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Full text of "Transactions of the Medical Society of the State of North Carolina [serial]"

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HEALTH SCIENCES LIBRARY 

OF THE 

UNIVERSITY OF NORTH CAROLINA 




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Digitized by tlie Internet Arcliive 

in 2009 witli funding from 

Nortli Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project 



http://www.archive.org/details/transactionsofme67medi 




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TRANSACTIONS 



OF THE 



MEDICAL SOCIETY 



OF THE 



STATE OF NORTH CAROLINA 



SIXTY-SEVENTH ANNUAL MEETING 

HELD AT 

CHARLOTTE, NORTH CAROLINA 

APRIL 20, 21,22, 1920 
DIVISION OF^ HEALTH SCIENCES LIBRARY 

President, DR. C. V. REYNOLDS, Asheville, N. C. 
Secretary, DR. BENJ. K. HAYS, Oxford, N. C. 
Reporter, MRS. S. W. SUMMERS, Raleigh, N. C. 




COMMITTEE ON PUBLICATION 

Dr. p. p. McCain Sanatorium 

Dr. C. a. Julian Thomasville 

Dr. W. L. Dunn Asheville 



"It is understood that the Society is not to be considered as endorsing all 
the views and opinions of authors of papers published in the Transactions 
of the Society." — Extract from By-Laws, chapter lo, section 8. 



CONTENTS 

See Index, Page 402 et seq. 

Carl V. Reynolds, M. D Frontispiece 

Committee on Publication iv 

Early History of North Carolina Medical Society viii 

Roster of Officers of Society, 1849 to 1920 ix 

Past Members Board of Medical Examiners xii 

Roster of State Board Health, 1877 to 1919 xiii 

Status of Membership by Counties, 1907-1920 xv 

Honorary Fellows, North Carolina Medical Society xvii 

Honorary Members, North Carolina Medical Society xix 

Officers of the Society, 1919-1920 xx 

Officers of the Society, 1920-1921 xx 

Councilors, 1919-1922 xx 

Chairmen of Sections, 1921 Session xx 

Program, General Sessions xxi 

Members of State Board of Health xxii 

Executive Staff of State Board of Health xxii 

Order of Business xxii 

Section Meetings xxv 

Foreword xxxi 

Page 

Opening Exercises 1 

Invocation — Dr. Bunyan McLeod 1 

Welcome to the City of Charlotte — Hon. F. R. McNinch, Mayor 1 

Welcome to Mecklenburg County — Hon. Cameron Morrison 3 

Welcome from Mecklenburg County Medical Society — Dr. C. M. Strong 4 

Response to Addresses of Welcome — Dr. Thompson Eraser 6 

Address of the President — Medical Legislation — C. V. Reynolds 7 

Practice of Medicine 18-87 

Report of Twenty-Five Autopsies on Influenza Pneumonia — Dr. James 

M. Bullitt 18 

A Case of Eventration of the Diaphram — W. M. Allen, M. D 22 

X-Ray Findings in the Lung Following Influenza, Tuberculous and Oth- 
erwise — Dr. R. P. Noble 25 

Preliminary Report on a Study of the Goetsch Test — Dr. R. McBrayer__ 27 

Essential Hypertension — Dr. R. F. Leinbach 32 

Mechanism of Convulsive Movements of the Orbicularies and Face, and 

the Manner of Their Removal — Dr. Tom A. Williams 37 

Anaemia, with the Report of Two Cases, One Secondary and the Other 

Primary — Dr. K. C. Moore 40 

Arterial Tension and Its Clinical Manifestations — Dr. Charles H. Peete 44 



VI CONTENTS 

Page 

Toxic Arthralgia — Dr. O. Edwin Finch 46 

Sjonptomatology of Typhoid Fever — Dr. P. R. Hardee 52 

Some Facts, Old and New, Concerning the Heart and the Pulse — Dr. Hu- 
bert Benbury Haywood, Jr : 55 

A Review of the Recent Work on Amoebic Dysentery — Dr. William Allan 63 

The Modern Therapeutic Value of Digitalis — Dr. Joseph A. Speed 67 

Radium in the Treatment of Skin Cancer — Dr. W. D. James 71 

Double Choked Discs — Operation, with Recovery of Vision — Henry L. 

Sloan, M. D 74 

Different Forms of Food Adulteration — W. M. Allen, 76 

Blood Chemistry in Nephritis — Dr. W. M. Copridge 83 

Surgery i 88-133 

Acute Pancreatitis Resembling Acute Intestinal Obstruction, Report of 

Cases — Eugene B. Glenn 88 

Saving Suppurating Incisions — Hubert A. Royster, M. D 94 

Goiter — Addison Brenizer, M. D 98 

Inguinal Hernia — Dr. J, T. Burrus 107 

Some Problems Met with in Gall-Bladder Surgery — Dr. J. W. Tankers- 
ley 109 

Treatment of Infected Bone Cavities — Drs. D. W. and Ernest S. Bulluck 

and R. H. Davis 112 

Closure of Belly Wall Based on the Healing Power of Tissue — Henry F. 

Long, M. D 115 

Hyperthropic Stenosis of the Pylorus — Dr. E. T. Dickinson 119 

End Results of One Hundred Cases of Cancer of Uterus — Dr. J. A. Wil- 
liams . 123 

Subphrenic Abscess — George Vv^'m. Pressley, M. D 124 

Ascariasis As a Surgical Complication — Henry Norris, M. D 127 

The Surgeon and Roentgenology — Dr. R. H. Lafferty 129 

A Troublesome Complication of Gonorrhoea, Its Treatment — Hamilton 

W. McKay, M. D 130 

Gynecology and Obstetrics : 134-150 

Some Phases of Obstetrics — Dr. J. M. Manning 134 

Concerning the Disease of the Cervix Uteri — Dr. Foy Roberson 137 

Cesarean Section in Eclampsia — C. A. Woodard 139 

Ovarian Tumors — Dr. John B. Nicholson 141 

The Termination of Pregnancy for Therapeutic Reasons — Dr. F. Webb 

Griffith 144 

Eye, Ear, Nose and Throat 151-162 

What Constitutes Good Tonsil Surgery — John W. MacConnell, M. D 151 

Conservatism in Treating Foci of Infection — J. G. Murphy, M. D 155 

The Relation of Public Health Work to the Business Interest of the Eye, 

Nose and Throat Specialists of North Carolina — G. M. Cooper, M. D. 156 



CONTENTS VU 

Page 

Pediatrics 163-212 

The Importance of Lumbar Puncture in Intra-Cranial Hemorrhage of 

the New-Bora — Dr. J. Buren Sidbury 163 

Acidosis— Dr. L. W. Elias I'^S 

Infection of the New-Born— Dr. Yates W. Faison 180 

Simplified Feeding and the Breast — Frank Howard Richardson, M. D.__ 186 

Laryngeal Stenosis— L. Y. Royster, M. D 203 

Public Health and Education 213-267 

Importance of a City Tuberculosis Sanatorium — Dr. R. L. Carlton 213 

City Abattoir and Meat Inspection — Dr. R. L. Carlton 214 

Remedial Conditions in School Children— Margery J. Lord, M. D 217 

The State Plan for Securing Medical and Dental Care of School Chil- 
dren— G. M. Cooper, M. D 224 

Our Tuberculosis Problems — Dr. B. O. Edwards 227 

Some of the Things Necessary to the Eradication of Tuberculosis — Dr. 

E. Brooks 231 

Venereal Diseases — A Public Problem — Millard Knowlton, M. D 236 

The State Program for Venereal Disease Control — Millard Knowlton_- 240 
An Ideal Venereal Disease Clinic Organization — Dr. Raymond Thompson 244 
The Importance of Laboratory Facilities for a Venereal Disease Clinic — 

Dr. L. C. Todd 248 

Gonorrhoeal .Complications in Their Relation to Infectivity — Dr. A. 

F. Toole 250 

The Diagnosis and Treatment of Syphilis — Dr. C. 0. Abernethy 252 

Central Nervous System Syphilis ;Its Incidence and Treatment — Joseph 

A. Elliott, M. D 255 

Report of Board of Examiners — H. A. Royster, Secretary 262 

Nominations for Members Board of Medical Examiners 268 

Election of Members of Nurses' Examining Board 270 

State Medicine— Dr.W. S. Rankin 272 

Proceedings of the House of Delegates 289 

Report of Secretary-Treasurer 290 

Report of Committee on Regulation of Work of Midwives 292 

Memorial Exercises 297 

Annual Report of Secretary of State Board of Health 321 

Official List North Carolina Officers of Officers' Medical Corps, U. S. A. 333 
Alphabetical List Members of Medical Society, with P. O, Addresses — 334 

Roster of Members for 1921, by Counties 350 

Transactions of North Carolina Health Officers' Association 415 



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ROSTER OF BOARD OF HEALTH 



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ROSTER OF MEMBERS NORTH CAROLINA STATE BOARD OF HEALTH 
FROM ORGANIZATION IN 1877 TO 1919 



Name 



S. S. Satchwell, M.D., President 

Thomas F. Wood, M.D., Secretary 

Joseph Graham, M.D 

Charles Duffy, Jr., M.D 

Peter E. Hines, M.D 

George A. Foote, M.D 

S. S. Satchwell, M.D., President 

Thomas F. Wood, M.D., Secretary 

Charles J. O'Hagan.M. D., President.^ 

George A. Foote, M.D 

Marcellus Whitehead, M.D 

R. L. Payne, M.D 

H. G. Woodfin, M.D 

A. R. Ledeux, Chemist 

WiPiam Cain, Civil Engineer 

R. L. Payne, M.D 

M. Whitehead, M.D., President 

J. M. Lyle, M.D 

Will'am Cain, Civil Engineer 

W. G. Summons, Chemist 

J. W. Jones. M.D., President 

John McDonald 

S. H. Lyle, M.D 

W. G. Simmons, Chemist 

Arthur Winslow. Civil Engineer 

R. H. Lewis. M.D 

Thomas F. Wood, Secretary 

William D. Hilliard, M.D 

Arthur Winslow, Civil Engineer 

W. G. Simmons. Chemist , — 

J. H. Tucker, M.D 

R. H. Lewis, M.D.. Secretary 

H. T. Bahnson, M.D.. President 

Authur Wins'ow, Civil Engineer 

W. G. Simmons. Chemist 

J. H. Tucker, M.D 

J. L. Ludlow, Civil Engineer 

J. H. Tucker, M.D 

F. P. Venable, Ph.D.. Chemist 

J. L. Ludlow, Civil Engineer 

J. A. Hodges, M.D 

J. M. Baker, M.D 

J. H. Tucker, M.D 

F. P. Venable, Ph.D., Chemist 

J. L. Ludlow, Civil Engineer 

Thomas F. Wood, M.D., Seci-etary* 

George G. Thomas, M.D., President 

S. Westray Battle, M.D 

W. H. Harrell, M.D 

John Whitehead, M.D 

W. H. G. Lucas 

F. P. Venable, Ph.D., Chemist 

John C. Chase, Civil Engineer 

R. H. Lewis, Secretary 

W. P. Beall, M.D 

W. J. Lumsden, M.D 

John Whitehead, M.D 

W. H. Harrell, M.D — __ 

W. P. Beall, M.D 

R. H. Lewis, M.D., Secretary 

F. P. Venable, Ph.D., Chemist 

John C. Chase. Civil Engineer 

Charles J. O'Hagan, M.D 

John D. Spicer, M.D 

J. L. Nicholson, M.D 

R. H. Lewis, M.D., Secretary 

A. W. Shaffer, Civil Engineer 

Charles O'Hagan. M.D 

J. L. Nicholson, M.D 

Albert Anderson, M.D 

R. H. Lewis, M.D., Secretary 

A. W. Shaffer, Civil Engineer 



Address 



Rocky Point 

Wilmington 

Charlotte 

New Bern 

Raleigh 

Warrenton 

Rocky Point 

Wilmington 

Greenville . 

Warrenton 

Salisbury 

Lexinsrton 

Franklin 

Chapel Hil* 

Charlotte 

Lexington 

Salisbury 

FrankMn 

Charlotte ;_ 

Wake Forest 

Wake Forest 

Washington 

Franklin . 

Wake Forest 

Raleigh 

Raleigh 

Wilmington , 

Asheville 

Raleigh 

Wake Forest 

Henderson 

Raleigh 

Winston-Salem 

Raleigh '_ 

Wake Forest 

Henderson 

Winston 

Hendereson 

Chapel Hill 

Winston 

Fayetteville : 

Tarboro 

Henderson 

Chapei Hill 

Winston 

Wilmington 

Wilmington 

Asheville 

Williamston 

Salisbury 

White Hall 

Chapel Hill 

Wilmington 

Raleigh 

Greensboro 

Elizabeth C!ty__ 

Salisbury 

Wi'liamston 

Greensboro 

Raleigh 

Chapel Hill 

Wilmington 

Raleigh 

Goldsboro 

Richlands 

Raleigh 

Raleigh . 

Greenville 

Richlands 

Wilson 

Raleigh 

Raleigh 



Appointed by 



State Society 

State Society 

State Society 

State Society 

State Society 

State Society 

State Society 

State Soc'ety 

State Society 

State Soc'ety 

State Soc'ety 

State Society 

Gov. Z. B. Vance 

Gov. Z. B. Vance 

Gov. Z. B. Vance 

State Society . 

State Society 

Gov. T. J. Jarvis 

Gov. T. J. Jarvis 

Gov. T. J. Jarvis 

State Society 

State Society 

Gov. T. Jarvis 

Gov. T. Jarvis-^ 

Gov. T. Jarvis 

State Board of Health 

State Soc-iety 

State Society 

Goov. A. M. Scales 

Goov. A. M. Scales 

Goov. A. M. Scales 

State Society 

State Society 

Goov. A. M. Scales 

Goov. A. M. Scales__ 

Goov. A. M. Scales 

Goov. A. M. Scales 

Gov. D. G. Fowle 

Gov. D. G. Fowle 

Gov. D. G. Fowle 

State Society 

State Society 

Gov. T. M. Holt 

Gov. T. M. Holt 

Gov. T. M. Holt 

State Society 

State Board of Health 

State Society 

State Society 

State Board of Health 

Gov. Elias Carr 

Gov. Elias Carr 

Gov. Elias Carr 

Gov. Elias Carr 

Gov. Elias Carr 

Gov. Elias Carr 

State Society 

State Society 

Gov. Elias Carr 

Gov. Elias Carr 

Gov. Elias Carr 

Gov. Elias Carr 

Gov. D. L. Russell- 
Gov. D. L. Russell__. 
Gov. D. L. Russell___ 

Gov. D. L. Russell 

Gov. D. L. Russell- — 

Gov. D- L. Russell 

Gov. D. L. RusselL__ 

Gov. D. L. Russell 

Gov. D. L. Russell ___ 

Gov. D. L. Russell 

Gov. D. L. Russell 



Term 



1877 to 
1877 to 
1877 to 
1877 to 
1877 to 

1877 to 

1878 to 
1878 to 
1878 to 
1878 to 
1878 to 
1878 to 
1878 to 
1878 to 
1878 to 
1881 to 
1881 to 
1881 to 
1881 to 
1881 to 
1883 to 
1883 to 
1883 to 
1883 to 

1883 to 

1884 to 

1885 to 
188.5 to 
1885 to 
1885 to 
1885 to 
1SS7 to 
1887 to 
1887 to 
1887 to 

1887 to 

1888 to 
1888 to 

1888 to 

1889 to 
1889 to 
1889 to 
1891 to 
1891 to 
1891 to 

1891 to 

1892 to 

1891 to 

1892 to 

1893 to 
1°'>'^ to 
1893 to 
1893 to 

1893 to 

1894 to 

1895 to 
1895 to 
1895 to 
1895 to 
1895 to 
1895 to 
1895 to 
1897 to 
1897 to 
1897 to 
1897 to 
1897 to 
1899 to 
1899 to 
1899 to 
1899 to 
1899 to 
1899 to 



*Died in 1892. leaving a five-year unexpired term, wh'ch was filled by the Board. 



XIV 



NORTH CAROLINA MEDICAL SOCIETY 



ROSTER OF MEMBERS— Continued 



Name 



George G. Thomas, M.D., President. 

S. Westray Battle, M.D 

H. W. Lewis, M.D 

H. H. Dodson, M.D. 

R. H. Lewis, M.D., Secretary 

W. P. Ivey. M.D 

George G. Thomas, M.D., President- 

Francis Duffy, M.D 

J. L. Ludlow, Civil Engineer 

S. Westray Battle, M.D 

H. W. Lewis, M.D 

W. H. Whitehead, M.D 

J. L. Nicholson, M.D 

J. L. Ludlow, Civil Engineer 

J. Howell Way, M.D 

W. O. Spencer, M.D 

George G. Thomas, M.D., President. 

Thomas E. Anderson, M.D 

R. H. Lewis, M.D 

E. C. Register, M.D 

David T. Tayloe, M.D 

James A. Burroughs, M.D.* 

J. E. Ashcraft, M.D 

J. L. Ludlow, Civil Engineer 

J. Howell Way, M.D., President 

W. O. Spencer, M.D 

Thomas E. Anderson, M.D 

Charles O'H. Laughinghouse, M.D.- 

R. H. Lewis, M.D 

Edw. J. Wood, M.D 

A. A. Kent, M.D 

Cyrus Thompson, M.D 

Fletcher R. Harris, M.D 

J. L. Ludlow, Civil Engineer 

J. Howell Way, M.D., President 

E. C. Register, M.D.* 

Thomas E. Anderson, M.D 

Charles O'H. Laughinghouse, M.D._ 

Cyrus Thompson, M.D 

F etcher R. Harris, M.D 

R. H. Lewis, M.D 

E. J. Tucker. D.D.S 

A. J. Crowell 



Address 



Wilmington 

Asheville 

Jackson 

MIton 

Raleigh 

Lenoir 

Wilmington 

New Bern 

Winston 

Asheville 

Jr.ckscn 

Rocky Mount 

R'chlands 

Winston 

Waynesville ^ 

Winston 

Wilmington 

States ville 

Raleigh 

Charlotte 

Washington 

Asheville 

Monroe 

Winston-Salem. - 

Waynesville 

Winston-Salem. _ 

States viTe 

Greenville 

Raleigh 

Wilmington 

Lenoir 

.Jacksonville . 

Henderson 

Winston-Salem.. 
Waynseville.. 

Charlotte 

Statesville 

Greenville 

Jacksonvil'e 

Henderson 

Raleigh 

Roxboro 

Charlotte 



Appointed by 



State Society 

State Society 

State Society 

State Society 

Gov. C. B. Aycocok.. 

Gov. C. B. Aycocok 

Gov. C. B. Aycocok 

Gov. C. B. Aycocok 

Gov. C. B. Aycocok 

State Society 

State Society 

State Society 

State Society 

Gov. C. B. Aycocok 

Gov. R. B. Glenn 

Gov. R. B. Glenn 

State Society 

State Society 

Gov. R. B. Glenn 

Gov. R. B. Glenn 

State Society 

State Society 

State Board of Healtl. 
Gov. W. W. Kitch-n. 
Gov. W. W. Kitchin. 
Gov. W. W. Kitchin 

State Society 

State Society 

Gov. Locke Craig 

Gov. Locke Craig 

State Society 

State Society 

State Board of Healt 

Gov. Locke Craig 

Gov. T. W. Bickett_- 
Gov. T. W. Bickett— 

State Society 

State Society 

State Society 

State Society 

Gov. T. W. Bickett_. 
Gov. T. W. Bickett_ 
Gov. T. W. Bickett._, 



Term 



1899 to 1901 
1899 to 1901 
1899 to 1901 
1899 to 1901 
1901 to 1907 
1901 to 1907 
1901 to 1905 
1901 to 1905 
1901 to 1905 
1901 to 1907 
1901 to 1907 
1901 to 1905 
1901 to 1905 
1903 to 1909 
1905 to 1911 
1905 to 1911 
1905 to 1911 
1905 to 1911 
1907 to 1913 
1907 to 1913 
1907 to 1913 
1907 to 1909 
1909 to 1913 
1909 to 1915 
1911 to 1917 
1911 to 1917 
1911 to 1917 
1911 to 1917 
1913 to 1919 
1913 to 1919 
1913 to 1915 
1913 to 1919 
1913 to 1919 
1915 to 1921 
1917 to 1923 
1917 to 1923 
1917 to 1923 
1917 to 1923 
1919 to 1925 
1919 to 1925 
1919 to 1925 
1919 to 1925 
1919 to 1923 



♦Died leaving unexpired term. 



tResigned to become member of General Assembly. 



STATUS OF MEMBERSHIP 



XV 



STATUS OF SOCIETY 


MEMBERSHIP BY 


COUNTIES FOR 


YEARS 1907-1920 




Counties 


1 1 1 
190711908 1909|1910|1911 

1 1 1 1 


1912 


1913 


1914 


1 1 1 
1915 1916|1917| 1918 


i 
191911920 


Alamance 


7 


17 


15 


14 


12 


11 


11 


13 


9 


10 


12 


10 


15 


1 

27 


A l«-u-r,T»,4oH n 






























Alleghany 

Anson 

Ashe 

Avery 

Beaufort 




_l 












2 


2 










1 


3 


1 1 


1 


1 


6 


8 


7 








1 


3 


2 






1 


1 














11 


15 


8 


7 




I 










8 


7 


9 


9 


7 


6 


4 


15 


1 151 11 


111 16 


15 


14 


14 


14 


14 


10 


111 10 


14 


Bertie 


4 


41 4 


51 2 


2 


2 


3 


3 


3 


3 


5 


5 


10 


Bladen 


4 
4 


3 


3 

4 


3 
2 


1 4 
2 


4 
2 


5 
5 


7 
4 


7 
5 


6 


9 


8 
2 


9 
2 


8 


Brunswick ." 

Buncombe 


2 


47 


48 


54 


58 


63 


64 


69 


68 


70 


71 


74 


76 


81 


83 


Burke 


10 


f 


1 10 


13 


12 


11 


13 


15 


17 


17 


16 


17 


6 


11 


Cabarrus 


13 


17 


16 


18 


21 


21 


19 


22 


23 


25 


20 


22 


19 


20 


Caldwell _ J 


10 


12 


12 


13 


12 


10 


12 


12 


11 


7 


9 


13 


12 


10 
































Carteret 


9 


10 


7 


7 


6 


7 


6 


7 


7 


9 


7 


4 


7 


9 


Caswell 


3 


3 


2 


1 


1 


1 


1 


1 


1 


1 


1 


1 


3 


2 




10 


q 


I'' 


12 










15 


13 


18 




5 


18 


Chatham 


6 


1 


2 


2 


6 





14 


15 


12 


11 


11 


11 


7 


10 


Cherokee 






9 


6 


7 
7 


9 
5 


8 
8 


7 
9 


10 

7 


9 

4 


11 
3 


10 


6 
6 


10 








8 


Clay c 












Cleveland 


14 


14 


13 


13 


14 


15 


15 


16 


13 


13 


16 


16 


17 


19 


Columbus 


9 


8 


8 


8 


10 


12 


12 


14 


9 


11 


7 


1 


6 


10 


Craven 


10 


14 


14 


14 


12 


14 


18 


15 


11 


8 


11 


7 


7 


6 


Cumberland 


12 


12 


17 


20 


20 


22 


23 


22 


24 


19 


17 


16 


15 


20 


Currituck 


6 


3 


3 


6 


4 


4 


4 


6 


7 


6 


6 


1 


5 


5 


Dare d 




Dav"-dson 


12 


12 


12 


13 


13 


15 


13 


17 


13 


9 


20 


20 


19 


18 




6 

8 


6 

8 


6 
10 


6 
10 


5 
9 


6 

8 








6 

7 


5 
10 


4 
9 


4 
9 


4 


Duplin 


9 


7 


4 


10 


Durham-Orange 


15 


18 


24 


26 


28 


31 


32 


38 


40 


41 


44 


35 


33 


45 


Edgecombe _ _ 


8 


8 


10 


10 


11 


11 


11 


13 


13 


13 


10 


10 


7 


15 


Forsyth 


21 


26 


30 


25 


29 


31 


32 


37 


39 


42 


45 


37 


37 


57 


Franklin 


10 


10 


9 


11 


11 


11 


10 


10 


12 


11 


10 


11 


11 


12 


Gaston _ _ _ 


22 


25 


25 


27 


29 


29 


30 


27 


26 


25 


27 


27 


26 


35 


Gates 


4 


4 




















' 


1 




























Granvi'le _, 


8 


11 


12 


12 


8 


13 


12 


14 


11 


16 


16 


14 


14 


15 


Greene _ 


5 


5 


• 6 


6 


6 


5 


5 


5 


5 


6 


5 


2 


5 


6 


Gu'lford 


54 
10 


62 
10 


64 

7 


65 
6 


56 
2 


58 
2 


59 
11 


62 
11 


71 

7 


66 
15 


68 

8 


67 

1 


72 

7 


77 


Halifax 


28 


Harnett 


16 


18 


19 


15 


14 


17 


17 


16 


17 


15 


17 


15 


14 


16 


Haywood 


10 


11 


15 


13 


10 


11 


13 


15 


11 


11 


11 


9 


9 


11 


Henderson-Polk 


n 


15 


14 


14 


17 


17 


11 


14 


14 


15 


15 


11 


13 


15 


Hertford _ . 


8 


9 


8 


6 


2 




S 


10 


4 


1 


5 


10 


10 


10 


Hoke- _ 






















10 


11 
1 


10 

2 


10 


Hyde _ 




5 


8 


6 


6 


6 


7 


7 






1 


Iredell-Alexander__ 


18 


18 


18 


17 


12 


9 


9 


14 


16 


9 


20 


11 


11 


21 


Jackson _ 


2 
11 


2 
15 










2 
18 


3 
19 


5 
21 


2 
19 


5 
22 


2 
16 


5 
24 


5 


Johnston 


13 


15 


19 


18 


22 


Jones _ _ _ 






























Lee 














7 
9 


8 
12 


7 
14 


8 
15 


8 
16 


6 
15 


8 
17 


8 


Lenoir ' 


12 


13 


9 


12 


6 


8 


22 


Lincoln 


8 


8 


10 


10 


10 


11 


12 


13 


14 


11 


9 


11 


15 


16 


Macon-Clay _ _ 


3 

11 

9 


4 

11 

9 


5 
12 
13 








4 

7 

13 


4 

8 

14 


5 
11 
14 


5 

9 

15 


4 
10 

17 


6 

"l2 


6 
11 
11 


fi 


Madison 






10 
12 


11 


Martin 


13 


13 


16 


McDowell 


7 




8 


4 


5 


6 


6 


7 


7 


7 


8 


7 


6 


6 




37 


54 


51 


57 


44 


50 


63 


69 


71 


74 


63 


49 


97 


104 


Mitchell 


3 


4 


7 


4 


5 


5 


4 


2 


2 


2 


1 




4 


5 


Montgomery 


6 


8 


7 


9 


7 


7 


8 


6 


10 


9 


9 


8 


6 


8 


Moore 


2 


14 


10 


11 


21 


21 


13 


16 


15 


18 


10 


15 


16 


16 


Nash 












1 
22 


~'31 


19 

28 


18 
33 


26 
41 


27 
•30 


21 
29 


26 
38 


?5 


New Hanover 


20 


21 


23 


21 


21 


40 


Northampton 


9 


9 


8 


11 


9 


1 


12 


12 


11 


10 


14 


11 


13 


10 


Onslow 


4 


4 


4 


6 


11 


10 


12 


10 


8 


9 


11 


7 


9 


8 


Orange e . 


1 

■ 31 


1 

4 


1 

5 


11 
41 


1 

4 


1 

4 


8 
5 
















Pamlico 


5 


5 


5 


5 


4 


41 


5 


Pasquotank-Camden- 






























Dare 


11 


10 


10 


11 


12 


12 


13 


15 


15 


171 19 


16 


15 


16 


Pender 








2 


2 


2 


2 






1 




1 

3 

12 


1 


Perquimans _ ._ _. 














4 




Person 


7 


8 


9 


9 


10 


11 


11 


8 


11 


131 12 


10 


Pitt 


11 


9 


14 


10 


10 


SI 


9 


5 


15 


9) 14 


5 


18 


24 


Polk f 

























___-! 






XVI 



NORTH CAROLINA MEDICAL SOCIETY 



STATUS OF SOCIETY MEMBERSHIP BY COUNTIES— (Continued) 



Randolph 

Richmond 

Robeson . 

Rockingham 

Rowan 

Rutherford 

Sampson 

Scotland 

Stanly 

Stokes 

Surry 

Swain , , 

Transylvania 

Tyrrell g 

Union 

Vance 

Wake 

Warren 

Washington-Tyrrell 

Watauga 

Wayne 

Wilkes 

Wilson 

Yadkin 

Yancey 



Totals. 



I I I I I I I I I I I I I 

1907|1908|1909|1910|1911|1912I1913|1914|1915 191611917119181191911920 

I I I I I I I I I I I 



6 


9 


9 


10 


8 


9 


7 


12 


14 


11 


13 


11 


12 


13 


11 


11 


1 


12 


1 


10 




10 


13 


13 


14 


11 


13 


12 


24 


24 


20 


15 


22 


23 


35 


. 24 


16 


22 


16 


8 


31 


35 


5 


5 


1 


16 


16 


16 


18 


19 


17 


10 


4 


15 


16 


20 


27 


25 


23 


24 


26 


24 


23 


26 


22 


25 


23 


22 


24 


28 


16 


17 


22 


23 


24 


18 


19 


20 


19 


21 


14 


17 


18 


?;o 


9 


11 


10 


11 


11 


12 


12 


14 


14 


18 


15 


• 10 


11 


13 


8 


11 


10 


11 


9 


9 


11 


12 


12 


12 


13 


10 


9 


10 


9 


9 


8 


11 


10 


11 


11 


13 


14 


9 


14 


11 


11 


15 


5 


10 


11 


9 


10 


11 


7 


12 


13 


12 


10 


5 


5 


10 


13 


15 


15 


15 


13 


14 


19 


21 


19 


18 


23 


24 


27 


28 


6 


6 

4 


8 
1 
















6 
5 


7 


2 
1 


3 


4 





5 


5 


6 


7 


6 


7 


1 


14 


14 


14 


14 


15 


16 


17 


16 


16 


12 


13 


15 


14 


16 


6 


8 


9 


12 


11 


11 


11 


10 


11 


13 


10 


4 


5 


11 


42 


44 


49 


53 


56 


54 


41 


53 


57 


62 


70 


56 


81 


68 





2 







4 


5 


5 


5 


8 


7 


7 


6 


3 


8 



13 



-I 4| 



11 

17 

6 



13 



28 

10 

29 

2 



865| 979|1012| 997| 996|1036|1133|1220|1221|1228|1271|1087|1306|1497 



a See Iredell-Alexander ; b see Pasquotank-Camden-Dare ; c see Macon-Clay ; d see Pasquo- 
tank-Camden-Dare ; e see Durham-Orange ; f see Henderson-Po"k ; g see Washington-Tyrrell. 



