a patient than a subject whose 
organism is undergoing a circulatory regime. 

2. Do not tell him his kidneys are good because his urine 
does not show albumin and casts, take his blood pressure. 

3. Do not give nitroglycerine or other pressure lowering 
drugs to your patient the moment you find that he has hyper- 
tension. Perhaps he requires a high pressure to force the blood 
through his small inelastic arteries. 

4. Do not attribute insomnia, nervousness, headaches, etc., in 
the middle-aged woman to "the change" — test her blood pres- 
sure. 



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426 BLOOD PRESSURE. 

5. Do not give any treatment to your case of hypertension 
until you have found the underlying cause. If the heart is well 
compensated and has a good response to effort it is very likely 
that he needs the extra pressure in order to live. 

6. Do not make a diagnosis of neuresthenia until you have 
taken the blood pressure and made a Wassermann. It may 
save you embarrassment. 

7. Do not exclude syphilis, especially a parental infection, as 
the cause of hypertension solely because the Wassermann is 
negative. If lues is the etiological factor in the production of 
the hypertension specific treatment may permanently lower the 
pressure. Hypertension from any other cause whatsoever can- 
not be permanently lowered by any therapeutic measure at our 
disposal. All drugs now in use are temporary in their effect 
and injudiciously used may aggravate the case. 

BIBLIOGRAPHY. 

1. Theodore C. Janeway. Important Contributions to Clini- 
cal Medicine from the Study of Human Blood Pressure. 

2. Faught, F. A. "Blood Pressure." 

3. Goodman. "Blood Pressure." 

4. Osier, W. "Practice of Medicine." 

5. Green. "Medical Diagnosis." 

6. Howell, W. H. "Physiology." 

7. N. Y. Med. Jour., June 11, 1910, and Dec. 3, 1910. 

8. N. Y. Med. Jour., March 4, 1911. 

9. Johns Hopkins Hospital Reports, 1903, XI, p. 502. 

10. Piersol. Penn. Med. Jour. May, 1914, p. 625. . 

11. Munich Med. Woch., 1913, p. 63. 

12. Newell, F. S. "Blood Pressure During Pregnancy," 
Jour. A. M. A., Jan. 30, 1915, p. 393. 

13. Evans. Cyc. and Med. Bull., Nov., 1912, p. 649. 

14. Irving, F. C. "The Systolic Blood Pressure in Preg- 
nancy," the Jour. A. M. A., March 25, 1916, p. 935. 

15. Mackenzie, Sir James: "Principles of Diagnosis and 
Treatment in Heart Affections." 

16. Bishop, L. F. Heart Disease and Blood Pressure. 

17. Warfield. Arterio-Sclerosis. 

18. AUbutt. Clifford. Diseases of the Arteries. 



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SURGICAL OPERATIONS DURING PREGNANCY. 



W. G. GEwnr, M. D., Birmingham. 

There is no truer phrase than "This is the age of specialties," 
yet what man dares to endeavor to establish a reputation as a 
specialist without feeling sure in his own mind that he is just 
as well equipped by hard study and application to be just as 
competent in many equally difficult branches. 

Just as pregnancy seems to invite as attendants, nearly all 
the ills woman is heir to, so must the skillful obstetrician meet 
and recognize all complications. And the surgeon of today 
must have as thorough knowledge of the variable physical 
changes caused or aggravated by pregnancy as if that were his 
sole ambition. 

We are never surprised at the necessity of operations upon 
the generative organs themselves in pregnancy ; such as Caesar- 
ean section, etc. ; those in which we aid delivery, while not al- 
ways expected, are always held in mind. 

But it is of conditions that confront us in the pregnant and 
non-pregnant alike, that I could speak. 

Even in the perfectly normal woman, pregnancy exerts its 
disturbing influence. There are cases in which the general 
health is seemingly much improved, but as a usual thing if any 
chronic weakness exists, it is intensified and aggravated at this 
time. 

Such is also the common belief among the laity; this is the 
cause no doubt for the serious condition of so many patients 
when the physician is at last consulted. 

During pregnancy the avoidance of major surgery is highly 
desirable as, at this time, the reserve power is freely expended 
and excessive exactions are frequently demanded. Moreover, 
the risks of abortion and liability of premature labor are addi- 
tional militating reasons. 

Despite the soundness of the foregoing statements, operative 
intervention during pregnancy is not inevitably injurious, nor 
is the interruption of pregnancy a certain consequence. There 



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428 OPERATIONS DURING PREGNANCY. 

exist innumerable records of abdominal operations performed 
during pregnancy. These include appendectomy, ovariotomy, 
cholecystostomy, nephrectomy, etc. In our experience of the 
last few years, we have many successful cases. 

It has been my experience that if I am confronted with an 
abdominal condition requiring immediate operation, it does 
require the operation principally to save the patient's life; 
therefore, it is that much more drastic when two lives hang in 
the balance. And I put the danger of abortion, imminent 
though it is, as a secondary consideration ; many times the dan- 
ger is as great as though the patient remain undisturbed. 

Owing to the fact that many people shrink from an opera- 
tion until an emergency forces it, the patient often suffers from 
some chronic trouble, prior to pregnancy. One attack of ap- 
pendicitis, as we know, predisposes another. She is very apt 
to think the sudden pain, high temperature, and other accom- 
panying symptoms, due to some disorder of pregnancy — espe- 
cially miscarriage ; and it behooves the physician to have other 
things in mind as well. 

Diagnosis is comparatively easy in the early months ; it must 
be held in mind that the position of pelvic and abdominal or- 
gans as pregnancy advances, is also far from normal. I recall 
one case, a primipara, aged 27, who was six months pregnant 
at the time of operation — a most dangerous period. She was 
brought in suffering from an acute attack of appendicitis. I 
operated immediately, finding a highly inflamed appendix, 
which would undoubtedly have bursted in a few hours. Every 
precaution was used in technic and after-care ; the patient made 
an uneventful recovery, and carried the child to term ; at end 
of which time she came back for perfectly normal delivery. 

It is possible, as we know, for gonorrheal infection of the 
tubes and ovaries to occur months after the initial introduction 
into the body. An acute exacberation of a chronic salpingitis, is 
at any time, in my opinion, a condition demanding immediate 
surgical treatment. Instead of waiting until the termination 
of pregnancy to operate, I consider it good judgment in selected 
cases to operate immediately. There is the same chance for 
recovery as in the non-pregnant woman and the probability of 
freeing her from even graver danger. 

One of the strongest causes for abdominal operation during 
pregnancy is the existence of ovarian tumors. In the great ma- 



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W, C. OEWIN. 429 

jority of cases it may safely be said that the progress of the 
pregnancy will not be materially influenced by operation. Ovar- 
ian tumors are removed before they attain a size A^hich will be 
sufficient to cause any symptoms attributable to pressure. 

When we consider the grave danger of abortion from the 
many causes attributable to ovarian tumors, the same fear of 
the operation shrinks considerably. Torsion of the uterus is 
perhaps more common than is usually believed; thus causing 
enough disturbance of the circulation of the uterus to bring 
about abortion. 

The prognosis as to the mother in cases of ovarian tumor 
associated with pregnancy, depends largely upon the location 
of the tumor is of much greater importance than its size, as a 
small tumor is very apt to occupy the pelvic cavity, causing an 
obstruction to labor. 

After the presence of the tumor is ascertained by the physi- 
cian, there should be no further delay in operating. Not only 
is the new growth a usurper of space, or an impediment to 
labor, but the progress of pregnancy seems to be a factor in 
supperation of ovarian cysts. It must be taken into considera- 
tion that twisting of the pedicle, rupture and suppuration, may 
be expected to occur in three-fourths of the cases. 

Not only is the operative risk of the mother no greater than 
the same risk assumed by the non-pregnant woman in the same 
operation, but the chances for the child are immensely improved 
by the removal of the mass which might cause great obstruc- 
tion to labor. 

I have in mind one very interesting case of an entirely differ- 
ent nature. We were consulted by a primipara of about twen- 
ty-six, three months pregnant, who was in a very toxic condi- 
tion. She gave a history of habitual constipation, now much 
intensified. She was unable to retain food in the stomach at 
all, which she had attributed to her condition ; however, she had 
suffered much with her stomach previous to this time. She 
was nervous to a marked degree and steadily losing in weight. 
As her symptoms seemed due to a gastric and colonic disturb- 
ance it was decided to give thorough X-ray examination. 

The bismuth stomach-meal and enema were administered; 
both fluoroscope and plates showed a marked ptosis of both 
stomach and colon. Notwithstanding her condition, or rather 
because of it, an immediate operation was decided upon and 



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430 OPERATIONS DURING PREGNANCY. 

was referred to my associate, Dr. Gaston Torrance, for opera- 
tion. 

Both the .stomach and colon were lifted and put in place by 
the celebrated Rovsing method; all precaution due her condi- 
tion was observed ; the patient was kept in bed for one month 
following. She made an uneventful recovery and was free 
from all former symptoms. Six months later she was deliv- 
ered of a fine baby boy. She is now in better health than at 
any time in her previous adult life. 

I admit there are adverse cases in operations during preg- 
nancy, just as in all other conditions; yet I think the difficulties 
with which we are beset justify us in using every artifice our 
knowledge yields us ; and if we are gratified with even an in- 
complete measure of success, still our results justify our en- 
deavors in this most difficult field. 

DISCUSSION. 

Dr. W. R. Jackson, Mobile : I think this is a very interesting 
subject indeed, and I would like to say a few words. Opera- 
tions during^regnancy heretofore have been considered very 
grave procedures, but recent work proves that almost any 
operation in the pelvis or abdomen can be performed during al- 
most any stage of pregnancy with the exception of the removal 
of the ovary in the early part of gestation. It has been shown 
experimentally and also by clinical work that if the ovary from 
which the impregnated ovum has escaped is removed during 
the first three months of pregnancy the ovum will be thrown 
oflf. The corpus luteum of the ovary from which the impreg- 
nated ovum escaped seems to be a fixing material for the ovxmi 
in the uterus. This has been shown repeatedly, and now is ac- 
cepted as a clinical fact. If you remove a cystic ovary before 
the third month, if it is the one from which the impregnated 
ovum came, you will lose that pregnancy every time. I have 
had two experiences along this line myself. Now if you re- 
move the other ovary, where there is no corpus luteum of preg- 
nancy, your ovum will stay. I have removed a large ovarian 
cyst of the ovary where the corpus luteum was not the cause 
of the pregnancy with perfect impunity to the patient. 

Recently the question came up as to whether to operate on a 
carcinoma of the breast during gestation. Carcinoma of the 
breast grows very rapidly during gestation and lactation, and 



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TT. C. GEWIN, 431 

this one grew in two months from the size of the thumb to the 
size of the fist, and the lymph nodes in the axilla were rapidly 
enlarging. So I operated. There is a reflex connection be- 
tween the mammary gland and the uterus, and any severe 
trauma will produce reflex emptying of the uterus, whereas the 
removal of the gland in toto will not do anything. 

Numerous operations for removal of large fibroid tumors 
have been performed on uteri from five to seven months preg- 
nant and pregnancy not interrupted. Of course, there seems 
to be exceptions. It is shown, however, that any serious dis- 
turbance by trauma with the muscularis of the uterus will cause 
uncontrollable contractions and expulsions of the contents. 

I enjoyed the doctor's paper very much. 

Dr. I. L. Watkins, Montgomery: I am delighted to have 
heard Dr. Gewin's paper. He has raised a question that may 
come to any of us. I think it unwise to resort to surgery dur- 
ing pregnancy, unless an operation is absolutely necessary for 
the purpose of delivery or for the purpose of saving the mother. 
There are conditions where it must be done. In acute appendi- 
citis, the first or second attack, I think it is better to operate than 
to take the risk of having to operate about the time the woman 
fs going to be delivered, but in chronic appendicitis, with the 
average pain, with a simple chronic appendicitis, I do not think 
we are justified in operating. I have always followed this 
course, and I do not recall having had any untoward results 
from it. But when the case is acute, it is rather questionable 
or dangerous to put the operation oflF. The question is whether 
you are going to be caught in a trap and have the two condi- 
tions at the same time. 