HONORARY FELLOWS XVII 

HONORARY FELLOWS, MEDICAL SOCIETY OF THE STATE OF 
NORTH CAROLINA 

Adams, M. R Statesville 

Alexander, Annie L Charlotte 

*Alston, B. P , Epsom 

Andereson, Albert Raleigh 

Anderson, Thos. Eli Statesville 

*Archey, L. M._ Concord 

Asbury, F. E Ashboro 

Attamore, Geo. S Stonewall 

*Bahnson, H. T Winston-Salem 

Baker, J. M - Tarboro 

*Barrier, P. A Mount Pleasant 

Battle, J. T. J Greensboro 

Battle, Kemp P Raleigh 

Battle, S. W ■_ - !___. Asheville 

Beall, Wm. P _ Greensboro 

^Bellamy, W. J. H Wilmington 

Boddie, N. P Durham 

Bolton, Mahlon Rich Square 

*Booth, Samuel D ^__i Oxford 

*Bulluck, D. Wm Wilmington 

Caldwell, D. G - _- Concord 

Cheatham, Archibald Durham 

Clark, G. L , Clarkton 

Council, J. B ..-.Salisbury 

*Croom, J. D Maxton 

Dalton^ Davie N _ Winston-Salem 

DeArmon, J, McC Charlotte 

Denny, Wm. W Pink Hill 

Dillard, Richard Jr Edenton 

Dodson, H. H Greensboro 

*Duffy, Charles New Bern 

*Duffy, Francis New Bern 

Edgerton, Jas. L Hendersonville 

Edwards, G. G Hookerton 

Faison, L W Charlotte 

Faison, Wm. W Goldsboro 

Fletcher, M. H Asheville 

Fox, M. F Guilford Colloge 

Freeman, R, A.__- Burlington 

Galloway, W. C Wilmington 

Gibbon, Robert L Charlotte 

Goodwin, A. W Raleigh 

*Graham, Joseph Charlotte 

Graham, Wm. A Charlotte 

Griffin, J. A Clayton 

^Deceased 



XVUl NORTH CAROLINA MEDICAL SOCIETY 

*Hall, Wright Wilmington 

Hargrove, R. H Robersonville 

Harris, F. R - Henderson 

Harris, I. A Alexander, R-2 

Haywood, F. J Raleigh 

Haywood, Hubert Raleigh 

Hicks, Wm. N Durham 

Hill, L. H Germanton 

*Hudson, Wm. L Dunn 

Hughes, F. W ^^ , New Bern 

Hunter, L. W Charlotte 

Irwin, J. R Charlotte 

Jewett, R. D Wilmington 

Johnson, N. M Durham 

Jordan, T, M Raleigh 

Knight, J. B. H Williamston 

Knox, A. W Raleigh 

Leggett, Kenelm Hobgood 

Lewis, H. W._- Jackson 

Lewis, R. H Raleigh 

Long, Benj. L Hamilton 

*Long, Geo. W , Graham 

Long, J. W '- Greensboro 

Love, W. J Wilmington 

McDonald, A. D Wilmington 

*McKay, A. M Summerville 

*McKay, John A._ Buies Creek 

*McKee, James , Raleigh 

McMillan, Benj. F Red Springs 

McMillan, J. D , . Edenton 

McMillan, J. L Red Springs 

McMillan, W. D ^Wilmington 

McNeill, J. Wm Fayetteville 

*McNeill, Wm. M Buies Creek 

Meisenheimer, C. A Charlotte 

Meisenheimer, Thos. F Morven 

*Miller, J. F Goldsboro 

Monroe, W. A Sanford 

Moore, C. E Wilson 

Moore, Edwin G ^ Elm City 

Munroe, J. P Charlotte 

*Nicholson, J. L Richland 

Nicholson, Sam T Washington 

Nobles, Jos. E Greenville 

Noble, R. J Selma 

*Pate, Wm. T Gibson 

Pemberton, Wm. D Concord 

Perry, M. P Macon 

Pharr, T. F Concord 

Pharr, Wm. W Charlotte 



HONORARY FELLOWS XIX 



Picot, L. J Littleton 

*Prinee, D. M Laurinburg 

Purfoy, G. W Asheville 

*Register, E. C Charlotte 

*Ritter, F. W Moyock 

Royster, W. I Raleigh 

Schomvald, J. T Wilmington 

Shaffner, J. F. Jr Winston-Salem 

Sikes, G. T Grissom 

Smith, R. A Goldsboro 

Speight, R. H., Sr Whitakers 

Stamps, Thos. Lumber Bidge 

*Stevens, J. A Clinton 

Summerell, E. M China Grove 

Tayloe, D. T Washington 

Taylor, L M Morganton 

Thomas, G. G Wilmington 

Trantham, H. T . Salisbury 

Tull, Henry Kinston 

Van Pool, C. M Salisbury 

Ward, W. H Plymouth 

Way, J. Howell Waynesville 

Weaver, H. B Asheville 

Whitaker, R. A Kinston 

White, J. W Wilkesboro. 

Whitehead, John Salisbury 

*Whitehead, W. H Rocky Mount 

Whitfield, Wm. C Grifton 

Whittington, W. P Asheville 

Williams, J. H Asheville 

Wilson, A. R Greensboro 

*Young, R. S Concord 



HONORARY MEMBERS, MEDICAL SOCIETY OF THE STATE OF 
NORTH CAROLINA 

'L. McL. Tiffany 1 Baltimore, Md. 

W. W. Keen Philadelphia, Pa. 

J. Allison Hodges Richmond, Va. 

=R. L. Payne , Norfolk, Va. 

J. N. McCormack Bowling Green, Ky. 

R. L. Payne, Jr Norfolk, Va. 

J. L. Ludlow, C.E Winston-Salem 

Paul V. Anderson Richmond, Va. 

Stuart McGuire Richmond, Va. 

William J. Mayo Rochester, Minn. 

William Seaman Bainbridge New York, N. Y; 

William Sharp__ New York, N. Y. 



XX NORTH CAROLINA MEDICAL SOCIETY 



OFFICERS, 1919-1920 

President Dr. C, V. Reynolds, Asheville 

First Vice-President Dr. H. D. Walker, Elizabeth City 

Second Vice-President Dr. F. Stanley Whitaker, Kinston 

Third Vice-President Dr. Thos. I. Fox, Franklinville 

Secretary-Treasurer Dr. Benj. K. Hays, Oxford 



OFFICERS, 1920-1921 

President Dr. Thos. E. Anderson, Statesville 

First Vice-President Dr. C. S. Lawrence, Winston-Salem 

Second Vice-President Dr. W. H. Ward, Plymouth 

Third Vice-President Dr. Jno. M. Manning, Durham 



COUNCILORS, 1919-1922 

First District— Dr. B. F. Halsey Roper 

Second District— Dr. K. P. B. Bonner Morehead City 

Third District— Dr. J. W. Tankersly Wilmington 

Fourth District — Dr. E. T. Dickinson Wilson 

Fifth District— Dr. A. McN. Blair Southern Pines 

Sixth District— Dr. W. C. Horton Raleigh 

Seventh District — Dr. L. A. Crowell Lincolnton 

Eighth District— Dr. J. K. Pepper Winston-Salem 

Ninth District— Dr. M. R. Adams Statesville 

Tenth District — Dr. Eug. B. Glenn Asheville 



CHAIRMEN OF SECTIONS 
1921 Session 

Public Health and Education Dr. Chas. P. Mangum, Kinston, N. C. 

Surgei-y Dr. J. T. Burrus, High Point, N. C. 

Eye, Ear^ Nose and Throat Dr. H. H. Briggs, Asheville, N. C. 

Gynecology and Obstetrics Dr. Moir S. Martin, Mount Airy, N. C. 

Pediatrics Dr. Yates Faison, Charlotte, N. C. 

Practice of Medicine Dr. F. M. Hanes, Winston-Salem, N. C. 

Chemistry, Materia Medica and Therapeutics — 

Dr. Ernest S. Bullock, Wilmington, N. C. 

Anatomy, Physiology, Pathology and Bacteriology — 

Dr. Paul H. Ringer, Asheville, N. C. 

Chairman Committee on Obituaries Dr. E. G. Moore, Elm City, N. C. 



PROGRAM 

GENERAL SESSIONS 



Tuesday, April 20, 9 a. m. 
OPENING EXERCISES— FIRST FLOOR, MASONIC TEMPLE 

Call to Order: 

Dr. J. B. Witherspoon, Chairman, Committee on Arrangements, Char- 
lotte, N. C. 

Invocation: 

Dr. Bunyan McLeod, Westminster Presbyterian Church, Charlotte, N. C. 

Welcome to the City of Charlotte: 

Hon. F. R. McNinch, Mayor, Charlotte, N. C. 
Welcome to Mecklenburg County: 

Hon. Cameron Morrison, Charlotte, N. C. 
Welcome from Mecklenburg County Medical Society: 

Dr. C. M. Strong, President, Charlotte, N. C. 

Response: 

Dr. Thompson Fraser, Asheville, N. C. 

President's Address: 

Dr. C. V. Reynolds, Asheville, N. C. 
Report of Committee on Arrangements. 
Announcements. 

Continue in this room with the Section on Public Health and Education, 

Tuesday, April 20, 2:30 p. m. 
THIRD FLOOR, MASONIC TEMPLE 

Meeting of House of Delegates. 

Subsequent meetings at same place; time fixed by House of Delegates. 

Tuesday, April 20, 8 p. m. 
FIRST FLOOR, MASONIC TEMPLE 
Pneumoperitoneum as a New Roentgen Diagnostic Procedure (with 
lantern slides) — Dr. Fred M. Hodges, Richmond, Va. 

Report of Obituary Committee — Dr. Arch Cheatham, Chairman, Dur- 
ham, N. C; Dr. E. G. Moore, Elm City, N. C; Dr. F. R. Harris, Henderson, 
N. C; Dr. N. D. Bitting, Durham, N. C; Dr. B. O. Edwards, Asheville, N. C. 

Wednesday, April 21, 11:15 a. m. 
FIRST FLOOR, MASONIC TEMPLE 
Nominations for seven vacancies on the Board of Medical Examiners. 
Wednesday, April 21, 12 m. 
FIRST FLOOR, MASONIC TEMPLE 
Conjoint session of the Medical Society of the State of North Carolina 
and the Noiiih Carolina State Board of Health. 



NORTH CAROLINA MEDICAL SOCIETY 



MEMBERS OF THE STATE BOARD OF HEALTH 

President, Dr. J. Howell Way, Waynesville, N. C. 

Dr. Richard H. Lewis, Raleigh, N. C. 

Col. J. L. Ludilow, C.E., Winston-Salem, N. C. 

Dr. Thomas E. Anderson, Statesville, N. C. 

Dr. Chas. O'H. Laughinghouse, Greenville, N. C. 

Dr. F. R. Harris, Henderson, N. C. 

Dr. Cyrus Thompson, Jacksonville, N. C. 

Dr. A. J. Crowell, Charlotte, N. C. 

Dr. E. J. Tucker, Roxboro, N. C. 

EXECUTIVE STAFF OF THE STATE BOARD OF HEALTH 

Secretary-Treasurer — Dr. W. S. Rankin, Raleigh^ N. C. 
Director Public Health Education — Mr. R. B. Wilson, Raleigh, N. C. 
Director of Bureau of Tuberculosis — Dr. L. B. McBrayer, Sanatorium, N. C. 
Director of Bureau of Medical Inspection of Schools — Dr. G. M. Cooper, 

Raleigh, N. C. 
Director of Bureau of Public Health Nursing and Infant Hygiene — Miss Rose 

M. Ehrenfeld, R. N., Raleigh, N. C. 
Deputy State Registrar and Epidemiologist — Dr. F. M. Register, Raleigh, 

N. C. 
Director of Bureau of County Health Work— Dr. K. E. Miller, R,aleigh, N. C. 
Director of Bureau of Inspection and Sanitary Engineering — Mr. H. E. 

Miller, Raleigh, N. C. 
Director of Bureau of Venereal Diseases — Dr. Millard Knowlton, Raleigh, 

N. C. 
Director of State Laboratory of Hygiene — Dr. C. A. Shore, Raleigh, N. C. 

ORDER OF BUSINESS 

Report of work accomplished and recommendations. 

Discussions. 

New Business. 

Adjournment. 

Wednesday, April 21, 2:30 p. m. 
FIRST FLOOR, MASONIC TEMPLE 

Balloting for seven members of the Board of Medicall Examiners of the 
State of North Carolina. Vote for seven different names. 

Program of the Section on Medicine, as per schedule, will be continued 
in this room iis soon as the ballots are taken up. 

Wednesday, April 21, 8 p. m. 
FIRST FLOOR, MASONIC TEMPLE 

New Conceptions Relative to the Treatment of Malignant Diseases and 
Some Other Refractory Pathological Conditions (illustrated by lantern 
slides) — Dr. Wm. L. Clark, Philadelphia, Pa. 

State Medicine — Dr. W. S. Rankin, President of the American Public 
Heallth Association, Raleigh, N. C. 



PROGRAM 

Thursday^ April 22, 11a. m. 
FIRST FLOOR. MASONIC TEMPLE 



Report of House of Delegates. 
Installation of Officers. 
Resolutions. 
Adjournment. 



SECTION MEETINGS ' 

Tuesday, April 20, 11 a. m. 
FIRST FLOOR, MASONIC TEMPLE 

Section on Public Health and Education 
Dr. C. C. Hudson, Chairman, Charlotte, N. C. 
(City Health Officer, Richmond, Va.) 
(This section must be finished by the close of the Tuesday afetmoon 
session.) 

1. Medical Needs of a Modern Community — Dr. A. McR. Crouch, Wilming- 

ton, N. C. 

2. An Ideal Nursing Organization — Miss G. E. Reynolds, R. N., Charlotte, 

N. C. 

3. (a) The Importance of a City Tuberculosis Sanatorium; (b) City Abat- 

toir and Meat Inspection — Dr. R. L. Carlton, Winston-Salem, N. C. 

4. Remedial Conditions in School Children — Dr. Margery J. Lord^ Ashe- 

ville, N. C. 

5. The State Plan for Securing Medical and Dental Care of School Children 

— Dr. Geo. M. Cooper, Raleigh, N. C. 

6. Our Tuberculosis Problems — Dr. B. O. Edwards, Asheville, N. C. 

7. Some of the Things Necessary to Banish Tuberculosis from Our Com- 

monwealth — Dr. Jas. E. Brooks, Blowing Rock, N. C. 

8. The Proper Education of Tuberculous Patients While in a Sanatorium — 

Dr. Benj. K. Hays, Oxford, N. C. (National Tuberculosis Association, 
381 Fourth Ave., N. Y. C.) 

9. Symposium' on Venereal Diseases: 

(a) Venereail Diseases a Public Problem — Dr. Millard Knowlton, Ral- 
eigh, N. C. 

(b) The State Venereal Disease Campaign — Dr. Millard Knowlton, 
Raleigh, N. C. 

(c) Ideal Venereal Disease Clinic — Dr. S. Raymond Thompson^ Char- 
lotte, N. C. 

(d) The Importance of Laboratory Facilities for Venereal Disease 
Clinic— Dr. L. C. Todd, Charlotte, N. C. 

(e) Gonorrheal Complications as Related to Infectivity — Dr. A. F. 
Toole, Asheville, N. C. 

(f) The Diagnosis and Treatment of Syphilis — Dr. C. 0. Abemethy, 
Raleigh, N. C. 

(g) Central Nervous System Syphilis, Its Incidence and Treatment — 

Dr. Joseph A. Elliott, Charlotte, N. C. 
(h) The Treatment of Gonorrhea in the Female — Drs. Jas. A. Keiger 

and A. B. Greenwood, Raleigh, N. C. 
(i) The Importance of Proper Treatment in Acute Gonorrhea — Dr. A. 
McR. Crouch, Wilmington. 
Discussion opened by Prof. Udo J. Wile, of University of Michigan (by 
invitation). 



XXVI NORTH CAROLINA MEDICAL SOCIETY 

Tuesday, April 20, 2:30 p. m. 

Section on Public Health and Education 

FIRST FLOOR, MASONIC TEMPLE 

(Continuing) 

Tuesday, April 20, 2:20 p. m. 

THIRD FLOOR, MASONIC TEMPLE 

Section on Eye^ Ear, Nose and Throat 

Dr. C. W. Banner, Chairman, Greensboro, N. C. 

1. Some Deductions from a Series of 200 Tonsilectomies — Dr. T. W. Davis, 

Winston-Salem, N. C. 

2. Report of 100 Cases of Tonsilectomy Under Local and General Anesthe- 

sia — Dr. L. L. Simmons, Greensboro, N. C. 

3. Query: What Constitutes Good Tonsil Surgery? — Dr. John W. Mac- 

Connelly Davidson, N. C. 

4. Title unannounced — Dr. S. Dace McPherson, Durham, N. C. 

5. Title unannounced — Dr. J. G. Murphy, Wilmington, N. C. 

6. Relation of Public Hea'lth Work to the Business Interest of the Special- 

ists of North Carolina — Dr. G. M. Cooper, Raleigh, N. C. 

7. Title unannounced — Dr. John Hill Tucker, Charlotte, N. C. 

8. The Relative' Value of Transillumination and X-ray in Diagnosing Dis- 

eases of the Nasal Accessory Sinuses, w^ith Description of the Au- 
thor's Method of Transilluminating the Maxillary Sinus (lantern 
slides) — Dr. H, H. Briggs, Asheville, N. C. 

Wednesday, April 21, 9 a. m. 
THIRD FLOOR, MASONIC TEMPLE 

Section on Gynecology and Obstetrics 
Dr. J. M. Manning, Chairman, Durham, N. C. 

1. Some Phases of Obstetrics — Dr. J. M. Manning, Durham, N. C. 

2. Subject unannounced — Dr. Foy Roberson^ Durham, N. G. 

3. Cesarean Section — Dr. C. A. Woodard, Wilson, N. C. 

4. Subject unannounced — Dr. J. L. Nicholson, Washington, N. C. 

No section meetings after 11:15 a. m. today (Wednesday) as nomina- 
tions for members of Board of Medical Examiners will be called at this hour. 

Wednesday, April 21, 9 a. m. 
THIRD FLOOR, MASONIC TEMPLE 

Sectiofi on Pediatrics 
Dr. J. Buren Sidbury, Chairman, Wilmington, N. C. 
1. The Importance of the Early Recognition of Intra and Extra-durai Hem- 
orrhage in the New^-Bom — Dr. J. Buren Sidbury, Wilmington, N. C. 



SECTION MEETINGS XXVll 

2. Focal Hemorrhagic Encephalitis: Report of a Case with Transfusion — 

Dr. A. S. Root, Raleigh, N. C. 

3. Intubation of the Larynx for Membranous Croup — Dr. L. T. Royster, 

Norfolk, Va. 

4. Acidosis — Dr. L. W. Elias, Asheville, N. C. 

5. Infection of the New-Born — Dr. Yates W. Faison, Charlotte, N. C. 

6. Simplified Infant Feeding^ — Dr. Frank Howard Richardson, Brooklyn^ 

N. Y. 

7. A Discussion of the Use of Purgatives in Infants — Dr. D. L. Smith, 

Saluda, N. C. 

8. Diabetes Mellitis in Childhood— Dr. R. M. Pollitzer, Charleston, S. C. 

9. Skin Tests with Foreign Proteins — Dr. Horace M. Baker, Lumberton, 

N. C. 

No section meetings after 11:15 today (Wednesday), as nominations for 
members of Board of Medical Examiners will be called at this hour. 

Wednesday, April 21, 9 a. m. 

FIRST FLOOR, MASONIC TEMPLE 

Section on Practice of Medicine 

Dr. Hubert B. Haywood, Jr., Chairman, Raleigh, N. C. 

(This section will adjourn promptly at 11:15 a. m. for the nomination of 
seven members of the Board of Medical Examiners. It will reconvene in 
the same room at 2:40 p. m. immediately after the ballots are taken up. 
This section must be finished at th/^ Wednesday afternoon session.) 

1. Specifics in Medicine — Dr. Frederic M. Hanes, Winston-Salem, N. C. 

2. A Study of Different Types of Bright's Disease: The Importance of 

Their Early Recognition— Dr. Wm. deB, MacNider, Chapel Hill, N. C. 

3. Pathologic and Lantern Demonstration of the Influenza and Influenza- 

Pneumonia Lung — Dr. Jas. B. Bullitt, Chapel Hill, N. C. 

4. X-ray Findings in the Lung Following Influenza, Tuberculous and Oth- 

erwise — Dr. Robert P. Noble, Raleigh, N. C. 

5. Hyperthyroidism and Tuberculosis: Studies on the Use of the Goetsch 

Test— Dr. R. A. McBrayer, Sanatorium, N. C. 

6. Essential Hypertension — Dr. R. F. Leinbach, Charlotte, N. C. 

7. Syphilis vs. Rheumatism and Neurasthenia, with Report of Illustrative 

Cases — Dr. J. Allison Hodges, Richmond, Va. 

8. Mechanism of Convulsive Movements of the Face and the Manner of 

Their Removal — Dr. Tom A. Williams, Washington, D. C. 

9. Anemia: Report of a Case Treated by Transfusions— Dr. K. C. Moore, 

Wilson, N. C. 

10. Arterial Tension and Its Clinical Manifestations— Dr. Chas. H; Pette, 

Warrenton, N. C. 

11. The Significance of Abnormal Blood Pressure — Dr. J. T. J. Battle, 

Greensboro, N. C. 



XXVIU NORTH CAROLINA MEDICAL SOCIETY 

12. Some Facts, Old and New, Concerning the Pulse and Heart — Dr. Hubert 

B. Haywood. Raleigh, N, C. 

13. Toxic Arthralgia, with the Teeth, Tonsils and Stomach as Etiologic 

Factors — Dr. O. Edwin Finch, Apex, N. C. 

14. Symptomatology of Typhoid Fever — Dr, P. E. Hardee, Stem, N. C. 

15. Eventration of the Diaphragm — Dr. Wm. Allan, Charlotte, N. C. 

16. Report of a Headache Cured — ^Dr. John H. Tucker, Charlotte, N, C. 

17. Syringomyelia, with Report of a Typical Case — Drs. J. P. Munroe and 

A. A. Barron, Charlotte, N. C. 

Thursday^ April 22, 9 a. m. 
FIRST FLOOR, MASONIC TEMPLE 

Section on Chemistry^ Materia Medica and Therapeutia 
Dr. Chas. S. Mangum, Chairman, Chapel Hill, N, C. 

1. Food Values from the Standpoint of the Vitamine Content — Prof. W. A. 

Withers Department of Chemistry, North Carolina State College, 
Raleigh,' N. C. 

2. The Problem of Food Values — Dr. W. P. Horton. North Wilkesboro, N. C. 

3. Different Forms of Food Adulteration — ^Mr. W. M. Allen, Food and Oil 

Chemist, State Department of Agriculture, Raleigh, N. C. 

4. The Chemistry of the Blood in Nephritis — Dr. W. M. Copridge, Durham, 

N. C. 

5. Treatment of Amoebic Infections — Dr. Wm. Allan, Charlotte, N. C. 

6. The Modem Therapeutic Value of Digitalis — 'Dr. Jos. A. Speed, Durham, 

N. C. 

7. X-ray and Radium Treatment of Skin Affections — Dr. W. D. James, 

Hamlet, N. C. 

Section on xinatomy. Physiology, Pathology and Bacteriology 
Dr. H. P. Barrett, Chairman, Charlotte, N. C. 

Illness prevented Dr. Barrett from taking care of the program for his 
section. 



section meetings xxix 

Tuesday^ April 20, 11 a. m. 

THIRD FLOOR, MASONIC TEMPLE 

Section on Surgery 

Dr. E. B. Glenn, Chairman, Asheville, N. C. 
(This section must be finished by the close of the Tuesday afternoon 
session), 

1. Acute Pancreatis, Suggesting Acute Intestinal Obstruction — Dr. E. B. 

Glenn, Asheville, N. C. 

2. Saving Suppurating Wounds — ^Dr. H. A. Royster, Raleigh, N. C. 

3. Goiter: Observations Drawn from 216 Cases (lantern slides) — Dr. Ad- 

dison G.. Bemizer, Charlotte, N. C. 

4. Imbrication Operation for Inguinal Hernia; 200 Cases Operated; Steps 

in Operation (lantern slides) — Dr. J. T. Burrus, High Point, N. C. 

5. Some Difficulties in Gall-Bladder Surgery — Dr. J. W. Tankersley, Greens- 

boro, N. C. 

6. Prostate Toxemia — Dr. Albert D. Parrott, Kinston, N. C. 

7. Management of Carcinoma of the Stomach — Dr. T. M. West, Fayette- 

ville, N. C. 

8. The Treatment of Infected Bone Cavities — Drs. D. W. and Ernest Bul- 

lock, Wilmington, N. C. 

9. Closure of the Abdominal Wall — Dr. Henry F. Long, Statesville, N. C. 

10. Hypertrophic Stenosis of the Pylorus — Dr. E. T. Dickinson, Wilson, 

N. C. 

11. The End Results of 100 Cases of Cancer of Uterus — Dr. J. A. Williams, 

Greensboro, N. C. 

12. Subphrenic Abscess — Dr. G. W. Pressley, Charlotte, N. C. 

13. Ascariasis as a Surgical Complication — Dr. Henry Norris, Rutherford- 
ton, N. C. 

14. The Surgeon and Roentgenology (lantern slides) — Dr. Robert H. Laf- 

ferty, Charlotte, N. C. 

15. A Troublesome Complication of Gonorrhea, Its Treatment — Dr. Hamil- 

ton W. McKay, Charlotte, N. C. 

16. Treatment of Skull Injuries by the Ordinary Surgeon— Dr. C. M. Strong, 

Charlotte, N. C. 

17. Flat Feet— Dr. Alonzo Myers, Charlotte, N. C. 

18. Drainage — Dr. W. O. Spencer, Winston-Salem, N. C. 

Thesday, April 20, 2:30 p. m. 
THIRD FLOOR, MASONIC TEMPLE 

Section on Surgery 
(Continuing) 



FOREWORD 

At the last session of the Medical Society of the State of North Carolina 
at Charlotte, April 20-22, it was understood that Dr. Hays would return 
to the State and take up his work here, including the Secretaryship of this 
Society, within the two weeks following the meeting. Instead, however, 
Dr. Hays took up work with the United States Public Health Service and 
has not as yet returned to the State. Therefore, it became my duty to 
continue the work as Acting Secretary-Treasurer and I am responsible for 
this volume of the Transactions. The diflficultics in getting out this volume 
have been many and we crave your indulgence for any errors or omissions. 

Respectfully yours, 

L. B. McBrayer, 
Acting Secretary-Treasurer. 



TRANSACTIONS 

of the 

Sixty-Seventh Annual Session of the 

Medical Society of the State of 

North Carolina 



OPENING EXERCISES 
Tuesday Morning, April 20, 1920.. 
Meeting called to order by Dr. J. B. Witherspoon, Chairman of Com- 
mittee of Arrangements, Charlotte, N. C. On the platform were seated 
all the Ex-Presidents and Guests of Honor. 

"It is my privilege and pleasure to call together the 67th Annual Meet- 
ing of the Medical Society of North Carolina. It is fit and proper that we 
should first ha^'e the Divine Blessing " 

INVOCATION 
Dr. Bunyan McLeod, Westminister Presbyterian Church 

Charlotte : 

"Almighty God who has phmted the day star in the heavens and scattered 
the night, restored unto us this morning thy heavenly light, ail things make 
us think of Thee. The radiant sunshine, the rapture of the birds, and above 
all the thrill that comes into our souls from far off days. Lift upon us thy 
light that we may see light, lighten every doubt and fear, lighten every cross 
and care, lighten every path and duty. We pray that Thou wilt bless this 
Medical Society and every physician that is identified with same. 

We offer thanks for the splendid service they render in ministering at 
our bed side, in relieving pain, in restoring back to health and strength those 
that have been at the bed-side of death. We would think now of the doc- 
trine that will never be forgotten in our minds ; serving, toiling, sayings and 
doings in the old country, and better still is impressed our God who is keep- 
ing his reward for such men. May every phj'sician here feel that the mem- 
ory and gratitude to those to whom they minister is far greater than they 
could ever anticipate. We welcome these men and pray that God will give 
them great deliberation. 

We ask this in the name of Him who came in this world not to be min- 
istered unto but to minister. Amen. 

WELCOME TO THE CITY OF CHARLOTTE 
Hon. F. R. McNinch, Mayor, Charlotte, N. C. 
Mr. President and Gentlemen of the N. C. Medical Association : 

It's a very sincere pleasure to welcome you on behalf of the people > : 
Charlotte to our city. Charlotte regards it as a distinct honor that your 
noble profession should have selected this place as the place of your gather- 
ing. We arje always glad to have meet with us any splendid body of men 
but there is a peculiar pleasure and honor to have meet within our gates 
the Medical Profession oi North Carolina. 



I NORTH CAROLINA MEDICAL SOCIETY 

1 believe I am perfectly sincere when I say that I regard your profession 
as the one that has contributed more greatly to the condition of mankind 
and to relieving of conditions that tend towards suffering and distress, than 
any other secular organization. Applause. 

It has been my good fortune to get a closer view of the Medical profes- 
sion localU'. It is a pleasure for me to testify to the devotion of the local 
physicians, to the cause 'A public good. I know of no class of men who have 
devoted themselves more to the community's good than the local physicians. 
Applause. 

1 recall very vividly the distressing times here during the two epidemics 
of Flu, particularly the first. To me it was amazing that human beings 
could so devote themselves to the relieving of sufiEering. Night and day 
many of them devested themselves in a perfectly beautiful manner to the re- 
lieving of suffering in their community. Charlotte shall never cease to be 
grateful or cease to acknowledge its gratitude to the Medical Profession. 
We remember, of course, the grand work done by our profession during 
that great war. Many lives were snatched from the very border land of 
the other world by the skill and devotion of your profession. 

Your highest endeavor and your greatest zeal and energy is directed to-, 
wards efforts that would seem at least, to tend towards making your pro- 
fession useful. I refer to preventative medicines. Marvelous things have 
been accomplished in the last ten years by your profession. Every time one 
has a prevention for contraction of a disease, there is one patient less for 
the doctors. 

The greatest part of your accomplishment in my judgment has been along 
the lines of preventative medicines. We not only appreciate the result, but 
we appreciate the motive which would prompt a body of men to set them- 
selves about for the discovery and removal of a cause which would take away 
from their practice. I believe that the highest mark of your profession, is 
not treating the disease, but it is in discovering and telling people in advance 
how they may escape that disease. That physician in that community who 
best serves his people, he is the most useful citizen in the community, save 
the Minister of the Gospel. I believe that the physician ought to, and I know 
that ihey do here, believe in the advancement of the community in medi- 
cine—in the teaching of the public A. B. and C. of health, in order that 
they may avoid the contraction of diseases. 

In Charlotte we have taken some interest recently in Public Health work. 
I don't desire to reflect anything on the past administration — all of us do 
the best we can. Charlotte has made an effort to build up a public health 
department, and I believe we now have a very efficient health department. 
This is due to your profession, the things it has discovered and imparted to 
the public. We are very grateful to you — therefore it is our honor in having 
you with us this morning. I may no longer truthfully welcome you to the 
largest city in North Carolina — may I not without undue modesty suggest 
that the little bit lacking in number is more than made up in quality. It 
has been three or four months since the census was taken and we are cer- 
tain since that time we have grown more. 

We hope your stay here will be pleasant and profitable to you, as we are 
perfectly certain it will be both to us. 



OPEXIXG EXERCISES i 

WELCOME TO MECKLENBURG COUNTY 
Hon. Cameron Morrison, Charlotte, N .C. 

On behalf of the largest County in North Carolina — Mecklenburg- 
rich in historic interest; rich in all material things; progressive in every as- 
pect of North Carolina life, I w^elcome you to the County of Mecklenburg. 

I hope that you will enjoy your stay in our city and I am sure you could 
not come among a people where the Doctor is more loved than in the in- 
telligent county of Mecklenburg. A great many of our people love the 
Ministers; not quite as they should, but all the people of Mecklenburg 
County, Saint and Sinner, love the Doctor. You have more friends than 
any other like number of men who live in our commonwealth. You have 
more friends than any other like number of men, because you have minis- 
tered to more men in trouble and distress than any other like number of men 
in North Carolina, and it is with pride and pleasure that I welcome you to 
our county and assure you that all we have is at your disposal. 

This done, I want you to let me trespass for a moment to congratulate 
you upon one of the many opportunities which you have to serve humanity 
and North Carolina. It is for your profession to say whether or not the 
people of North Carolina should be protected in the future by having all 
the knowledge of preventative medicines which this enlightened age carries 
through you, thrown around the home-life of the State. In this important 
aspect of our future the Physicians of North Carolina are the Statesmen of 
North Carolina and there is no greater duty before North Carolina in the 
future than to see to it that all the knowledge of preventative medicine 
which an enlightened world possesses is thrown around the home life of 
the people of this State. This duty is the highest duty of Statesmenship and 
■. et it cannot be performed except under your guidance, advice and direc- 
tion. Applause. 

Of .'ill the fools I come in contact with, and they are numerous, of course, 
who aggravate me. it is the ignoramus who wants to tell the Doctors of 
North Carolina how to protect health and life in the State. We want the 
government in North Carolina, which holds itself absolutely subservient to 
the advice and skill and wisdom of your great profession. We must have 
the best possible Health Administration in North Carolina and in every 
community in North Carolina, and the Doctors must organize and guide 
the people to see to it that fewer people are sick and suffer and die in North 
Carolina in the future than in the past. 

We have the reactionary and ignorant ones to deal with, but under the 
influence of your profession North Carolina can be blessed by having thrown 
around the life of every man, woman and child in North Carolina all the 
knowledge of the preventative medicine which your great profession has 
worked out for the happiness and protection of humanit\\ The people of 
Mecklenburg County recognize your profession as the greatest servant of 
humanity, save the man of God. Nearly every preacher is a man of God. 
I nevei saw a Doctor in my life who was not a gentleman. I have seen 
some that had some sins alright, you know they are not all sanctified. I 
never saw many w^ho were not gentlemen, at least in a practical sense, a 
Christian. The influence of the Doctors in North Carolina, is next to that 



4 NORTH CAROLINA MEDICAL SOCIETY 

of the Ministers, and all, the people of Mecklenburg County and North 
Carolina are not unmindful of your courageous lives. I can conceive of a 
man in the battle-field with the music cheering him on, standing in the 
midst of thousands, with all the world and ages to come looking on, but 
when I think of a student of medicine or a Doctor off in the laboratory, in 
the sick-room, in the midst of disease and death battling with these myster- 
ious germs, every day living in the midst of death and danger, I believe you 
are braver than any soldier on the battle field. 

We never think of anything killing a doctor. We forget "I am scared of 
germs." The doctor goes from one room of germs to another as fast as 
his poor tired body can carry him for humanity's sake every day of his life. 
I believe that as the world becomes enlightened; as education is spread 
among the people, they are appreciative of these great enlightened scientific 
men who worked out and discovered the mysteries to protect the human life 
from suffering ; these men are becoming appreciative more and more as time 
goes on. 

We may think of the Imperial German — Wilhelm — the greatest one of 
misery and warfare, Napoleon the mighty, Foch the recent hero and mili- 
tary savior of i-he world are both appreciated but the day will come when 
Pasteur, the silent student, who worked in the mysteries of chemistry has 
already saved more human lives than these two men ever destroyed, their 
work is ended, but the work of Pasteur will go, on, saving and protecting 
life, until God winds it all up. 

In the future it will be appreciated more by the masses, because the 
masses will become more intelligent. I want to urge ever}- Doctor who 
hears me to make himself a leader in his community, an organizer in his 
community so that North Carolina and every community in it shall cease 
the picaunish policy and disregard to the expenditure of money for the pro- 
tection of life and health of the people of North Carolina. We alone can 
do this. I congratulate you upon the great opportunity which you have to 
render this service to the community. We want an Administration in 
North Carolina that recognizes that the protection of health of our people 
is the highest type of politics and Statesmanship. I hope if it is ever my 
good fortune to be Governor of North Carolina (Applause) that the Doc 
tors before me in this State will consider me their servant and their agent, 
as well as their instrument — that I may win the proud title in the history 
of North Carolina — The Health Governor of North Carolina. 

WELCOME FROM MECKLENBURG COUNTY MEDICAL 

SOCIETY 

Dr. C. M. Strong, Pres., Charlotte, N. C. 
Members of the North Carolina Medical Society, Ladies and Gentlemen : 

The tide of time with its ebb and flow has brought the medicine men 
of North Carolina to our city again. Eleven years ago we had the honor of 
having you with us, since then the personnel has changed, many new faces 
greet us with the blooming hopefulness of the future and also many of the 
old guard are missing, and many here are going down the hill. Hence oc- 
casions like this bring mingled feelings of gladness and sorrow, but we are 
always to remember that the sweets of life are tinged with the wormwood 



OPENING EXERCISES J 

and the gall and however perfect the day, though its sunset radiates a beauty 
not of earth, is followed by the dark. 

All over North Carolina today there is medical darkness on account of 
your absence from home while here we are basking in the effulgency of an 
"Esculapian Sun." We congratulate ourselves on having you medical men 
with us also your clientele at home, they will have a chance to get well, a 
rest from ills and pills and doctor's bills, what doctors are made of. Then 
you doctors will, for a short time, get away from coughs and moans, aches 
and groans and all such things that patients are made of. And again you 
have a chance to get off your accumulated jokes and rich and rare are the 
jokes of the old doctor. A doctor's jokes always goes for he usually sees into 
and hears everything at the drug store or country store and blacksmith shop 
or, as they are latterly called garages and smaller the shop the larger the 
sign like some doctors I know. 

Don't fail to tell how many cases of flu pneumonia you had without a 
single death and this does not mean that you will not have a "pleural death." 
How many young Americans you have ushered into this Bolshevic world in 
one night, ten miles apart. How many appendix and tonsils removed which 
were not diseased. What make of a Ford car you are driving, what specialty^ 
you are going into and city to locate in. Don't forget Charlotte. We have 
a few vacancies left and are inventing new specialties every day. Talk at 
length of the high cost of living and how you are going to meet it charg- 
ing the same old fees. By the way have you ordered your overalls, they are 
going up every day and will soon be too high to buy. Order now — perhaps 
you can get a pair by the first of October, not up to specifications perhaps 
and may be striped instead of blue and you must make a deposit of $25.00 
down the balance can be paid monthly through the Morris Plan bank. How 
you are going to take a rest every year and never do it because Mrs. Smith 
is expecting, and you wear yourself out and soon your meeting days are 
over. 

From the Sand Dunes of the Atlantic, up to the Fertile Lowland, the 
industrial Piedmont and the Land of the Sky you come, like the Moham- 
medan to his Mecca's Shrine for inspiration or the Hindu to the Sacred 
Ganges to wash his sins away. Where will you find a greater inspiration 
than at a meeting of the North Carolina Medical Society or where will you 
tmd purer water than the sacred Catawba, brewed as it is in natures 
Grand Distillery of the Blue Ridge. However, it has been known to be 
contaminated with a little corn. Some of the older members can recall that 
at a former meeting of this society it was all corn. If, therefore, you find 
a single grain in it now please hand it to the Historian as it is more valuable 
than the diamond. 

As President of the Mecklenburg County Medical Society, of which we 
are justly proud, none better and few equal, we bid you welcome, ask 
you to visit our five hospitals overflowing with patients and impatience, our 
Mayonett Clinics of which we have a few and thus is the trend of medi- 
cine. Our Medical Library full of lore and dust — in fact everything medical 
except our patients and only talk to them of the weather, as they have some 
medical secrets about us doctors which we do not care to have divulged. 
Besides they think a visiting doctor knows more than a local one, a pity 
ris often true, and we want to avoid anv focal infections. 



b NORTH CAROLINA MEDICAL SOCIETY 

As North Carolina doctors we welcome you Fellow North Carolinians 
and all others wherever you are from, also especially our Suffragette Allies. 
Would here say if there is anything characteristic of North Carolinians 
it is their individualism you have to show him, not once like the Missou- 
rian, but many times and besides we have no big cities to hog it over us 
but many good towns. Therefore our doctors are all city and country 
doctors and are on an equality hence our coming together is more like a 
big family reunion. And at this great family reunion of Tar Heel Doc- 
tors throw off all reserve, sit around old Mother Mecklenburg's Big fire- 
place, smoke plug tobacco and cob pipe, expectorate in the fire, tell all the 
yarns you want, drink a little of the corn, if you can find it and no Pa- 
triotic Tar Heel will drink any other kind, speak out in meeting with 
no one to molest or make you afraid. After you have received your in- 
spiration and your medical sins are washed away may you leave here invig- 
orated in body and mind. 

Would conclude with the admonition and blessing of the sweet singer of 
Israel of the long ago ; when he touched his harp's strings and sang his first 
song and said: 

"How blessed and happy is the man 

Who walketh not astray 

In paths of ungodly men 

Nor stands in sinners way 

You shall be like a tree 

Set by the river's side 

Whose leaves and fruit 

Shall ever green abide 

And all you do shall prosper well. 

The wicked are not so 

But like chaff" before the wind 

Are driven to and fro 

And may goodness and mercy all your life 

Always follow thee 

And in "God's House" forever more 

Your dwelling place shall be." 

RESPONSE 
Dr. Thompson Eraser, Asheville, N. C. 

"It is nice to be told that we are welcome, even though we feel that 
we are, but it is especially nice to be welcomed to Charlotte. I feel that 
our stay here will be profitable to us all. I think these medical meetings 
are always a sort of inspiration. 

"I think we have an opportunity to absorb some of what we may call the 
Charlotte spirit, the spirit which has made Charlotte the Queen City of 
the Carolinas. She stands before us as an object lesson, civic pride and 100 
percent American. I don't need to tell you that Charlotte leads all Amer- 
ica as the Textile Center, as second Auto, center in the South, and is fast 
pushing Atlanta for its place. I am told that its Hospital accommodation 
has increased one thousand percent in the last 15 years. We know that it 
is the spirit and energy of Charlotte physicians that has made its Board 



OPENING EXERCISES / 

of Health what it is. I think you will agree with me that we have an op- 
portunity to profit by what we have seen and to carry back some of these 
ideas to our home towns. It is a great pleasure to be with you, and in be- 
half of the North Carolina Medical Association, I wish to thank the speak- 
ers for the courtesy of inviting us here and for their hospitality during our 
stay here." 

MEDICAL LEGISLATION 
ANNUAL ADDRESS OF THE PRESIDENT 
' C. V. Reynolds, M. D., Asheville, N. C. 

INTRODUCTION 

In appearing before you this morning as President of the Medical Society 
of the State of North Carolina, and before reading the message, please let 
me say that it is with inestimable appreciation that I serve as your presiding 
officer and the honor is deemed the greater in that it is the highest that the 
State has to offer. 

We trust that you are pleased with the scientific program and just here 
allow me to express publicly my personal thanks to Dr. L. B. McBrayer 
for his wise council, and persistent effort in our behalf. It is largely due to 
him, and the chairman of the various sections, that we have such an inter- 
esting program. 

In searching for a subject to present to you, I could find nothing of un- 
usual interest in my possession, so it occurred to me that an economic prob- 
lem of such vast importance to the Medical Profession as "Medical Legis- 
lation" would be timely, appropriate and, I trust, interesting. 

Problem 

Rate Per 

Typhoid fever caused 10.113 deaths in 1917 13.4 100,000 

Malaria fever caused 2,387 deaths in 1917 3.2 100,000 

Diph. Croup caused 12,453 deaths in 1917 16.5 100,000 

Pneumonia caused 12,821 deaths in 1917 149.8 100,000 

Diarrhea (under 2 yrs.) caused 48,231 deaths in 1917 64.0 100,000 

186,005 

Tuberculosis caused 110,203 deaths in 1917 146.4 100,000 

Cancer caused 61,429 deaths in 1917 81.6 100,000 

Infants (under 1 yr.) caused__ 17 1,204 — 20% of deaths under 5 vrs. of age. 



342,656 deaths in 1917. 
Injuries at birth 3.2 in 1910— but 4.6 in 1917. 
Premature births increase 17.5 in 1910 to 21.1 in 1917. 
What is the cause? It certainly is food for thought. 

There were in hospitals for the insane and blind 55,435 due to syphilis and 
gonorrhea. 

There were 292,519 deaths from diseases for which gonorrhea and syphilis 
were greatly resp>onsible. 



6 NORTH CAROLINA MEDICAL SOCIETY 

There were 1,068,932 deaths in the registration area in 1917- — one-half of 

which are preventable. 
Then maj^ 1 ask in the beginning — have we a problem ? 

With this situation before us — ^with the recent evidence that 35% of our 
prime manhood physically defective, with the general citizen of our country 
enthusiastically crying for a general re-adjustment, do you think for one 
moment that the real and fundamental secret to the success of human en- 
deavor will, or should be, overlooked? 

Medicine, as an applied science, has through individual, rather than a 
collective effort, made marvelous advances through her various avenues of 
research ; this reward of merit through individual attainment should not be 
lost. 

Then it behooves us for the sake of self preservation, if not for the higher 
motive, the preservation of humanity, to have a Strong committee to watch, 
plan and outline, for those who are endeavoring to pass Medical Legisla- 
tion, that we may guide their efforts in the proper way. Never before did 
we need, as we do now, intelligent leadership. 

THE DOCTOR 

The Doctor — "God bless him" — for the people have never paid him, he 
has worked harder, longer, suffered more, endured more, and received less 
than any other professional man. But this sacrifice has been made in a field 
of curative medicine — useful, but growing less important as preventative 
measures develop. 

No w^ords of appreciation can begin to give justifiable praise to the 
doctor, for his willingness to serve humanity, his forgetfulness of self, and 
his duty to his family, when facing the rain, the snow, the hail, the wind and 
the heat- — no road too long, no hill too steep, no phobia of contagion too 
great to prevent his rendering a service to his fellowman. For remunera- 
tion ? — yes — but his altruism is, and, I hope, will ever be unquestioned. 

Yet, may I ask, have we not neglected our greatest asset to man in await- 
ing his call for aid and then attempting a cure, rather than anticipating hi> 
ills and preventing his calls. We advise how to (/et well where we should 
advise how to keep well. 

We are constantly discussing our problems, making known our mistakes, 
as well as our accomplishments; we have forged ahead and have done much, 
yet we know and the public knows that with our present method we arc 
not by one-half, doing what could be done. 

Through various agencies, we can do most effective work in preventing 
one-half of the present injuries and illnesses. The trend of the public mind 
(let this mind be in the control of the philanthropist, the socialist, the re- 
publican, the democrat, the mugwamp, the braying mule or the politi- 
cian) is toward some type of socialistic medicine. Our apathy, indifference, 
or our somnolence toward the passing of Workman's Compensation laws 
has caused us, as well as those whom it was intended to serve, to be led mto 
\insound, unprofitable, and poorly administrated medical practices. 



OPEXINX, EXERCISES 9 

Experience has taught us something and we should awaken, ere it is too 
late, and realize that certain fundamental changes are to be made, and that 
this is necessarj' to society, before we are embarrassed by having our duties 
poorly done by incompetents. 

Our already accumulated knowledge, if awakened and put into active 
service, can reduce sickness and accident one-half. The philanthropists, 
the politicians and the people at large have this interesting knowledge — 
made possible for them by us, and given to them by our press. Do you 
think for one moment that they are going to sit idly by and see this vast 
waste of human life ? 

Our individual problems may cause us to sit idly by, forgetful of, or, 
with indifference to, the greater problems of the community, the state, or 
tjie United States health program and we will suffer the consequences of 
the inactive, thoughtless, indifferent citizen, and suffer in consequence of 
our inactiveness. 

The physician is still an individual, and deals with his patient as an in- 
dividual, failing to recognize that community interest must and should be 
conserved, even at a loss to the individual for the good of many. 

The doctor is not mercenary — neither is he pessimistic — nor would I 
call him an optimist. He is schooled and trained to think for the preser- 
vation of human life, for the betterment of the physical being, realizing 
that health is the foundation of happiness, prosperity, and independence, 
and that sickness leads to inefficiency, which produces misery, poverity, de- 
gradation, crime and vice. 

In colonial days, under pioneer conditions, the first requirements in es- 
tablishing a village, it matters not how small, was the erection of a church, 
a school house, and the securing of a physician — those were the recognized 
essentials for the development and. care of the moral, mental and physical 
well being. 

From the smal) church, the little red school house and the willing physi- 
cian, there has grown the glorious cathedral, the advanced facilities for ed- 
ucational purposes in our public and private schocjs, and state universities — 
the modern phvsician, fresh from colleges of highest advantages, the exper- 
ienced surgeon, clinician and bacteriologist. 

Vast and wonderful opportunities are most universally offered, yet col- 
lectively we have not prospered and made what we should out of our op- 
portunities. 

In the war census there was found one-fourth illiterate — an utterly in- 
adequate number of skilled mechanics and technicians, and one-third of our 
young manhood physically unfit. 

Of late we have come to realize many of our short comings and is it not 
high time for us to set about to prevent the preventable, to correct the cor- 
rectable and to cure the curable? 

This is an age of reconstruction, and a readjustment of conditions there 
will and must be. This, it seems, is the time, and the tide is growing 
stronger day by day. As time and tide wait for no man, it behooves us to 
■itep in and guide or mold our future before some well meaning philanthro- 
pist guides or molds it for us. 



10 NORTH CAROLINA MEDICAL SOCIETY 

There are numerous ways and not many definite plans already proposed, 
and many more will be forth coming — none of which will please us all. 

Then the first step in the solution of such a vital question is to select a 
special committee to analyze the various suggestions and pick out the fun- 
damental element — this committee working in conjunction with a similar 
committee from the American Medical Association, the Public Health As- 
sociation, the State Board of Health, and the Southern Medical Associa- 
tion, to report back to this Society their conclusions for ratification, the 
adopting of which should and I believe would bring about a co-operative 
effort to work for a common objective. 

INSURANCE 

When industries were small and the employer did his daily work with 
the employee, and w^as the guiding brain, there was a friendly bond be- 
tween the two — strife, jealousy and the feeling of the general in-equality i^f 
it all was forgotten through this relationship. 

As industry has grown, machinery has become the guiding brain of the 
former employer, and the personal equation has disappeared. The employee 
began to realize that he was an integral part of the industrial machinery, 
and that to the injured or those suffering from illness, the employer should 
make reparation just as he did in any damage done to the mechanical de- 
vices. 

The employer removed from this personal equation did not so consider it. 
Common la\\- was appealed to by the employee— more justice was not re- 
ceived, so in recent years the barriers protecting the employer were broken 
down, when the European conception was adopted — replacing the common 
law system by a law, based "not on fault, but on the fact of injury resulting 
from accident in the course of employment." 

The method adopted was insurance by many for the benefit of the in- 
jured. 

There are various forms of insurance adopted; the lodge insurance, fra- 
ternal insurance, social insurance, Vol. Compulsary Accident and Sickness 
Insurance, Mutual Insurance, State Insurance, Workman's Compensation 
laws, etc., all of which have their advocates and their bitter opponents. 
This kind of self perservation on the part of the employer and employee is 
taking on vast proportions in this country, and it means a new conception 
of law and order regarding the proper placing of the responsibility of the 
ill and injured. This new social and economic condition that is upon us, 
and growing in vast proportions daily, is of serious moment, especially to 
the Medical profession. The present lodge and contract practice has re- 
ceived a well deserved censure from us, and has merited a greater condem- 
nation than it has received at our hands. 

The form of insurance in about one-half of the large countries in Europe 
is Compulsory sickness insurance, adopted in Germanv in 1884, Austria, 
1887, Report" AMA Hungary, 1891, Norway, 1894, Finland 1895, G. B. 
1807, Italy and France 1898, Spain 1900. 

U. S. for Federal employees only 1908. About 26 states of the American 
union 1911-1913. 



OPENING EXERCISES 



11 



ARGUMENTS 



FOR INSURANCE 

Real or imaginary conditions in 
the U. S. have caused many welfare 
and social refonners to organize the 
American Association for Health In- 
surance evolved from this Associa- 
tion as the best method for social 
betterment. 

Practically every one who has con- 
sidered the matter, recognizes that 
the distribution of the loss from 
sickness by means of insurance is 
desirable. 

Compulsory Insurance is necessary 
because under voluntary insurance 
those who need it most are the ones 
who remain uninsured (lack of 
funds). 

Compulsory insurance will stimu- 
late the needed campaign for the 
prevention of illness. 

Life expectancy increases in C. 
.between the ages of 18-60 (12 
years). 

Reduce the time lost by the wage 
earner. 

Malingering would be negligable 
in Comp. Ins. 

Disease cause of poverty. 

Will solace the abuse of Medical 
Charity. Individual will receive less, 
but the physician as a whole will re- 
ceive more per capita (AMA). 

AGAINST INSURANCE 

Social evils do exist and some 
remedy or remedies should be sought, 
but while organized labor, the em- 



ployer and the employed and the 
physician are opposed and the ones 
most vitally interested are opposed 
to compulsory insurance. Why is it 
best ? 

No new health insurance legisla- 
tion should be enacted before we en- 
tirely rectify the unfairness of the 
present comnensation law. 

The present system whereby the 
poor are treated by the most effi- 
cient medical men is far better than 
medical service furnished by physi- 
cians which H. Ins. obtains. 

Untrue — the State bemg already 
taxed through sickness, insurance 
would not be available. 

M. M. Dawson says that this is 
not true — the increase was only 1.6 
years have non-insured countries a 
bstter showing. 

This assertion contradicted by ex- 
perience. Germany and Austria 6-19 
to 9-19, increase A-16.4 increase. 

In G. malingering and pension 
hysteria has become a regular epi- 
demic. 

Poverty cause of disease. 

Will extend Medical charity abuse 
— ^unemployed casually employed. 
Self-employed — ^poorly paid in insur- 
ance act. 

Decrease medical efficiency. De- 
stroys incentive for medical research 
and individual effort. Competent and 
incompetent get same pay. Destroys 
personal relationship between patient 
and M. D. 



To lessen human waste through preventable accidents, occupational dis- 
ease, in fact, every preventable that will prevent, is an economical essential 
to material busmess, as it is to the human agents that guide it. 

Notwithstanding the various pros and cons — we have under the old 
scheme 38,000,000 employed in the U. S. and of these 1,385,856 are ill at 
any given time — estimating nine days individual loss, gives a grand total 
of 12,022,104 sick days in the year. 

Now one-half of these illnesses are preventable. To say nothing of 
greater and accumulative loss due to a lessened future earning power on 
account of illness and the sequel of such illness. It is not an economic 
waste to allow it to proceed. 

The monetary loss, and the number of sick are important factors and the 
State — the employer and the employees are beginning to consider them. as 



12 NORTH CAROLINA MEDICAL SOCIETY 

Serious problems to be reckoned with. They now realize that the length 
of illness and the amount of medical aid is not the object sought, but rather 
the complete restoration of the individual to useful citizenship, which ele- 
vates the common standard of American physical fitness. Adequate care, 
not based on time or money, will be, and should be, insisted upon. 

Anything and everything that tends towards raising the general health 
standards through preventive or curative measures should deserve serious 
consideration, but our ambition to better conditions should not force any- 
thing upon us hastily. Wise and judicious council should be sought, prompt 
action should be taken, lest we inherit the avoidable mistake of others. 

The Insurance acts in the foreign countries and in this country are most 
ambitious in an effort to raise the physical standard of a certain class of 
laborers — an immense piece of P. H. legislation, based upon certain princi- 
ples of Democracy for the benefit of all the people, acceptable by the people, 
and for the best interest of the people, the State, the employer and the em- 
ployee, each realizing their relative responsibility, will pay a percentage of 
the cost, thus distributing the expense. 

Under insurance, the annual death rates have been lower in infancy, and 
between the ages of 5 to 19. Between the ages of 20 to 39 not steady — 
17.7 to 16. Between the ages of 40 to 59 there is a decided increase, 17.6 
to 20.8. 

If the insurance act will lessen morbidity, mortality and poverty, it will 
increase health, happiness, efficiency and prosperity of the insured. Then 
by all means, let's have it, but we must remember that the fundamental 
factor lies in the intelligence and the integrity of the Medical profession, 
and its ability to administer intelligently, adequately and honestly. 

There are many objectionable and serious handicaps to the successful ad- 
ministration of Health Insurance as handled in the old country, such as low- 
ering the standard of the medical profession — the lack of individual inspir- 
ation to excel, lack of remuneration for services rendered, etc. All of these 
evils should and must be remedied before Health Insurance is endorsed by 
the Medical profession. It is your duty and my duty to guide any legislation, 
either state or national, that is of such vital importance to the people. 

STATE MEDICINE 

The greatest asset -in any state lies in the efficiency of the moral, mental 
and physical development of her womanhood and manhood. 

It is my opinion that health is the basic element of human efficiency, and 
upon it stands or falls the power or perfectedness of the state or nation. The 
state is constantly and without objection, looking after and controlling her 
inferior assets, why then is it not to her greater advantage to seek to raise 
the standard of, and to aid in protecting her greatest asset, the human fam- 
ily. 

There is not a voice raised against the state's efforts towards the preven- 
tion of disease, but there has not been a sufficient effort on the part of the 
physicians in the prevention of disease, nor in their effort to aid the state in 
securing sufficient funds to advance the work, nor pay adequate salaries to 
the doctors for services rendered. When, through the activities of the State 



OPENING EXERCISES 13 

Health Board, there are found to be curables, uncured, operatables, unoper- 
ated upon, defects unremedied, focal infections, still infecting — it is high 
time for some agencj to be set in motion to correct this existing block in her 
progress. 

Again, nothing is said when these curables or operatables are among the 
indigent — the poorest human asset the state possesses, but a storm of indig- 
nation is immediateljf raised when the state begins to protect her great- 
est asset, the better element of society. 

Illness, injury and deformity, the great factors in inefficiency, suffering, 
sorrow, poverty, vice and crime are not limited entirely to the indigent, but 
occur throughout the en\tire population. 

The surgeon, the internist, the pediatrician, the dentist, etc., have had the 
indigent, the ne'er-do-well and the well to do under their professional care 
and guidance for years, and those who sought advice have received much, 
but by a diliEerent scheme of things. We must be willing to admit that a 
great deal more could be accomplished and that through omission rather 
than commission, we have rendered a less efficient service. Some form of re- 
formation will and should be made, and the present scheme of not differen- 
tiating between classes is the best, until we, as Medical men, offer a better 
one and one which will accomplish as much, if not more good. 

The state can handle its charity, assume the entire expense and accom- 
plish much good among her lowest type of citizenship. 

The state, by not differentiating, can reach her greater asset and charge 
a sufficient sum to save her harmless as to expense, and gain much more by 
restoring to health a higher type of citizenship. 

Health work is a stupendous problem and upon its continued reformation, 
depends the preparedness of everything that lives, and the perfectedness of 
everything material. 

The value of the physician's superior knowledge in formulating plans, is 
essential to its development, as well as to its success or failure. Then it is a 
serious question that is confronting us and it behooves us, in fact it is of par- 
amount importance that we should properly estimate its value — realizing 
that it is to our collective as well as our individual advantage to give it care- 
ful consideration. By so doing we will save the dignjity of our profession, 
and not be at the mercy of some poorly prepared political scheme. 

The Crimean war, the Civil, the Spanish American war, all stand out 
with sad histories of having lost more men from bacterial diseases than from 
enemies bullets. Contrast this with our present method of prevention of dis- 
ease, and we are doubly proud of our late victories in that we conquered the 
German and controlled disease. (Controlled the pest and the parasite at 
one great blow. ) 

The preventative measures that have passed the experimental stage, and 
that have proven beyond all question their value, were legally enforced in 
the army. If these measures are so imperative and essential in the army, 
why may I ask, are they not alike imperative in civil life ? 

It has been my pleasure to see compulsory vaccination against variola for 
the past ten years in school children, and it is indeed gratifying to note the 
father, who escaped vaccination, come down with the disease : children, dir- 



14 NORTH CAROLINA MEDICAL SOCIETY 

ectly exposed, escape infection, and again it is gratifying to see those vac- 
cinated against typhoid fever, escape and the stubborn member of the same 
household fall ill, thus proving the efficacy of the immunization. Again, it 
was a very pleasing experience during this year's epidemic of influenza to 
have a school of boys — 140 in number — with not a single case of pneu- 
monia. Contrast this with the same school unvaccinated the year previous, 
with 50 cases of influenza, 5 severe cases of pneumonia. A school of girls — 
130 in number — same prevention — not a single case of pneumonia. 

I am sure such instances could be multiplied by us all, yet at the present 

time immunization is a voluntary proposition and the general practitioner 

'has not immunized his people, nor has he made a strenuous effort. The State 

should be empowered, through legislation, to enforce such highly efficacious 

measures. 

The public health problem is to the casual observer an intangible propo- 
sition, and it may yet be some time before the legislators realize its full im- 
portance, and appreciate the fact that man is its greatest asset when his mor- 
al, mental and physical well being is conserved — and its greatest liability 
when these essentials are neglected. 

Surely the cow, the sheep, the hog are tangible assets, and the loss of one 
is felt by the owner, and effects directly his pocket book. But man has been 
made the legislative goat until his efficiency has been so lessened that it has 
become retro-active, to the extent that the entire man power has awakened 
a new era demanding self perservation, and thereby proclaiming man's effi- 
ciency superior to that of the beasts. 

Public health work is the prevention of disease, the preservation of health 
the prolongation of life, the lessening of morbidity, the lowering of mortali- 
ty — through its laboratories, its field workers, its statisticians — has shown 
through this method of education that a high standard of health can be ob- 
tained. It has also been shown that its conservation has been sorely neg- 
lected. 

Subjects for immunization have remained unimmunized. 
Curables have remained uncured. 
Operatables have remained unoperated upon. 

To relieve this situation, let the physician wake up to his individual re- 
sponsibility and see to it that his clientele comes up to a high standard of 
physical fitness. Should the State, through its laboratories, its field workers, 
its statisticians, ascertain that a member of a physician's clientele has been 
neglected — in that event the state should, and it becomes its duty, to enter 
in and protect its defectives. 

Any one of the State's agents should make every effort to relieve the de- 
fective through the parent, guardian and family. 

A monthly report should be made to the county medical society, which 
should in turn endeavor to meet the situation. This failing, the State 
should take prompt measures for the relief of the sufferer. 

There is a clear and distinct duty the State owes to its citizens who are 
in need of and have not received medical or surgical treatment. This re- 
lief should be given by the best qualified medical and surgical men, who 
should receive adequate remuneration for services rendered. This service 
should be financed through taxation and with disregard to class distinction. 



OPENING EXERCISES 15 

Where the individual physician fails to respond to his greater duty to the 
community at large, his individual and personal relationship as a family ad- 
visor should become a matter for collective action by the community phy- 
sicians; otherwise, this situation should be improved through the State. 

In conclusion, I would suggest for your attention the advisibility : — 

First — the appointing a special committee to prepare a plan for a public 
health administration. 

Second — The committee shall have the power to associate with itself ex- 
perts who are interested in and are well versed in the facts which are fun- 
damental to the success or failure of such a plan. 

Third — That this committee should act in conjunction with the Ameri- 
can Public Health Association, the State Board of Health, the Public 
Health Association, the Southern Medical Association. 

Fourth — That this committee submit a plan on organization — outline its 
administration, and pay especial attention to health supervision and treat- 
ment of school children — the handling of the unimmunized — the curing of 
the curables — the operating upon the operables, etc. 

Fifth — This committee to serve without remuneration, but their actual 
expenses incurred shall be paid by this societ}\ 

SUMMARY 

Finally, I would like to quote from the report of the Special Committee 
of the A. M. A. for 1919, Social Insurance Series, Pamphlet XI: 

"The responsibility, is threefold: communal, industrial and individual. 
But the burden today is almost entirely individual. The community has ac- 
cepted part of its liability and endeavored, by sanitation, preventive medi- 
cine and hospitalization, to improve the situation. Industry has, until now, 
evaded its entire responsibility and liability. The individual still bears the 
brunt of the burden and the cost of sickness as a personal calamity. The 
community and industry have begun to realize and accept their share of the 
liability. We have in the past received from southern and southeastern 
Europe enormous numbers of hardy, vigorous laborers and industrial work- 
ers. We have used them lavishly, and their labor extravagantly. We have 
neither wisely harbored their energy nor salvaged the damaged. We have 
recklessly used this labor as if the supply were unlimited- We have indeed 
treated it as we dealt with our forests and our mines. We have been mining 
out our labor and burning it up. Now the war is over, hundreds of thou- 
sands of these people are returning to their former homes, not to return 
here. This country is facing a scarcity of labor, and must care for it and 
salvage it, w^hen injured, as never before. 

The remedy for this situation lies economically in a redistribution of costs, 
not of adding new costs, but rearranging the present method of expending 
the costs already being expended. Large numbers of wage-earners probably 
a majority of them, now spend each week enough money on funeral insur- 
ance, that they may be sure of a decent burial, which would equal or more 
than equal their share of any just sickness insurance scheme to give them 
'sick benefits, maternity and adequate medical care, and a hundred dollar 
Mineral benefit. Improved medical care must come from more cooperative 



16 NORTH CAROLINA MEDICAL SOCIETY 

and less purely individualistic care from the medical profession. Free 
choice of physician by patient, and present relation of patient to physician, 
and just and assured remuneration for work done by the physician can easi- 
ly be assured to the physicians under an insurance plan. 

Preventive and curative medicine can equally be more fully developed 
with free play for individual development of physicians. The alternatives 
offered by the funeral insurance companies are a further development of 
preventive medicine, state care of the sick by salaried physicians and leaving 
the profits of funeral insurance undisturbed." 

There is a tremendous problem before us, and we, as medical men, realize 
its vast proportions; it does not take a spectacular epidemic of infantile par- 
alysis, not the too recent outbreak of Influenza, to make us appreciate the 
vast waste of human endeavor, due to the constant but less spectacular dis- 
ease. 

The laity are accustomed to and accept as a natural law of nature the us- 
ual number of deaths, one-half of which are preventable. We have trusted 
too much to personal liberity; to the idea that self preservation is the first 
law of Nature. In prevention, it has been my experience that self preser- 
vation is the last law of Nature. 

We inherit, through our profession, the distinction of being the guardians 
of the health of our people, and, it is our duty, and should be our privilege, 
to safeguard it. 