As to the operation for ovarian cyst, I think they should be 
removed. I have done the operation, and I do not recall hav- 
ing but one miscarriage. 

Regarding the operation of myomectomy during pregnancy, 
that is a condition also where we can take a good many lib- 
erties. I haven't any doubt that most of you have delivered a 
woman with fibroid tumors. There is no question about a 
woman aborting if you operate on a fibroid in the lower seg- 
ment of the uterus. Many women are delivered of a living baby 
at term from a fibroid uterus. I have no doubt that many of 
you have seen just such cases. 



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432 OPERATIONS DURING PREGNANCY, 

Now, as to the other operations on the vagina : the essayist 
made one remark that I thought was unusual, namely, the oper- 
ation for acute salphingitis Personally I do not think he is 
over justified in operation for acute salpingitis. That may be 
a very broad statement, but it is true from my standpoint. We 
have no right to take out a tube until we see whether it is 
going to get well ; you would not cut oflF your thumb or finger 
because it was inflamed, and why take out a woman's tubes 
because they are inflamed. You may have to do it in the end 
before you get the woman well, but that result is not the rule. 
Almost nine out of ten of them will get sj'mptomatically well, 
and many of them will have babies afterwards. Do not take 
out a woman's tubes and ovaries simply because they are in- 
flamed, even if it is gonorrhoeal. It is very easy to take out a 
woman's ovaries and tubes, but I would like to see you put 
them back, but if you do that woman is not much account af- 
terwards. That may not be a very popular statement to make, 
but I do not hesitate to show my feeling about that. We ought 
not to take them out unless it is absolutely necessary. Taking 
out an acutely inflamed ovary or tube I do not think is good 
surgery. 

In cancer, of course, we cannot question the necessity of oper- 
ation. It is a question of what is best for the woman. It is a 
question of common sense. It is not your statistics you are 
trying to take care of, but you are trying to take care of a 
woman. Let the statistics go. If the woman has got cancer 
operate on it; if she miscarries let her miscarry; you are trying 
to save the woman's life. 

As to operations elsewhere in the upper part of the abdomen, 
I think the doctor was very. fortunate in his operation, because 
the woman has enough to contend with when she has an eight- 
pound foetus below and the stomach and liver trying to press 
down and get in the same place; she is in a great deal of 
trouble, and I think he was wise in doing his operation. Oper- 
ations in the upper abdomen the uterus will stand very well. 

As Dr. Jackson has said, this theory of the corpus luteum 
taking care of the foetus in the first three months is a most 
timely thing; in my opinion it is absolutely correct and most 
important. I think we ought to wait until after the third 
month if we are going to do anything with the ovary. 



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W, 0. OEWIN. 433 

Dr. E, V. Caldwell, Huntsville : I would like to bring out 
one point which has been omitted in this discussion. Suppose 
an abdominal section is done for some pelvic trouble and the 
patient is found to be three months or less pregnant, even 
though one or both ovaries should, from a pathologic stand- 
point, be removed, yet in view of the fact that it has been dem- 
onstrated that the patient would abort if the ovary from which 
the pregnant ovum came was removed at this stage of preg- 
nancy, it would be necessary to leave this ovary unless its path- 
ology was such to threaten the life of the patient. Then the 
question would arise, How would you tell from which ovary did 
the pregnant ovum come, and consequently the one to be left ? 

Examination of the ovary for the corpus lutea, and its rela- 
tive size would determine whether it was a corpus lutea of 
menstruation or pregnancy. 

Dr. Gewin: As to operations during pregnancy, I think 
most surgeons agree so far as the indications are concerned, 
and it is largely a question of being able to judge correctly the 
importance of the conditions we are dealing with, and to deter- 
mine its probable result, with and without an operation. 

Relative to the condition mentioned by Dr. Watkins — acute 
salpingitis — I am glad that he brought it up, and felt disposed 
to criticism. Evidently the doctor misunderstood me. What I 
said was, "An acute exacerbation of a chronic salpingitis." 

I think we all agree that to operate on an acute salpingitis at 
any time is to be deprecated. 

As to the question Dr. Jackson brought up — I would like to 
make it plain that I do not ever consider an abdominal opera- 
tion of any sort upon a pregnant woman, at all advisable, un- 
less the patient's life is endangered by the delay ; if such is the 
case, I believe it is our duty to operate. 

In regard to the eflfect upon the ovum by the removal of the 
ovary, which was mentioned by the doctor, I thoroughly agree 
with what he said ; yet if the condition demands the operation 
to save the life of the mother, I consider the operation justified. 

I agree with Dr. Watkins that no tube or other organ should 
be removed unless necessary. It should always be made a point 
to consider final results, as well as the immediate effect of the 
operation. 

28M 



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THE PRESENT STATUS OF THE LOCAL APPLICA- 
CATION OF RADIUM AND X-RAYS. 



Walter A. Weed, M. D., BirmiDgbam. 

Owing to some obscure quality in our being which we, for 
lack of a better term, call "Human Nature," are very much 
prone to either, ban or bless, most unreservedly and whole- 
heartedly, any new discovery or inventic«i. 

It may be that desperation over our inadequacy to success- 
fully cope with such urgent problems as malignant growths, 
was the prime reason for the enthusiastic welcome extended to 
the use of the X-ray. That the X-ray was a valuable agent to 
the surgeon was soon demonstrated, but because it did not im- 
mediately prove itself a wonder-worker, it was relegated to the 
background to make way for the spectacular introduction of 
radium. 

First greeted as a modern mystery of miracles — now, after 
the passing of a few years, bearing the condemnation of a few 
of the best known surgeons, radium is becoming known at its 
true value, it is not a panacea — it is not a fake ; it is, properly 
used, one of the greatest agents known to the medical profes- 
sion, and one whose value is not lessened by recognizing its 
limitations. We have not yet, in any branch of medical science 
or surgical art, discovered any remedy or method that we can 
truthfully consider infallible, even in carefully selected cases. 

Over a decade has passed since the accidental discovery of 
the therapeutic value of radium — over ten years of active use ; 
yet only in the last four years have the really practical methods 
of treatment been developed. We have been hampered by the 
extreme scarcity and great expense; yet, now that such large 
quantities of pitchblende have been discovered and utilized in 
our own country, we may hope for greater opportunities for 
the therapeutic application of radium. 

It is essential that some of the properties of radium and 
X-rays, and methods of application be understood in order to 
demonstrate their value in the treatment of disease. The mul- 



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WALTER A. WEED. 435 

titude of X-ray equipments all over the country has to a cer- 
tain degree worn away its novelty ; while the comparative scarc- 
ity of radium clinics leaves much to the conjecture of even tlie 
average doctor. 

Radium is eternally giving off three grades of invisible rays ; 
the alpha, beta, and gamma; the range of penetration of the 
alpha is very short, but its chemical action great. The beta 
ray is more penetrating, easily influencing living tissue several 
centimetres below the surface, also possessing certain chemical 
properties. The gamma ray is similar to the hard X-ray, but 
of shorter wave-length and more powerful penetration. There- 
fore, we have four factors to consider in the therapeutic appli- 
cation of radium ; amount of radium and the area to be treated. 
In the Use of X-rays, we take into consideration the voltage and 
amperage of the current use, instead of 'quantity,' as with 
radium, the other factors being the same. 

So far as is definitely known the action of both radium and 
X-rays is purely local. They have no effect favorable or ad- 
verse on metastases, nor will the treatment of the primary 
lesion effect a secondary growth of some other part of the 
body, — the rays must be directly applied to the circumscribed 
area. 

Noted research workers, both at home and abroad, have 
proved and recorded for our benefit these laws of radium : near 
the location of a tube of radium, a complete local destruction 
of all tissues, if so desired ; at slightly increased distance there 
is more or less gradual destruction of malignant cells with 
increased growth of connective tissue ; still more distant there 
is only partial destruction of cancer cells, but still overgrowth 
of connective tissue ; beyond this there is possibly a stimulating 
effect to the malignant cells, after which the radium has no ef- 
fect. 

The changes produced in the tissues by X-rays are similar 
to those of radium but not identical, notwithstanding evidence 
to the contrary by a number of X-ray and raditun workers of 
more or less repute. Wickham and Degrais say that, "If a 
current of electric sparks be passed into and split up in a glass 
vacuum tube (Crook's Tube), it is filled with special fluores- 
cence, and that certain rays, such as the anode, cathode, and 
X-rays are produced respectively analogous, but not identical 
with the alpha, beta, and gamma rays of radium." My own 



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486 APPLICATION OF RADIUM AND X-RAYS. 

experience is in accord with this, and leads me to believe that 
there is a difference in the biological effect of the two agents ; 
that a radium dermatitis or ulcer heals much more rapidly 
than one produced by X-rays. Admitting that there is a close 
similarity between the effects of both radium and X-rays there 
would still be clear-cut indications for both their separate 
and conjoint use. This is especially true in gynecological work, 
and in the treatment of malignant conditions involving cavi- 
ties. Generally speaking, where there is a large area to be 
treated as in carcinoma of the breast or a large area of obstinate 
eczema the X-rays are to be desired, while in the treatment of 
uterine conditions, which will be mentioned later, or in epitheli- 
omata of the mucous surfaces, radium is preferable because of 
its ease of application and of the fact that it can be brought 
into close proximity with the part to be treated. It might be 
said in this connection, that, in my opinion, their combined use 
is often better than either when used alone. 

Doubtless, as we gain in knowledge and experience, we will 
understand more clearly the varying and equal properties of 
these two great agents ; we will no longer look upon them as 
rivals, but as partners ; we will no longer madly advocate one 
because we possess it, but endeavor to utilize it to its greatest 
capacity, and, when necessary, call upon the other. As our 
technic improves (and we are constantly altering it) we will 
doubtless discover that in a great many conditions one is as 
applicable as the other. 

The X-ray was first given great prominence in the treatment 
of epitheliomata, and although its first ardor of enthusiasm is 
passed, it is not only holding its own, but is constantly gaining 
ground in the treatment of malignant conditions of the cutan- 
eous surface. In the hands of competent workers the relative 
percentage of cures is contesting strongly those produced by 
radium. In several cases I have been able to obtain cures 
with radium that had resisted treatment with X-rays by some 
of the most capable roentgenologists of the South. Perhaps 
the experience of other men may prove the reverse. A thought 
here is, that after all, it might have been the combined use that 
did the work successfully. In the treatment of naevi, small 
eczematous patches, keloids, etc., the concensus of opinion 
seems to favor radium as the agent of choice. 



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WALTER A. WEED. 487 

In the field of gynecology both X-rays and radium are of 
inestimable value, and are going to be utilized more and more 
as our technic improves, and as our results become known. 

In cancer of the breast, unless hopelessly inoperable, an oper- 
ation is always advisable, followed up by a thorough X-ray or 
radium radiation. The X-ray is preferable because of the pos- 
sibility of irradiating a large area more homogeneously than if 
done with radium. The X-rays are also, in my opinion, pref- 
erable in large pelvic and abdominal growth for the same rea- 
son. 

For thirty years and more, the surgical cure of cancer of the 
uterus was the aim of some of the brightest minds of the pro- 
fession; tireless efforts were exerted to prevent, by surgical 
methods, the extension of the disease. The different methods 
of hysterectomy, and in involvements of the cervix, amputa- 
tion and cautery — ^all were tried with varying degrees of suc- 
cess. But even in carefully selected cases the list of fatalities 
was appallingly high. Even with present improved methods, 
and in the hands of our most skillful men, more than half of 
the cases fail to respond. 

Admitting these things ad true surgery still has precedence 
in certain cases; the operative treatment of malignancies in- 
volving the fundus, is many times preferable. Cancer of the 
cervix is another story. When the involvement is general, it 
is a moot question as to whether operation is advisable. It is 
impossible to remove all the diseased tissue; tissues that for- 
merly clung to the central organs are forced to retract back 
upon the posterior anchor^ — that is, the pelvic wall. The pres- 
sure upon the sacral nerves is thus intensified, sometimes to the 
extent of involving the lower limbs, rendering the pain almost 
unendurable ; at the same time the recurrent growth rapidly in- 
creases. 