It may not be through Insurance, it may not be through State Medicine : 
it must be a remedial measure that will reach all the people all the time. 

This remedy should and must come from the Medical profession. 

Dr. Parrott: I wish to congratulate Dr. Reynolds on that splendid 
paper and that the Society should also be congratulated. In order that it 
may receive the attention it should I make a motion to appoint the following 
committee — to which the address should be referred to for consideration : 

Dr. Laughinghouse, of Greenville; Dr. Long, of Lexington; Dr. Man- 
ning, of Durham. 



Scientific Papers 



SECTION OX PRACTICE OF MEDICINE 

SECTION ON CHEMISTRY, MATERIA MEDICA AND 
THERAPEUTICS 

SECTION ON SURGERY 

SECTIONv ON GYNECOLOGY AND OBSTETRICS 

SECTION ON EYE, EAR, NOSE AND THROAT 

SECTION ON PEDIATRICS 

SECTION ON PATHOLOGY, PHYSIOLOGY, BAC- 
TERIOLOGY AND ANATOMY 

SECTION ON PUBLIC HEALTH AND EDUCATION 



Practice of Medicine 

REPORT OF TWENTY-FIVE AUTOPSIES ON INFLUENZA 

PNEUMONIA 
James B. Bullitt 

During the Influenza epidemic of 1918 the patients landed from the trans- 
ports quickly filled all the hospitals at Brest. It became necessary to ac- 
commodate the overflow at the unfinished embarkation hospital at Kerhuon, 
three miles away. Base Hospital 65 (a North Carolina unit), with a small 
personnel, with almost no equipment and in uncompleted buildings, cared 
ior about 3500 patients at Kerhuon Hospital Center during October. 

The deaths from pneumonia during that month were something over 600. 
Under the conditions existing it was practicable to perform only 25 autopsies 
lack of time and the shortage of equipment prevented taking bacteriological 
culture and also prevented microscopical study of the tissues at that time. 
During the past few months these tissues have been sectioned and are made 
the basis of this report. For tissue stains hematoxylin and eosin and eosin- 
methylene blue have been used, while the combination of Goodpasture's and 
the Weigert fibrin stain (published by MacCallum) has been used for the 
demonstration of the bacteria in the tissues. Gram positive cocci occurring 
in pairs and in short straight chains are referred to herein as pneumococci. 
Several lungs, which in the gross were suggestive of tuberculosis, were also 
stained with carbol fuchsin. 

The numbers involved are too small to be of much statistical interest, 
especially in view of the many extensive reports of the past month. In 
many respects these cases accord closely with those reported from other hos- 
pitals, but it is desired to call attention to certain points at variance with or 
not touched upon in the findings of other observers. All the cases exhibited 
a broncho-pneumonia or a lobular pneumonia, with a striking tendency to 
confluence. In eight cases this confluence was so great that only the anterior 
borders of the lungs and occasional patches here and there seemed to con- 
tain air. Such portions were of course markedly emphysematous. Seven 
others showed definite lobar consolidation. In four of these the lobular in- 
volvement of the remaining portions of the lungs was conspicuous, while in 
the other three it was scarcely noticeable in the gross, though quite evident 
under the microscope. Only one case was essentially an interstitial pneu- » 
monia. 

Bacteriological study without cultures from either the living patient or the 
autoDsied body is necessarily incomplete and unsatisfactory. But the ex- 
cellence of the Goodpasture — Weigert stain is such as to justify some fairly 
definite conclusions from the bacteria stained in the tissues. Nothing re- 
sembling the influenza bacillus is found in any of these sections. The pneu- 
mococcus, occurring in 24 of the 25 cases, is the predominant organism. The 
streptococcus appears in but three, and in two of these it is much less numer- 
ous than the pneumococcus. The one case in which the streptococcus pre- 
dominates showed complete consolidation of the middle and lower lobes of 
the right lung, with extensive necrosis. The remainder of the right lung 
and the whole of the left lung seemed almost normal in the gross, but mic- 
roscopically there is extensive capillary engorgement with slight hemorrhag-e 



PRACTICE OF MEDICINE J9 

and an extensive but slight interstitial exudate. Both organisms are numer- 
ous in the consolidation portion, both are scarce elsewhere. The streptoc- 
occi are chiefly in the alveolar walls, the pneumococci about equally distri- 
buted in these walls and in the alveolar exudate. In several cases miscel- 
laneous bacteria are found which are doubtless postmortem invaders. In 
nine cases an unidentified bacillus, morphologically much like the colon bac- 
illus but Gram positive, is found. Since these do not appear in the other 
organs thus far studied, since they do not occur in the blood vessels but only 
in the alveolar exudate and since large numbers have been engulfed by the 
leucocytes, it is reasonable to presume that they have played some part in 
the pathology. Unfortunately the inability to make cultures renders iden- 
tification impossible. It is probably a mere coincidence but the only two 
cases in which this organism is more numerous than the pneumococcus are 
the only two in which mediastinal and cutaneous emphysema occurred. The 
one case in which pneumococcui do not occur died after an illness of thirty 
days. His acute symptoms had subsided after about ten days, but a slightly 
elevated temperature, a rapid pulse and some prostration continued. His 
condition was not considered serious until the twenty-eighth day when he 
became dyspnoeic, and cyanotic and sank rapidly. Extensive tough fibrous 
adhesions bound both lungs to the parietes. Both lungs were riddled with 
small cavities and shot through with old scars. Both lower lobes exhibited 
a caseous pneumonia. Fresh exudate consisting of fibrin and endothelial 
leucocytes occurs in all parts, and innumerable tubercle bacilli are found 
everywhere. It is impossible to distinguish accurately between the damage 
done by tuberculosis and that done by the influenza pneumonia. Unless 
influenza had stirred a quiescent tuberculosis processs into enormous activity 
it is hard to understand how this officer had passed the physical examination 
for overseas service only a month before. 

The distribution of bacteria presents points of some interest. None are 
found in the areas of mere engorgement and hemorrhage, few or none where 
the alveoli are filled with hyalin exudate, and few where the exudate consists 
chiefly of endothelial leucocytes, lymphocyes and plasma cells ; though they 
may be abundant in neighboring areas containing polymorphonuclear leu- 
cocytes. When the illness has been of short duration the tissues are teeming 
with the organisms, both free in the exudate and enclosed in the leucocytes. 
The numbers are greatly reduced after a week, and after three weeks they 
are practically limited to pleural exudates and to spots of focal necrosis and 
abscesses. This seems to be true even though there may still be considerable 
areas of what seems to be fresh exudates, both enterstitial and intraveolar. 
The absence of organisms, above referred to, in alveoli containing only blood 
and hyalin material might be explained by the view that these represent out- 
laying zones of toxic absorption, surrounding foci of bacterial accumulation 
and leucocytic exudate. The structural picture in confluent lobular pneu- 
monia would seem to accord with this view. But there are numerous cases 
in which the foci of lobular pneumonia with leucocytic exudate are rather 
widely separated, while all the intervening areas show this tendency to con- 
gestion and hemorrhage. The size of these areas and the relatively sharp 
transition as we approach the leucocytic zone militate against the idea that 
this is merely a part of the lobular pneumonic process. Moreover there is 
often a somewhat extensive necrosis, similar to that described by LeCount, 



20 NORTH CAROLINA MEDICAL SOCIETY 

at considerable distances from the distinct pneumonic foci. It seems legi- 
timate to suspect that we ma)' be upon the track of a primary influential 
pathology. 

A full description of the gross and microscopical picture in this series 
would be in large part a mere repetition of the descriptions given by many 
others. It is desired to call attention merely to certain points of difference. 

Emphasis has been repeatedly laid upon the differences in the inflamma- 
tory reaction dependent upon the complicating organism. A more or less 
definite correspondence appears to have been established for the tissue 
changes in the presence of the pneumococcus, the streptococcus and the in- 
fluenza bacillus respectively. Although nearly all the cases discussed in this 
paper were clearly of pneumococcic etiology, yet the pathological processes 
correspond more closely with those usually associated with the streptococ- 
cus. I epitomize one author's excellent description based upon a large ex- 
perience with these pneumococcus pneumonias. 

1. Pleura smooth; exudate absent or scarcely perceptible, though in late 
cases the microscope may show a leucoytic infiltration. 

2. Bronchi not conspicuous ; empty or containing fluid ; walls not in- 
filtrated; mucosa usually normal. 

3. Blood vessels normal. 

4. Alveoli contain fluid or a delicate fibrin mesh ; they may be lined with 
a hyalin skim ; contain many red blood cells but few leucocytes ; walls nor- 
mal or but slightly infiltrated. 

In contrast with the above the following outline of my cases could almost 
be substituted for the usual description of streptococcus infection. 

1. Fourteen showed extensive fresh fibrinous adhesions binding the lungs 
to the parietes. These include the three that exhibit the streptococcus as 
well as the pneumococcus. Six, including three of the above mentioned 
fourteen, had dense fibrous adhesions. In the gross these appeared to be 
healed lesions of a previous process, but microscopically the richness in cap- 
illaries, fibroblasts and leucocytes indicates that at least four of them are 
of recent origin. Three cases (one pure pneumococcus and two pneumococ- 
cus-streptococcus) had large pus collections in one pleural cavity. Two 
others had from 150 to 200 c.c. of slightly tinged fluid in each pleural 
cavity, while several others had smaller amounts of similar fluid. 

2. In many the large bronchi were intensely inflamed and contained con- 
siderable amounts of muco-purulent material. The smaller bronchi are al- 
most invariably full of polymorphonuclear leucocytes; the epithelium us- 
ually shows much necrosis, and is often entirely lifted from its base by an 
exudate of fibrin and leucocytes. The walls are usually much infiltrated 
with leucocytes — chiefly polymorphonuclears but often endothelial leucocy- 
tes and plasma cells as well. Very frequently the infiltration and necrosjs 
are so marked as to render recognition of the bronchus difficult. 

3. Infiltration of the walls of the small arteries is usual. Thrombosis in 
both arteries and veins is common, and in late cases organization of these 
thrombi is often seen. 

4. The alveolar picture is very variable in different lungs and in differ- 
ent parts of the same lung. Many places show the appearance characteris- 



PRACTICE OF MEDICINE 21 

tic of ordinary lobar pneumonia, i. e., well preserved, essentially normal 
walls, alveolar cavities filled with a delicate fibrin mesh entangling innumer- 
able red blood cells and few or a moderate number of leucocytes. But there 
is scarcely a case in this series that does not show wide areas where the al- 
veolar walls are greatly infiltrated, often completely obscured, sometimes 
by polymorphonuclears, sometimes by endothelial leucocytes and plasma 
cells. The air sacs in such instances are packed with similar cells to which 
are added the exfoliated epithelium. Frequently the fibrin mesh is not ap- 
preciable. In other places a dense hyalin material fills the alveoli, often 
seeming to fuse through the walls rendering them scarcely visible. At times 
this hyalin seems to have Its origin from fibrin, at times from the fusion of 
red blood cells. Both in these hyalin areas and in the areas of intense cel- 
lular infiltration necrosis of the pulmonary framework is common. These 
necroses may involve only one or two alveoli here and there or may extend 
over the greater part of a lobe. Pulmonary abscesses of microscopic size are 
seen in nearly every case, while four showed large numbers of cavities vary- 
ing from one to five centimeters in diameter. In four others without actual 
cavity formation, large areas involving from one-fourth of a lobe to a whole 
lobe were soft, gray and friable, tearing from a touch of the finger. Micro- 
scopically these areas are completely necrotic, the pulmonary framework be- 
ing scarcely recognizable and the whole mass consisting of disintegrating 
cells and granular debris. Bronchiectatic dilatations are common. 

5. Marked tendency to organization is usually regarded as characteris- 
tic of infection with streptococcus or the pheiffer bacillus rather than the 
pneumococcus. In my cases however there is scarcely any one feature more 
striking than the rapid and extensive fibrosis. In every case surviving as 
much as a week this process becomes evident ; in those living three weeks it 
is very prominent. The alveolar walls and intraelveolar exudate, the bron- 
chial w^alls and to a lesser extent the bronchial exudate, the vascular walls 
and thrombi, all are involved. It is not uncommon to find nodules resem- 
bling tubercle or small gummata. Sometimes a thin capsule of newly formed 
connective tissue surrounds a soft granular necratic mass. Sometimes the 
whole nodule has become organized. In some cases large areas of pulmon- 
ary tissue are completely obliterated. In two men living about five weeks 
the condition is particularly interesting. Each of these had entered upon 
apparent convalescence after an acute illness of about ten days. Although 
physical examination showed no especial reason why they should not recover, 
yet they did not regain strength, their pulse rates continued rather high and 
very slight effort produced dyspnoea and cyanosis. One sank gradually 
with a steady increase of the symptoms above described. The other seemed 
to be improving. The night nurse reported him in good condition at 4 A. 
M. He was found dead in bed at 5 A. M. No embolus nor other cause 
for the sudden death could be found. Both cases showed a slight degree of 
chronic myocarditis. There was scarcely any acute patholog}^ remaining in 
the lungs, but the extreme condition of fibrosis left little serviceable pulmo- 
nary- tissue. The picture suggests an analogy to those cases of nephritis in 
which recovery from the acute disease is followed by a fatal crippling from 
the repair processes. 

The presence of large amounts of pigment from distintegrated hemoglobin 
is to be expected in lungs with such extensive hemorrhage. It is uniformly 



22 NORTH CAROLINA MEDICAL SOCIETY 

present in this series, often in such quantities as render difficult the search 
for bacteria in the tissues. Sometimes every endothelial leucocyte is loaded, 
many polymorphonuclears contain goodly amounts, and much is free in the 
exudate. I have been constantly impressed with the large quantity of this 
pigment, not only in the lungs but also in the heart, liver, spleen, kidney 
and other organs. In the kidney it is contained partly by endothelial leu- 
cocytes; but most of it appears in the epithelium to some extent in that of 
Bowman's capsule and the convoluted tubules, but especially in the cells 
lining the ascending tubes of Henle and the collecting tubules. It occurs 
chiefly in the basal portions of these cells. 

As in the epidemic elsewhere necrosis and hemorrhagic inflammation of 
the rectus abdominus muscles was common in our hospital. There were two 
cases among those autopsied. I have not seen mention of, similar myositis 
in other muscles. In one of my cases it occurred in moderate degree in the 
serratus magnus. Severe pain in the right side had caused suspicion of 
empyema. Needle puncture gave negative results. At autopsy the pleura 
was normal, but over a space of two or more inches in diameter the muscle 
was soft and dark in color. Microscopically there is a moderate hyalin 
necrosis, a small amount of hemorrhage and a slight leucocytic infiltration. 
This suggests a possible explanation for the localized pains in the back, sides 
and elsewhere that are so often troublesome a long time after recovery from 
influenza. I have in mind three men of our personnel who had not been 
seriously ill with influenza but who were largely incapacitated for several 
months afterward with muscular pains, in the left calf, the left hypochar- 
dical and right scapular regions respectively. 

A CASE OF EVENTRATION OF THE DIAPHRAM 

W. Allen, M. D., Charlotte, N. C. 

Eventration of the diaphram, sometimes known as dilatation, insufliciency, 
"hochstand", or elevation of the diaphram denotes a condition in which 
half the organ is thinned out and distended, rising high into the thoracic 
cavity with corresponding upward displacement of the abdominal viscera 
on the affected side. There is no break in continuity as in diaphranatic 
hernia. 

The subject has been well reviewed in our literature by Sailer and Rhein 
(1) in 1905 and particularly by Bayne-Jones (2) in 1916, so that no ex- 
tended review will be given here. The latter collected 45 cases, only four 
of which had been reported from this country. Aronson (3) reported a 
case in 1916 which with the present case makes a total of 47 cases. In 
four instances the right side was affected, in forty-four the left. Eppinger 
(4) has shown that the ratio of eventration to hernia of the diaphram is 
about 1.37. 

Cruveilhier (5) considered the condition secondary to disease of the 
phrenic nerve, of the diaphramatic muscle, or abdominal disease causing un- 
equal pressure on the two sides of the diaphram; but most subsequent ob- 
servers have adopted Thoma's (6) view, that eventration is an anomaly 
caused by defective development. Bayne-Jones points out that pregnancy, 
the commonest cause of abdominal distention, has not been associated with 
this condition (only 8 out of 43 adults were females) ; that it has been found 



PRACTICE OF MEDICINE 23 

in tour foetuses or young children, and that in nine of the fort_v-five cases 
which he reviews, other developmental anomalies were present. 
Aronson's case had Hirschsprung's disease, and the case here cited had 
bilateral inguinal herniae. 

Post mortem examination has shown the affected half of the diaphram re- 
duced practically to a thin fibrous sheet with almost no muscle tissue re- 
maining. The dextro-cardia, which has heretofore invariably been founds 
in eventration of the left side has generally been attributed to mechanical 
displacement of the heart and mediastium by the bulging up of the diaphram. 
Sailer and Rhein take issue with this view, showing that the elacticity of 
the right lung is more important, and citing a number of cases of displace- 
ment of the heart to the left with hypoplasia of the left lung, both with and 
without elevation of the diaphram. In the present case the heart was not 
displaced to the right but directly upward. 

The left lung is not compressed, being only partially developed, at times 
showing incomplete division into three lobes. The development of the 
thoracic walls is normal. Below the diaphram, developmental anomalies 
of the colon and mesentery have been found with a varying amount of up- 
ward displacement of the abdominal viscera. 

These cases may have no symptoms referable to the diaphramatic condi- 
tion ; some have cough and dyspnea, probably due to cardiac displacement ; 
others have gastro-intestinal symptoms. 

On physical examination lagging of the left side with displacernent of 
the apex beat will be seen. The lower left chest is usually tympanitic with 
absence of breath sounds, and fremitus, and Litton's sign. In Sailer and 
Rhein's case the lower left back was dull because of an enlarged spleen. In 
the present case the lower left chest was dull possibly from the same cause 
or from a preceding tubercular pleurisy. 

The Roentgenological examination has been well set forth in Becker's 
(7) article. When the distended stomach fills the left lower thorax, the 
clear area is free from the usual pulmonary markings and its upper surface 
is bounded by a smooth elliptical line. Fluoroscopic examination shows 
this line to be the diaphram, which during respiration may reveal the left 
half contracting normally or paradoxically. 

Eventration is apt to be mistaken for hydro-pneumothorax and needled, 
and the differentiation between eventration and hernia of the diaphram is 
at times extremely difficult. 

Case Report; — A real estate agent, aged 31, single, was referred for ex- 
amination Feb. 7, 1916, by Dr. R. L. Gibbon. His mother had died at 
51 of stomach trouble; a brother, who had had no disease, had never been 
strong; two brothers had died in infancy. The patient at the age of seven 
had nearly died with dysentery lasting a month. No other illness until the 
age of 24, when he had a fever of ten day's duration, called malaria. Had 
no chills with this, but during this fever developed a cough which he has 
had ever since. Five years ago took a cure for alcholism, and has abstained 
since. Chews and smokes. Had gonorrhea and venereal herpes some years 
ago. Two years ago had a nervous breakdown and stayed in bed two 
months. Four years ago, after cranking his car, felt a sharp pain In right 
lower abdomen, and found he was ruptured slightly on both sides. 



24 NORTH CAROLINA MEDICAL SOCIETY 

At present complains of general weakness, walking up hill brings on dysp- 
nea and cough and at other times pain over sternum. If he lean forward 
and coughs, the upper abdominal muscles, at the costal margins, will con- 
tract violently leaving lumps which he has to massage until they disappear. 
Coughs some at night and on rising, and brings up an ounce or more of 
purulent sputum in the morning. No night sweats in four years. Has 
dumb chills in spring and fall and on damp days, with enough fever to make 
him sit close to a stove. Before his fever seven years ago, he weighed 135 
pounds, and now weighs 105 pounds. Appetite good. Sleeps very poorly, 
averaging three hours a night. No gastro-intestinal or genitourinary symp- 
toms. His cough, dyspnea, weight, and weakness have not varied much in 
the past seven years. He takes no exercise, has few amusements, works 
steadily and worries a great deal. 

Physical Examination: — A small, weak, pale, thin man. Eyes and 
throat normal. Epitroclear and left posterior cervical glands enlarged. 
Skin dry and looks transparent. Chest ; The lower left side seems smaller 
than right and lags on respiration. The right side is hyperresonant through- 
out, with small moist rales under middle third of scapula behind. The re- 
sonance over the upper third of the left side is considerably less than the 
right side, but has no tympanitic quality. The lower half of the left front 
is tympanitic ; the lower two-thirds of the left axilla and the lower half of 
the left back are flat. Breath sounds harsh and broncho-vesicular over up- 
per half of left side, absent below. No rales. Voice sounds and tactile 
fremitus absent over lower half of left lung. Abdomen flat, nowhere tender, 
thin walled ; liver dulness normal and spleen not palable. Both inguinal 
rings are weak and stretched with small incomplete herniae, direct on the 
right, oblique on the left. The femoral rings bulge considerably on cough- 
ing. Extremities and genitals normal. Superficial and deep reflexes nor- 
mal. Joints normal ; there is a moderate spinal curvative with apex oppo- 
site the left scapula; this does not modify the mobility of the vertebral col- 
umn. Apex beat in midclavicular line, third interspace, left. Heart size 
and sounds, rate and rhythm normal. Blood pressure 118-80. 

Laboratory Examination: — Haemoglobin 75%. White count 14,800. 
Polynuclears 72%, lymphocytes 17%, large mononuclears 7%, eosinophils 
2%, basophils 2%. Red count 4,800,000. No plasmodia. Shape and stain- 
ing reaction of red cells normal, some variation in size. Wassermann 
strongly positive. 

Urine acid, 1023, negative for albumen, sugar, indican ; microscopically 
negative. 

Feces negative for eggs and protozoa. 

Sputum showed tubercle bacilli. 

Roentgen Examination : — The plates showed on the right side a tuber- 
cular focus below the right apex, corresponding with the moist rales heard 
in this area. The left side showed over the lower half of the chest a uni- 
formly dense shadow bounded above by a smooth curved line, level with the 
sixth rib behind and fourth in front. The heart shadow was high and 
largely behind the upper end of the sternum. (The Roentgenograms were 
made by the late Dr. J. W. Squires and unfortunately destroyed after he 
entered the army.) 



PRACTICE OF MEDICINE 25 

Under the impression that this was a left pleural effusion the left back 
was needled, but no fluid obtained. The needle, inserted in several places, 
seemed to be always in solid tissue. A fluoroscopic examination now demon- 
strated that the smooth upper border of the left chest shadow was the dia- 
phram which could be seen contracting normally on inspiration. The car- 
diac contractions could be seen above this, from the third interspace to the 
sternal notch. Gastro-intestinal plates revealed no abnormality and a cor- 
rected diagnosis of eventration of the left side of the diaphram was made. 
The patient died a year or so later from pulmonary tuberculosis. 

The two unusual points in the case were the displacement of the heart 
dirc'^tlv upward, and the dulness in the left lower back and axilla which 
may possibly have been due to an enlarged spleen as in Sailer and Rhein's 
case, or to a previous tubercular pleurisy. 
References: 

(1) Sailer. ].. and Rhein, R. D. ; Amer. Jour. Med. Sc, 1905, 
CXXIX, 688. 

(2) Bayne-Jones, S., ; Arch. Int. Med., 1916, XVII, 221. 

(3) Aronson, E. A.; N. Y. Med. Jour.. 1918, CVIII, 196. 

(4) Quoted by Bayne-Jones. 

(5) Cruveilhier: Traite d'Anatomie pathologique generale, 1849, II, 
617. 

(6) Thoma, R. : Virchows Archiv., 1882, LXXXVIII, 515. 

(7) Becker, T. : Fortschr, a. d. Geb. d. Roentgenstrahlen, 1911. XVII, 
183. 

X-RA^ FINDINGS IN THE LUNG FOLLOWING INFLUENZA 
TUBERCULOUS AND OTHERWISE 

Dr. R. p. Noble, Raleigh, N. C. 

Numerous patients are presenting themselves to the general practitioner 
and specialist, following an attack of influenza with varying symptoms, 
some complicating the chest and others without apparent chest symptoms. 
The cases are very often referred to the roentgenologist for his opinion of 
the pre*sent lung condition and an x-ray examination follows. Before I go 
further, let's get clearly in mind what has taken place in the lung of the 
influenza pneumonia subject. 

Lung involvement complicating influenza is a most severe type of infec- 
tion and produces tissue changes in varying degrees, in trachietis, trachio- 
bronchitis, broncho-pneumonia and pneumonia. From the microscopic ex- 
amination of infected lungs of monkeys in which the influenza bacillus had 
been directly applied to the mucous membrane of the nose and throat, pro- 
ducing the same symptoms as influenza pneumonia in man ; and of human 
lungs following death from influenza pneumonia there was found exten- 
sive hemorrhage, peri-bronchial areas of consolidation with an exudate of 
leucocytes, mono-neucler cells and desquamated alveolar epithelium and 
thickening and infiltration of the alveolar walls. There were considerable 
patchy emphysema of the periphreal lobules. The pleural surfaces were 
rarely involved. This amount of inflammation caused certain thickening and 



26 NORTH CAROLINA MEDICAL SOCIETY 

tissue changes that cast an x-ray shadow. It remains for the roentgenologist 
to find and properly interpret from the x-ray plates evidences of these patho- 
logical changes. The x-ray examination during or immediately after an at- 
tack of influenza pneumonia shows nothing beyond the well known opacity 
of a pneumonia lung and is of little value. 

Only a small proportion of the cases give a history of having had any 
lung trouble previous to the attack of the influenza. The lung infection at 
the time of the pneumonia so lowered the bodily resistence, enabling a latent 
tuberculous foci to exert itself. It is this tuberculous complication which 
requires our most careful investigation. The previous inflammatory condi- 
tion has produced a general thickening of the lung tissue so that a hazy ap- 
pearance is given to the x-ray plates. 

These tuberculous conditions verj^ often affect the periphery of the lung, 
giving a fan like appearance of increased density. The apices, one or both, 
are frequently affected, showing ;i cloudiness and sometimes contain- 
ing a faint floculent looking mass of tuberculous deposits, having the appear- 
ance of half cooked oatmeal. These soft tuberculous deposits may be seen 
anywhere in the lung and are often widely separated. Heavy hilus shadows 
and otherwise dense calcifications indicate a condition of long standing. It 
often happens that a slightly increased density of a soft tuberculous mass will 
develop in the area of a previous pneumonia consolidation. There will be 
noticed perfectly normal lung near an erea of increased density and the 
comparison is apparent. 

In these cases in which there is evidence of tuberculous deposits there is 
one sign that is worth all the others. If the costal and sternal cartilages of 
a young person are heavily calcified, or show the deposits isolated, indicating 
a sufficiency of lime salts in the blood, the tuberculous infection if seen (and 
it generally will be in these cases) will be cared for under proper treat- 
ment. 

Now, on the other hand there are lungs that have not fully recovered 
from the influenza attack and coupled with certain nervous and digestive 
disturbances give many and varied symptoms- No tuberculous deposits are 
seen in these lungs, though there is a general haziness not seen in otherwise 
normal lungs. The areas most affected during the influenza illness show 
more pronounced haziness and often a mottling, approaching in appearance 
the tuberculous mass. This condition is seen at an earlier date after the ill- 
ness than does the tuberculous deposits and does not hold on or increase, 
whereas the tuberculous area becomes more pronounced. The walls of the 
bronchial tubes are thickened and the bronchial and peri-bronchial glands 
show increased shadows. The priephery of the lungs and the apices are less 
frequently involved while the central and lower portions contain more of 
the shadows. Both lungs are generally involved. These findings are to be 
thought of as a normal lung following such a marked inflammatory reaction 
during the previous illness. Many normal lungs show shadows caused by 
some previous lung infection, but we have come to regard them as norma! 
lungs at the present time, having fully recovered but still showing the marks 
of the infection. But these normal lungs show more clear cut, definite 
shadows and the haziness has disappeared. The object of this paper is to 
show the importance of careful lung examination with the x-ray following 



PRACTICE OF MEDICINE 27 

the influenza pneumonia cases and the appearance of the tuberculous and 
non-tuberculous lung. 

As complications following influenza pneumonia we also get pleurisy 
with effusion, empyema and empysematous areas but they are more easily 
noted and will not be discussed in this paper. 

In studying the lung plate there are many conditions to be dealt with 
and it is not necessary that the roentgenologist do the ground hog stunt, for 
in the case of seeing no shadows to frighten him he may be caught out in 
some unpleasant season : yet if he runs from every shadow he sees and re- 
treats he will miss many of the beauties of the next forty days. 

There are shadows and if correctly interpreted will help in the proper 
diagnosis and subsequent treatment. 

PRELIMINARY REPORT ON A STUDY OF THE 
GOETSCH TEST 

Dr. R. AIcBrayer, Clinician and Director of Laboratories, North 

Carolina Sanatorium, Sanatorium, N. C. 

This study has been undertaken with the hope that out of it may come a 
more practicable test for the busy practitioner of today who in my opinion 
does not have the time to devote to such a lengthy technique as is used by 
Dr. Goetsch. We think that we have gotten very satisfactory results from 
this test during its use of six months or a little longer by us. Let me say in 
the beginning that to the men who have the time I would strongly advise 
their utilizing the test as laid down by Dr. Goetsch. I believe it is based on 
fundamental physiologic principles and in the right hands will certainly 
give accurate results. 

First let us review the Goetsch Test or better termed "The Adrenalin 
Hypersensitiveness Test." The following is an extract of a paper published 
by Drs. Norman Clive Nicholson and Emil Goetsch of the Trudeau Sana- 
torium, Trudeau, N. Y., under the heading of "The Differentiation of Ear- 
ly Tuberculosis and Hyperthyroidism by Means of the Adrenalin Test," 
•Which article was published in the American Review of Tuberculosis, vol- 
ume 3, No. 2, April, 1919. Dr. Goetsch has been using this test for about 
five years during which time he has had many of his positive findings to 
come to operation where, he claims, the accuracy of the test has been "con- 
firmed by operation and microscopic study of the gland tissue." 

The technique of carrying out the test is as follows : 

"We want the patient to be as calm and restful as possible before the test 
so that the reaction to the adrenalin will stand out sharply in contrast. 
Accordingly the patient is put to bed the previous day and is reassured by 
the attending physician that the test will be in no way painful or associated 
with any danger. At this time, too, the standard case-history is supplement- 
ed by a history taken with special reference to symptoms of thyroid disturb- 
ances. One must determine the presence or absence of nervousness, throb- 
bing, tachycardia, tremor, depressions, crying spells, struma, apprehensions, 
hot and cold flushes, cold hands and feet, fainting spells, memory lapses, 
dermatographism, amplified by a detailed scrutiny of the signs suggestive of 



Zb NORTH CAROLINA MEDICAL SOCIETY 

hyperthyroidism, such as positive eye-signs, (Joffroy, Moebius, von Graefe 
and Dalrymple) tremor, struma, thrills or bruits over the thyroid, throbbing 
of the carotids and of the abdominal aorta, the condition and distribu- 
tion of the hair, and slight edema of the eyelids, legs or hands. In this con- 
nection it should be borne in mind that hyperthyroidism may exist with 
negative eye signs and only indefinite clinical findings in the thyroid gland. 
Consequently we feel that the response to adrenalin is a much more de- 
pendable criterion of hyper-activity of the gland. 

"On the day of the test the patient is placed as nearly as possible under 
normal conditions. By this we mean in a warm room without the appli- 
ances such as hot water bottles, heating devices, etc., which are common to 
the outdoor treatment of tuberculosis. The patient, of course, is to take 
his meals in bed. We emphasize these precautions because of the well- 
known hypersensitiveness and irritability of hyperthyoid and tuberculous 
patients. Because of the tendency of the thyroid to hyperactivity at the 
menstrual period the test is not given during this time. 

"We proceed with the test as follows: 

"Two readings are taken, at five minute intervals, of the blood pressure, 
systolic and diastolic, pulse rate and respiration. A note is made of the 
subjective and objective condition of the patient. This includes the state 
of the subjective nervous manifestations, the throbbing, heat and cold sen- 
sations, asthenia, and the objective signs, such as pallor or flushing of the 
hands and face, the size of the pupils, throbbing of the neck vessels, and 
precordium, tremor, temperature of the hands and feet, prespiration, and 
any other characteristic signs or symptoms noticed. These signs are all 
noted previous to the injection of the adrenalin so that comparison may be 
made after the injection. 

"A hypodermic syringe armed with a fine needle which, when inserted, 
causes little discomfort, is then used to inject 0.5 cc. (7.5 minims) of the 
commercial 1-1000 solution of adrenalin chloride (Parke, Davis & Co.) 
into the deltoid region, subcutaneously. Intramuscular and intravenous in- 
jections are not given. Readings are then made every two and one-half 
minutes for ten minutes, then every five minutes up to one hour, and then 
every ten minutes for half hour or longer. At the end of one and a half 
hours the reaction has usually entirely passed off, sometimes earlier. The 
repeated early readings are made in order not to miss certain reactions on 
the part of the pulse and blood pressure that may come on in less than five 
minutes after the injection is made. This is particularly true of cases of 
active hyperthyroidism. 

"In a positive reaction there is usually an early rise in blood pressure and 
pulse of over ten points at least; there may be a rise of as much as fifty 
points or even more. In the course of thirty to thirty-five minutes there is 
a moderate fall, then a second slight secondary rise, then a second fall to 
the normal in about one and one-half hours. Along with these one sees an 
exaggeration of the clinical picture of hyperthyroidism brought out, es- 
pecially the nervous manifestations. The particular symptoms of which the 
patient has complained are usually increased, and in addition there are 
brought out many symptoms which have been latent. Thus it is not uncom- 
mon to have extrasystoles brought out, after the injections of the adrenalin. 



PRACTICE OF MEDICINE 29 

The patient is usually aware of them and may tell one that she has felt this 
same thing a year or two previously, at which time the symptoms of the dis- 
ease were more active. 

"The following may all or in part be found: increased tremor, appre- 
hension, throbbing, asthenia, and in fact an increase of any of the symptoms 
of which the patient may have complained. Vosomotor changes may be 
present ; namely, an early pallor of the face, lips and fingers, due to the vas<j- 
constriction, to be followed in fifteen to thirty minutes by a stage of vaso- 
dilation with flushing and sweating. There may be a slight rise of temper- 
ature and a slight diuresis. 

"In order to interpret a test as positive we have regarded it is as necessary 
to have a majority of these signs and symptoms definitely brought out or in- 
creased. Thus there is at times a considerable increase of pulse rate with- 
out much increase in systolic blood pressure, but with a considerable in- 
crease or exacerbation of the objective signs and symptoms ; or there may 
be an increase of ten points in the pulse and blood pressure and a moderate 
increase of the symptoms and signs; or again, there may be only slight 
changes in pulse and blood pressure and considerable change in signs and 
symptoms. These may be regarded as positive. In a word, then, one must 
consider the entire clinical picture produced in order to gain a correct in- 
terpretation, just as in the disease itself one cannot expect every one of the 
characteristic signs and svmptoms to be present in order to make a diagno- 
sis." 

In the beginning I stated that in my opinion this test was based on physi- 
ologic truth. A slight review of your knowledge of physiology and phar- 
macology will show you that the secretion of the thyroid glands, be it iodo- 
thyrin, thyroiodin or whatever it may be, is a stimulant to the autonomic 
nervous system. Now when this system is continuously bathed in this toxin 
of hyperthyroidism it becomes hypersensitive. Another look at your phar- 
macology will tell you that adrenalin is the quickest and most practical ob- 
servable drug in its action that we possess for stimulating the autonomic 
nervous system. With this in mind adrenalin is the drug for this use. Too, 
you will agree with me that it is perfectly plain that w^e have a need for 
such a test for how many times do we find a case of tuberculosis we call 
hyperthyroidism or how many times we find a cause of hj'^perthyroidism that 
we call tuberculosis? Only a glance at our previous errors will prove that 
we have a serious need for such a test as this and most welcome will it be if 
this is it. As stated above I am of the opinion that Dr. Goetsch's test is 
impracticable for the busy general practitioner of North Carolina and for 
that reason the following studies have been undertaken with the hope that 
out of them may come a more practical test for the general practitioner. 
This preliminary report is upon a study of a series of fifty-five patients. 
Five normal persons, twenty having tuberculosis in different stages but hav- 
ing no signs or symptoms of hyperthyroidism, twenty-two suspicious thyroids 
having tuberculosis and six tuberculous patients known to have hyperthy- 
roidism. We have taken the following list of symptoms and signs of hyper- 
thyroidism and have classified these findings in each case under the follow- 
ing headings: Systolic blood pressure, diastolic blood pressure, pulse pressure, 
pulse rate and quality, tremor, nervousness, palpitation, diuresis, temperature. 



30 NORTH CAROLINA MEDICAL SOCIETY 

respiration, apprehension, pupilary changes, vasomotor changes in face, hands 
and feet and sugar in the urine. I could not think of taking up your time by 
reading the tabulation, as interested as I am in it. For that reason I will 
proceed to make a comparative study of these signs and symptoms. In each 
of the four classes of patients named above, systolic blood pressure rose prac- 
tically the same number of points reaching its maximum in the known 
cases of hyperthyroidism in nineteen minutes, having a secondary rise in 
forty-one minutes and remaining above normal for an average of an hour 
and seventeen minutes. In the twenty-two suspects the systolic blood pre- 
sure rose to its maximum in an average of eighteen minutes. In four sus- 
pects, the systolic blood pressure made a second rise in thirty-nine minutes 
and remained up for an average of fifty-nine minutes. The other eighteen 
cases of this suspect group reached their highest in thirteen minutes and re- 
turned to normal in twenty-three minutes. The twenty "no hyperthyroids" 
reached their maximum systolic blood pressure in an average of 11.5 minutes 
and returned to normal in an average of twenty-two minutes. The normal 
class reached its maximum systolic pressure in seven minutes and returned 
to normal in nineteen minutes. 

Diastolic pressure: In the "known hyperthyroids" the diastolic blood 
pressure fell seventeen points, the maximum fall corresponding in minutes 
to the maximum rise in systolic pressure and continued in the same propor- 
tion until a normal level was reached by the systolic pressure. In the same 
four suspects mentioned above the diastolic blood pressure fell sixteen points 
with the maximum systolic rise and returned to normal along with the 
systolic blood pressure. In the other eighteen cases the diastolic blood, pres- 
sure fell an average of nine and one-fifth points corresponding to the maxi- 
mum systolic rise. It also returned to normal with the return of the systolic 
pressure to normal. The "no hyperthyroids" gave a diastolic fall of seven 
points which occurred at the same time as the maximum systolic increase 
and returned to normal therewith. The normals had a fall of six points 
in diastolic blood pressure corresponding to the maximum systolic rise and 
returned to normal with that of the systolic. 

Pulse pressure: The "knowns" had a maximum increase of fifty-six points 
which pressure returned to normal with the systolic pressure. Four suspects 
had an increase of forty points while eighteen suspects had an increase of 
twenty-nine and one-half points. The class of "no hyperthyroids" had an 
increase of thirty-one points while the normals had an increase of twenty- 
eight points. 

Pulse: In the "knowns" the pulse rate increased an average of twenty- 
seven points. In four suspects there was no increase or decrease. In 
eighteen suspects there was an average increase of fifteen points (maximum 
increase thirty, minimum increase six.) The "no hyperthyroids" had' an 
increase of fourteen points while the normals decreased three points per 
minute. 

Quality: In the "knowns" the pulse became irregularly, unequal and 
varied in volume. Fourteen suspects had the same type of pulse while 
eight had a normal, full, well rounded pulse. In the "no hyperthyroids" the 
pulse was equal and regular in sixteen cases but there was a slight irregulari- 
ty present. In the normals the pulse was full and bounding, no irregulari- 
ty or inequality was detected except slight inequality in one case. 



PRACTICE OF MEDICINE 31 

Tremor : Tremor was increased in every case in the series as well as 
was nervousness. Palpitation was present in each case of the series and slight 
diuresis was present in all. A temperature increase of three- fifths of a de- 
gree in the "knowns" was found reaching its highest at the end of forty- 
seven minutes. It increased in all suspects an average of two-fifths of a 
degree reaching its highest in an average of forty minutes. In the "no hy- 
perthyroids" temperature was increased two-iifths of a degree reaching its 
highest in forty-two minutes. In the normals the temperature was increased 
an average of one-lifth of a degree reaching its highest in forty-six minutes. 

Respiration: In the "knowns" this was increased an average of five 
points. In six suspects increased an average of four points. In sixteen sus- 
pects increased an average of two points. In the "no hyperthyroids" it in- 
creased an average of one point and in the normals decreased an averagv. jf 
one and one-half points. 

Apprehension : This was increased in each case of the series. 

Pupilary changes: These changes were present in the w^hole series 
though in the six "knowns" and in three suspects there were frequent pupi- 
lary changes. In all others there was a primary slight dilitation followed 
by an early return to normal. 

Vasomotor changes: These were present in the hands, feet and face of 
the entire series. 

Sugar in the urine: None was found in any specimen. 

Conclusion : I frankly state that as yet I do not consider this small 
amount of work reported upon as sufficient evidence for warranting any de- 
finite conclusions. However, if future studies substantiate these findings 
we will find that the differential diagnosis of tuberculosis and hyperthy- 
roidism will be made easier for the general practitioner of our state when 
after the subcutaneous injection of adrenalin he finds, between fifteen min- 
utes and one hour and thirty minutes after the injection, the following: 

First: A systolic blood pressure rising ten or more points and remaining 
above normal for fifty minutes or more. 

Second: Increased pulse rate of ten or more points per minute propor- 
tionate to the systolic rise. 

Third : An increase of pulse pressure of thirty-five or more points. 

Fourth : Pulse irregular and varying in volume. 

Fifth : An increase in respiratory rate of four or more points per min- 
ute. 

Sixth : Varying pupilary changes. 

1 firmly believe that this test can be made more practical for the general 
practitioner and for that reason we are diligently pursuing these studies at 
the State Sanatorium and hope to have at a future date some more definite 
and positive report to make. Again let me state that this paper is not a 
rriticism of the work done by Dr. Goetsch, for, as I stated above, if any 
doctor has the time certainly the thing in my opinion for him to do is use the 
Adfenolin Hypersensitiveness Test verbatim as given in Dr. Goetsch's 
technique which I read to you in the beginning. 



32 north carolina medical society 

Discussion of Dr. McBrayer's Paper 

preliminary report on a study of the goetsch test 

Dr. W. deB. MacNider, Chapel Hill: I wish I were in position to 
discuss from a clinical point of view the validity of this test. I can not do 
that, because I am removed from clinical medicine, but I would feel asham- 
ed of myself if I did not get up here and congratulate Dr. McBrayer, Sr.. 
on having a son who is sufficiently interested to make use of the material at 
hand and get up such an excellent paper. It is a thing that many of us 
could do and ought to do. 

ESSENTIAL HYPERTENSION 
Dr. R. F. Leinbach, Charlotte, N. C. 

Some time ago my attention was attracted to an article appearing in tiie 
Journal of the A. M. A., written by the former Chief Cardiovascular and 
Lung Examiner of the Medical Officers Training Camp, Camp Greenleaf, 
Ga., in which certain personal views and opinions concerning the nature and- 
relations of blood pressure were set forth. I was impressed with the fact 
that certain of these views were at variance with what I regarded as the 
sanest teachings on this subject. Though much less common than in for- 
mer years it is still not remarkable now and then to encounter somewhat 
radical and iconoclastic theories in the literature regarding medical condi- 
tions of unproved nature. However, this article served to impress on my 
mind the divergence of opinion obtaining today after fifteen and more 
years of study and observation concerning the nature and relations of blood 
pressure. 

I do not expect to clarify any of the unknown elements in hypertension 
but merely to present a few phases of the subject in such relations as seem 
warranted by a careful review of the literature of the past eight or ten years. 

Doubtless to a certain extent the discordance of opinion with regard to 
the nature of hypertension has been contributed to by the varying names 
under which the subject has been presented, none of which has gained a 
wide spread currency; and again to the lack of a suitable clinical classifi- 
cation. It is a striking fact that in everyday intercourse among medical men 
and even in consultation work one chooses to refer to this or that patient as 
"a case of nephritis with high blood pressure" or "a case of arterial sclerosis 
with high blood pressure" or simply as "a case of high blood pressure" rather 
than to venture to designate it by any particular descriptive term based on 
the probable type of pathology. This I take it is often an evidence of wis- 
dom as it is often difficult and sometimes impossible to predict the type of 
pathology which autopsy will reveal, from symptoms presenting during life. 
This is of course especially true in dealing with nephritis. 

From the work of Gull and Sutton in 1872 on the pathology of Bright's 
Disease came a term highly descriptive of the pathology- found in certain 
cases of permanent high blood pressure — namely, Arterio-capillary fibrosis. 
The appropriateness of this term based on the pathology of a certain type of 
the disease, namely a diffuse fibrosis of the smallest arterioles not limited to 
the kidney, is, I think, unquestioned today, yet one rarely encounters the 
term in diagnosis. Dr. Theodore Janeway, while still at Columbia Uni- 



PRACTICE OF MEDICINE 33 

versity, New York, published the first analytical study of a large series of 
clinical cases of high blood pressure in this country under the name "Pri- 
mary Hypertensive Cardio Vascular Disease." This term he continued to 
use in his later writings until his death. But for its awkward length it is 
one of the most satisfactory terms yet offered in that it excludes all secon- 
dary hypertensions if such there be, and yet admits of sufficient variation in 
pathology to be clinically applicable in diagnosis. Sir Clifford Albutt's 
term of "Hyperpiesis", descriptive only of the dynamic phenomena of the 
disease in the early stages, is inadequate and indeed scarcely ever encount- 
ered in the literature of this country today. It is worthless as a diagnostic 
term. 

The Hopkins School, in general, employs the term Cardio- Vascular-Re- 
nal Disease in essays on the subject, though recently Mosenthal of Hopkins 
and some other writers elsewhere have begun to employ the term "Essen- 
tial or Benign Hypertension." The term is borrowed from the German of 
Volhard and Fahr who in 1914 described the benign uncomplicated type of 
high blood pressure. It is true that many hypertensive cases run a practi- 
cally symptomless course for years, and to such it may be entirely appropri- 
ate to apply this term. It is to be sure a very acceptable term in naming the 
disease to the unhappy subject of a high blood pressure, and by suggestion 
is more useful in quieting his state of apprehensiveness as to his early disso- 
lution than a multitude of words and explanations. As a medical diagnos- 
tic term it can have no great value or permanence. The pathology is that 
of the old Gull and Sutton type of arterio-capillary fibrosis of mild grade. 

Since we know practically nothing of the physiologic mechanism which is 
productive of states of permanently high blood pressure we cannot deny 
that it is possible that this mechanism may be set in action by different 
causes or by various chemical substances present in the blood stream or else- 
where and thus may be a secondary condition. In accordance with this pos- 
sibility and in harmony with our desire to ascribe a cause for all observed 
morbid symptoms we are accustomed to speak of arterial sclerosis, renal scler- 
osis, cerebral sclerosis as cause of high pressure. Yet one cannot doubt that, 
there is a definite underlying unity in the various types of high blood pres- 
sure seen and that the earliest observed manifestation in all types is the hy- 
pertension itself. For a time the statement that a regional vascular sclerosis 
was the cause of high pressure was considered sufficient but there are many 
able minds who now hold the view that these sclerotic changes in the blood 
vessels are the result and not the cause of the hypertension. To this view 
were committed vonBasch and Jores in Germany, Huchard in France, Al- 
butt and many others in England, Janeway in this country while Dr. Bar- 
ker in 1917 at the Atlanta session of the Southern Medical Association ex- 
pressed his views as follows: 

"No matter how important a contributing factor to the hypertension the 
arteriolar sclerosis may be in advanced cases, either as offering a mechanical 
obstruction to the circulation in the kidneys (or in the viscera generally), 
or as leading to toxic vaso-constriction by injuring the kidney and causing 
retention of metabolic constituents that are normally eliminated, I can but 
think that the origin of the initial hypertension must be sought elsewhere." 

Practically all authorities are agreed that the hypertrophied heart is to 



34 NORTH CAROLINA MEDICAL SOCIETY 

be looked upon as the result of a persistently high blood pressure. The fund- 
amental idea enunciated by Gull and Sutton that back of the disease we call 
chronic interstitial nephritis is a disease of small blood vessels and that the 
lesions of the kidney are secondary manifestations, was abandoned for a 
time but already in 1913 the work of Jores, Aschoff and Gaskell showed a 
return to this idea. 

Harvey and Klotz experimentally maintained a state of high pressure con- 
tinuously in young animals by placing them in an inverted position for three 
minutes over a period of 120 days and at the end of that time were able to 
demonstrate the production of marked sclerotic changes in the blood ves- 
sels. Again arterio-sclerotic lesions have been produced by repeated injec- 
tions of such blood pressure raising substances as adrenalin, nicotin, barium 
chlorid, etc. Other evidence for the priority of the hypertension to the 
vascular sclerosis is seen in the fact emphasized by Sir Clifford Albutt that 
atheroma of vessels is especially common at those points in the arteries in 
which pressures are greatest, such as at bifurcations, and at narrow points 
and at dilatations. A number of autopses are on record of high pressure 
cases in which vascular sclerosis was not found, and it is a commonplace ob- 
servation now-a-days, that many cases of sclerosis of the large arteries show 
no elevation of blood pressure. 

The relationship of certain types of glomerular and diffuse nephritis to 
hypertension is perhaps more problematical as to which is primary in point 
of time. There are certain evidences which we cannot fail to take into con- 
sideration as tending to show a probable primary character of the hyperten- 
sion. Thus all experimental attempts to bring about a persistent hyperten- 
sion by direct injury to the kidney by removing large portions of the renal 
parenchyma or by ligating the renal vessels have been unsuccessful, and also 
that extensive destruction of the kidneys as by chronic infections and amy- 
loid disease causing severe functional impairment of the kidneys do not lead 
to hypertension. Renal extracts have not been shown to exert a continuous 
pressure influence. 

Given these facts then which represent the result of experiment and in- 
ductive analysis the question arises can we still look on high blood pressure 
as a compensatory phenomenon. It is not too much to say that if we con- 
sistently held to the view that an elevation of blood pressure represented in 
all its phases, systolic, diastolic and pulse pressure a conservative and com- 
pensatory reaction for the maintenance of efficient function in one or an- 
other organ, that we would make no efforts toward its reduction and give 
no advice which would tend toward such a result. It is to be realized, how- 
ever, that heart and vascular system have reciprocal relations and functions 
to perform in the maintenance of efficient circulation of the blood and it is 
possible that a compensatory mechanism is in play in some phases of high 
pressure, the generally prevailing view being that cardiac hypertrophy and 
increased systolic pressure are compensatory to increased peripheral resist- 
ance as measured by the diastolic pressure. 

So far, then, as research and study have led us, it is recognized today that 
a state of high blood pressure which is permanent represents the first stage 
of the disease which we may call after Janeway Primary Hypertensive Car- 
dio-Vascular Disease or after Barker Cardio-Vascular Renal Disease. 



PRACTICE OF MEDICINE 35 

What then is the cause of high blood pressure? The answer is, of course, 
that ^ye do not know. Certain general etiological factors have been under 
suspicion, of course, as various pre-existing diseases. Warfield in 1917 stud- 
ied 500 cases of arterial sclerosis with relation to the infectious diseases as 
possible causes. He arrived at the conclusion that the general infections 
played no part in the etiology of this condition. 

Syphilis: Janeway in 1916 studying the possible relation of syphilis to 
high blood pressure found a lower incidence of positive Wassermann's in 
320 cases of hypertension than in all the cases of his series as a whole. Stoll 
in 1915 concluded from the study by Wassermann's and luetin tests of a 
fairly large percentage of cases that syphilis was the underlying factor in a 
much larger percentage of cases than had previously been realized. The 
luetin test was shortly afterward discredited however. Walker and Haller 
in 1916 found less than 7% of positive reactions in chronic nephritis with 
hypertension. Levison of Toledo in 1916 studying 18 cases of syphilis with 
high blood pressure concluded that anti-syphilitic treatment cannot be ex- 
pected to reduce hypertension in syphilitics who have also high blood pres- 
sure though admitting that occasional reductions may take place. 

Focal Infections: It is most important to correct all foci of chronic in- 
fection in any disease. However, Elliott of Chicago, studying 68 cases of 
high pressure with relation to focal infections, was unable to find any reason 
to think that hypertensive vascular disease bore any relation to focal in- 
fections. In 1917 Strickler of Atlanta reported one case of hypertension 
cured by the removal of dental focal infections, and stated that he could 
quote others due to Rigg's Disease and sinusitis. Apart from this one case 
I have failed to find in the literature of the past ten years any cures of hy- 
pertension ascribed to the clearing up of focal infection. No reference is 
made here to the cure of nephritis in general by eradication of focal infec- 
tions, for brilliant results were reported last year by Hunt of New York in 
this connection. 

Foods and Intestinal Intoxication as a cause are indeed under suspicion 
and must continue to be. There is much circumstantial evidence to im- 
plicate the intestinal tract but nothing very definite has been worked out be- 
yond the fact that various substances of a pressor nature. have been isolated 
from the intestinal current, as well as substances which have a damaging 
eflFect on the kidney substance. 

CLASSIFICATION 

As one studies cases of high pressure carefully it is impossible to avoid the 
tendency to classify them into various groups on a clinical basis. If we 
await the autopsy in order to group them on an anatomical basis we lose an 
invaluable guide in treatment. Dr. Cabot has said that treatment must 
often be on a symptomatic basis. 

Classifications have been advanced by Stone, Stengel, Barker and others. 
From the clinical point of view as a guide to treatment and prognosis the 
classification of Warfield has served us best in the differentiation of cases. 

By this classification. Group 1 is the so-called chronic interstitial nephritis, 
characterized by marked impairment of renal function and the predominance 
of renal symptoms, polyuria, nycturia, low sp. gr., constant traces of al- 



36 NORTH CAROLINA MEDICAL SOCIETY 

bumen in urine, renal type of low grade edema. The phthalein output is 
low, there is retention of urea and creatinin. Both systolic and diastolic pre- 
sure are high (200; 120-140) and there may be a high leucocyte count. The 
heart is enlarged to the left. At autopsy the type shows small red coarsely 
granular kidneys with thin cortex and adherent capsule. Death in this 
group is by uremia most often or by cardiac failure. 

Group 2 include cases often found by accident. They are large fleshy ro- 
bust apparently healthy people who with years of freedom from ailments of 
■any kind suddenly appear in the physician's office. On examination and 
questioning renal symptoms are absent. There is neither edema, polyuria 
nor nycturia. The urine is normal and renal function is normal or nearly 
so. Blood urea and creatintin are only slightly increased if at all. There 
is marked cardiac hypertrophy. The blood pressure is very high. There is 
high grade left ventricular hypertrophy and slight enlargement and dilata- 
tion of the aorta. At autopsy the kidneys are not contracted, the cortex is 
not decreased in size and the capsule strips readily. Microscopically the 
principal change is a diffuse fibrosis of the arterioles with only slight changes 
in the epithelium and glomeruli. Death is usually by apoplexy or perhaps 
by cardiac decompensation. 

Group 3 is found typically in well nourished individuals who are over- 
weight or who have been overweight at some previous time of their life. 
They present no renal symptoms. There is no polyuria and no nycturia 
and the urine is nearly normal. Phthalein output is only slightly reduced, 
and blood urea and creatintin are only slightly elevated. The blood pressure 
picture is characterized by a high systolic pressure, and by a nearly normal 
diastolic with a pulse pressure higher than that seen in either of the other 
two groups, equal to or greater than the diastolic pressure. The heart is 
much enlarged. This type in our experience is particularly often found in 
women over fifty years of age, and their symptoms are essentially cardiac 
with palpitation, and a tendency to anginoid pains. Often gaseous disten- 
tion of the abdomen is one of their most chronic and annoying symptoms. 
Death in this group is by gradual cardiac decompensation. At autopsy 
there is high grade hypertrophy of the heart and the kidneys are said to be 
enlarged with cortex of normal thickness. I say said to be enlarged, for I 
have not had the opportunity of obtaining an autopsy in this type of case, 
though it is a common clinical type to find. Microscopically the chief 
changes are again found in the arterioles with but minor changes in the 
epithelium and glomeruli. 

These three groups will, I think be readily recognized by every clinician. 
Is it necessary that they should be differentiated and how may they be diff- 
erentiated? Above all it is necessary that high blood pressure cases should 
be properly studied and grouped. Because we have no specific remedies 
these unfortunate people are too often passed over with but cursory exami- 
nations and with the brief hasty advice to cut out all meats from theiir diet 
and not to exert themselves. 

Janeway said in 1915 "To tell every patient with albuminuria or hyper- 
tension to stop eating red meat, or worse still to go on a milk diet is evidence 
either of ignorance or inexcusable laziness. To group properly cases of 
hypertension requires first of all a careful study of renal function by obser- 



PRACTICE OF MEDICINE 37 

vation of daily water intake and water output, phthalein tests, estimations 
of blood urea and creatinin and chlorides and a careful study of blood pres- 
sure reactions and cardiac function. With increasing experience one may 
often forecast from the symptoms and pressure reactions the group into 
which a case will fall when carefully studied later. However, such a meth- 
od of classification without a study of renal function is mere guess work. 

It is nothing less than a moral duty to work out thoroughly these cases 
and to give them appropriate advice and treatment. In cases of group 1, 
diet will be vitally important, requiring the reduction to a reasonable degree 
of their protein intake, a diet yielding a basic ash, and purin free. In group 
2 the treatment will aim above all to avert a cerebral calamity while in 
group 3 every care and attention must be given to avert cardiac decomf>en- 
sation. The wise pilot is he who focuses his attention on the particular 
rock toward which the ship is drifting and not those which lie far from the 
course of the ship. 

MECHANISM OF CONVULSIVE MOVEMENTS OF THE OR- 

BICULARIES AND FACE, AND THE MANNER 
OF THEIR REMOVAL. 

Dr. Tom A. Williams^ Washington^ D. C. 
Corres. Member Neurological Society of Paris, etc. 

We are all familiar with convulsive movement of the face due to chorea. 
It is physical, due to cerebral infiltration by organismal products. Another 
type of convulsive movement of the face, of physical origin, due to encephal- 
itic irritation, has been seen by some of us in cases of encephalitic during 
the recent epidemic. The mechanism of that is also simple. Another type 
of convulsive movement of the face of physical origin is that of orbicular 
spasm, in which the eyelid twitches. That, again, is due to irritation of the 
facial nucleus, of encephalitic origin. The management of a disorder of 
that kind is laid down in the textbooks. There exists quite a different type 
of convulsive movement of the face. 

For instance, a woman of fifty was sent to me some years ago by Dr. 
HefFron, of Syracuse, New York, because of a grimacing of the face. At 
the snme time this woman's head. turned toward the right. She had seen 
an eminent neurologist in New York, and he recommended that the sterno- 
cleidomafi-oid muscle be sectioned. This done, I need not say that no bene- 
fit was obtained. She was later sent to me and the discovery was made that 
this movement had nothing to do with any physical disorder, but was a 
movement directed toward an end, which was brought about not from a 
disturbance of the sterno cleidomastoid muscle, but the whole mechanism of 
turning the head and pulling the face to the right was involved. What was 
the stimulus? It was found to be a psychological one. It was found that 
the woman had a niece with whom she had been in the habit of walking, 
the niece always walking to the left of the aunt. The niece was about to be 
married. So determined was the aunt not to consent to this that she could 
not help turning her head away from the niece, so painful was the idea of 
her prospective marriage to one of a class of foreigners who had always 
caused misery to their wives in the manv instances she knew. 



38 NORTH CAROLINA MEDICAL SOCIETY 

Another case of like character was a young woman in Washington whose 
neck turned because behind her sat a woman with whom she was always try- 
ing to make up a quarrel. 

Another case of the kind occurred this Spring, a lady from South Caroli- 
na, was sent to me by an ophthalmologist because she could not open her eyes 
and had not been able to do so for two years. She could not go on the 
street, could not conduct her household affairs, could not read, and could 
scarcely write. Also she had a high blood pressure and looked like an old 
woman. Altho I recognized the psychogenetic nature of the condition, I 
was unwilling to undertake treatment because of her condition and age. 
However, examination showed that there was no serious arteriosclerosis nor 
kidney disease. She was a much more intelligent woman mentally than she 
looked. First we found out the cause of this effect. It had come on during 
the war, when she had great responsibility and anxietj^ Why responsibili- 
ty and anxiety caused the convulsions of the face which caused her eyes to 
close so tightly was that when a young girl she had formed the habit of 
closing her eyes whenever any painful sight or even thought would occur. 
It seemed more bearable then. When this occurred she tried to abstract 
herself, which she did by not seeing what was before her, so she closed her 
eyes. It was a manner of withdrawal. This had become a habit but had 
never given any trouble until the great distresses of the war. Then the 
eyes remained closed. At the same time her vision began to age, so she 
went to an ophthalmologist for the fitting of glasses. But the constant clos- 
ing of the eyes produced an effort to keep them open, which led to spasmodic 
movements. So she was sent to another ophthalmologist, who told her that 
the glasses she had were wrong and gave her some others. Naturally, no 
good was done, because the trouble was not in the vision but in the mind. 
So she became worse and worse. Explanation and re-education enabled her 
to go home in a month vastly improved. She was able to read and write, and 
go out alone. 

Another, a man from Wilmington, tried to keep his face straight by 
chewing his lips. He was a sea captain and had great responsibilit}' during 
the war. Finally he got so that he could not open his eyes at all. He too 
was much improved. 

The last case is that of a Washington man who, during my absence in 
France, was sent to a famous clinic. There he was seen by ophthalmologist, 
neurologist, psychiatrist, internist, serologist, and all sorts of examinations 
were made, nothing objective being found. He could not open his eyes. 
This man when I saw him was in a stage of phobia in reference to his eyes. 
He feared that he was going to lose his sight. He was so terrorized by his 
visits to different doctors and hospitals that he could not get his eyes out of 
his head. The phobia on which the whole thing really depended had been 
reinforced by injudicious management, which was not based on a knowledge 
of the cause. The genesis was interpreted as follows: The conjunctiva had 
become irritated by considerable driving along dusty roads in an automobile 
in the glare of the summer sun ; in conjunction with the short sleep and the 
conviviality entailed by late hours. The protection of the eye-balls by lower- 
ing the lids was the consequence. In the manner of the tics, this physiolo- 
gical response eventually became a psychological habit. This habit the pa- 



PRACTICE OF MEDICINE JV 

tient might have shaken off as he had done previously with other tics; but 
in consequence of repeated medical opinions expressed during six weeks be- 
fore him by distinguished men in a famous hospital there was added to the 
habit, the phobia of the inability to open the eyes and the fear of loss of 
sight, and, with it, earning capacity. 

These cases all illustrate the fact that convulsive movements ot this kind 
depend upon mechanisms of psychological nature. They originate in an un- 
easiness. That may be of physical origin. There may be some general con- 
dition toxic like Bright's Disease, high blood pressure or endocrine, as in 
dysthyrodia and dyspituitarism. 

For example, a physician's daughter, aged eleven years, was brought be- 
cause of loss of interest in her lessons, of which she had previously been very 
fond, grimacing of the face and eyes in spite of all correction, equivocation 
and fibbing in attempts to evade her duties, and greediness amounting to 
gluttony. She had always been a stout child, but had become enormous dur- 
ing the preceding year or so. 

Exploration of a possible psychological cause for this change of behavior 
was fruitless ; so psychomotor exercises were begun for the facial tics. The 
only effect of these w^as to arouse the patient's resentment; they were not 
perserved with. Some time after, great somnolence manifested itself, the 
child becoming very lethargic and even dropping ofi to sleep in the middle of 
a task or at the table for a few moments. This directed attention to the 
function of the pituitary gland so this was immediately explored by the 
levulose test. As this showed great increase of the tolerance of the system 
to large amounts of sugar, it was decided that the pituitary gland was func- 
tioning insufficiently; great increase of weight, torpor, psychic inadequacy 
and its attendant changes in behavior being symptoms of lack of pituitary 
secretion. Feeding with increased doses of pituitary gland was at once be- 
gun. The child recovered completely in a few months, and after the onset 
of puberty was able to dispense with the pituitary gland ; and now, seven 
years late>r, is active and comparatively thin. 

Whether physiological or psychological the patient is made uneasy, and 
so he changes position to get relief. On the other hand the urge may be 
purely psychological, due to worry, anxiety, etc. It is the business of the 
physician to find out the cause of the movement so that he can overcome it. 
The first step is to find out exactly with what you are dealing. The second 
is to teach the patient to perform movements in a controlled fashion. 