We have, therefore, adopted these rules: operate in every 
approved operable case, as in former days ; use X-ray or radium 
radiation about eight weeks later, guided by the patient's condi- 
tion; radiate all borderline cases; use radium in all advanced 
inoperable cases, not in the hope of effecting a cure except in 
a small percentage of cases, but because, when not too far 
advanced it may retard the growth over a considerable period 
of time, nearly always alleviating the pain, and checking the 



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438 APPLICATION OF RADIUM AND XRATS. 

foul discharge. Also, it is sometimes possible to render an 
inoperable case operable. 

In cases in which there is a large pelvic involvement, I high- 
ly favor a combination of X-rays and radium. It is thus pos- 
sible to completely cross-fire the tissues, and thereby obtain 
the combined beneficial results from the hard rays of the 
radium and the hard X-rays of the Coolidge tube. 

Doubtless to a great many the use of both radium and 
X-rays in the treatment of deep-seated malignant conditions 
has been more or less a disappointment; however, there are 
other conditions, not of a malignant nature, confronting the 
gynecologist in which our expectations have been more than 
realized, and our optimism justified. I refer especially to uter- 
ine fibroids, with or without menorrhagia and metrorrhagia. 
Also, to menorrhagia and metrorrhagia due to remote and in- 
definite causes. Speaking of the radium treatment of uterine 
fibroids. Dr. Howard Kelly says, "That all kinds of tumors 
have been treated, the submucous, the subperitoneal, and even 
the pedunculate, seeming to respond as well as the interstitial. 
In reporting 36 cases he says, "The results (in every case but 
one) have been either the shrinkage of the tumor or its com- 
plete disappearance, and the time occupied varied from two 
months to a year and a half." "One of the most striking ef- 
fects," adds Kelly, "is upon the menstrual function, where the 
radium can in all cases be depended upon to bring about a 
complete amenorrhoea * * *" If care is taken to avoid 
giving too large a treatment, it is possible in some cases, espe- 
cially with young women, to avoid amenorrhoea." 

Lange, of Cincinnati, says, "The X-ray treatment of menor- 
rhagia and uterine fibroids by the production of the artificial 
menopause has been given a new impetus by the invention of 
the Coolidge tube. "If the proper technic is employed the ef- 
fect of Coolidge tube radiation On the ovaries is the most cer- 
tain of medical phenomena. "If sufficient radiation be ab- 
sorbed by the ovaries they will cease to functionate in their 
fullest physiologic aspect and a cessation of menstruation will 
result." 

It is thus seen that in the hands of competent men the re- 
sults obtained, although produced by different agents, are prac- 
tically parallel. 



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WALTER A. WEED. 489 

My own opinion is, that in selecting the method of treatment 
of uterine fibroids, we should be governed by the type of tumor 
to be treated, also, should take into consideration other condi- 
tions that might be complicating factors. As suggested by 
Kelly, "While radium has thus made a place for itself as the 
treatment of election, * * * the best possible treatment 
of fibroid tumors, — it does not take the place of operation in 
the exceptional case — for instance, where tiiere are urgent pres- 
sure symptoms, or other complicating conditions, such as dis- 
eased appendix, gall-bladder, etc." 

The submucous varieties, owing to their location and conse- 
quent composition, cause copious and weakening hemorrhages ; 
there is a resulting complication of the endometrium. For this 
reason radium is preferable to X-rays in such cases, as it acts 
directly upon the endometrium, thus causing a cessation of the 
bleeding by its eifect upon the endometrium primarily and the 
ovaries secondarily. While the X-rays perform the same phe- 
nomenon, it is by effecting the ovaries primarily, and to a less 
degree, the endometrium. Therefore the symptoms of radium 
produced menopause are, in most cases considerably less pro- 
nounced than when produced by X-rays. In the interstitial and 
subserious varieties, I, also, believe that radium is more de- 
pendable than X-rays, for reasons already explained, while in 
the pedunculate, the X-rays are probably as efficient as radium. 
In tihe subserous and pedunculate tumors I think their com- 
bined use, that is radium in the uterus, and X-rays through the 
abdominal wall, is theoretically and practically correct. 

Radium is of equal value in the treatment of obstinate cases 
of menorrhagia and metrorrhagia not associated with fibroid 
tumors. In a great many of these cases ft is desirable to bring 
on the menopause, as there is often danger of impending ma- 
lignancy. This is invariably accomplished easily with but few 
of the pronounced symptoms which sometimes accompany 
the menopause. It is preferable to the X-ray for reasons men- 
tioned above, — the action is more pronounced upon the endo- 
metrium than upon the ovaries. In the treatment of menor- 
rhagia of young women the dosage is so easily regulated that 
the desired eflfect is produced in most cases without the danger 
of bringing on a complete amenorrhoea, the functionating 
power of the ovaries not being entirely destroyed. I have 
treated a number of patients for uterine hemorrhage, who had 



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440 APPLICATION OF RADIUM AND X-RAYS. 

had repeated curettages without receiving permanent relief; 
not one of these cases has failed to yield to radium. One ad- 
vantage not mentioned that radium has over X-rays in the 
treatment of pelvic conditions is, by virtue of its method of 
application there is no danger of dermatitis. It is a known 
fact that the mucous membrane is far more tolerant of both 
X-rays and radium rays than is the cutaneous surface. This 
is no little consideration in the treatment of these conditions. 
When both are used conjointly it is always possible to keep the 
dose of X-rays well within the bounds of safety. 

I have made no attempt to discuss the various conditions 
amenable to radium and X-rays, but to mention some of those 
in which they, as therapeutic agents, are firmly entrenched 
and their supremacy acknowledged. 

DISCUSSION. 

Dr. L. C. Morris, Birmingham : I am sorry I did not hear 
all of Dr. Weed's paper, for I was immensely interested, and 
particularly that part of it which pertains to the treatment of 
fibroids by means of the Coolidge tube and by means of radium. 
I have had some opportunities to observe the effect of the Cool- 
idge tube, more than I have of radium. I have had some few 
cases that have been treated in the Kelly Clinic in Baltimore, 
and I have had a number of cases that I have had treated by 
the Coolidge tube at home, with, on the whole, quite satisfac- 
tory results. When treatment with the Coolidge tube and 
radium come in competition with hysterectomy, if it will re- 
lieve, it is infinitely to be desired, provided, of course, the dan- 
gers of malignancy from the presence of atrophied tumors 
are not greater than they would be if the tumors did not exist. 
I think I have had fifteen or twenty cases treated in the last 
two years with the Coolidge tube, with quite good results, and 
I know of at least fix or six cases that have gone to Dr. Kelly 
and Dr. Burnham and have been treated. 

Dr. Weed : We do not know why one tumor will respond to 
radium treatment, and another of similar microscopical appear- 
ance fail to respond. 

I think we should still be conservative in our claims for both 
X-rays and radium in the treatment of malignant conditions 



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WALTER A. WEED, 441 

for, as a matter of fact, there is a large percentage of them not 
cured by either or both methods. 

With reference to the small round cell sarcoma, my experi- 
ence has been that it is much less amenable to radium than is 
the giant-cell tumor. 

In carcinoma of the uterus we get a relatively high per cent 
of apparent cures, especially if treatment is given in the early 
stages. 

In cutaneous epitheliomata and menorrhagia and metror- 
rhagia due to, or independent of uterine fibroids, allow me to 
reiterate that we have in radium and X-rays a means of cure 
that, so far as I know, is not approached by any other method. 



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VICARIOUS MENSTRUATION. 



M. Y. Dabitky, M. D., Birmingham. 

From antiquity down to the present day, the phenomenon 
of ^menstruation has been shrouded in more or less mystery. 
This is largely due to the fact that with the exception of certain 
species of monkeys, we have no process among the lower ani- 
mals analogous to menstruation which may be subjected to ex- 
perimental study. By the ancient Hebrews, during her men- 
struation and for a certain time thereafter, woman was con- 
sidered "unclean." In other words, they appear to have re- 
garded it in the nature of an excretory function, a view which 
of late years again seems to be gaining ground among certain 
investigators. 

Accepting Englemann's statistics, which covered 20,000 cases 
collected in the United States and Canada, a normal menstrua- 
tion begins as a rule at the age of 14. Its duration averages 
from 3 to 5 days and the intervals are 4 weeks, though individ- 
ual variations entirely compatible with good health, form by no 
means unusual exceptions to the rule. 

From a physiological standpoint we know that during men- 
struation the pelvic viscera become greatly congested, which 
is evidenced anatomically by a swelling of the endometrium and 
the formation of hematomata beneath the mucous membrane. 
The latter eventually rupture with an outpouring of blood, mu- 
cous and a relatively small number of detached epithelial cells. 
The work of Heape in monkeys revealed the interesting fact 
that an intra-uterine menstrual blood-clot is formed. Hence, 
we may logically suppose that the same thing takes place in 
woman, the clot becoming liquified during its passage through 
the cervix and vagina through the action of an enzyme termed 
thrombolysin which is found in the excretions. The normal 
menstrual flow, therefore, on reaching the vaginal orifice is free 
from clots. 

Various workers have shown that the premenstrual stage is 
accompanied by a slight rise in temperature, pulse rate and 



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M. r. DABNEY. 448 

bteod pressure, which during the flow reach a slightly sub- 
normal registration, only to rise again to normal when the 
period is concluded. So much for the normal process. 

VICARIOUS BLEEDING. 

Even among the ancients, vicarious bleeding was observed. 
The 334 cases reported by Rontier, in 1885, are largely collect- 
ed from early literature. In the "Publications from the Jef- 
ferson Medical College and Hospital," Volume VI, 1915, page 
136-146, Funk and Ellis give an excellent review of the litera- 
ture which will be made free use of below. 

Much academic discussion has been indulged in regarding 
the propriety of the name, "vicarious menstruation," and hence 
the terms ectopic or vicarious bleeding, compensatory bleeding 
or menstruation, xenomenia and memnes devii have been of- 
fered as substitutes. 

It is convenient to use the following classification : 

1. Substitutional, when the vicarious Jiemorrhage replaces 
the bleeding from the uterus ; and 

2. Supplemental, when it accompanies uterine bleeding. 
Possibly a third division could be made, comprising those 

cases which have never menstruated through the normal chan- 
nel, but in which periodic bleeding is extremely rare. 

THE author's cases. 

Case L — M. H., aet. 18, single and white. Presented herself 
at the University Free Dispensary on November 8, 1916, com- 
plaining that she spat blood for three days before and for the 
same length of time after her monthly periods. Her family 
history was negative for any similar trouble, for tuberculosis 
and for new growths. Two years previously she had had an 
appendectomy performed. She had always enjoyed excellent 
general health. 

The menstrual periods began at the age of 13J^ years, oc- 
curred from 2 to 4 weeks apart, continued on an average of 5 
days each time, were of excessive amount, and were associated 
with much griping across the lower abdomen. The more re- 
cent periods had begun on November 1, October 26, and Sep- 
tember 1, respectively. 



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444 VICARIOUS MENBTRUATION. 

The patient asserted that for the previous three months, be- 
ginning three days before and ccmtinuing for three days after 
the menstrual flow, she had spit blood several times each day. 
The amount of blood was small in quantity and was not asso- 
ciated with coughing, dyspnea nor vomiting. As the menstrua- 
tion in her case lasted usually for 5 days, and since the hemop- 
tysis began three days before and lasted for three days after 
the periods, it will be seen that the total number of days during 
which this spitting of blood occurred was 11 each month. 

Examination revealed a healthy-looking young while girl of 
18, of good frame and well nourished. 

Abdominal examination was negative. 

Pelvic Organs. — Leucorrhea was seen on the vulva. As the 
vaginal outlet was virginal, only a rectal examination was 
made. However, this failed to disclose anything more than a 
retroverted uterus. Neither tubes nor ovaries could be made 
out, as the patient was very nervous and quite rigid. 