Some ten years ago I succeeded in healing some cases of the kind, but also 
failed on several. I only discovered in the last few years that we failed by 
pushing exercise too rigidly. The greatest discretion is needed to prevent 
further constraint being developed by the patient. Much patience is needed. 
When that is done, I think that nearly all of these cases should get rid of 
their convulsive movements. But that must depend also upon the re-edu- 
cation of the patient's attitude toward the difficulty, because the condition 
is fundamentally psychological. 



40 NORTH CAROLINA MEDICAL SOCIETY 

ANAEMIA, WITH THE REPORT OF TWO CASES, ONE SEC- 
ONDARY AND THE OTHER PRIMARY. 

Dr. K. C. Moore, Wilson. 

, This paper has principally to deal with the report of two cases of anae- 
mia. I am reporting the first case, a case of secondary anaemia for two 
reasons, first that it taught me some very valuable lessons in making a diag- 
nosis, and second on account of its being a very interesting case. 

Mrs. W., age 22, married, came to me on account of general weakness, 
numbness in the extremities, shortness of breath, palpitation and occasion- 
ally pain around the heart, loss of weight, sleeplessness and complained of 
being very nervous. She had been going backward for about two years. 
Her loss of weight was very gradual, had only lost about twenty pounds 
during the two years. She had been married for two years to present hus- 
band. First husband died after living with her only a few months. First 
husband was supposed to have died of tuberculosis. She has had no children 
by either husband but has had two mis-carriages during her second married 
life and is now five months pregnant. She has suffered with a great deal of 
nausea during this entire pregnancy. She has had two abdominal operations 
during the past three years. The first about three years ago for appendici- 
tis, the second about twelve months ago for a large right cystic ovary. She 
had no complications with either operation, wounds healed nicely. 

Examination: The patient is very pale, the conjunctiva and mucous 
membranes are very pale, her teeth are good, tonsils are of normal size and 
appearance, there is no glandular enlargement in the neck, the chest is thin, 
ribs rather prominent, breasts are very small, showing an atrophy rather 
than an enlargement. On inspection, palpation, auscultation and percus- 
sion the lungs are normal. The heart is of normal size. There is a low 
systolic murmur heard at the base and is not transmitted. With this excep- 
tion the hearts sounds are normal. Rate is rather fast, 90. Abdominal ex- 
amination is negative with the exception of an enlarged uterus reaching to 
the umbilcus. Patella and eye reflexes are normal. 

Blood pressure at this time was 110, urine normal, both chemically and 
microscopically. Blood: Hemoglobin 65, RBC 3,400,000, WBC 6,700. 
Diff. Poly 59 large lymph small lymph 24 and eisin 2. The red blood cells 
were fairly constant as to size, they showed a distinct diminution of color- 
ing matter. There were no nucleated reds, very slight poikilocytosis. This 
patient was put on tonics and digestants with no improvement. I question- 
ed the husband very closely as to venereal diseases. He admitted having had 
Gonorrhoea, but flatly denied ever having syphilis. I knew the people well, 
they were of the better class of people, and although I suspicioned syphilis 
1 could not make myself believe it strong enough to have a Wassermann 
made. This is where I made my mistake. The patient went from bad to 
worse as the pregnancy advanced. She began to show albumin and casts in 
the urine, the blood pressure slowly began to rise and the blood condition be- 
came worse. Finally, I suggested consultation and the consultant made a 
Wassermann which showed four plus. She was then put on mercury in- 
unctions daily and fifteen drops of the syrup of iodine of iron was given 
after each meal. She was put to bed and kept there on practically a protein 



PRACTICE OF MEDICINE 41 

iree diet. Her condition improved wonderfully. Labor pains started up 
just a little after the eighth month, and she had a normal delivery of a dead 
baby. The inunctions were continued for two or three weeks and then 
small doses of neo-salvarsan were given weekly. After three doses the 
Wassermann was negative and has remained negative until the present 
time. She has given birth to a normal child who is now two years old. The 
kidney condition has entirely cleared up, her blood is normal, and she has 
gained about twenty-five pounds. 

There was never at any time anything suggestive of syphilis about this 
case with the exception of the miscarriages. A wassermann of the husband 
was negative. She has never had any eruption of any character. This case 
has taught the lesson that you can never be sure of the absense of syphilis in 
any one until you have thoroughly investigated. I have made it a rule since 
this case came under my observation to take a Wassermann of every case I 
examined, and never be sure of any thing until I had looked for myself. 

The second case I wish to report is a case of primary anaemia. 

Wm. W., male, 61, married, wholesale merchant and farmer. P'irst ex- 
amination Aug. 27, 1917. At this time patient came to me complaining of 
indigestion with a severe diarrhoea. (A year or two previously I had ex- 
amined this patient for life insurance and turned him down on account of a 
Chronic Bright's Disease, at this time he had a blood pressure of about 
180). Until he began to suffer from the indigestion and diarrhoea he had 
always been in good health. There was nothing else of any importance in 
the history at this time. Examination : Patient is well nourished, weight, 
169, muscles are well developed, tongue is a little red, especially at the tip, 
teeth and gums are in good condition, there is no glandular enlargement in 
the neck. Examination of the chest shows the lungs to be normal. The 
heart is slightly enlarged, apex extending to left and below the nipple line. 
Its sounds are normal. The abdomen is some what distended and slightly 
tympanitic; on palpation there are no tender areas. The liver and spleen 
do not show any enlargement. Patellar and pupil reflexes are normal. 

Stomach analysis : There is no free hydrochloric acid, the total acids are 
much diminished, lactic acid negative, Microscop. examination negative. 

Blood: Hem. 80% red blood cells 3,336,000, whites 7,800, Differ. Poly- 
mor. 60, small lymph. 22, large lymph, 16, and eisin, 2. There is a very 
large variation in the size of the red cells, some of them being two or three 
times the size of a normal red cell and others being a great deal smaller. 
There is a marked poikilocytosis — Wassermann negative. 

Urine: Slight trace of albumin, sugar negative, acid, and a few small 
hyalin casts. Blood pressure 135-90. 

Stools are watery with a great deal of undigested food particles, repeated 
examinations showed the absense of occult blood. 

A diagnosis of Primary Anaemia was made and dilute hydrochloric acid, 
arsenic in the form of Liq. Potass Arsenit. was prescribed. The diarrhoel 
condition improved for the time being and the blood remained fairly station- 
ary through the winter of 1917 and 1918. In the spring the diarrhoel con- 
dition returned, and the anaemia began to become more marked. Sodium 
cacodvlate was substituted for the Fowlers with no improvement. By June 



42 NORTH CAROLINA MEDICAL SOCIETY 

1918 the red count had gone as low as 2,500,000 and hemoglobin to about 
fifty-five percent. At this time I advised transfusions. Not being willing 
to trust myself with them, I advised him to go to Dr. Barker of Baltimore. 
I carried him there in July and his blood count on arrival, about three 
weeks after my last count was Reds 1,792,000 hemoglobin 50%. He was 
given a transfusion of 2500 cc. of blood which raised his count to red 
blood cells 3,000,000 and hemoglobin 75%. He remained in Baltimore 
about six weeks receiving two other transfusions, and returned home about 
the middle of August with a count red blood cells 4,800,000 and hemo- 
globin 100%. He was greatly improved in every respect. Was troubled 
with diarrhoea very little, weighed 178, and looked after his business dur- 
ing practically all of the fall and winter. In March, 1919, he reported to 
me again, saying that he had not been feeling so well during the past few 
weeks. At this time diarrhoea was very severe, and blood examination 
showed as follows* Red blood cells 3,000,000 hemoglobin 70%. I ad- 
vised him to take further transfusions before he got down so low. He be- 
came rather despondent and said he would let me know. I did not see very 
much of him any more until June, when I was called to his home. At this 
time I found him very weak, the color of a ],emon, suffering a great deal 
with dizziness and numbness in the extremities. Blood exam, as follows: 
Red blood cells 750,000 and hemoglobin less than 30%^. I told him that if 
he didn't have some transfusions and as soon as possible that he would die. 
We sent him to Baltimore again. On this trip he received seven trans- 
fusions in eight weeks time and returned to Wilson with a count of red 
blood cells 3,100,000, hemoglobin 80%o. He did not feel as well from these 
transfusions as after the first. Remained very weak and on Sept. 3rd, had 
dropped back to 2,022,000. I again advised transfusions and on Sept. 14th 
transfused 500 cc blood, Sept. 21st, 500 cc, Sept. 28th, 650 cc, Oct. 5, 1200 
cc, 12th 1000 cc, 19th 1000 cc, Nov. 16th, 350 cc, and on Nov. 30th, 
1200 cc. This was the last transfusion given and the following are counts 
made since the beginning of the last series of transfusions: Sept. 22, 2,- 
352,000, Sept 27. 2,104,000, Oct. 6, 2,920,000, Oct. 18, 3,472,000, Oct. 
27, 3,048,000, Dec. 10, 4,236,000, Jan. 27, 1920, 3,368,000, Feb. 20, 
3,992,000 and April 12, 2,280,000. During this past winter he has been 
fairlv comfortable, has been up and about most of the time, has suffered 
very little from the diarrhoeal condition. He has maintained his weight 
pretty well, weighs now 168. For the past two or three weeks he has been 
losing ground very rapidly and is very much in the need of transfusions. 
I intended to give him another transfusion the past week, but have not 
been able to get a sufficient amount of blood worked up, so he will be trans- 
fused again the latter part of this week. During the intervals between the 
transfusions he has been getting arsenic in various forms. I believe this has 
helped to hold his blood up, but I have never been able to influence it ai 
the least when it was low with anything except blood. 

This case has been kept alive for nearly two years with blood. Other 
remedies were tried very extensively on him without results. The cost of 
his living these two years has been rather expensive, but I am sure that he 
feels that he has gotten his moneys worth, because he is still ready and will- 
ing to take the transfusions, and does not hesitate to pay for the blood. 



PRACTICE OF MEDICINE 43 

The method used in this case was the citrate method. This is very sim- 
ple and there is practically no danger if the bloods are properly matched. 
To each 250 cc blood, nine grains of chemically pure sodium citrate dis- 
solved in one ounce of normal salt solution, made with freshly distilled 
water, is added and stirred constantly while the blood is being drawn. The 
blood is drawn by inserting a thirteen to fifteen gage needle into the medium 
basillic vein, the arm is corded above and the donor instructed to open and 
shut the hand. I prefer to use the thirteen gage needle as there is less likeli- 
hood of the needle becoming stopped up. It is also a very good idea to pin the 
vein to the skin with a fine combric needle to prevent it from rolling about. 
It is also easy to reinsert the needle when pinned, if from any reason, it 
should slip out. It is best to draw the blood in the same room with the 
recipient, and keep the vessel covered with a hot towel to keep it warm. 
This very often prevents a chill. I think it is very important to keep the 
blood warm. Where the blood has been transfused quickly and has not 
been allowed to become chilled I have had practically no reactions. 

The most important part of the technique in giving a transfusion is in 
having the bloods properly matched. This is a very simple procedure and 
any one can do it who knows how to use a microscope. The method I have 
used is as follows: One drop of each the donors and recipients blood is 
added to about one cc of a one and one-half percent solution of sodium cit- 
rate in normal salt solution, each blood of course, in a separate test tube. 
This gives us the blood cells. Into a centrifuge tube about one cc of blood, 
from the donor and recipient are put aside and allowed to coagulate. After 
coagulation takes place the clot is removed and the serum is run for a few 
minutes in the centrifuge to separate all the cells. A hanging drop is then 
made of a drop of the donors serum with a drop of the recipients cells, and 
one with a drop of the recipients serum with the cells of the donor. The 
slides are looked at with a low power every four or five minutes and the 
slides shaken to insure a thorough mixing. If the bloods match the cells in 
each slide remain evenly distributed, if they do not match the cells in one 
or both slides become clumped together. If agglutination does not take 
place within thirty minutes the bloods match and are safe to use. There 
are four blood groups, and if we have a known group 2 blood it is easy to 
group any other blood by testing against this blood. 

Transfusions are becoming more widely used every day, with an accurate 
matching system the dangers have been reduced to a minimum. They are 
not only indicated in the treatment of primary anaemia, but in the treat- 
ment of any severe case of secondary anaemia after the exciting cause is re- 
moved. They will save many lives in surgical patients who have suffered 
from hemorrhage. A transfusion is an absolute specific for an oozing hem- 
orrhage. A patient can hardly bleed to the point where transfusion will not 
save, providing it is properly matched and given while there is still life: 
In these cases the greatest source of failure is in not giving enough blood. 

The bloods of brothers and sisters usually match, but this is not always 
true. No case should be transfused without first doing an agglutination 
test. The donor should be a healthy person, and a young person is alvi^ays 
perferable to an elderly one. No person should be used as donor until a 
Wassermann has been made and found to be negative. 



44 NORTH CAROLINA MEDICAL SOCIETY 

DISCUSSION OF DR. MOORE^S PAPER: ANEMIA. 

Dr. R. a. McBrayer, Sanatorium: One thing that I would like to 
ask the doctor is what kind of Hemolytic anaemia the man had ? Another 
is whether he has ever employed the blood pressure apparatus in taking 
blood from the vein or in putting blood or medicines into it. In doing this 
I take the blood pressure, and after ascertaining the systolic, diastolic and 
pulse pressures, divide the latter by three. Now substract this quotient 
from the systolic reading. This gives the pressure, when applied, that will 
allow the arterial blood to come thru the arm band and will at the same 
time obstruct the venous return which means that you will get a permanent- 
ly distended vein and the flow therefrom will be constant and under pres- 
sure which adds much to the ease in which blood can be withdrawn from a 
vein. Equal advantage is in intravenous injections for as soon as the needle 
enters the vein (the blood which is under pressure) the blood begins to 
flow into the syringe. Immediately an assistant opens the air valve on the 
blood pressure apparatus and there is then in the vein an increased and more 
rapid flow centrally which is very desirable in such work. 

Dr. Moore^ closing the discussion: Dr. McBray^r's point about 
the blood pressure is very important. I have never used the blood pressure 
instrument, but have always been careful to see that the pulse is not cut off 
when the arm is corded. 

The case I mentioned was one of pernicious anemia. 

ARTERIAL TENSION AND ITS CLINICAL 
MANIFESTATIONS. 

Dr. Charles H. Peete, Warrenton, N. C. 
Ho7iored Presidentj and Gentlement of The Medical Society of The State 
of North Caroli?ia : 

In venturing to make a few remarks on Arterial Tension I recognize at 
once that I am entering into a field of extreme extent, and one that has 
been, and is being explored and investigated from every angle. And still 
we are confronted with no problem of greater importance; and I am speak- 
ing not to air any views or pet theories of my own, but to get the subject 
under discussion in a simple way, and see what the genlemen of this great 
State can advise in the way of prevention and treatment. 

Arterial Tension, high or low, is really an abnormality of circulation; 
it is a condition ; it has a cause ; it does not exist as an entitv with no be- 
ginning. It has been found from time immemorial. But it is hti/ie/ found in 
greater frequency as the years roll by. One cause of this may be that hav- 
ing been awakened to the fact we look for it ; and we have greater diagnos- 
tic facilities. But the fact remains that there is more arterial disturbance 
than there has ever been. I take it that it is the pace of present-day life, 
or living, a faster if not a fast, life, that is the chief cause of arterial abnor- 
mality. The tension may be high, or it may be low. The high pressure 
man struggles and hustles and keeps up with life; the low pressure man 
cannot keep up with the pace, and like a toddling infant he stumbles and 
falls as he tries to advance ; but the high pressure man has kept up with the 



PRACTICE OF MEDICINE 



45 



pace until he gets exhausted, or nearly so, and then wearily falls into the 
arms of the ever-ready medical friend and wonders why he is tired or feels 
wrong. The queer point is that they never think their manner of life or 
struggle causes their condition: — I do not here refer to the introspective 
neurasthenic. Life now is a competition, a race. And one engaged therein 
feels it, and the stimulation of it. The man who lives his life with an even 
mind and an easy attitude of life is seldom bothered with arterial abnor- 
mality. But he is a rare person indeed who does not permit the cares and 
worries of life to disturb his equanimity of spirit. It is my opinion that this 
mental attitude and lack of knowledge of the rules of proper living are the 
chief causes of arterial abnormality as we see it nowadays. I tell you frank- 
ly, gentlemen, it is appalling how little the average man knows how he 
should live. I mean in regard to food, rest, sleep, work, recreation, and 
mental activities. Mr. Business Man always asks how to run his automo- 
bile, how to run his factory, studies minutely how to run his business ; but 
he practically never asks or studies how to use the wonderful machine God 
has given him so as to keep it in the best shape and repair. The knowledge 
of the rules of right living, and their observance, is both the preventive and 
treatment of our subject; and it is the key problem of it. But we get the 
man when he is about down, or feels the wear; and we have an impaired 
mechanism to make over, — a difficult job. We all know about the "type" 
of man with arterial degeneration; we know that improper eating and 
drinking is a great cause of it. Right here though, I want to say that it is 
not always too much food; the correct preparation and the correct foods 
are too seldom used, and faulty foods, limited number of foods, and faulty 
cooking, will cause arterial degeneration just as quickly as other toxic causes 
and do it more insidiously. There are the multitudes of toxins, syphilis, 
and what not, that are responsible ; and there is no need to enumerate them, 
if one could. Nor is it necessary to more than mention worry, business 
pressure, lack of sleep, lack of recreation, — all these with improper eating, 
improper foods, and the toxic causes are the reasons of this degeneration. 
I do not believe that work per se is a cause ; but work and worry is a great 
cause. We find the increased tension in any person, man or woman ; proba- 
bly it is more frequent in men, but it is getting more prevalent with women. 
Thinness or stoutness makes no difference. I believe one outstanding fea- 
ture we all recognize is that increased pressure is an abnormality of advanc- 
ing years, although often we can measure a man's age better by the sphygmo- 
manometer than we can by the number of his birthdays. Nearly all show 
vertigo; many have a heart so strong as to shake the whole body or head 
when they are sitting quiet. There is the angina not only of the heart or 
aorta, but of the leg, abdomen, or arms. And the feeling of oppression in 
the chest, all sorts of digestive disorders, with weakness after eating by giv- 
ing the heart more exertion. Often a woman cannot arrange her hair or 
raise her arms. There is the tendency to fall in certain directions; the var- 
ious paresthesias, and the hot and cold flushes as well as the inability to 
keep warm or to get cool in hot weather. The kidney symptoms are too well 
known to need comment. Often tinnitus is the first symptom that brings 
the patient to the doctor, and like the vertigo, it is one that is apt to re- 
main. I believe the fat high-tension man suffers more than the thin ; he 
can't get about so well, nor can he arrange his position for comfort as well. 



46 NORTH CAROLINA MEDICAL SOCIETY 

Under treatment he often gets thin, but it is unwise to try to reduce to 
thinness a man who has always been stout, he is very apt to be made ex- 
hausted. In regard to the low pressure subject we are apt to find him a 
thin person, phlegmatic, with little energy. He is apt to have a hereditary 
condition, for his parents or their family are apt to have shown the same 
characteristics. He is prone to have abdominal ptoses of all sorts, and piles; 
as well as digestive disorders and melancholic mental views ; he is apt to be 
a pessimist. He fatigues easily and does not like exertion ; also he passes 
into a neurasthenic state very quickly. I have never been able to find any 
definite ascertainable cause for low blood pressure, and I have found it in 
the young adult as well as in the old. It would seem almost to be a part 
of the individual or his make-up. And from observation I have been forced 
to come to the conclusion that in spite of his ptoses, dyspepsias, etc., he is apt 
to be long lived. One thing is that he never has energy enough to over- 
work himself; and his heart beats so slow it gives itself plenty of time to 
rest itself. And I have never found any treatment, and I have given them 
all known cardiants, tonics, baths, massages, diets, ets., that would alleviate. 
I do not advise office life however, but ask them to go to the farm if pos- 
sible. 

I shall not speak of medicine for the hig'h-tension man ; we all have tried 
the whole Pharmacopeia and have made no definite cure. We have to try 
and relieve the symptoms, and we should. But the best plan is to put the 
patient to some likable occupation with moderate bodily work, and get him 
into a mental attitude that will prevent worry, and instruct him how to 
live properly with food, sleep, rest, recreation. I do not believe we should 
take proper work in right amounts from the patient; it leaves his n^ind too 
mudi unoccupied ; but at the same time he must learn that it is just as im- 
portant to rest with relaxation as it is to work. One type of hypertension 
I fear has been injured by too much solicitation on our part is the big man 
who has what seems to be essential hypertension ; in other words the pres- 
sure of 170 to 180 seems to be really his measure. I have seen such men go 
for years with no urinary or other damage. But I do think such cases ought 
to be properly warned, directed, and observed, but not overly coddled. I 
should like to get an expression from this assembly what it thinks in regard 
to the use of tobacco in hypertension. I have never been able to decide the 
question to my satisfaction. We see tobacco users live very old. I cannot 
say I think it causes hypertension ; but I do think the continued use of to- 
bacco once hypertension is established does not tend to reduce the condition. 

TOXIC ARTHRALGIA. ' 
Dr. O. Edwin, Finch, Apex 

By this condition I mean. Painful Joints, with but slight swelling, and 
usually an associated myositis, which is more commonly known as "rheu- 
matism." In some cases a mild infection of the joint may be associated. 
The prime etiological factor being toxins, produced directly or indirectly 
by bacteria at some distant focus or foci. In this paper I do not intend 
to discuss the various locations in which foci of infection may be found, 
capable of producing toxic arthralgia. 



PRACTICE OF MEDICINE 47 

Toxic arthralgia is found more frequently involving the shoulder, sacro- 
iliac, hip, knee, cervical spine, wrist and ankle joints. Rarely involving the 
lesser joints — toes and fingers. It is also rarely symmetrical. If more than 
one joint is involved, the hip of one side and shoulder of the other or vice 
versa. 

The onset is usually insfdious. Pain the chief symptom which is but rare- 
ly definitely localized to the joint, usually radiating in the line of muscle 
and nerve distributions. For instance, if the hip is involved, the pain us- 
ually radiates in the course of sciatic nerve. On exercise the condition is 
made worse. Pulse and temperature are but rarely affected. 

The areas in which foci of infection may be found, in order of their im- 
portance are — 1st, teeth, 2nd tonsils, 3rd gastro intestinal tract — a key to 
which may be expressed by three "T's", teeth, tonsils and 'testines. By the 
tonsils, I mean the naso pharynx. 

The teeth : Dr. Mayo recently said, "The next great step in preventive 
medicine will come from the dentist, — will they take it?" Six years have 
elapsed since Billings published the important fact that septic foci, even 
when small, are a source of infedtion when transmitted by the blood stream. 
Oral sepsis has come into prominence only recently in connection with what 
is called focal infection. The particular pathological condition found in 
the mouth, of which we are especially concerned are : 

(A) Pyorrhea or supperative gingivitis. 

(B.) Alveolar abscesses. 

(C.) Infected pulps. 

(D.) Apical abscesses. 

(E.) Discharging sinuses and 

(F.) Granulomas . 

The most important factor about these conditions are that for years they 
drain their insidious toxins into the alimentary canal, lymph and blood 
channels without giving the slighest symptom that would cause the patient 
or physician to suspect their existence. Even should they produce symp- 
toms, when 3'ou first mention such a condition as the source of trouble, be- 
ing in the teeth, the patient will declare you are insane for he believes every 
tooth in his head to be as sound as a silver dollar. Those lesions that are 
more or less enclosed are the most dangerous, for here the toxin is drained 
into the circulation and sooner or later, alone or in conjunction with some 
predisposing factor, they will break down the resistance of the patient and 
produce toxic arthralgia and other systemic ills too numerous to mention. 
I have in mind a white male, age 45, who came into my office on crutches. 
He complained of severe pains located in the shoulder and hip joints. Un- 
der the care of another physician the salicylates had been used with no de- 
gree of improvement. On examination of his teeth I found pyorrhoea in- 
volving two lower molars and three lower incisors, with free pus easily ex- 
pressed from around these teeth. Without prescribing, he was referred to 
a dentist who extracted the five teeth, and rendered surgical treatment. In 
two weeks time the patient had obtained complete function. This case is 
not the typical, to the contrary his condition was atypical. It is in the 
typical cases that we find those obscure infections of the teeth, particularly 



48 NORTH CAROLINA MEDICAL SOCIETY 

blind abscesses and pulpless teeth ; for they require our most diligent work. 
In fact the diagnosis of oral sepsis is not a one man's job, particularly for 
the physician. It is necessary for the physician, dentist and xray man to 
work together. The dentist taking the clinical and xray findings into con- 
sideration, is alone qualified to make the final diagnosis. I make it a rule 
to but rarely advise a wide and complete extraction of all teeth without 
first invoking the aid of the xray man. So often we are prone to make a 
superficial examination of the teeth and refer the patient to a dentist, with 
instructions to leave not a tooth. Almost as often we fail to get results 
with these cases, for more than one reason, but one particular, is because we 
have not made a diagnosis with the aid of the xray man and a dental sur- 
geon. Taking for granted that our diagnosis is correct we fail to obtain 
results because there may still exist pus pockets in the gums or alveolar 
processes, which mere extraction of the teeth has failed to drain. The den- 
tist should lightly cureette the alveolar pockets and break up any shell that 
may be protecting the pus pockets. Even though extraction has been com- 
plete in some cases and no results obtained, you should have an xray picture 
made of the alveolar processes for the presence of pus pockets. It is my 
honest conviction that a part of the dental profession are responsible for a 
large percentage of oral sepsis by the insane practice of destroying nerve and 
blood supply, i. e., removing the pulp, treating root canals and allowing 
pulpless teeth to remain. Drs. Rosenow, Billings and Hartzell contend 
that pulpless teeth are a menace to the human system, and should, without 
exception, be removed. A pulpless tooth is a devitalized tooth, (Dr. A. D. 
Black reports that 47% of devitalized teeth have alveolar abscesses; others 
report as high as 80%.) When the pulp is removed from a tooth its dentin 
becomes dead dentin in the same sense that bone in which the bone corpus-" 
cles have been killed is necrosed bone. How many of you would like to 
have the surgeon leave dead bone in your osteomyelitic femur or tibia as 
the case might be? Recently, I inquired of a dentist why it was that he 
continued to practice such dentistry. He replied: "Should I insist on re- 
moving those teeth the patient would discharge my services and seek a den- 
tist who would give "treatments" and encourage the patient to retain his 
so-called sound teeth." So long as such an attitude as this exists in the den- 
tal profession just so long will we continue to have septic oral conditions 
and innumerable systemic ailments traceable to such foci. 

It is not the removal of a sound tooth we desire, therefore, a word of 
precaution is not amiss. Teeth should never be removed unless the indi- 
cations are clear. We have passed the area of ovariectomy, appendectomy, 
with our patients, be careful what we promise them, save serviceable 
teeth whenever possible. It is not the counsel of the radical, nor the ultra- 
conservative dentist that we desire, but a happy-medium-fellow who 
is willing to launch out in mid-stream and by the grace of God and 
the aid of the Xray do that which he feels and knows to be good den- 
tal surgery. Having found such a dentist sustain him in his ef¥orts to 
educate the public in oral hygiene. 

Tonsils or Nasopharynx: It is to the faucial tonsils that we owe an 
apology for so many of our sins of misdiagnosis. I am not referring, 
necessarily, to those tonsils that are enlarged and obstructive ; it is the 



PRACTICE OF MEDICINE 49 

infected tonsils; whether it be enlarged, obstructiv^e or embedded. I 
know of no better way to emphasize this than by relating, in a super- 
ficial manner, a case record — Miss S., white, aged 19, came to me 
complaining of pains in her left shoulder joint, and the joints of her 
right Icnee. She had been the rounds of general practitioner, electro- 
therapeutist, stomach specialist, etc. Examination was negative with 
the exception of her tonsils. She had a pair of embedded and infected 
tonsils. From the cryptic areas free pus could be easily expressed. She 
was referred to a throat man who removed her tonsils under ether. In 
three months time from the date of her tonsillectomy, she was free from 
all pains. Had good digestion, appetite and color. During this time 
she gained thirty-one pounds. Previous to her operation she stated that 
she could not digest or retain but very little food, for this reason she 
consulted the stomach man, — -I cannot understand how the somach spec- 
cialist could pass a stomach tube down her throat and not see (or smell) 
that he was slipping his tube past the primary into the secondary condi- 
tion. He finally informed her to go home and not return for further 
treatments, as he could not benefit her condition. I could not help but 
admire his frankness after he had given her two months stomach tube 
treatment with its associated scientific fractional test. Dr. Thos. McCrae 
says "More of us make our mistakes by not looking and feeling — not that 
we do not know." In our effort to determine if the tonsils are at fault 
it is very necessary that a close and pains-taking examination be made. 
Merely using a tongue depressor and making a superficial inspection is 
not an examination. It is necessary to use a probe guarded with cot- 
ton and search out the crypts, and other obscure areas of the tonsils. 
Have the patient make digital pressure at the angle of the jaws, which 
will push the tonsils nearer mid-line, then grasp the anterior pillar with 
a tonsil retractor, make pressure with a blunt instrument over the body 
of the tonsil. In many instances pus pockets will be identified that 
would otherwise be unobserved. Get the idea out of your mind that the 
wall bracket lamp and head mirror are intended only for the ear, nose 
and throat specialist. The physician who fails to equip his office with 
modern fixtures will not be able to locate these finer points in diagnosis. 
Very often tonsils are infected secondarily from the teeth. I do not 
think that tonsils should be removed without first attending to the teeth. 
Dr. Rosenow declares that the lymphatics of the mouth and jaws drain 
into the tonsils. Some of the infections of the tonsils improve, or may 
entirely disappear following extraction of infected teeth. 

Accessory Sinuses: Infection here is more common following influenza. 
It is not the acute sinusitis that is most likely to produce arthralgia; to the 
contrary, it is the chronic variety that produces a continuous stream of 
poisons that is most likely to produce arthralgia. Evidence of such infec- 
tion is usually found in a patient sufiEering with so-called "Catarrh of the 
head," usually a profuse yellowish, fetid, nasal discharge; more commonly 
it is unilateral. He will complain of a bad taste in his mouth, appearing 
irregularly during the day. Pain is an indefinite symptom but if present 
it is usually located over the eyes and in the temporal region. As a means 
of diagnosis the xray and trans-illumination are the most reliable. 

In conjunction with nasopharynx the chronically infected middle ear, 



50 NORTH CAROLINA MEDICAL SOCIETY 

and mastoid are not to be forgotten. I believe that a long continued at- 
track of otitis media is responsible for more chronic joint pains than is gen- 
erally credited to this area. 

Gastro Intestinal Tract: The stomach as a primary focus for the ab- 
sorption of toxins producing arthralgia is rarely at fault. In fact the 
stomach is but rarely ever the primary seat of any systemic affection. We 
recognize gastroptosis of some importance on account of the slowness in 
which food passes, allowing chemical and bacteriological changes to occur — 
thereby serving as a medium for the production of toxins, which, if ab- 
sorbed may in this manner produce a toxic arthralgia. 

More commonly do we find the gall sac the seat of trouble. In order to 
have elaboration of toxins it is not necessary for gall stones nor an acute 
cholecystitis to be present, altho a history of having had such a condition 
is a predisposing factor. It is the chronically infected gall bladder that is 
more commonly the greatest factor here. The most prominent symptom 
here is a slight intermittent pain, made worse by deep palpation at the angle 
of the ribs ; with heavy percussion an area of soreness may be elicited at the 
angle of the right scapula. History of slight indigestion, eructation of gas 
after meals, frequent toxic headaches. The symptoms referable to the gall 
sac are in proportion to the pathological changes. The point I wish to em- 
phasize is the absence of the more prominent signs and symptoms of gall 
bladder trouble, which may lead us to ignore this region as a possible focus 
of infection. Infection of the gall bladder may gain entrance thru the blood 
stream or by way of the ducts from the intestines. Inflammation of the ducts 
produces stagnation and stagnation predisposes to infection. Such a gall 
bladder may contain a thick mucoid secretion ; — a veritable hot bed for the 
progressive multiplication of bacteria and their toxins. Xray examination 
here will be practically negative. 

The large and small intestines as factors in producing arthralgia may be 
summarized as chronic intestinal stasis. The conditions producing such a 
stasis are numerous, a few of which I will mention: Chronic appendicitis, 
adhesions, kinks, enteroptosis fecal impaction, foreign bodies, volvulous, 
mtussuseption herri;e's, cicatricial stricture, tumors, paralysis, etc. What- 
ever the factor in producing stasis, the essential truth to bear in mind is the 
production of toxins by bacteria and chemical changes of food. The stasis 
permits more absorption of these poisons by the cfrculation, thereby pro- 
ducing constitutional symptoms, particularly arthralgia. The large intes- 
tines play such an important part in the absorption of poisons that Metch- 
nikofif. Lane and others would regard it as a useless and dangerous en- 
cumberance and would take it out and throw it away. 

The appendix I will endeavor to consider alone on account of the pre- 
valence of chronic appendicitis. In such a chronic infection we find an area 
that is directly or indirectly responsible for toxic arthralgia. I feel that we 
have passed the age when it was not safe, nor wise, for a patient to come to 
us with a pain located in the right iliac fossa. Therefore, we are to adopt 
a conservative idea of appendicial inflammation. A chronically inflammed 
appendix is a focal infection absolutely as capable of producing arthralgia 
as an apical abscess or pussy tonsils. The patients so afiEected are not, but 
in few rare instances, aware of any trouble located in this region. They 



PRACTICE OF MEDICINE 51 

may in some cases complain of pain in the region of the right sacro iliac 
articulation or in the right flank or perhaps the right hip joint. I do not 
mean by this that every patient who has a pain in these regions is afifected 
with chronic appendicitis, but a careful examination and painstaking his- 
tory for such a condition may help to confirm or eliminate this focus. In 
chronid appendicitis, dyspepsia may so dominate the clinical picture as to 
lead us to believe the case to be one of gastric disease. There may or may 
not be tenderness in the region of the appendix, altho, occasionally in those 
recurrent attacks, tenderness may be found at McBurney's point. 
, In attempting a diagnosis of any gastro-intestinal lesion producing toxic 
arthralgia, the greatest aid will be a thorough clinical examination sup- 
plemented by a thorough x-ray analysis. 

In making your diagnosis as to cause of toxic arthralgia, do not stop 
when you have found one focus, for there may be many foci, which are to 
be remedied before your patient will realize relief. Search diligently for 
those areas of focal infection. Let your motto be similar to that of the 
Royal Northwest Mounted Police, "In attempting to find your man, let 
your trail lead you to the uttermost parts of the earth, but find your man." 
So it should be with us — even tho the symptoms should lead you to the 
uttermost parts of the human anatomy — find your focus or foci of infec- 
tion. The treatment of toxic arthralgia may be summarized with three 
words, — "Remove the cause." 

Dr. J. M. TempletoNj Cary : I want in the first place to express my 
gratification that so many young men are reading papers at this meeting 
and I wish to discuss them not so much in the hope of shedding more light 
on the subject, but rather to encourage young men in such efforts that they 
may profit by my mistake not waiting till they are too old to write well. I 
would be especially glad to say something on the paper of my friend, Dr. 
McBrayer's son, but I must admit I never heard of the test of which it is 
the subject until this good hour ; also that of my friend Leinbach, but I 
know too little about "hypertension" to do so. My friend Dr. Findh has 
just read an excellent paper on an up to date subject. It presents two 
points that impress me: First, the futility of treating symptoms; second, 
the importance of looking back of the effect to find the cause. 

When I graduated some 40 years ago I knew that a pain in the knee was 
sometimes a symptom of disease of the hip-joint and I was often on the 
"anxious seat" lest I prescribe chloroform liniment applied to the knee for 
a case of morbus coxarious. 

The first important reflex, if I may call it such, of the character with 
which Dr. Finch's paper deals, that I recall was eye strain, which was so 
ably championed by Dr. Ambrose L. Ranney. That was years and years 
ago and I guess I was impressed by it because Dr. Ranney was one of the 
faculty at the University of New York City when I was a student there. 
He made the mistake most pioneers in such things made in carrying them to 
extremes, professing to cure everything from "corns to consumption," by 
correcting eye-strain, still he succeeded and got where he could keep his 
private yacht. 

Next we had the era that attributed everything, especially everything 
feminine, to the condition of the organs of generation, celiotomies and ab- 



52 NORTH CAROLINA MEDICAL SOCIETY 

dominal section became the fashion with a holocaust of sacrificed wombs, 
tubes and ovaries. Next, I think, taking them in chronological order, we 
began to attribute a multitude of diseases to the appendix and gall bladder 
and these organs were cut out by thousands. After a time we found that 
these operations would not cure everything, and sanity and system and 
common sense led us to discriminate when and when not to operate. 

Now we turn to the tonsils and teeth and there's a tendency to go to 
extremes in getting rid of them, and bye and bye, we'll know when and 
when not to remove them. Then it will be something else, possibly follow- 
ing the hints in Dr. McNider's paper. When we find albumen in the urine 
we'll treat the liver as the offending organ. It's strange to me that for 
thousands of years we never traced these diseases back to these causes. I 
expect it would have astounded Old Hippocrates if he'd been told rheuma- 
tism could be cured by extracting a tooth or tonsil. Yet we may have some 
equally wonderful things ahead of us. Do you know I never treated a case 
of Osteo myeltitis in a baldheaded man in my life ; will we cure it some day 
by pulling out a tuft of hair ? 

The cardinal symptoms of meningitis are connected with the feet ; Kernig 
and Babinski's signs and will we cure it some day by pulling out toe nails? 

SYMPTOMATOLOGY OF TYPHOID FEVER 
Dr. p. R. Hardee, Stem. 

Since promising to write a paper on typhoid fever, and not having done 
so, I feel that I am due the stenographer an apology. I feel that I am also 
due the Society an apology for promising to write a paper when I knew 
full well that I could write nothing that would be legible. 

In taking up this subject, which goes back into tradition, I know that 
you are not going to expect anything new or startling from one who can 
not write anything, legible. The thing, gentlemen, that we are most in 
need of in the symptomatology of typhoid fever is some cardinal symptom 
which, in the early stages of the disease, will point the way and help to 
make the diagnosis easy. Unfortunately, however, the symptomatology of 
typhoid fever is somewhat as it is in tuberculosis — there is no cardinal symp- 
tom by which we can recognize the disease in its early stages — and often 
before it is recognized it makes great inroads and many lives are thereby 
lost. 

Now, it is true that we have some tests by which we can say with some 
degree of positiveness that our patient has typhoid fever, provided those tests 
are positive, but none of these tests are supposed to be positive under about 
six to eight days. For instance, the Widal reaction is not supposed to be 
positive before the eighth day of the disease, and the test that I have found 
to be of more benefit to me than any other is the Russo test. I think that 
you will find it positive earlier than by any other test. 

In treating this disease, and studying the symptomatology, it may be that 
I am a little bit presumptuous, but I believe that I have found that symp-, 
tom which we, as general practitioners, are so much in need of in the early 
stage of the disease. I have found what, to me, is a cardinal symptom. It 
is a symptom that I have found present in a large majority of the cases on 



PRACTICE OF MEDICINE 53 

my first or second visit. It enables me to say with a good bit of certainty, 
certainly on the second visit, that the patient has typhoid fever. It is this 
symptom about which I am going to talk to you this afternoon. It was 
first noticed by me on taking over a case of typhoid fever in the month of 
September, 1917. 

In taking over this patient, who was in about the fourth week of the 
disease, in going over him in my examination I found the heart and lungs 
normal, or as nearly normal as you would expect to find in a patient in the 
fourth week of the disease. But when I placed the stethoscope in the upper 
gastric region, well nigh under the ensiform cartilage, I detected a sound 
that I had never before heard in that region. It was something that was 
new to me, and I did not know what to make of it. The sound that I 
heard was more like the sound produced in a loud murmur in mitral regur- 
gitation than anything else to which I could compare it at the time. I went 
back and put the stethoscope over the heart, but there was no mitral regur- 
gitation. I should have said that this sound was synchronous with the pulse. 
I knew that it was a heart sound. Instead of getting a pulsation at the end 
of the ensiform cartilage, we got an explosion. It was much like the noise 
of an aneurysm, but there was no tumor and no pulsation, I knew that it 
could not be an aneurysm. So I left that patient confounded and non> 
plussed, not knowing what could produce the sound in his stomach that I 
heard. Two days later I saw some other patients that had gotten infected 
from this source, and I listened for that particular noise and found it pres- 
ent in each one at the first visit. There were six or eight cases from that 
source of infection which I treated in the next few weeks, and every one 
produced that same noise in the very early stages of the disease, except one. 
I have had one patient since who was short and stout and in whom the dis- 
ease ran a very light course, and I detected no abnormal sound in his abdo- 
men in the whole course of the disease. He is the only one I have seen 
since 1917 who has not had that symptom from the very beginning and alJ 
along through the disease. After seeing six or eight of these patients and 
finding this sound almost always present I began to think that I had found 
a new symptom of typhoid fever. 

I realized, gentlemen, at once that if this noise which I heard in the epi- 
gastric region, well nigh under the ensiform cartilage, was a symptom of 
typhoid fever, it is valuable as a symptom in proportion as it is absent in 
other conditions. So I went to work and examined the abdomen of every 
patient I saw for quite a while, with negative results. After a few months 
of patient searching there came to my office one day a small, thin, anemic 
woman. I judged from the contour of her abdomen that she had reached 
the sixth month in pregnancy. In going over her abdomen to see if I could 
find the old familiar sound, I did not hear it in the epigastrium, but when 
I got down to the right siliac region I heard the sound. I at once recog- 
nized that it was what writers call the uterine bruit of pregnancy. So I 
argued that if this was called the uterine bruit of pregnancy, I would 
christen the sound which I discovered the epigastric bruit of typhoid fever. 
It seems that the pulsation comes to the end of the ensiform cartilage and 
splits up into a bruit. 

I continued these examinations on every patient I saw, and the succeeding 
spring there came a young man to my office suffering with symptoms which 



54 NORTH CAROLINA MEDICAL SOCIETY 

I thought were produced by a peptic gastric ulcer. In going over him 
I detected the same sound. My tentative diagnosis in this case was gastric 
ulcer. Knowing the young man's disposition as I did, I knew that I could 
not cure him at home, so I sent him to a hospital, where they verified the 
diagnosis with the different tests and put him to bed and cured him. He 
came back home, but the bruit remained there for quite a while after he 
was cured of the ulcer. Still I continued. A few months later I w^as called, 
one night to see a woman, and when I got there they told me that she had 
been vomiting blood and that she had vomited until she fainted. From the 
amount of blood on the floor, I did not doubt a word about her having 
fainted. I made a tentative diagnosis in this case of gastric ulcer. That 
night the hemorrhage had stopped. As soon as I could make a manual 
examination I listened for that particular sound, and about four inches 
from the end of the ensiform cartilage, to the left, I heard it. I believe you 
vvill get this bruit in gastric ulcer. I hope the gastroligist will take up that 
hint and follow it out. 

Now, as to the time, I have told you that you will find this bruit in the 
very earliest stages of typhoid fever. A young man came to my office one 
evening suiiFering with what he called indigestion and dyspepsia, but I no- 
ticed that he had an epigastric bruit, the old familiar sound I had so often 
heard in typhoid fever. Two days later I received a message from his fa- 
ther stating that the boy was no better and to come to see him. He ran 
the usual course of typhoid fever for four weeks and had hemorrhages. I 
believe that we have in that bruit a cardinal symptom of typhoid fever in 
the early stages. It has never failed to be present in every case I have seen 
since I first detected it, except one. The number, however, is not large. 
As to the time, you will find that bruit present not only in the beginning, 
but present all the way through. I remember the last patient whom I 
treated. It was the most prominent symptom all the way. When I dis- 
charged that patient, when he was told it was unnecessary to come again, 
the bruit was just as loud as at any time during the disease. I thought I 
would follow up that case and see how long it would follow a case of 
typhoid fever, so I instructed the patient to report once a week for an ex- 
amination. He reported promptly for eight weeks and the bruit was still 
there. I saw that he was getting tired and was wondering why I continued 
to examine him so often, so I told him t6 come again at the end of a month, 
which was three months after his recovery from typhoid. The bruit was 
just as prominent then as during the disease. 

I do not think there is anything more. I hope that you gentlemen will 
look for this thing, and I believe you will be interested in it. It will help 
you to say with a good deal of certainty to the patient, on the second or 
third visit that he has typhoid fever. The symptoms are so indefinite in 
early typhoid, so unreliable, that it takes a good time to say whether it is 
typhoid. This is the one reliable symptom that I have been able to find in 
the early stage of the disease, and it stays there all the way through. 1 do 
not know to what it is due. One doctor said that it might be due to anemia, 
but I have treated cases of pernicious anemia and have not found it. 1 
hope some scientific man will take up this matter and find out what pro- 
duces this bruit. 



PRACTICE OF MEDICINE 55 

SOME FACTS. OLD AND NEW, CONCERNING THE HEART 

AND THE PULSE 

Dr. Hubert Benbury Haywood, Jr., Ralj^gh, N. C. 

The advances in this branch of medicine in recent years have been so 
marked and the changes of opinion so great that they strike one as being 
almost revolutionary in character. 

The polygraph and electro Cardiagraph have come into use and enabled 
Clinicians of diagnose abscure conditions, as auricular fibrillation, heart 
block, and other diseases of the myocardium and its valves. 

However, Sir James MacKenzie, in a recent work states: "The em- 
ployment of instruments of precision fosters the idea that medicine is be- 
coming more scientific with the extension of their use, and there is a ten- 
dency to rely more and more upon them, and to substitute them for the 
senses of the physician. I have little hesitation in saying that this attitude 
towards methods of examination which is dominant today is based on a 
fallacy. So far from the clinical methods of examination by the unaided 
senses being exhausted, they-have not been sufficiently cultivated, and the 
substitution of mechanical methods for them shows a lack of understanding 
of what clinical medicine means and how its study should be presented." 

The classification of symptoms in dealing with a diseased heart will show 
the functional efficiency of that organ. The symptoms revealed by a me- 
chanical device cannot well do this, for they belong to the structural group. 

The Stethoscope shows a heart murmur, and too often we put this down 
as the whole story and write finis after the patient's name. 

We do this in spite of the fact that the heart is in full compensation and 
there is no evidence of disease of the myodardium. Why not study the 
clinical symptoms and find the real potent condition ? Is the myocardium 
diseased, or is there only a valvular condition present? May not the so- 
called functional murmur heard over the heart, if it fits in with the clinical 
symptoms, be indicative of disease of the myocardium and really be of more 
importance as to prognosis at the time than a loud systolic murmur at the 
mitral valve? 

Valvular disease of the heart is with few exceptions easy of recognition. 
Changes in the heart muscle are, on the other hand, often extremely diffi- 
cult of recognition. Although the term "Heart disease" is in the hands of 
many of the laity, and the profession also, associated with a valvular lesion, 
it cannot be too strongly emphasized that the ability of the heart to carry 
on its functions is dependent almost entirely on the condition of the Cardiac 
muscle. The majority of valvular lesions are for a long time, and in many 
instances, always of secondary importance. 

So long as the heart muscle remains healthy, the heart subject to chronic 
valvular disease is capable of performing its work as well as a normal heart. 

When, however, the heart muscle becomes exhausted as the result of com- 
pensation having reached its limit, or when the heart muscle becomes de- 
generated as the result of disease, with or without valvular defects, the 
most serious circulatory disturbance takes place. 



56 NORTH CAROLINA MEDICAL SOCIETY 

Degenerative changes of the heart muscle are too often over looked, al- 
though the etiological factor should put us on our guard. Diphtheria is a 
well recognized cause of acute degenerative changes in the muscle, and may 
end fatally unless prompt recognition is made. Too often a condition that 
is real and vital is passed up and diagnosed as "weak heart." 

The structural changes which take place may be: Physiological or path- 
ological hypertrophy. 

Dilation of one or more of the chambers. 

Degenerative changes of the muscle, which may be acute or chronic. 

Unusual conditions such as syphilitic gummata, abscess and aneurysm. 

Two forms of hypertrophy are noted. 

Simple hypertrophy without change in the size of the cavities of the 
heart. 

Hypertrophy plus dilation of the cavities. 

Valvular disease is the commonest cause of hypertrophy. Chronic adhe- 
sive pericarditis is another cause. Arteriosclerosis and chronic Nephritis 
are the next commonest cause of hypertrophy. Excessive beer drinking is 
a common cause. Tachycardia, as seen in Graves' disease, due to increased 
cardiac action, is often noted as a cause. 

The changes in a myocarditis which impair the structure and the func- 
tion of the muscle may affect all ot only a portion of the heart muscle. 
The severity of the lesion will therefore often depend upon its location 
rather than its extent. For instance, a degenerative change may affect the 
auriculo-ventricular bundle of His and lead to a complete or partial heart 
block. With a few exceptions, an acute myocarditis occurs as a result of 
some acute infectious process. 

Among the acute infectious diseases noted as affecting the myocardium 
are acute Rheumatic Fever, Diphtheria, and Influenza, as we have all 
learned to our sorrow, when often the signs of Cardiac weakness do not 
appear for some time after the disappearance of the disease. 

Syphilis may cause an acute myocarditis during the acute stages of the 
disease. Typhoid Fever often leaves the myocardium permanently damaged. 

It too often happens that in our anxiety over the primary disease we lose 
sight of the secondary condition. Often the symptoms are so slight as to 
be readily overlooked. Usually they are restlessness or apathy, breathless- 
ness on exertion, and a sense of constriction in the chest, and sometimes 
anginoid pain. In the more serious cases there will be evidences of dilatation 
of the heart, cyanosis, dyspnea, precordial and hepatic pain, vomiting and 
edema. 

Physical signs show: 

The patient is rather pallid and either restless or apathetic. If dilatation 
has occurred there may be cyanosis and more or less edema of the lower 
extremities. If dilatation has occurred the apex is diffuse and displaced to 
the left. 

The pulse is usually feeble, with or without an increase in rate ; after 
influenza a slow pulse may be encountered for weeks after an attack. The 
blood pressure is usually low after an acute myocarditis. 



PRACTICE OF MEDICINE 57 

If dilatation has occurred there is an increase in the transverse diameter of 
the heart. If myocardial weakness is at all marked the valvular sounds are 
accentuated and short, and the first sound lacks the normal muscular 
quality". 

The second pulmonic is usually sharply accentuate; either the first or 
the second sound may be reduplicated. If reduplication of the first sound 
occurs it is one of the first intimations of a dilatation. 

A functional murmur at the mitral area is heard often, and at the same 
time a similar murmur may be heard at the tricuspid area. 

The causes of chronic myocarditis are varied. The chronic lesion is in 
nearly all instances a sequel of an acute process. 

The change is usually insidious and gives no evidence if its presence until 
serious muscular inefficiency develops. One of the commonest causes is 
disturbances of the coronary circulation with consequent poor nutrition of 
the cardiac muscle. The causes of the coronary sclerosis are the same as 
those of arterio-sclerosis in the body elsewhere. 

The final stage of valvular disease usually is muscular inefficiency due to 
myocardial degeneration. This is caused by overwork and perversions in 
cardiac metabolism. 

Included in this group are those instances in which the heart has for a 
long time beat at greatly increased rate, the most notable example of which 
is seen in exopthalmic goitre. 

The muscular inefficiency usually manifests itself in that part of the heart 
Avhere the strain has been greatest. Thus in general arterio-sclerosis, aortic 
insufficiency, and the hj'pertrophy due to excessive exercise, it is the left 
ventricle which is subject to the greatest strain. 

On the other hand, chronic pulmonary changes produce the greatest 
change in the right ventricle. 

The clinical picture is a varied one. Often sudden death may be the first 
intimation that the disease exists. Cabot states that the condition was rec- 
ognized correctly in 22 per cent, of cases, overlooked in 22 per cent., and 
diagnosed when not present in 52 per cent. 

The most pronounced symptom is that of cardiac insufficiency. Very 
often the symptoms of cardiac weakness are overshadowed by some special 
symptom complex, as Angina Pectoric, Stokes-Adams disease, or hyperten- 
sion with or without nephritis. The first intimation of myocardial weak- 
ness may be transient attacks of dizziness and faintness, and this is espe- 
cially apt to occur in robust middle aged men with hardening of the arteries. 
Breathlessness and a sense of oppression in the chest after some light but 
unusual exertion are early symptoms. Pain is especially apt to occur if 
the exertion follows a meal. The pain passes ofi with the eructation of 
gas. The trouble is oftimes erroneously called dyspepsia. Slight swelling 
of the feet and ankles may be an early manifestation. 

Dyspnoea may be associated with these symptims. In other instances the 
patient suffers from collapse in which he sweats and has a feeble but slow 
pulse. In these individuals with fatty overgrowth of the heart asthmatic 
attacks are common. Their puffing respiration is usually ascribed to obes- 
ity, but it is more often an evidence of cardiac weakness. In some corpulent 



58 NORTH CAROLINA MEDICAL SOCIETY 

individuals the face has a dusky, congested appearance which is commonly- 
ascribed to ruddy health, but which in reality is due to venous stasis result- 
ing from faulty heart action. 

Examination of the heart will show some increase in dullness to the left, 
and intensely accentuated second aortic sound, and accentuation of and a 
valvular quality to the first sound at the apex. A harsh systolic murmur 
at the aortic area is a frequent finding. 

Briefly, it may be stated that the etiology and symptomatology of chronic 
degeneration of the myocardium and the blood vessels are often essentially 
the same and the presence of one almost invariably implies the other. It is 
interesting in this connection to note some of the irregularities affecting the 
contractions of the myocardium as shown in the pulse. The chief forms nre. 

Sinus arrythmia. 

Premature contraction or extra systoles. 

Heart Block. 

Auricular Fibrillation or delerium Cardis. 

Auricular Flutter. 

Paroxysmal tachycardia. 

Pulsus alterans.. 

As we know, the heart muscle is composed of two types of tissue, the 
mature, which is purely muscular and responds to the impulses; the primi- 
tive, or neuro-muscular, which originates and conveys the impulses. 

The sino auricular node, or pacemaker, situated in the wall of the right 
auricle near the opening of the superior vena cava, under normal conditions 
gives rise to the impulses exciting the heart to action. Nerve impulses pro- 
ceeding from this node are distributed throughout the auricle and to the 
nodal tissue at the auriculo ventricular junction, from which tissues they 
are carried to every part of the ventricles by the Bundle of His or its 
branches. 

Under certain conditions, either temporary or permanent, the tissues of 
the heart may become hypersensitive and give rise to impulse formation 
which is more rapid than the pacemaker. These impulses may arise in any 
part of the heart tissue either auricular ventricular or nodal, and replace 
the impulses from the peacemaker. From these facts it seems that irregu- 
larities occur in at least three ways. 

1. Alteration of impulse formation at the sinoauricular node, due to 
altered vagal impulses. 

2. Hypersensitiveness in some portion of the heart, giving rise to im- 
pulses which replace those from the sino auricular node. 

3. Some disturbance, either temporary or permanent, in the conducting 
system, which so interferes with its function as to block or delay the trans- 
mission of impulses, the severity and location of the disturbance determin- 
ing the degree and effect of the block. From the first of these it will be 
seen that the heart itself is not necessarily impaired, but is simply respond- 
ing to influences that are changed either in rate or rhythm, and that this 
change is due entirely to extra cardiac conditions and is dependent to a 
large extent, if not entirely, on altered excitability' of the vagal center. 



PRACTICE OF MEDICINE 59 

In the second the trouble is in the heart muscle but is due to hyper- 
sensitiveness, the result of nutritional changes which may be purely tempor- 
ary in character and without pathological change in structure. The third 
group is more likely to be due to permanent alteration in the tissue, but may 
be seen in acute infections when the heart muscle is involved, and which will 
entirely disappear with disappearance of the infection and restoration to 
normal. 

Sir James MacKenzie, in commenting on irregularities, says, "Although 
so little has been said about irregularities by teachers and writers, the sub- 
ject has been by no means ignored in practice. So ingrained has the belief 
become that a heart to be normal must be regular that when an irregular 
heart was met with it was looked upon with suspicion and many persons 
with sound hearts have been rejected for life insurance because of the pres- 
ence of an innocuous irregularity, while tens of thousands have had their 
lives restricted and have been subjected to prolonged and useless treatment 
for a condition that called for no treatment. On the other hand, cases 
where the irregularity should have revealed the necessity for treatment 
were never properly understood and so were never properly dealt with." 

Tht great majority of irregularities are of two kinds, one which occurs 
in youth rind one which occurs in adult life. 

Proceeding on these lines, after I had collected over a thousand cases, I 
sought for some definite basis of classification. With the assistance of the 
jugular pulse 1 ^vas able to recognize different forms according to the 
mechanism of their production. Two large groups, which included be- 
tween them 90 per cent, of all cases, emerged distinctly. These two groups 
differed. In one all of the chambers of the heart participated in the irregu- 
larity, the contraction in each case being normal, while in the other, the 
ventricle contracted prematurely while the auricle maintained its rhythm, 
or both auricle and ventricle contracted prematurely, the irregularity which 
is now called the ventricular and auricular extra systole. 

I was now able to separate the two groups by a second method, namely, 
the age incidence. I found that the former group occurred predominantly 
in the young (the youthful type of irregularity) and the latter group oc- 
curred predominantly in the latter decades of life (the adult type of irregu- 
larity.) 

Accepting MacKenzie's statements as based on experience with persons 
believing themselves to have heart disease, we must believe that the majority 
of the cases are not suffring from disease of the myocardium. 

Sinus arrythmia. MacKenzie goes so far as to claim that this form of 
arrythmia is an indication that the heart is not damaged. He looks upon 
the presence of this irregularity as an evidence that the heart has escaped 
damage when the rate is found below 70. 

Lewis claims: "The commoner forms of cardiac irregularity due to the 
sinus are of little prognostic value and are to be regarded as slight exaggera- 
tion of a normal phenomenon, respiratory irregularity, or as evidences of a 
mild or insignificant instability of tonic inhibitory nerve action." 

If it is respiratory in type, the change in rate with the rise and fall in 
respiration will be easily detected. If it is not established by these means 
it may be detected as the breathing is deepened. 



60 NORTH CAROLINA MEDICAL SOCIETY 

There is no irregularity in the force of the pulse, the waves being equal 
in volume and the irregularity disappears as the pulse rate accelerates. It 
is almost confined to rates below 100 per minute, is more noticeable as the 
pulse rate decreases in frequency, and usually disappears after exercise. 

Extra Systoles. MacKenzie states: "Seeing that healthy men and 
women may present this irregularity, it can be accepted that extra systoles 
in themselves are not indications of disease or impairment of the heart's 
efficiency. When there are signs of heart failure the prognosis should be 
based upon the other symptoms present and not on the presence of extra 
systoles. It may therefore be stated that when the extra systole is the only 
abnormal sign the prognosis is good and when it is associated with other 
signs the prognosis should be based on these other signs. 

Another authority (Wiggens) states that premature contractions may 
arise in a perfectly normal heart. More often they arise in hearts that are 
abnormally irritable. It may be assumed in these cases that irritability ot 
the heart is increased through toxins, internal secretion, caffein, nicotine, 
etc., so that it reacts to the tiny normal ineffective stimuli that bombard it, 
or that pathological disturbances of structure are actually present. 

Their chief clinical value is that they attract attention to the cardiac 
condition, which leads to a search for the presence or absence of other symp- 
toms of cardiac impairment. 

Lewis, on the other hand, states that premature contractions constitute 
and bear witness to defects ; that there is mechanical imperfection and there 
is the evidence of altered cardiac nutrition, and the more frequent the in- 
terruptions the greater the degree of such defects. Premature beats, true 
paroxysmal tachycardia, auricular flutter and fibrillation have a common 
pathological basis : they are one and all the outcome of new impulse forma- 
tion in the heart. 

The prominent points in diagnosis may be mentioned. The beats missed 
at the pulse are heard at the heart and occur in threes and fours with a pro- 
longed pause following, the number of beats being determined by the force 
of the extra systole. 

If not sufficiently strong to open the aortic valves but three beats will be 
heard, otherwise four will be noticed. 

The pulsations between the extra systoles are regular in both rate and 
rhythm. The premature contractions very rarely accompany rates of 120 
and over. While they not infrequently disappear after exercise, they do 
not always do so. Extra systoles usually increase in frequency as the pulse 
rate becomes slower. 

In this connection I was interested in writing to several of the leading 
Life Insurance Companies of this country. Their figures are rather 
startling. 

Group 29. Irregular Pulse found on examination or at some time within 
ten years of the date of application. That group was made up of nearly 
2,800 lives and showed a general average mortality of 95 per cent., biit 
with a tendency at the later ages of life to a higher mortality, ages 50 and 
over showing 22 actual deaths and 19 expected. 

The next group studied was made up of persons with an intermittenr 



PRACTICE OF MEDICINE , 61 

pulse found at the time of the examination or within ten years of that time. 
The number of lives involved in the study was over 2,100. The mortality 
at the earlier ages was small and showed a tendency to increase with ad- 
vancing age. 

A third group was made up of persons who showed a pulse rate between 
90 and 100 on examination. The mortality in this group was 172 per 
cent., and this high mortality rate was not confined to any age but extended 
through the entire historj- of the group. There were over 6,200 lives in the 
group. 

Finally, a group made up of persons with a pulse rate of over 100 found 
on examination or within ten years. There were 740 odd cases under ob- 
servation. The mortality was high everywhere. The general experience- 
was 205 per cent. 

In conclusion: A pulse of 90 and over is abnormal. Irregular and in- 
termittent pulse is of decidedly less significance at the earlier ages of life 
than at the later ages. 

There is a distinct relationship between the amount of disturbance of the 
pulse and the extra mortality incident thereto. 

Finally, a heart murmur does not tell the whole story as to the condition 
of the heart. 

DISCUSSION OF DR. HAYWOOd's PAPER 

Dr. Hardee, P. R., Stem: I wish I were able to discuss that paper^ f?r 
this is a subject in which I have been very much interested. 

There is one part of the paper that puzzles me as much as anything with 
which I am confronted in the practice of medicine, and that is diagnosing 
the different lesions when the myocardium is affected. I can usually, in 
valvular affections, tell with some degree of certainty what particular lesion 
it is, but when there is myocardial degeneration, with irregular pulse and 
vague symptoms, it troubles me as much to make a diagnosis as anything I 
meet with. . 

Dr. O. Edwin Finch, Apex: I was very much interested in the doctor's 
statement as to slow pulse, because I feel that I have been responsible for 
some men's not getting insurance on account of that. Feeling that it was 
due to some organic lesion, I have stressed it, and probably that applicant 
may have been entitled to insurance. 

I would like to ask Dr. Haywood if he has any explanation for slow 
pulse following influenza. 

Dr. Hajrwood: The only explanation that I have seen that is reasonable 
at all is that it is due to a myocarditis associated with the disease. 

Dr. A. McNiel Blair, Southern Pines: Dr. Haywood has presented 
facts on a subject of special interest to us all, as we all have hearts, and of 
particular interest and benefit to some of us, w^ho have been endeavoring to 
give this subject special study. 

It is indeed a broad subject, and the subject material is difficult to handle 
in one paper. 

In reference to myocardial changes, the grouping of certain clinical find- 
ings is essential for the proper determination as to the integrity of a heart 



62 , NORTH CAROLINA MEDICAL SOCIETY 

muscle. Occasionally one or more constant factors exist which should al- 
ways suggest further investigation, lest in the consideration of a patient 
with other ailments, the heart muscle status per se be overlooked, as we all 
know myocardial changes are presented in unusual ways, and are variable 
indeed. 

To be sure one notes rather constantly in many of the so-called classical 
cases, palpable arteries that feel thick and resisting, or tortuous and un- 
even, like a string of beads, and it is safe to presume that the heart muscle 
in this case is not sound. 

Palpatation of the liver should not be neglected, as the physical signs of 
hepatic congestion are not improperly secondary to more or less cardiac 
inadequacy. 

Auscultatorv percussion helps to confirm ordinary percussion, and should 
be practised more frequently. 

The disparity noted between the first and second heart sounds has often 
been the first factor in calling my attention to an abnormal heart muscle, 
especially in a patient who presents strong, usually regular pulse, with no 
Cardiac impulse, apparently normal heart dullness, clear heart tones without 
murmur, and often radial arteries that are not stif¥, along with negative 
urinary findings. The real nature of the case would have been overlooked 
had it not been for this one sign ; accentuation of the second, with weaken- 
ing of the first sounds. 

The blood pressure findings, along with the study of the pulse rate, taken 
not only in the recumbent position, but also sitting and standing, have been 
helpful in determining the heart muscle strength. So also the Cardio- 
radiogram or the fluoroscopic picture permits of outlining the heart and 
large trunk vessel, revealing the approximate extent of dilatation, as well as 
any other outside factor that may play a part in the disturbed mechanism 
of the heart per se, as for example, in certain forms of pleural adhesions. 