Impression of the Case. — (1) Retroversion of the Uterus. 
(2) Vicarious Mensti;pation of the Supplemental T)rpe. 

Advice. — Further examination under anesthesia and curet- 
tage. This was refused. 

Note. — It was hoped that the patient could be prevailed upon 
to return to town for a thorough study of the respiratory tract, 
but a letter failed to persuade her to come. 

Case IL — M. W., aet. 29, married and colored. Was first 
seen at the University Free Dispensary July 24, 1916, when 
she came complaining of pain in the hypogastric region. There 
was no similar trouble in the family nor was there a history of 
tuberculosis or neoplasms. She claimed that one year previ- 
ously she had had some sort of abdominal operation and that 
she had been informed that ever)rthing had been removed but 
her uterus. However, several careful searches through Ac 
files of the hospital she named failed to show any record of her 
admission, although she had a lower midline scar as evidence 
of a surgical operation's having been performed somewhere at 
some time. 

She had pneumonia in childhood and malaria at 12. Other- 
wise her past history was quite uneventful. The maises began 
at 14, were painful and were of the 28-day type until the opera- 
tion, since when they have not returned. She was married 8 
months ago but has never been pregnant. 



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M, Y. DABNBT. 445 

Ever since the operation (one year ago) the patient asserts 
that she has had two or three nose-bleeds a day for four days, 
regularly every four weeks. Three or four months ago she was 
taken with pain in the hypogastrium which has been present 
continuously since that time, but becomes worse at intervals. 
The urination was painful and there was urgency. 

Examination of the abdomen showed it to be large and fat. 
Negative save for tenderness on palpatation in the hypogas- 
trium. The pelvic outlet was marital. The cervix was normal, 
but the fundus and right adnexa seemed to have been removed. 
On the left side was a nodule the size of a hen's tgg, smooth, 
sensitive and freely movable. 

Impression. — (1) Cystic Left Ovary. (2) Vicarious Men- 
struation of the Substitional Type. 

Advice. — Operation for cystic ovary. 

Note. — Unable to get in further touch with patient by letter, 
which accounts for the failure to study the respiratory tract, 

CASES IN THE LITERATURE. 

The part from which bleeding is most commonly observed 
is the nose and the next in frequency is the nipple. Lloyd 
Thomas speaks of a well-developed girl of 17, who had never 
menstruated, who was taken with violent headaches followed 
by vomiting and ending in nose-bleed, lasting for three or four 
days, and occurring each month. There was never any uterine 
bleeding. McGay's case was of epistaxis occurring with month- 
ly periodicity during pregnancy. Larrabee's patient had her 
menopause at 35, which was followed by attacks of epistaxis, 
bleeding from the mouth and hemorrhagic purpura. 

The woman reported by Stear was 50 years of age, was mar- 
ried but had never been pregnant. She had menstruated regu- 
larly and had undergone the menopause at 48, which was fol- 
lowed by blood from the nipples for three or four days during 
which time the breasts were painful and of a similar character 
to those found during the normal menstruation. Cleveland 
narrates an instance of a similar case of periodic bleeding from 
the nipples lasting for 8 years after the menopause. The woman 
mentioned by DeLee had a bloody discharge from the nipples 
for several days each month for nine years after labor. 

Funk and Ellis give a detailed account of a patient who, 
after two years of scant menstruation, ceased to flow, it being 



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446 VICARIOUB MENSTRUATION. 

replaced by bleeding from the mouth every 28 days until the 
47th year. It was unassociated with cough or epistaxis. Par- 
vin's case had swelling of the lips and tongue with oozing of 
blood at the menses. Hauptman's bled from the lip. 

There is recorded an instance of a woman of 31 who had 
never had any uterine bleeding but who had anal hemorrhages 
each month (Sinety). Again, a robust girl of 16 had vicarious 
bleeding from the rectum alone and none from the uterus. As 
the pelvic organs seemed perfectly normal, she was advised to 
marry. Later she bore three healthy children. During each 
pregnancy the rectal bleeding would cease, only to return when 
lactation was over (Barrett). 

Lermoyez tells of a woman who at times for three years 
would have a periodic discharge of blood from the right ear 
each month, followed by regular menstruation, and then an 
aural discharge. 

There is an account by Paget of a small eif usion of blood oc- 
curring each month at the menstrual period in the anterior 
chamber of the eye, the extravasation becoming absorbed dur- 
ing the intervals. 

Among other interesting examples may be mentioned the 
bleeding from the lupus of the face (Bozzi) ; from a nevus 
(Brown) ; from a sloughing leg ulcer; from the sweat glands 
(Gould and Pyle), etc. 

e;tiology. 

It occurs at all ages, in both nulliparous and the parous. 
Both the cachectic and the robust are represented. Women 
who have menstruated regularly and those with primary 
amenorrhea are alike involved. It does, however, seem to oc- 
cur much more frequently at sites of active or latent disease. 

As to the role of heredity, Ventura reports vicarious men- 
struation in a mother, sister, and two daughters in the form 
of periodical hemoptysis at times in place of the menses and 
without any signs of tuberculosis, lues, hemophilia or cardiac 
disease. Withrow recounts the cases of two sisters and a 
niece, all married and sterile, though general physical and pel- 
vic examinations could reveal nothing wrong. One of the sis- 
ters had never flowed, but the other had epistaxis at intervals 
roughly suggestive of menstrual periods, and dating from 



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M. r. DABNET. 447 

puberty to the age of 41. The niece, who never had menstru- 
ated, had nose-bleeds every four weeks, always at night, for 
many years. 

The glands of internal secretion are known to be intimately 
interrelated and to exert a profound influence upon menstrua- 
tion. Like a well-balanced piece of machinery, in the normal 
woman, they work in perfect harmony. The ovary is antago- 
nistic to the action of the adrenals ; for instancy, after the meno- 
pause, when the ovary no longer is active, there appear violent 
vaso-motor disturbances as evidenced by hot and cold flashes, 
which are undoubtedly due to the unbridled action of adrenalin 
"storms." Furthermore, Blair Bell has shown in animals that 
the removal of one adrenal gland will cause partial atrophy of 
the uterus. The relation of the thyroid is shown by the tend- 
ency to enlargement during puberty, pregnancy and the meno- 
pause, and the exacerbation of Graves' disease after bilateral 
oopherectomy. Cushing's interesting experiments reveal the 
fact that partial removal of the pituitary gland in animals is 
followed by atrophy of the uterus and disappearance of the fol- 
licles from the ovary. As regards the thymus, the onset of 
puberty is associated with its atrophy. 

In 116 double oophorectomies reported by Pfister, 12 cases 
of vicarious bleeding from the nose and bowels followed over 
a period of one or two years. Granting that all the ovarian 
tissue was removed, this would seem to indicate that in the ab- 
sence of the ovaries, other endocrine glands are capable at 
times of taking up some of the ovarian functions. As a slight 
argument in favor of this, we might cite the occurrence of 
periodic bleeding in males where no ovarian tissue is supposed 
to exist. Chopart reports a soldier of 19 who had a monthly 
discharge of bloody urine accompanied by the regular symp- 
toms of menstruation in the female. Rainer's two cases were 
very similar to it. 

TREATMENT. 

As in every disease, the treatment varies with the cause. 
Amenorrhea may be due to anemia, in which case it should 
be remedied as far as possible. 
Hot douches are advised at the regular time for bleeding. 
Some recommend scarification of the cervix. 



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448 VICARIOUS MENSTRUATION. 

If the bleeding is so severe as to impair health or endanger 
life, transfusion by radical interference may become necessary. 
In two cases Webster was obliged to perform oophorectomies. 
Harlan removed the ovaries for bleeding from the lower unde- 
veloped one-third of the vagina of a patient. Fisher did the 
same thing for alarming hematemesis. Likewise for hema- 
temesis Cantwell stopped the condition by removal of a healthy 
uterus and the adnexa. 

Patton claims to have cured a case of vicarious menstruation 
from the nose (supplemental type) by submucous resection of a 
badly deviated septum. 

In conclusion, we would like to say that careful history- 
taking would show that supplemental vicarious menstruation 
is quite common, that the substitutional type is less so, and 
that instances of its occurrence in cases of primary amenorrhea 
are extremely rare. In the absence of menstruation through 
the normal channel, in some instances the increased blood pres- 
sure would seem to pick the vascular area of least resistance, 
and hence the vicarious bleeding. 

Many points still remain to be worked out in this very re- 
markable condition. For example, Blair Bell's study of uncon- 
taminated hematocolpos-fluid showed that there is neither 
thromhogen nor thrombokinase present. He also has demon- 
strated that there is an excessive calcium content in normal 
menstrual blood. It would be quite interesting to know wheth- 
er or not this vicarious blood possesses the same properties as 
that from the normal woman. If so^ would it not somewhat 
justify our calling vicarious bleeding a menstruation? 

BIBLIOGRAPHY. 

Kelly. Medical Gynecology, Appleton, 1909. 

Eden and Lockyer. Gynecology, McMillan, 1916. 

Funk and Ellis. Report of a Case of Periodic Bleeding 
from the Mouth (Vicarious Menstruation) Associated with 
Hypoplasia of the Uterus and Tubes and Aplasia of Ovaries 
and Mammary Glands, Publications from the Jefferson Medi- 
cal College and Hospital, Volume VI, Philadelphia, 1915, page 
136-146. 

Condit, W. H. Compensatory (Vicarious, Ectopic) Men- 
struation, Xenomenia, Memmes Devii, Am. J. of Obstetrics. 
No. 458, pages 238-251. 



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M. r, DABNEY. 449 

Richter, George. On the Physiology and Pathology of the 
Menopause, Medical Record, Volume 91, No. 11, March 17, 
1917, pages 446-450. 

DISCUSSION. 

Dr. W. P. McAdory, Birmingham: It is an easy thing for 
a practitioner or a specialist to call these bleedings vicarious 
menstruation. I may be old fogey in my ideas of menstrua- 
tion, but I have got a notion that menstruation is simply where 
the uterus prepares itself to take care of a child and does not 
get it and throws it oflF. We all understand that during the 
menstrual period we have the changes in blood pressure and 
the changes in the nervous elements of the patient atU over 
that are liable to cause bleeding from any point, but for the 
profession to feel that a flow of blood from the nose or from 
the lips or from the mouth or from any other place except the 
uterus is relieving the patient, it is all a mistake. It is a good 
thing to say vicarious menstruation, because the patient likes 
that, and I don't know of any better term for it, but let's don't 
fool ourselves. Tho- thing is that if a woman is to menstruate 
let her menstruate normally; when she loses blood from the 
nose it doesn't get rid of the material prepared there by nature 
to take care of a child every twenty-eight days. That is the 
whole proposition ; we can call it vicarious menstruation for 
the benefit of the patient, but let's don't fool ourselves. 

Dr. L. C. Morris, Birmingham : I enjoyed very much hear- 
ing what Dr. McAdory said. In rebuttal I want to report a 
case that has never been reported. 

About ten years ago, before the days of radium, and before 
the invention of the Coolidge tube, a woman, the mother of 
seven or eight children, came to me for excessive uterine 
hemorrhage. She had been curetted twice before I saw her and 
once by me without influencing the bleeding. As the bleeding 
was most excessive I finally did a supra-vaginal hysterectomy. 

Three months after the hysterectomy this woman began hav- 
ing hemorrhage from the stomach, which recurred periodically 
about once a month for about a year. There were no digestive 
or stomach symptoms except the periodical bleeding. There 
was certainly no throwing off of the decidua in this case, as the 

29M 



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450 VICARIOUS MENSTRUATION. 

Uterus had been removed. She is living today in perfect health. 
I believe this was a case of vicarious menstruation. 

• Dr. Dabney: Dr. McAdory and I are absolutely together, 
I think, on this question. I was reporting what to me is an ex- 
tremely interesting phenomenon. I did not want to bore you 
too much by going into the details of an academic discussion 
of the question of the best term to apply to this phenomenon. 
That is a mere incident. Of course, it is not a flow from the 
uterus. If you look into any dictionary you will find that men- 
struation is defined as a periodic flow from the uterus consist- 
ing of blood, mucous and a slight amount of epithelial elements. 
Dr. McAdory is right in saying that there is usually some 
pathology at the site of the bleeding. But because of the 
periodicity of the hemorrhage and in lieu of a better term we 
call it vicarious menstruation or vicarious bleeding. 

I would like to differ from him in the statement that the 
throwing off of this blood is a necessary prerequisite for preg- 
nancy. We all know of cases in which pregnancy has occurred, 
for instance, during lactation, when there was no menstruation 
at all. We have all either seen or read of cases in which 
pregnancy has occurred even before the onset of menstruation, 
that is, before there was any evidence of puberty. Young girls 
who have never menstruated have become pregnant, and we 
have all known of cases who have become pregnant a few 
years after the menopause. Now these represent three distinct 
instances in which there is no menstruation immediately pre- 
ceding pregnancy. 

Dr. McAdory : We understand that all these phenomena that 
the doctor talks about occur, but so far as menstruation is con- 
cerned, my understanding of it is, as I said, that it is not neces- 
sary for a woman to menstruate to become pregnant, but when 
she does menstruate it is evidence that the mucous membrane 
of the uterus has been prepared to take care of a child and the 
child doesn't get there. 

Dr. Dabney: I grant you that, doctor. I appreciate the 
discussion of the paper. 



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THE CARREL METHOD OF USING DARIN'S SOLU- 
TION IN BOTH THE PRIMARY AND SUBSE- 
QUENT TREATMENT OF ALL OPEN 
WOUNDS. 



Maok Roqebs, M. D., Birmingham. 

At the same time that Lord Lister announced the facts con- 
cerning wound infection, by bacteria, he inferentially enunci- 
ated the necessity for an agent that would successfully combat 
them. 

And in selecting this combatting agent, we naturally ask our- 
selves the question, What is necessary? And in answering it 
we reply: 

First. An agent that positively will not affect unfavorably 
the body cells, but on the contrary, will actually promote a 
more vigorous and healthy growth of them. 

Second. An agent that will certainly both inhibit and destroy 
all forms of wound-infecting organisms, and 

Third. An agent that will promptly and positively neutralize 
all toxins that are incident to both the life and death of these 
organisms. 

And now, all three of these requisites must be combined in 
one concrete form. 

And this agent must be universally applicable to all forms 
of open wounds, it must be cheaply produced, easily kept, easily 
handled, easily transported, and easily applied to wounds. 

It should not be painful, but rather soothing, and should 
minimize the discomfort incident to subsequent dressings. It 
should not offend either the sense -of smell or sight, by stain- 
ing the wound, the dressings or the hands. 

These are some of the chemical and physical properties that 
should characterize this ideal agent for sterilizing wounds. 

And yet, in our nearly half century of zealous, though de- 
sultory search for this coveted agent, we have been, like the 
children of Israel, wandering in the dismal wilderness of all 
our so-called antiseptics. 



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462 TREATMENT OF OPEN WOUNDS. 

And all to so little purpose ! For practically no progress had 
been made in wound sterilization until Carrel's first paper was 
read by Professor Pazzi before the French Academy of Medi- 
cine in Paris in October, 1915. 

In discussing Carrel's method of wound sterilization we are 
conscious that many of us are already familiar with all the 
facts concerning it, but for the benefit of those who are not, 
we will briefly recite a few of the more important things con- 
nected with its history, application, results, and so forth. 

In the autumn of 1914, when the European War had fully 
impressed its magnitude upon all civilized nations, the Rocke- 
feller Institute for Medical Research of New York City, sent 
Dr. Alexis Carrel, as the expert surgeon, and Dr. H. D. Dakin, 
as the expert chemist, with a full hospital corps, to the French 
battle front, for the purpose of establishing there a fully 
equipped base hospital, where Dr. Carrel could have an abund- 
ance of clinical material and could have full control, in carry- 
ing out his research work on wound sterilization. 

Obviously this hospital afforded Dr. Carrel an infinite oppor- 
tunity for observing all forms of wounds. 

This vast amount of observation of not only wounds, but 
also of the alarming facts, that from 90 to 100 per cent of all 
wounds brought into the hospital were infected, and that 80 
per cent of all amputations were due to infection, and that 
practically the same thing was true of all other permanent de- 
formities and disabilities. All these facts again confirmed Dr. 
Carrel's conclusion that wound sterilization was the paramount 
problem to be solved. 

But, what is the Rockefeller Institute? 

The Rockefeller Institute for Medical Research is an institu- 
tion founded in 1901 by Mr. John D. Rockefeller, by giving 
$200,000 to an incorporated board of seven trustees for the 
purposes indicated by its name. 

As the work grew under the directorship of Dr. Simon Plex- 
ner, the necessity for additional funds appealed to Mr. Rocke- 
feller, and in 1902 he gave $1,000,000 more to enable them to 
buy a permanent home for the institution, that now comprises 
seven and a half acres, between 54th street on the south and 
57th street on the north, Avenue A on the west and East river 
on the east, situated on a high cliff overlooking East river in 
the poor section of Eastern New York City, and that is now 



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MAOK ROGERS. 468 

valued at more than four millions of dollars. They have a 
modern hospital, isolation pavilion, laboratory building, animal 
house and power plant, — the latter three were completed last 
fall. In addition to the lyi acres of land, buildings and equip- 
ment in New York City, the institute owns and operates a farm 
of five hundred acres near Trenton, New Jersey, for animal 
breeding, and care for the Department of Animal Pathology. 

And, besides all this, Mr. Rockefeller has given more than 
twelve millions of dollars as an endowment fund for its per- 
petual maintenance, and to afford pensions for the staff of 
workers composed of more than sixty men. 

This is the institution that is behind Dr. Carrel and Dr. 
Dakin in their research work. 

Who is Dr. Carrel? 

"Doctor Alexis Carrel was born at Lyons, France, June 28th, 
1873 ; was graduated from the University of Lyon, M. D., in 
1900; was an assistant professor in the University of Lyon, 
1900-02 ; came to America in 1905 ; became affiliated with the 
Rockefeller Institute for Medical Research in 1909. In 1912 
he was awarded the Nobel Prize for his work in blood vessel 
suture, and for his success in the transplantation of vital organs, 
also for his success in the cultivation of tissue 'in vitrio.' In 
August, 1914, when the present war broke out, Dr. Carrel was 
on a visit in France, and, being still a French citizen, his serv- 
ices were immediately requisitioned. The present hospital at 
Compeigne is supported by the Rockefeller Institute under Dr. 
Carrel's supervision by a special arrangement between the 
French Government and the Rockefeller Institute." 

Who is Dr. Dakin? 

"H. D. Dakin, D. Sc, University of Leeds, England, was 
connected with the Herter Laboratory in New York at the 
time the European War broke out. Dr. Dakin went to France 
under the auspices of the Rockefeller Institute where he worked 
with Carrel for about two years. Until recently Dr. Dakin has 
been . working with Professor Cohen, of the University of 
Leeds, and Dr. Kenion, representing the British Medical Re- 
search Society." 

So in December, 1914, these two scientists, Carrel and Da- 
Idn, with the support of the Rockefeller fund, began, in 
earnest, the solution of this problem of wound sterilization, — 
and, after experimenting with more than two hundred antisep- 



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454 TREATMENT OF OPEN WOUNDS. 

tics, they finally adopted sodium hypochlorite as the base on 
which to construct their ideal antiseptic. 

But it was June, 1915, before they determined definitely the 
other agents, and the proportionate parts of each that should be 
combined with it, together with the exact chemical technic that 
is absolutely necessary for the correct production of Dakin's 
solution. 

You will observe that we are purposely avoiding both the 
chemistry and technic of preparing this solution. 

We are doing so for two reasons ; one is that it would make 
this paper too long, and the other one is that we realize the 
force of the warning sent out by Carrel, Noland and Sherman, 
that none but the competent and well-equipped chemist and 
laboratory should attempt to produce it. 

A full and comprehensive description of this whole subject 
may be found on page 1059 in the December, 1916, number 
of the Southern Medical Journal, by Dr. Lloyd Noland, of Bir- 
mingham, Alabama, or on page 257 in the March, 1917, num- 
ber of Surgery, Gynecology and Obstetrics, by Dr. William O. 
Sherman, of Pittsburgh, Pa. And in this connection, we wish 
to gratefully acknowledge our indebtedness to both of these 
splendid young surgeons, for their generosity in permitting us 
to use these articles so liberally in the preparation of this paper. 

When Dr. Carrel had finally perfected both Dr. Dakin's solu- 
' tion and his own exact technic of appl)ring it, and this latter 
was not completed until February, 1916, he realized what had 
been accomplished, and at once sought to promulgate these re- 
sults. 

The announcement was made directly to the authorities of the 
United States Steel Corporation and the suggestion was of- 
fered that since they sustained so much commercial loss on ac- 
count of the disability of their employees, incident to these 
infected wounds, that it would be a good commercial invest- 
ment, to say nothing of the relief to suffering humanity, to send 
one or more of their medical representatives over there to 
study in his hospital his method of wound sterilization. These 
suggestions were immediately acted upon, and Dr. Lloyd No- 
land, Medical Director of the Tennessee Coal, Iron and Rail- 
road Company, of Birmingham, Alabama, and Dr. William O. 
Sherman, Medical Director of the Carnegie Steel Company, 
of Pittsburgh, Pa., were commissioned. 



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MACK B0GBR8. 455 

These two progressive young surgeons made this pilgrimage 
together last summer, and brought back to us this magnificent 
contribution to both scientific medicine and to suffering human- 
ity, and just how faithfully they acquitted themselves can never 
be properly appreciated until we have carefully read their re- 
ports that have already been referred to. 

And now we will quote to you directly from Dr. Noland's 
paper, "The Carrel Method of Wound Sterilization with Da- 
kin's Solution": 

"As soon as a patient is received he is taken directly to a 
dressing room, where his clothing is removed and a preliminary 
examination made. He is then wheeled to the X-ray room 
for careful fluoroscopic examination. If the patient's general 
condition permits, he is then taken to the operating room and 
put under ether anesthesia. After shaving and preparation 
of the field with tincture of iodine, the entire tract of the mis- 
sile is opened widely and all foreign bodies, such as fragments 
of shell, pieces of clothing, completely detached bone frag- 
ments, etc., are removed. All blackened and badly macerated 
tissue is excised, followed by the most careful hemostasis. 

The entire procedure is carried out under the most rigid 
aseptic and antiseptic precautions, the wound being frequently 
wiped out with sponges soaked in Dakin's solution. Small in- 
stillation tubes consisting of rubber tubing about one-eighth 
inch in diameter, closed at one end, and with eight to ten small 
perforations near the closed end are then introduced into the 
wound, the number used depending upon the size of the 
wound ; the object being to reach all parts of the wound with 
the fluid instilled through the tubes. These tubes are held in 
position by gauze sponges wet with Dakin solution which are 
lightly placed about them, but never packed tightly into the 
wound. Neighboring skin surfaces are then protected by vase- 
line gauze and the whole covered with a light gauze and cotton 
dressing from which the tubes protrude. 

After the patient is placed in bed the installation tubes are 
connected with a glass "telltale" with the necessary number of 
tips. The "telltale" is connected by rubber tubing with a glass 
container, filled with Dakin's solution, suspended about thirty 
inches above the level of the patient. An ordinary tubing clip 
is placed on the tubing just below the container. At two-hour 
intervals throughout the twenty-four, the attending nurse re- 



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466 TREATMENT OF OPEN WOUNDS, 

leases the clip sufficiently to allow the filling of the wound 
with the solution. A little practice will enable her to do this 
accurately enough to prevent soaking the dressings or bed. 

Once in twenty-four hojurs the wound is dressed, observing 
the most careful asepsis. The lightly-placed gauze sponges 
are removed with forceps and the tubes inspected and replaced 
if necessary. Any secretion is wiped out of the wound with a 
sponge wet with Dakin's solution, fresh sponges wet with 
Dakin's solution are placed. about the tubes, and the dressing 
applied as before. It is usually necessary to replace the tubes 
every third or fourth day, as the solution destroys them in a 
very short time. 

Every second day a smear of material taken from various 
parts of the wound with platinum loop is made, is fixed by heat, 
stained, and examined in the laboratory. A report showing the 
average number of bacteria by field is sent to the ward and 
entered on a microbic chart attached to the patient's record, 
which shows graphically the bacteriological condition of the 
wound, and which at Compiegne is regarded as much more 
important than the temperature chart. 

When the bacteriological report shows a microbic index of 
less than one microbe to every five fields for two consecutive 
days, the patient is taken to the operating room, anesthetized, 
and the wound closed by suture exactly as though it were a 
fresh operative incision. 

The above methods have been followed for six months, or 
since February, 1916, with brilliant results. The vast majority 
of wounds, even though involving long bones, with great de- 
struction of tissue, are sterilized and closed in from five to 
twelve days. Ninety-eight per cent of the wounds closed with 
a microbic index of one to five have healed by first intention. 
Of one hundred and fifty-five wounds treated prior to and dur- 
ing my visit, one hundred and twenty-one were closed within 
the first twelve days, and fourteen in from twelve to eighteen 
days. The remaining twenty were allowed to granulate for 
experimental reasons, or on account of large loss of substance. 

This method for the first time puts wound treatment on 
really a scientific basis and demonstrates that sterile wounds 
will granulate with surprising rapidity and with practically no 
pain, and proves that what was formerly called sluggish granu- 



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MACK R0GER8. 467 

lation was always due to infection, even though there was no 
visible evidence. 

The treatment is kept up until the wound is entirely closed 
even when the bacteriological report is satisfactory, as reinfec- 
tions may develop even under the most rigid precautions." 

Dr. Sherman tells us that Dakin's solution represents but 20 
per cent of the cure, while Carrel's technic in the use of it rep- 
resents 80 per cent of the cure. This should emphasize the 
necessity for carrying out Carrel's method to the last detail. 
Because if this solution and technic of using it will certainly 
keep a wound sterile and sterilize one that is already infected, 
so thoroughly that after only a few days it can be brought to- 
gether and sutured securely, it abundantly repays for all the 
time and trouble incident to its use. 

Dr. Noland tells us that this method of treating wounds has 
reduced the wound-day-loss-of-time more than 52 per cent in 
his work. 

The following are a few case reports of the results that have 
been achieved by this method: 

Dr. Charles Whelan, of Birmingham, reports the following 
case : 

On February 10th, Mrs. A. B. was burned in cleaning 
gloves with gasoline. The bums were on both forearms, ex- 
tending from elbows to finger tips. In degree both bums were 
of the third degree throughout their entirety. On first or emer- 
gency visit no attention was paid to the burned surfaces. Mor- 
phine to quiet and overcome shock was given, the bums being 
merely covered with sterile gauze. At the end of 12 hours 
the entire burned areas were covered with sterile gauze, 4-ply 
thidcness, which had been saturated in Dakin's solution. The 
nurse was ordered to keep the gauze wet by using the fluid 
every 2 hours — a Dakin outfit, composed of flask and dropper, 
being employed. The wound was dressed^that is — gauze 
changed every second day for three or four days. By this time 
the burned area began to separate, the exudate increased to such 
an extent, that for the purpose of cleanliness the wound was 
dressed twice daily. At the end of the seventh day sloughs 
were easily and painlessly lifted away. I was able to remove 
sloughs each day, all the while applying Dakin's fluid every two- 
hours until at the end of 14 days the entire burned area ap- 
peared as bright red granular surfaces, scattered over which 



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4SB TREATMENT OF OPEN WOUNDS, 

were islands of new growth. Each day thereafter, the 4-ply 
gauze saturated in Dakin's solution, was changed, the nurse 
still keeping gauze wet every two hours. On the 35th day, the 
right hand had entirely recovered itself, except for a small 
"rare" surface, the size of a dollar. There are no "tendon" 
catches, she had good use of her right hand and what impaired 
function she now has is attributable largely to non-use. The 
left hand was slower to heal than the right. For some reason 
it seemed impossible to keep the gauze saturated with Dakin's 
fluid (the sine quo non of this treatment). We then gave up 
the use of gauze and applied four ordinary lamp wicks to the 
arm, employing them as splints. We found Aese of great 
value, being able to keep the wicks well soaked. They proved 
more cleanly than gauze and gave less pain at dressing. (The 
ordinary lamp wicks are sometimes woven quite closely and it 
may be necessary to remove one weave in order to hold fluid.) 
On April 12th, just eight weeks after bums, the patient is able 
to do her household duties, dresses herself and has good use 
of both hands. As already stated, what impaired function she 
has, is largely due to non-use. There are no tendon catches 
on either hand. The left hand, except for a small area midway 
between elbow and wrist, has entirely covered over. 

After seventy-two hours, notwithstanding the severity of the 
bums, at no time did the patient's temperature exceed one hun- 
dred and a haJf. The pulse was never over 100 and she took 
nourishment regularly with relish. 

Dr. C. A. Donnelly, Birmingham, Ala., reports the following 
case: 

Mr. G. H., age 35 years. Developed lobar pneumonia Febm- 
ary 18, 1917. The entire left lung was involved; he had a 
crisis on the 11th day of the disease, five days after crisis his 
temperature showed an elevation of 101 F., physical examina- 
tion pointed to fluid in the left pleural sac ; 

The temperature continued to fluctuate between 99 F. and 
101 F. until March 14th, 1917, at which time I did a paracen- 
tesis which revealed pus. 

The eighth and ninth ribs were resected and three pints of 
pus evacuated, drainage was instituted, the drainage was very 
profuse and pumlent until March 21st, at which time I started 
the use of Dakin's solution, which consisted of two hourly in- 
stillations of the solution through three small mbber catheters ; 



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MACK ROGERS, 459 

they were perforated at five or six places near ends and placed 
in the most remote recesses of the cavity and connected up to a 
single distributor tube ; the arc at the site of the opening was 
very much inflamed and contained a slough in the center. Gauze 
was wrapped around tube and laid over the slough and inflamed 
tissue so that it would be continually moist with the solutioij. 

The character of the drainage showed a decided change in 
quantity and quality within 48 hours, the slough disappeared 
in five days and general appearance of the wound became 
healthy, the tubes were shortened every third day and skin 
kept protected with vaseline ; 

At present writing, April 11th, 1917, the drainage has prac- 
tically ceased and wound is ready for closure, 21 days since. the 
institution of Dakin's solution. 

Dr. Lloyd Noland, of Birmingham, Alabama, reports the fol- 
lowing cases : 

Case I. — W. E. B., white, American, male ; age 28 ; machin- 
ist. Admitted to Ensley Hospital October 26, 1916, at 11 :00 
P. M. Temperature 101**; pulse 100; respiration 20; white 
blood corpuscles 28,000. 

History. Patient has been ill for eight days with intense 
pain in right side of abdomen, but had consulted a physician 
only on first day of illness and on day of admission to hospital. 

Physical Examination. Showed a large mass in right iliac 
region with marked local rigidity. Diagnosis, appendiciceal 
abscess. 

Operation 8 :00 A. M., October 27th ; ether anesthesia. Grid- 
iron incision. At least 500 cubic centimeters of fetid pus 
escaped when the peritoneum was incised. A gangrenous ap- 
pendix perforated near the base was found laying fairly free 
in the large abscess cavity and was removed. The cavity was 
sponged free of pus and two Carrel installation tubes were in- 
serted. Two silkworm gut sutures which included only skin 
and the external oblique were inserted, one at each end of the 
incision. Ten cubic centimeters of Dakin's solution was in- 
stalled into each tube at two-hour intervals for the first twenty- 
four hours, and at three-hour intervals for the succeeding period 
of convalescence. On October 28th the patient's temperature 
dropped to normal. There was a slight elevation (100-99) on 
each of the two succeeding days, but from the 30th, the tem- 
perature remained normal. The abscess cavity and the abdomi- 



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400 TREATMENT OF OPEN WOUNDS, 

nal incision closed rapidly, and on November 18th, twenty- 
three days after operation, the patient returned to work. 

Case 2. — C. M. B., white, American, female ; age 15 ; school 
girl. Admitted to Ensley Hospital November 16, 1916, at 11 :00 
A. M. Temperature 101**; pulse 134; respiration 32; white 
blood corpuscles 18,000. History — Patient had been violently 
ill for five days with intense pain which began in right side, 
but rapidly spread over entire abdomen. The family physician 
had made a diagnosis of typhoid fever. 

Physical Examination. Showed a greatly distended and 
markedly rigid abdomen. The patient's expression was anxious 
and all indications pointed to a general peritonitis. 

Diagnosis. Probably perforated appendix, with general 
peritonitis. Operation 1 :00 P. M., November 11 ; ether sLnes- 
thesia. Right rectus incision. On incision of the abdomen a 
large quantity of pus escaped. The parietal and visceral peri- 
toneum showed an advanced peritonitis, with the presence of a 
large amount of shaggy exudate. The appendix was lying free- 
ly in the abdomen, was gangrenous and perforated near the 
base. 

The appendix was removed as rapidly as possible, but with 
some difficulty. The abdominal cavity was sponged fairly free 
of pus and a counter incision was made at McBumey's point 
on the left side. Two cigarette drains were inserted into the 
pelvis on either side, and in addition six Carrel installation 
tubes were inserted, three on each side, distributed over the 
cavity. No closure of incisions was made. At two-hour inter- 
vals throughout the first twenty-four hours, 10 cubic centi- 
meters of Dakin's solution was instilled into each tube. Prom 
the second to the fourth day, the installation was made at three- 
hour intervals. From the fourth day to the seventh day, at 
six-hour intervals. 

The patient's improvement within twelve hours after opera- 
tion was most marked, and within three days her temperature 
reached normal, where it remained. Convalescence was unin- 
terrupted and on the twenty-seventh day, the patient was dis- 
charged from the hospital as cured, the abdominal wounds be- 
ing entirely cured. 

Case J. — A. D. N., white ; American ; male ; age 21 ; crane- 
man. Admitted to Ensley Hospital December 16, 1916, at 1 :00 
P. M. Temperature 102**; pulse 104; respiration 24; white 
blood corpuscles 20,000. 



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MACK R0GBB8. 461 

History. Patient had been ill for five days with all symp- 
toms of acute appendicitis, but had been advised by his physi- 
cian against operation. 

Physical examination showed a large mass in right iliac re- 
gion. 

EHagriosis. Appendiceal abscess. 

Operation. 2 :30 P. M., December 16th, 1916. Right rectus 
incision. From four to five hundred cubic centimeters of pus 
was evacuated and the appendix which was perforated was 
removed. The cavity was sponged free of pus and two Carrel 
installation tubes inserted. Subsequent treatment was similar 
to that in Case 1. On his third day, the patient's temperature 
fell to normal where it remained. The closure of both abscess 
and incision was very rapid and on December 30th, fifteen days 
after operation, the patient returned to work, the external 
wound being entirely healed. 

Report of one of my own cases : 

January 19th, 1917. W. M. K., while working with a circu- 
lar saw had his hand drawn into it, resulting in the teeth of the 
saw cutting into the middle joint of the left thumb and the 
meta carpophalangeal joint of the index finger in such manner 
as to destroy the articulating surfaces of both bones in both 
points, doing great damage to the soft parts but only partially 
destroying the tendons of each joint, the backs of all the fingers 
were badly lacerated, exposing the tendons excessively. 

I saw him in twenty minutes after the accident, the bleeding 
had partially checked and he said it was not very painful. I 
applied dry sterile gauze all over everything at once, making 
no attempt to clean up the hand, placed him in my auto and car- 
ried him to my office. I obtained fresh Dakin's solution at once 
and as I removed the original gauze dressing, I cleaned up the 
wound with forceps holding pledgets of absorbent cotton with 
Dakin's solution, and by applying forceps controlled all bleed- 
ing. 

I then twisted strips of gauze to such sizes as adapted them- 
selves to the particular wound and placed them well down into 
the bottom in such way that I was sure the fiuid could find its 
way to the remotest part by following the gauze. Of course 
they were all very superficial ; we then applied gauze bandages 
lightly and saturated all with Dakin's solution. 

I explained to the patient how necessary it was to keep the 
dressing moist and provided him with plenty of fresh fluid 



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462 TREATMENT OF OPEN WOUNDS. 

each day when he came to the office for dressings. These 
twisted strips of gauze were removed with forceps and new 
ones applied each day without pain or discomfort till the 
wound began to fill up. We then simply used the surface 
dressings. 

I had given a very unfavorable prognosis about the joints 
and tendons, but at each successive dressing he assured me he 
could use those joints. This continued until the 19th day of 
February, when I discharged him entirely healed and he had 
good use of both the joints and no tendon catches or deform- 
ity, just one month to a day in obtaining this splendid result. 

He is working now every day as efficiently as ever as an 
expert wagon and auto body maker, where these joints are 
constantly in active use. 

Dr. Torrance, of Birmingham, reports the following case : 

Patient was admitted to infirmary with temperature of 101* 
and ran a septic temperature for four days. Patient's condition 
prevented operation. The mass by this time had extended 
down into calf of the leg. The knee joint was swollen. A 
tubercular and Wasserman test were negative as well as the 
X-ray picture. It was finally decided after the palliatine treat- 
ment proved useless, to open the leg. An operation. The leg 
was opened. The pus was evacuated and incision was made on 
the internal surface for drainage, which was a gauze wick. The 
following day the drainage was removed, two rubber tubes in- 
serted. A Dakin's solution drip was started and used every 
two hours, the dressing being changed twice a day. The tem- 
perature began to drop and the third day was normal. The 
patient began to improve. The infection ceased on the fifth 
day. The wound healed by primary union. The patient left 
the hospital in twelve days. 

''infection of foot.'' 

The patient was admitted to the hospital with a painful and 
swollen foot which had been mashed by a motor car four days 
previous with an infection. The necratic tissue was removed. 
The third and fourth metacarpal bones and toes were removed. 
Iodoform gauze was packed in incision and no suture was 
taken. The following day the iodoform gauze was removed 
and wound dressed and Dakin's solution two-hour drip method 



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MACK ROGERS. 468 

was started. The infection began to cease and the fourth day 
had disappeared and on the fifth two silkworm sutures were 
used to approximate wound which soon healed by primary 
union. 

I will now exhibit to you a few bottles of Dakin's solution 
which I hope you will pass around. Also the apparatus used 
in applying it. 

Caution. — Keep the solution in a cool, dark place and espe- 
cially well stoppered. On standing, or by exposure to air, it 
becomes custic and will irritate the tissues and excoriate the 
skin and should not be used. Therefore, it should be compara- 
tively fresh when used. 

DISCUSSION. 

Dr. A. L. Nourse, Sawyersville : I should like to add an 
emphatic endorsement of the Dakin's solution and express my 
appreciation of the presentation Dr. Rogers made. I was an 
early user of Dakin's solution. In chancroidal infections where 
there is a phymosis if one will take the Dakin's solution and 
have the patient inject it under the prepuce at frequent inter- 
vals the results are almost marvelous. 

Dr. Rogers: This solution is being tried out on mucous 
membranes. It has been found that the peritoneum bears it 
perfectly, and it is being tried now in the eye ; it is being tried 
out in the urethra, and wherever they find an infection they are 
trying it out now on a very conservative and safe scale. They 
are feeling their way. But it is certain that it does not irritate 
the conjunctiva and the cornea. They have tried it out on a 
number of eye cases, where they had injuries of the eye with 
infection, and they have been sterilizing those eyes with this 
solution. And they have been using it in the urethra in a very 
limited way, but I cannot vouch for the result as yet. But 
they are using it in the peritoneum with splendid results. A 
number of cases have been reported where the appendix abscess 
cavities have been flushed and instilled with this solution, and 
they have healed more rapidly than by any other way. It costs 
fifteen or twenty cents a gallon to actually produce the fluid, 
but by all means keep it well stopped, and obtain it fresh as 
often as possible. These are essential warnings and protect 
the skin around the wound by vaseline. 



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ACUTE ILEUS FOLLOWING ABDOMINAL OPERA- 
TIONS, WITH REPORT OF TWO CASES. 



D. C. DoNAU), M. D., Birmingham. 

Intestinal obstruction as a result of operation, recent or late, 
furnishes us today with a large number of cases requiring post- 
operative surgical interference. Post-operative intestinal ob- 
struction is of two kinds, — one directly follows and complicates 
an abdominal operation, — the second results from subsequent 
formation and persistence of adhesion due either to the per- 
formance of an operation or the existence of conditions under- 
lying such operation. With the great increase of abdominal 
operations it is but quite natural that there should be a seeming 
increase in the number of post-operative obstructions in spite 
of the recent modern surgical skill. In this paper I will only 
mention those conditions leading up to acute intestinal obstruc- 
tions directly following abdominal operations. This form is 
often seen by the surgeon doing much intra-abdominal surgery 
and is of two different kinds, — one mechanical, the other para- 
lytic. In many cases it is difficult or impossible to tell which 
variety is present. Under paralytic obstruction we have a sub- 
division called adynamic and dynamic ileus. 

Etiology. — The conditions favoring acute ileus of a para- 
lytic type most often follow extensive operations on the mesen- 
tery, disturbing its circulation and motor nerve supply, paraly- 
sis of a loop bowel returned after a prolonged strangulaticm 
such as femoral hernia, injuries to the spinal cord, injuries to 
the afferent nerve. Under this head we have reflex paralysis 
produced by the transit of gall stones in the ducts, torsion of 
the omentum, pelvic operation and operation of the kidneys, 
etc. 

Mechanical ileus comes on several days afterwards due to 
compression of bowels by adhesion such as appendix operation 
and kinking of the ileum with obstruction and of structural 
ileocecal valve. 

In order to be able to intelligently treat any condition one 
should have a thorough understanding of its etiology and this 



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D. 0. DONALD. 465 

is particularly pertinent as regards the question of post-opera- 
tive ileus. 

The two questions for consideration primarily are, is the con- 
dition mechanical or paral)rtic. Both premises have for many 
years had supporters, those of the mechanical conception fath- 
ered by observers as far back as 1842, and those maintaining a 
primary paralytic factor following the precepts laid down by 
Brinton in 1859. There is no question that both factors are 
present when the condition has developed but which is pri- 
mary ? Does the dilatation cause the kinking in the duodenum 
or the kink in the duodenum cause the dilatation ? As has been 
so definitely demonstrated, the evidence favoring compression 
of the duodenum by the root of the mesentery is a primary 
factor in producing dilatation of the stomach is equally con- 
clusive that the compression is secondary. The recent literature 
with reports from analyzing a large series of autopsied cases, 
only one-third of them showed evidence of duodenal compres- 
sion. Possibly more illustrative is the fact that acute dilatation 
has occurred in several instances after a gastroenterostomy 
which was found potent at autopsy. All of these clinically ob- 
served phenomena have been satisfactorily and conclusively 
substantiated by experimental studies and would indicate that 
the compression of the duodenum is secondary. How are we 
to explain its occurrence for it does occur as shown by the 
regurgitation of bile indicating that the obstruction is distal 
to the papilla of Vater and high up in the intestine evidenced by 
the lack of fecaloid and further by its absolute demonstration 
at autopsy. With these facts in mind consider what may oc- 
cur at the only absolutely fixed portion of the small intestine, 
namely the transverse duodenum where it is crossed by the 
root of the mesentery. It is pictured clearly that there is what 
may be termed a physological tendency to obstruction or con- 
striction. This fact is present in the paralysis of the intestines. 
The potential obstruction quickly becomes an actual one. The 
secretion from the stomach and duodenum continue to be 
poured out and the vomiting reflex is absent. Thus a vicious 
circle is formed, each factor accenuating the other. 

Considering these facts it seems reasonable to conclude that 
the original factor in the production of this gastroenteric 
paralysis is not to be explained on a purely mechanical basis. 
This then leads to but one inference, that the condition must 

80 M 



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466 ACUTE ILEUS. 

be one of nerve exhaustion produced either through direct 
trauma or through reflex impulses. 

In substantiation of this inference we have confirmatory ex- 
perimental evidence. It has been proved that the excitation of 
the splanchnic nerves markedly inhibits both the gastric and in- 
testinal peristalsis, while it has been demonstrated that if the 
vomiting reflex is destroyed by cutting the vagi, acute dilata- 
tion invariably occurs. This interference with the normal nerve 
tone of the intra-abdominal structures is probably caused in a 
majority of cases reflexly as it very infrequently follows opera- 
tions on the stomach itself, but rather manipulation of adja- 
cent organs. One theory has been advanced from an experi- 
ence in two cases that intoxication from the over activity of the 
colon bacillus in the bowel may possibly prove of etiologic im- 
port, but neglect to appreciate that in many instances where we 
have known foci of extensive cdon infection there is no ac- 
companying paralysis of the gut. Most probably the phenom- 
ena is due to the absorption of peculiar and highly specialised 
toxins of unknown nature. 

Symptoms and Signs. — ^The symptoms are few, characteristic 
and easily recognized. The cardinal factors in the condition 
are vomiting, distention and collapse. The less important 
symptoms, pains, thirst and constipation, regurgitation of fluid 
from the stomach, first of a dark brown color, later becoming 
a fecal in color and odor. 

Distention, — Is general. In some cases most marked in the 
region of the stomach where the stomach can be outlined by 
external abdominal examination. 

Collapse, — Collapse rapidly develops in this condition and al- 
most pathognomonic languor on to which there is engrafted 
the very evident symptoms such as small, wiry, rapid, running 
pulse and shallow respiration. Thirst is unbearable. Consti- 
pation is absolute. Temperature not of any special significance, 
not exceeding 99 J/^. 

Prognosis. In untreated cases is bad. In cases early recog- 
nized and properly treated the mortality is reduced practically 
to nil. 

Treatment, Treatment may be considered under two heads, 
— prophylactic and active. 

Under prophylactic for those highly nervous cases where the 
operation is not for an emergency, allow them to remain in the 



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D. 0. DONALD, 467 

hospital or in bed at their home for several days. Avoid ex- 
citement, give some sedative to assure quiet rest to the mind 
and refrain the patient from worrying over the approaching 
operation, thorough evacuation of the intestines, restrict diet to 
soft food up to day before operation. Allow them to have 
liquids up until six hours before operation. 

Active Treatment Consists primarily of immediate lavage 
of the stomach, using soda solution, tcfaspoonful of soda to a 
quart of warm water; washing out the stomach with large 
quantities of water acts in two ways — by its cleansing properties 
and by stimulating the muscular fibre of the stomach to con- 
tract. Repeat the stomach washings ever four to six hours. 
Relieve the bowels by high rectal enemas of a stimulating na- 
ture, using glycerine, alum, and in cases of nervous patients, 
tincture of asafoetida. Repeat enemas three or four times 
daily, restrict fluids by mouth, relieve thirst by cold ice cloths 
to lips. Supply the necessary fluids of the body by hypoder- 
moclysis of normal salt solution, pint every four hours. 

Medical Treatment, Do not administer any form of a cath- 
artic. There are several drugs on the market which stimulate 
contraction of involuntary muscles. Of these I may mention 
the two most popular. Eserin salicylate given 1/30 grain 
doses and putruitin, but personally I have never resorted to 
either. Sometimes an intravenous administration of 20 to 40 
c. c. of hormoman has given good results. 

Operative Treatment, Should be done in all mechanical 
ileus as early as diagnosed, but if in doubt it should be discon- 
tinued until the above conservative treatment has been consci- 
entiously observed and carried out by an intelligent orderly or 
nurse with the assistance of the surgeon or resident doctor ; but 
in paral)rtic ileus, if surgical interference is attempted, we are 
aggravating the grave condition and will certainly increase the 
mortality rate. 

Case No, i, — A. A. D., white, male, age 42; family and 
previous history negative. March 15, 1915, patient was sud- 
denly stricken with pain in the right side. This pain persisted 
of a severe, colicky nature until I reached him, which was 
three hours after the beginning of the attack. The attack was 
relieved by a hypodermic administration of morphine and a 
diagnosis of appendicitis was made. Temperature normal; 
pulse normal. Leucocyte count 9,000. Patient was treated with 



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468 ACUTE ILEUS. 

ice bag and high enemas for 48 hours, at which time he had 
a colicky attack similar to that of the first day, with elevation 
of temperature and symptoms of infection. He gave his con- 
sent to be operated on and under ether anesthesia a low right 
rectus incision was made, appendix found markedly inflamed 
with two stones in its lumen and heavy bands of membrane 
thrown up from the base of the cecum binding down the ap- 
pendix. Some trauma was produced to the bowel in freeing 
the appendix. Otherwise the removal of the appendix was ac- 
complished in an easy, satisfactory way. Closed without drain- 
age. Patient recovered from the anesthetic and made an un- 
eventful recovery until the fourth day, when he began to have 
abdominal distress, eructation of liquids from the mouth, ab- 
sence of bowel movement, very weak, wiry pulse, and all symp- 
toms of approaching collapse. All liquids were forbidden by 
mouth ; high rectal enemas were administered and repeated hy- 
podermiclisis, but patient went from bad to worse, and on the 
eighth day following operation mechanical ileus was diagnosed 
and under local anesthesia of J4 P^^ cent novocain solution the 
abdomen was reopened and there was found a contraction of 
the ileum for a distance of from 10 to 12 inches from ileocecal 
valve without any formation of adhesion producing a kinking 
of the gut. Finding this condition I thought best not to do 
enteroenterostomy. Patient was closed without any surgical 
procedure to the contracted gut, and for three days more this 
stormy condition of the patient persisted, when there began to 
be an escape of gas from the rectum and appearance of a col- 
ored fluid on the return of the enemas. This condition of the 
patient improved and on the 14th day all the symptoms of ob- 
struction had subsided and patient made a rapid convalescence. 
Dia<T^nosis, acute paralytic ileus. 

Case No. 2. — Mrs. T., white, female, age 36, married. Moth- 
er of 3 children. Family history negative. Previous history, 
had typhoid fever at age of 19 ; sick 6 weeks. Present illness. 
Upon examination of the pelvic organs there was found mass 
in right iliac region size small cocoanut firmly adherent. Oper- 
ation was advised and under general anesthetic of ether median 
incision was made, pelvic organs explored and right ovarian 
cyst was found and was freed of its adhesions and delivered 
without emptying its contents. Appendix was removed at same 
time. Abdomen was closed without drainage. She began to 



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D, C. DONALD, 469 

show some toxic condition 36 hours following operation, which 
was thought to be narcosis from the ether anesthesia. Stom- 
ach was emptied and washed by the use of stomach tube with 
soda solution, high enemas were given, all fluids restricted by 
mouth, hypodermoclysis given every four hours. This condi- 
tion persisted for seven days which cleared up without any 
surgical intervention. 

Diagnosis — Paralytic ileus of a reflex origin. 

DISCUSSION. 

Dr. W. C. Gewin, Birmingham : This is indeed a very inter- 
esting subject, and I wish to thank Dr. Donald for presenting 
it. In speaking o£ the paralytic form of the ileus, I think the 
main thing is diagnosis, but it must be remembered that an 
absolutely correct diagnosis is necessary, as it is the founda- 
tion of our future work. I agree with Dr. Donald that in the 
paralytic type, complete rest is usually eflficacious ; on the other 
hand, where we are sure of obstruction, an immediate opera- 
tion is indicated. Of course, the viscera must be handled as 
delicately as possible, lest we superinduce that paralytic condi- 
tion we so much dread. 

Dr. W. P. McAdory, Birmingham : The hour is late, there 
are but few here, but the doctor read a paper on post-operative 
ileus. In his paper he has described intestinal obstruction. 
Post-operative ileus, as I understand it, is not a mechanical ob- 
struction ; it is an acute dilatation of the stomach and a paralysis 
of the bowels, all of which we have following abdominal opera- 
tions. Now, when it comes down to post-operative ileus, as I 
understand it, it is an acute distentiori of the bowel, without the 
fecal vomiting and without the mechanical obstruction. If you 
have a mechanical obstruction from a kink or an adhesion you 
have got intestinal obstruction, not post-operative ileus. If you 
have the previous fecal vomiting you have acute dilatation of 
the stomach as a rule, but if that vomiting is not accompanied 
by a mechanical obstruction you haven't got ileus, you have got 
an acute dilatation of the stomach. 

Of course, the great trouble that has come in the writing and 
discussion of this post-operative ileus and acute dilatation of 
the stomach and all that has come about by the mistaking of 



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470 ACUTE ILBUa. 

terms. Post-operative ileus means one thing to one man and 
another thing to another man, but to me post-operative ileus is 
where the bowels do not move, not a mechanical obstruction. 
Now, it just happens that whenever you have a mechanical ob- 
struction you might just as well throw up your hands and go 
in there and puncture a hole in the bowel. If you have an acute 
dilatation of the stomach and do not wash it out and do not 
turn your patient out you are a criminal. But, so far as my 
individual feeling is concerned, the thing is for me to deter- 
mine, first, whether it is a mechanical obstruction due to adhe- 
sions or kinks, or whether it is simply a paralytic affair where 
the bowel will not contract, or whether it is an acute dilatation 
of the stomach due to the sagging down, with the mesenteric 
vessels pressing on the duodenum and all that sort of business. 
That is the first thing — to make your diagnosis. If I make up 
my mind that it is not an acute dilatation of the stomach and 
what I consider a post-operative ileus, the thing is simple to 
me ; I know how to go to work. If I make up my mind it is a 
mechanical obstruction, I go in there and puncture a hole in the 
bowel ; if I make out an acute dilatation of the stomach I treat 
that ; and it is very important for us and the people to be oper- 
ated on that this be understood. You will find a great many 
men who do not think they have an ileus unless thev have an 
obstruction. That is not ileus to me. 

And I wish to say another thing, that the idea of the cure of 
suppurative peritonitis from ruptured appendix, ruptured pus 
tubes, perforated duodenal and gastric ulcers, is all a .question 
of degree. What is suppurative peritonitis to one man is not 
suppurative peritonitis to another, and it is the same thing with 
this ileus. Whenever you have post-operative ileus pure and 
simple, not mechanical, not acute dilatation of the stomach, then 
morphine, rest and proctoclysis will relieve your patients in 999 
cases out of a thousand. If you have a mechanical obstruction 
you can give all the proctoclysis in the world, you can use all 
the morphine manufactured and you get no relief. If you have 
acute dilatation of the stomach the same is true. 

Now then, Dr. George Brown, of Birmingham, years ago 
in a paper before the Southern Surgical and Gynecological So- 
ciety in Atlanta reported twelve or fifteen cases of acute peri- 
tonitis treated by the use of enemas and morphine. Dr. Mur- 
phy was present at that meeting and ridiculed him, but a few 



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D. C. DONALD. 471 

years afterwards advocated the Murphy drip and morphine in 
those cases. Dr. Brown is the man who is the pioneer in that 
field. 

Now, whenever you have acute dilatation of the stomach, if 
you lose that patient it is because you do not take him in time. 
Remember, in conclusion, when you have a mechanical ob- 
struction you are gone if you do not open the belly ; if you have 
acute dilatation of the stomach if you do not wash out the stom- 
ach you are gone ; when you have ileus you must give water. 
In the paper the doctor gave the three conditions, and you have 
got to make up your mind which of the three you have. I am 
very sorry that there is not a larger attendance, and I am sorry 
that in the discussion and reading of papers on this subject 
they don't make this distinction, because it is so important, so 
far as the patient is concerned. You can call it acute dilatation 
of the stomach, acute ileus or whatever you want. 

In regard to the use of pituitrin, if you want to get any bene- 
fit from it you want to use it in double doses. I have gotten 
very good results from eserin salicylate in the paralytic type or 
the real post-operative ileus. If you wait two or three days, 
the patient is not vomiting, but is puffing up ; they won't do a 
thing in the world ; they won't pass a thimbleful of gas. Just 
simply shoot them with eserin salicylate 1/100 grain every 
two hours, and after a while they will begin to toot, and it's 
mighty pretty music. 

Dr. W. R. Jackson, Mobile : I want to thank the leader for 
the paper. I think it is a very nice, very precise and very com- 
prehensive paper, but I wish to say that by the term ileus cus- 
tom and usage make it mean obstruction of the bowel ; obstruc- 
tion means to stop up. That is the common custom and usage. 
Now we can have the bowel obstructed several ways ; we can 
have it mechanically obstructed and we can have it adynamical- 
ly obstructed. Now, remember that there are about four things 
that produce adynamic obstruction of the bowels, and I defy 
any man in this audience to tell me the difference between 
adynamic obstruction and mechanical obstruction without cut- 
ting a hole in the belly. For instance, they tell you if you have 
a thrombosis of the mesenteric artery you cannot get the bowels 
open to save your life. Or if you have gangrene of a loop of 
the gut you have the same thing. This is virtually a mechanical 



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472 ACUTE ILEV8. 

obstruction, because you have no motion there, but in adynamic 
obstruction, not mechanical, the vis a tergo, the kinesis, of the 
gut is paralyzed. You cannot get these bowels to move, be- 
cause the feces do not pass through the alimentary tract by 
gravity but by the vermicular action of the intestines, and you 
cannot get anything beyond this paralyzed gut, and very often 
we hame thrombosis and embolism of the superior mesenteric 
or branches of it that paralyzes the loop of gut. I have had 
this in three or four cases, opened up and found complete ob- 
struction, nothing passing through this point. The same obtains 
with reference to inflammation of certain loops of the bowels. 
When we get inflammation of the peritoneum we have paralysis 
of the muscularis of the gut, and we have violent gaseous dis- 
tension, we have paralysis and obstruction. 

Now inflammation from peritonitis and appendicitis, throm- 
bosis and gangrene of a loop of gut are the adynamic causes 
of obstruction of the bowel. This is not an intussusception, 
this is not a volvulus or kink, it is not mechanical, but simply a 
paralysis from these peculiar conditions. Very often when we 
do a suspension of the uterus we have a loop of gut getting in 
between the fixation point, and we get mechanical obstruction 
in that way. 

As to the diagnosis, it is a very important thing to make, and 
we cannot always make it. If we manipulate the intestines ex- 
tensively during an operation we have temporary paresis of the 
muscularis, but very soon nature asserts itself and we have 
peristalsis re-established. Now suppose we have a case coming 
on after an operation for inflammatory conditions. We would 
always suspect that there were inflammatory adhesions or 
paralysis of the gut from the visceral peritoneum or throm- 
bosis going up into the mesentery or possibly a gangrenous sec- 
tion of a loop of gut. We would suspect that. Now as to the 
mechanical. Of course, we would have sudden, immediate 
obstruction, vomiting, first of the contents of the stomach, next 
of biliary matter and finally of fecal matter. Whenever we have 
stercoraceous vomiting we suspect a mechanical cause. When 
you get fecal vomiting it is time to open up, and the sooner you 
open up the quicker the patient will get well, but if you wait 
until you have obstruction from any cause, of three days' dura- 
tion, your patient is going to die nearly always ; no matter if 



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D. C. DONALD, 473 

you open up and make an artificial anus your patient will die 
anyway. So don't wait three days. 

Dr. McAdory: Dr. Jackson emphasized more fully what I 
said, that the point is to make your diagnosis as to what you 
have got. If it is an obstruction due to a gangrenous gut it is 
a mechanical obstruction, and nothing in the world except to 
open is going to do any good. But the thing is this, that unless 
you have such an obstruction, why it is all foolishness to go into 
the gut. If you have such an obstruction go in; the whole 
thing is diagnosis; but my plea was this, that the profession 
recognize these different conditions and not call them all ileus. 

Dr. Marye Y. Dabney, Birmingham: I think in justice to 
Dr. Donald, Dr. McAdory will have to admit that in the text- 
books they do class what we call obstruction as ileus, and under 
the term ileus they give the dynamic and the adynamic. Now,