Dr. Haj'wood touching the subject of fibrillations, with associated heart 
muscle changes, brings to mind a case of auricular fibrillation, where heart 
muscle degeneration was not evidenced immediately, but was delayed some 
little time, between two or three months. The one symptom predominating 
during that period of apparent compensation was the extreme rapidity of 
the pulse. Then there followed, in the advent of a cold, the degenerative 
heart muscle changes in an aggravated form, with partial heart block, with 
associated pericardial and pleural transudate. 

I wish to express my personal appreciation to Dr. Haywood for present- 
ing his able paper to the section. 

REMARKS BY DR. HAYWOOD 

A letter to an authority on the heart as to auricular fibrillation and heart 
block brought this reply: 

"So far as I know, a definite diagnosis of auricular fibrillation can only 
be made with the cardiograph. It may be inferred in a case where the pulse 
after reasonable exercise remains persistently irregular while the rate is 
above 120 — and by pulse I mean the pulsation of the heart, not the radial 
pulse. 



PRACTICE OF MEDICINE 63 

"Heart block can only be determined with the polygraph, but may be 
suspected when beats are definitely dropped or when the apex beat as deter- 
mined by the stethoscope does not coincide with the pulsations of the jugu- 
lar bulb. A good plan is to put a small black piece of sticking plaster over 
the jugular bulb to make any pulsations there more obvious." 

Dr. J. T. J. Battle, Greensboro: Dr. Haywood spoke of how to test the 
myocardium. That question used to bother me considerably, until I met 
Dr. Lankford, of San Antonio. He gave me a very simple experiment to 
go through with, which I have found quite satisfactory in every case. That 
is. get the patient quiet, so that the systolic blood pressure will not be af- 
fected by exercise or excitement. Take his blood pressure, both diastolic 
and systolic. Exercise him equal to walking up two flights of steps, with 
the arm band still on his arm but deflated. Then, thirty seconds after he 
is seated, take the pressure again. If the heart is normal the systolic pressure 
will have gone up from 15 to 25 millimeters, while the diastolic pressure 
has remained stationary. It will return to normal within one to three 
minutes. If there is a weak myocardium, it is slow in coming back to 
normal. If there is a very weak myocardium, it does not respond to the 
exercise and the systolic does not go up. If the systolic falls you have an 
exceedingly weak myocardium. If the diastolic pressure rises and the sys- 
tolic falls you have a man in a very dangerous condition. If you try that 
you will find it exceedingly satisfactory. Of course, you must deflate the 
c\\fi after each reading. 

A REVIEW OF THE RECENT WORK ON AMCEBIC 
DYSENTERY 

WiLLi.AM Allan, Charlotte, N. C. 

During the period of tlie war considerable advance has been made m 
our knowledge of several of the factors of the amoebic infection problem, 
particularly by our British allies. In their campaigns in the Eastern Med- 
-iterranean area they were promptly confronted with serious casualty rates 
from dysentery, and as the Gallipoli dysentery was reported as largely 
amoebic by early observers, they met this situation by intensively training a 
number of protozoologists and concentrating their chronic dysenteries in 
special hospitals. 

This war work has increased materially the definite statistical data ot 
the incidence of amoebic infections among different races and in different 
parts of the world. In examining about 31,000 British troops returned 
from the Near East, the majority if whom had had dysentery^ or other 
bowel disorders, 9.8% were found infected with Entamoeba histolytica: 
(1). Of nearly 7,000 troops and civilians without any history of bowel 
trouble, examined in the Eastern Mediterranean area, or invalided from 
that region, 10.5% were found infected. In 5,000 persons with a record 
of intestinal disorders examined in France and England, mostly troops from 
the Western Front, 8.9% were found infected, while in 3,761 individuals 
without bowel troubles, 5.8% were infected. Kofoid found 10.8% ot 
1,200 American soldiers returning from France infected. The great ma- 
jority of these individuals received a single examination, which Dobell has 
shown brings to light less than one-half of histolytica infections, so that the 



64 NORTH CAROLINA MEDICAl SOCIETY 

figures given above are something less than half the true incidence of this 
protozoal infection. Such a brief summary may give some idea of the 
magnitude of the problem; of the approximately 50,000 persons examined, 
both in Western Europe and the Near East, both healthy and dysenteric, 
between 13% and 25% were infected with Entamoba histolytica. 

Medical men have been handicapped by a lack of zoological knowledge 
of the intestinal amcebae but have had to go blundering ahead because of 
the slowness of trained protozoologists to lead the way out of this wider- 
ness. Schaudinn in 1903 adopted the placing of the intestinal amoebae in 
a new genus, Entamoebse, by Cassigrandi and Barbagallo, and emphasized 
anew the distinction between pathogenic and non-pathogenic species. Dur- 
ing the next ten years many new species were described by many observers, 
the Entamoeba tetragena of Viereck being the most important. Walker's 
(2) work in Manila in 1911 finally led to the abandonment of Schaudinn's 
erroneous description of Entamoeba histolytica and to the boiling down of 
the Entamoebas of man into two species, Entamoeba histolytica, pathogenic, 
and Entamoeba coli, non-pathogenic. As the former has 4-nucleated cysts 
and the latter 8-nucleated cysts, all seemed plain sailing for the easy difiFer- 
entiating of species. But in 1917 Wenyon and O'Connor (3) described a 
non-pathogenic Entamoeba of man, with 4-nucleated cysts, calling it En- 
tamoeba nana. Their work has been accepted, confirmed and extended by 
other British workers, and by our own protozoologist, Kofoid, who has 
shown (4) that this new species is fairly common. Dobell (5) in his re- 
cent excellent monograph on the zoological status of the amoebae living in 
man has created a new genus for this amoeba, Endolimax, calling the organ- 
ism Endolimax nana. So that we now have to deal with and differentiate 
three species of parasitic amoebas, namely. Entamoeba histolytica, patho- 
genic, with 4-nucleated cysts. Entamoeba coli, non-pathogenic, with 8- nu- 
cleated cysts, and Endolimax nana, non-pathogenic, with 4-nucleated cysts. 

The earlier work on differentiating the intestinal amoebae consisted largely 
in staining active forms and then interpreting the amount and arrangement 
of the nuclear chromatin. Needless to say this could never become a 
popular method. Due to the work of Walker in 1911 (2) and of Mathis 
in 1913 (6) and of many others, we have been led to turn from the study 
of trophozoites to the study of cysts. This has been rendered very much 
easier by the introduction of iodine, or such iodine stains as Donaldson's 
(7), with which the specimen of stool is rubbed up in order to differentiate 
the cysts. Iodine makes cysts much more readily recognizable and brings 
out the nuclei sharply. 

Dysenteries unsuccessfully treated become convalescent carriers, dis- 
charging cysts in their stools intermittently for an indefinite length of time. 
Besides these, there are many s(3-called healthy carriers, who present neither 
past history nor clinical evidence of dysentery. When possible these cyst 
carriers should be given the same course of treatment that acute or chronic 
cases of dysentery receive, for besides being a source of infection to others, 
some will eventually develop dysentery, and some liver abscesses. 

Since Roger's introduction of the use of emetine in 1912, one advance in 
the treatment of this infection has been made, namely; the introduction of 
emetine bismuthous iodide. This preparation was first suggested by Dumez, 



PRACTICE OF MEDICINE 65 

A. G. (8) in Manila in 1915. A year later the British began using it and 
seem to have demonstrated its value. Emetine bismuthous iodide, contain- 
ing about 29% emetine, is given by mouth in salol or keratin coated tablets, 
one grain two or three times a day. It may be used alone or combined with 
emetine injections; at present there is a tendency to use emetine injections 
for 10 to 12 days followed by two to three grains of the double iodide for 
12 days in acute cases, and to give 12 to 14 day courses of the iodine alone 
in treating carriers. Lillie and Shephard (9) cleared up 62 out of 104 
carriers with 12 day courses of 3 grains of Emetine bismuth iodide alone. 
Jepps and Meakins (10) cleared up 20 out of 24 carriers, and McKinnon 
cleared up 70 out of 131 carriers. Savage and Young cured 14 out of 17 
carriers and 8 out of 16 acute cases, with the iodine alone, 2 to 3 grs. for 12 
days. Gunn and Savage (11) using emetine injections for 12 days, fol- 
lowed by emetine bismuthous iodid for 14 days, treated 120 acute cases; 
82 were discharged as cured, 46 after being kept under observation for 
more than 30 days, 36 for less than 30 days; 38 of their acute cases re- 
lapsed. They treated 190 carriers in the same way; 171 were discharged 
as cured, 106 after more than 30 days, 65 after less than 30 days, 29 of 
their carriers relapsed. Turner and Taylor (12) in 366 carriers had 67 
to clear up without treatment; 215 were cleared of cysts with emetine bis- 
muthous iodid, and '84 failed to clear up. 

• These results from British military hospitals seem very encouraging, but 
their men could be held for observation for only four or five weeks. In 
spite of Dobell's findings that 90% of relapses in treated carriers takes 
place within three weeks (13), McAdam has shown that many so-called 
carriers relapse later on, and Walker long ago found the incubation period 
of experimental Entamoebic infection running as high as 90 days.^ In civil 
life, it would be better to follow cases for a year before pronouncing a cure. 
In the few acute cases the writer has had the opportunity of treating during 
the past year, emetine bismuthous iodid has cleared out the cysts, temporar- 
ily at least, after emetine injections had transformed the dysenteric into the 
carrier state. This new therapeutic agent will doubtless prove very useful, 
but an estimate of its exact value must await a much more prolonged obser- 
vation of its effects. 

. The most important addition to our knowledge of the treatment of 
amoebic dysentery has been presented by Dale and Dobell (14) who under- 
tuok to work out carefully the strength of emetine solutions which would 
be lethal to Entamoebas in dysenteric stools. They found that when em- 
etine in solution was applied directly to the Entamoebae, it was not particu- 
larly toxic, while it is a well known fact that emetine injections in human 
amoebic dysentery have a specific amoebacidal efEect even in very small 
doses. They also found that injections of emetine had absolutely no effect 
on clinical amoebic dysentery in the cat. Therefore, as emetine seems to be 
without efEect both directly and through the medium of the cat, but is very 
effeotive through the medium of man, it is pointed out that the specific 
action in clinical human Entamoebic Dysentery must be because of its action 
on the host and not on the parasite. 



56 NORTH CAROLINA MEDICAL SOCIETY 

REFERENCES 

( 1 ) The figures in this paragraph were obtained by tabulating the re- 
ports of 
Archibald, R. G., Hadfield, G., Logan, W. and Campbell, W. 1916. J. R. A. 

M. C. XXVI-6-695. 
Arkwright, J. A., York, W., Pi-iestly, O. H., Gilmore, W. 1916. Brit. Med. 

J. p. 683, May 13th. 
Aubert, P. 1917, Bull. Soc. Path. Exotique, Vol. X, No. 7, p. 611. 
Barratt, J. O. W. 1916. Brit. Med. J., Nov. 4th ,p. 617. 
Bayliss, A. A. 1919. Lancet, Jan. 11th, p. 54. 
Bayma, T. 1916. Ann. Paulis. Med. e. Cirurg, 7-5-97. 
Boney, T. K., Grossman, L. G., Benlanger, C. L. 1918. J. R. A. M. C., 

XXX-4-409. 
Christie, W. L. 1915. Brit. Med., J. July 17, page 89. 
Cowan, J. M., Miller, H. 1918. J. R. A. M. C, XXI, Nos. 3 and 4. 
Cragg, F. W. 1917. Ind. J. Med. Research 5-2-301. 

Cutler, D. W., Williamson, R. 1919. J. R. A. M. C. XXXIII, No. 3-252. 
Dobell, C. 1917. Special Report Series, No. 4, Med. Research Com. 
Dobell, C, Gettings, H. S., Jepps, M. W., Stephens, J. B. 1918. Special 

Report S. No. 15. 
Dobell, C. 1916. Brit. Med. Journal, Nov. 4th. 
Fantham, H. B. > 1916. Lancet, June 10th, p. 1165. 
Ficker, M. 1915. Ann. Paulist. Med. et Cururg. 5-2-335. 
Findley, G. M. 1917. Lancet, May 19th, page 755. 
Fischer, W. 1918. China Med. Journal XXXII, No. 1, page 13. 
Fischer, W. 1915. Dent. Arch. f. Klin Med., 118-2-129. 
Flu, P. C. 1918. Abs in Trop. Dis. Bull, Vol. 12, No. 5, page 287. 
Gunn, J. W. C, Savage, R. E. 1919. J. R. A. M. C. XXXIII, 5, 418. 
Hall, I. W., Adam, D. C, Savage, R. E. 1916. Brit. Med. Journal, Aug. 5, 

p. 174. 
Hughs, T. A. 1919. Ind. Med. Gazette 54-4-139. 

Jepps, M. W., Meakins, J. C. 1917. J. R. A. M. C, XXIX, 6, page 704. 
Jepps, M. W. 1916. Brit. Med. Journal, Nov. 4th, page 616. 
Kofoid, C. A., Komhauser, S. I., Smeezy, Olive. 1919. Arch, Int. Med. 

24-1-35. 
Leb@uf, A., Brown P. 1916. Bull et Mem. Soc. Med. des Hopit. de Paris 

31-27-1602. 
McAdam, W, 1918. Lancet, Jan. 5th, page 15. 
McKinnon, D. L. 1918. Lancet, Sept. 21st, p. 386. 
Martin, C. J., Kellaway, Williams, F. E. 1918. J. A. R. M. C. XXX, No. 1, 

page 101. 
Matthews, J. R., Smith A. M. 1919. Ann. Trop. Med. & Parasital. 13-1-88. 
Rangel, Prestana B. 1917. Ann. Paulist. Med. e Cururg. 8-5-101. 
Ravaut, P., Krolunitski, G. 1916. Presse Medicale, Vol. 24, No.37, page 289. 
Rocke, W. 1917. Lancet, Feb. 24th, page 297. 
Sanford, A. H. 1916. Journal A. M. A. 67-26-1923. 
Savage, R. E., Young, J, R. 1917'. J. R. A. M. C. XXIX; No. 3. 
Tribondeau, Fichet. 1916. Bull Acad. Med. 75-11-317. 
Turner, O. P. & Taylor, N. 1919. J. R. A. M. C. XXXIII-3-245. 



PRACTICE OF MEDICINE 67 

Wenyon & O'Connor. 1917. "Human Intestinal Protozoa in the Near East." 
Wenyon, C. M. 1916. Journal R. A. M. C, 26-4-445. 
Woodcock, H. M. 1917. J. R. A. M. C. XXIX, No. 3, page 290. 
Woodcock, H. M. 1919. J. R. A. M. C. XXXH, No. 3, 231. 

(2) Walker, E. L. 1911. Phil. Journal Sc. VI, page 259. 

(3) Wenyon, C. M. & O'Connor, F. W. 1917. "Human Intestinal Protozoa 
in the Near East." 

(4) Kofoid, C. A., Komhauser, S. I. & Plate, J. F. 1919. J. A. M. A. 72, 
page 1721. 

(5) Dobell, C. 1919. "The Amoebae Living in Man." 

<6) Mathis, C. 1913. Bull d. d. Soc. Chirurge de I'Indo. Chine, June 8, 
Sept. 14th, Nov. 9th and April 19th, 1914. 

(7) Donaldson, R. 1917. Lancet, ii, page 571. 

(8) Du Mez, A. G. 1915. Phil. Jour. Sc. X, Sec. B, page 73. . 

(9) Lillie, D. G. & Shepheard, S. 1917. J. R. A. M. C. XXIX-6-700. 
(19) Jepps, M. W. & Meakins, J. C. 1917. Brit. Med. Journal, Nov. 17th, 

p. 645. 

(11) Gunn, J. W. C. & Savage, R. E. 1919. J. R. A. M. C. XXXIII, 
No. 5, 418. 

(12) Turner, O. P. & Taylor, N. 1919. J. R. A. M. C. XXXIII, 3, 245. 

(13) Dobell, C. 1917. Special Report Series No. 4, page 51. 

(14) Dale, H. W. & Dobell, C. 1917. Jour. Pharm. & Exp. Thor. X-6-399. 

Dr. T, E. Anderson, Statesville : I would like to ask Dr. Allen vs^hat 
are the comparative results of giving Emetine hypodermically and by mouth ? 

Dr. Allan, closing discussion : Emetine has been given by mouth in 
keratin coated tablets.* However, this irritates the stomach and is not a 
successful method. Several years ago, I reported the use of Alcresta ipecac 
in ten cases, four of which responded to treatment. This is about half 
as good as the results by hypodermic injection. At present bismuthous 
emetine iodid by mouth is being tried extensively. Any method that 
avoids the necessity of making the chronic cases stop work daily and go 
to the doctor for a hypodermic, would be very welcome. 

Dr. Taylor has asked what to do with cases that do not respond to ipicac. 
I find that a course of emetine cures permanently about 40% ; about the 
same number are temporarily relieved of symptoms, but will relapse, and 
about 20% do not respond to ipecac. This latter class can be made com- 
fortable by colon irrigations of saline, or magnesium sulfate, or silver ni- 
trate, and the course of the disease tends toward recovery after a period of 
years. 

THE MODERN THERAPEUTIC VALUE OF DIGITALIS. 

Dr. Joseph A. Speed, Durham, N. C. 

The use of Digitalis in disease is chiefly based on its powers in giving 
rest and tone to the heart and as a diuretic by virtue of its ability to im- 
prove the general circulation. It is distinctly a cardiac stimulant, and upon 
the circulatory system finds its greatest field of usefulness. It does not stim- 
ulate the renal epithelium or have any effect on the renal structures. In 
moderate and effective amounts it increases the pulse force, slows the pulse 



Ob NORTH CAROLINA MEDICAL SOCIETY 

and increases the pulse wave. The increased pulse force is said to be due 
to a stimulating influence which the drug has on the muscular fibres of the 
heart itself. And some observers have claimed the drug permits the heart 
to do two and one-half times the amount of its normal work. By its ability' 
to stimulate the ventricles to greater effort it restores greater tonicity to the 
heart, by the prolongation of diastole it can regain its irritability, contracti- 
lity and conductivity. These being normal physiological functions of the 
heart and each is essential if the heart does its best work and functionates 
properly. By its action on the vaso-motor center and the muscular coats 
of the vessel wall Digitalis has long been thought to raise arterial tension 
and would therefore be contra-indicated in conditions in which the blood 
pressure was materially raised. This seems true in animal experimentation 
but according to Eggleston in humans this is not the case, certainly in 
proper Therapeutic doses. 

Digitalis by improving the circulation naturally improves pulmonary 
ventilation and respiratory function with a resulting relief of cyanosis and 
abolition of the vaso-constrictor effect of carbon dioxide on the center of 
respiration. The improved circulation results in better functioning of the 
various organs and tissues of the body and therefore tends to restore to nor- 
mal the several mechanisms by which the circulation is kept and maintained 
at its most effective and efficient level. By stimulating the Vagus both cen- 
trally and peripherally Digitalis slows down the running heart to a safe gait 
that is best for itself and the other organs which it so materially presides 
over. It is like lines on the running away horse, a sort of emergency brake 
which is able to check and quiet the irritable, laboring fleeting heart. It 
however, is not necessarily an emergency drug for indeed it acts very slowly 
and lasts long once it has attained its full and proper physiological effect. 

The other chief action of this very useful drug is the value as a diuretic. 
It relieves renal congestion however not by any particular action which it 
has on the kidney, but by improvement of the circulation. 

Heart failure naturally is the result of exhaustion of the cardiac muscle 
and cardiac function and this exhaustion may be the result and often is of 
persistent rapid cardiac action. It is going a gait it cannot keep. And the 
remarkable efficacy of the drug lies in its ability to increase the cardiac 
force and slow the rate of the pulse and heart to a reasonable gait which it 
can maintain and supply blood over the body as it normally should. When 
a cardiac abnormality was found present it has been the custom of many 
physicians to blindly give digitalis with no accurate observation as to when 
benefit accrued from its use. Its administration therefore was surrounded 
by so much confusion and lack of real knowledge of what was going on 
that its usefulness and uselessness was never clearly determined and often 
the drug was given due credit or discredit was placed upon it. Digitalis ac- 
cording to most modern experimenters and careful observers should be giv- 
en for effect. There is not necessarily more therefore than a general offi- 
cial idea as to the proper dosage. It all depends on the disease and the pa- 
tient. An unusually large dose, much larger than the official amount may 
be required, effect and results are what is desired by the patient and phy- 
sician. 

In auricular flutter the allied condition of auricular fibrillation Digitalis 



PRACTICE OF MEDICINE 69 

finds some of its greatest usefulness and most gratifying results. The flut- 
ter of the auricle is said to be more intermittent but may eventuate in the 
fibrillatory quivering of the auricle. When the rapid heart is due to fever, 
exophthalmic goiter, the infections and intoxications it is said that the drug 
has little effect on the heart gait. 

The most gratifying and dramatic effects of Foxglove is seen in heart 
failure with dilatation of the heart and dropsy. According to leading ob- 
servers and authorities on heart disease 80-90% of these cases suffer from 
auricular fibrillation and indeed the failure of the heart may be due to or 
induced by the very rapid rate of the heart in auricular fibrillation. It 
starts very suddenly and dilates. The response to Digitalis in some of these 
cases, as you know, is most striking. The patient who has Cheyne-Stokes 
breathing, orthopnea, edema, ascites, restless, sleepless with that anxious 
peculiar facies seen in these cases, with a heart beat of 120 or more beats 
per minute, this distressed patient appears as a new individual once they 
have become sufficiently influenced by this drug. They lie down and sleep 
quietly, the swelling is gone, everything is different and they are so grateful! 
The whole picture has changed, the heart is now beating 70-80 times per 
minute, full and of good volume, regular and quiet. Of course, rest, pur- 
gation and other things are contributory factors which should be remem- 
bered but digitalis is the drug which has essentially changed the picture. 
Patients do better in bed when taking the drug and should not suddenly 
move about. 

According to Sir James McKensie Digitalis does not slow the heart in 
Aortic Regurgitation. It has been taught that as the drug prolonged dias- 
tole it therefore allowed the reguggitant stream to do more damage by the 
return flow this however has not been the experience and observation of the 
well known authority in cardiac disease. McKensie states that he has re- 
peatedly pushed the drug to full Physiological effect with vomiting with 
no slowing of the heart rate. 

In Lobar Pneumonia when the heart is tired and has been laboring, 
pumping blood through a consolidated liver like lung. Digitalis is often an 
invaluable drug and a life saving agency. In cardiac asthenia, the "tired 
heart," in the very irritable palpitating heart if it be not due to Gastro- 
intestinal disturbance Digitalis is of value- It is the best antidote in 
Aconite poisoning. It acts slowly however and ammonia and more fleeting 
agents should be used until the drug can take hold. High temperatures al- 
ways prevent Digitalis from slowing the heart because as proved by Brun- 
ton and Cash fever has a depreissant action on the vagus centers in the 
Medulla and also when the temperature is very high the peripheral termi- 
nals of the vagus. This is very important and should always be remem- 
bered by the busy practitioner. 

Of the preparation to use there are a large number from which to choose. 
McKensie favors the use of the Official Tincture provided it is fresh and 
of a guaranteed strength. The drug should be physiologically tested and 
if it is not fresh should not be used. There are more elegant preparations 
on the market, many of them proprietary and some fat free and can be used 
hypodermically to better advantage. They are much more expensive how- 
ever, and this should be remembered in prescribing the drug. Digitalin 



70 NORTH CAROLINA MEDICAL SOCIETY 

in one fiftieth of a grain is often used. Digitalone (Houghton) is given in 
one-tenth grain doses hyperdermically and represents 16 minims of the Tinc- 
ture. It is fat free and can be given hypodermically to advantage, is readi- 
ly absorbed and is not irritating. Powdered digitalis leaves seem very ef- 
fective in one grain doses combined with an equal amount of squill and 
mercury and indeed often this so called Guy's or Neymer's pill or the grain 
each of calomel, squill and digitalis will give results when all other pre- 
parations fail. I have now a woman of 56 years who has had Auricular 
Fibrillation with edema, dyspnea and unable to sleep who has been influenced 
only by this combination. One has to be careful and not salivate the pa- 
tient. And often one is at a loss to know whether the calomel, squill or dig- 
italis has been the efficient agent. Some are partial to the Fluid extract. 
It does not matter so much, whether one uses the infusion, Tincture, Fluid 
extract or some proprietary remedy, they all should be tested physiological- 
ly, and freshly prepared. The Tincture and Infusion if fresh are probably 
the best two preparations, and should be given for effect and once the 
eflect is gained keep it. This is done by stopping the drug when the rate 
has fallen to 70-80 beats per minute and give half as much as the rate be- 
gins to increase. 

By giving and witholding the drug and diligent observation as far as is 
practicable and possible the quantity necessary to keep the heart gait at 
a moderate and safe level can be found. The patient should, if intelligent, 
be instructed to correlate his sensations of relief so that he may acquire a 
keen knowledge of when it is necessary for him to take the drug. If this is 
done intelligently many patients especially those with auricular fibrillation 
may be able to live useful, comfortable lives free from these extreme at- 
tacks of heart failure which are so apt to occur in this condition. 

The armamentarium of the well informed Physician is not complete un- 
less he has a clear knowledge of this drug, when, how and why to use it. 
It is one of the most gratifying and useful drugs in medicine. It is a slowly 
acting effective cardiac stimulant of first choice in certain cardiac condi- 
tions and should only be used intilligently and carefully for its physiologi- 
cal effect. If used in this way no danger or deleterious effect need be 
feared. 

T. E. Anderson : I thank Dr. Speed very much and am certain that he 
and Dr. Faison are the only two men here that know anything about it. 

DISCUSSION 

Jas. M. Northington : I was in a position to follow the details of the 
work done on digitalis in the University of Minnesota by Morris and 
White. A report of this work had for its object the determination of the 
relative potencies of specimens of the drug under different conditions. Speci- 
mens grown in the botanical gardens on the grounds of the University 
were found to compare favorably with those of English and German 
growth obtained through the most reputable channels. Very recently, pro- 
bably because of the interest stimulated by a discussion on this subject at 
the meeting of the Southern Medical Association, an inquiry as to his meth- 
od of estimating doses was addressed to Dr. Eggleston. He replied through 
the J. A. M. A. about four weeks ago. It is well worth looking up, as it 



PRACTICE OF MEDICINE 71 

can be readily made use of by every physician. Practically all investigators 
ilong this line are agreed that the Tincture is the most reliable and satis- 
factory preparation. 

RADIUM IN THE TREATMENT OF SKIN CANCER 
Dr. W. D. James, Hamlet, N. C. 

The scope of this paper has been intentionally limited to a consideration 
of the value of radium in the treatment of cancer of the skin. The value 
of this therapeutic agent is obtainable only after all methods of using it 
have been tried and the results classified. After a reasonable amount of ex- 
perience one is able to regulate the dosage so as to obtain the best possible 
results. One cannot prescribe radium in certain number of millegram 
hours — as you would prescribe drugs. 

In considering the effect of radium on tissue it is important to know 
there are three types of rays emitted from radio-active bodies which have 
been called alpha, beta, and gamma. Alpha and beta are the burning rays 
and are of low penetrating power. The gamma rays are more penetrating 
and are not burning or irritating rays. Due to its high penetrating power 
the gamma ray is commonly spoken of as the therapeutic ray of radium. It 
acts directly on the nucleus of malignant tissue cells and since they are em- 
bryonal in nature, such malignant tissue is acted on and destroyed before 
the normal tissue cells are appreciably affected by the radium irradiation 
The alpha ray is soft and is of no practical value in radium therapy. The 
beta ray is of value and should be employed where the radium can be ap- 
plied directly to the lesion. 

If normal tissues intervenes between the pathology and the surface in 
which the radium is applied, one must screen the radium so that the beta 
rays are absorbed to such an extent as to prevent radium burn on the nor- 
mal skin. Unless the beta rays are cut off by a suitable thickness of metal, 
the superficial tissues will be subjected to a much greater action than the un- 
derlying layers which may result in a surface injury, or so-called beta ray 
burn. Where you can bring the radium in direct contact with the malig- 
nant cells and only superficial effects are required the beta rays are very 
useful. The resistance of the patient is of importance. The common ob- 
servation that in two cases with the same type of growth, subjected to the 
same radiation, different results are obtained; that in one the cancer dis- 
appears promptly and in the other it is not affected at all, suggests the re- 
sistance in the patient. Again you cannot lay too much importance on the 
extent of local involvement ; large growths may disappear and small ones 
fail to do so. The most easily injured normal tissue is the eye and the 
rectum. Radiation carried to the extent of severe injury may defeat its 
aim in the end. 

In every patient, radiation up to but not beyond the toleration of the 
normal tissue should be given. This part of the treatment can be learned 
by reasonable amount of experience. The theropeutic value of radium is 
based on the fact that the radiations from fadioactive substances, if suffi- 
ciently intense are capable of destroying living cells. This effect has proved 
beneficial in the treatment of diseased tissue, since the discovery was made 
that diseased cells are more susceptible to radiation than normal cells of 



1 1 ■ NORTH CAROLINA MEDICAL SOCIETY 

health)' tissue. That is, the radium rays exercise a selective action, attack- 
ing the diseased cells more readily than the normal ones. By suitable pre- 
caution and very simple technique of screening, it is possible with very few 
exceptions to effect complete retrogression of a tumor w^ithout injury to the 
surrounding healthy tissues. Whether radium is used in the form of a salt 
in an air tight container or as an applicator the principle of the technique 
is the same. 

The compound of radium, preferably the insoluable sulphate is sealed 
in a thin walled glass tube, about two millimeters in diameter and in length 
no longer than is necessary to hold the firmly packed material. The sealed 
glass tube is placed in a silver container with one-half millimeter wall 
thickness and the container fits into a brass capsule of one millimeter wall 
thickness. These containers serve in the capacity of filters; the silver tube 
being used in cases where light screening is indicated and both metal tubes 
in cases where most of the beta rays should be absorbed. 

Besides the three primary forms of rays already described, there are sec- 
ondary rays which are produced when the primary rays pass through the 
metal screens. This form of secondary radiation is of no practical value 
from a therapeutic standpoint. These rays are comparable to very soft beta 
rays and in order to prevent a burn it is necessary to provide additional ab- 
sorbing material by surrounding the metal screening with a few millimeters 
of rubber dam — a very convenient material for filtering secondary rays may 
be found in ordinary unvulcanized tube repair gum as sold by automobile 
supply houses. 

Generally speaking, the deeper the ulceration or the larger the nodular 
mass, the greater the dosage required. 

The dosage required in each particular case is readily determined after 
certain amount of experience. The factors to be considered are the quanti- 
ty of radium used, the time of exposure, the filtration and distance between 
radium and the disease tissue. Within certain reasonable limits the same 
results may be obtained by increasing the quantity in the same proportion 
in which the time exposure is decreased and vice versa, but extreme vari- 
ations are not covered by this general rule. You can get the same results 
by applying 25 milligrams for four hours as you would by 100 milligrams 
for one hour. The expression of dosage in milligram hours is not correct, 
because it leads one to think that the only factors which enter into the speci- 
fication of a dose of radiation are quantity and time, whereas the filtration 
and distance are just as important. 

To the beginner in radium therapy the question of filtration seems to be 
a difficult problem. Where the radium is in direct contact with malignant 
tissue or where the tissue is very superficial, one should use beta rays, and 
therefore a screening should be very light; on the other hand if the path- 
olog\' is deep-seated or if normal tissue intervenes between the radium and 
the diseased tissue, then the beta rays cannot be used to any great amount 
and the screening should be heavy. Beta rays are comparatively easily ab- 
sorbed and a screen of 2 millimeters of lead for the plaques of half-milli- 
meter of silver and one millimeter brass for the tubes with the added rub- 
ber damming to screen off secondary rays is all that is necessary for ordi- 
nary cases. 



PRACTICE OF MEDICINE 73 

Distance also is an important factor when the lesion is deep seated and 
overlying healthy tissues have to be protected from injury and when a more 
uniform radiation is desirable. (For 100 millegrams of radium the dis- 
tance for the average deep-seated lesion for 6 hours exposure is 3j^ cm.) 
The required distance is obtained by inserting gauze or rubber slabbing be- 
tween the radium and tumor. It is to be remembered however that dis- 
tance should be only employed when it is impossible to bring the radium in 
direct contact with the malignant cells. 

In the treatment of epithelioma with radium, one should not insist upon 
a certain technique as the only correct one. Equally good results may be 
obtained by different methods of treatment. For many epithelioma of 
small size and relatively superficial base the following technique may be 
used. A varnish apparatus of 1-4 strength may be close. One apparatus 
of this type covers 4 sq. cm. of surface and contains about 10 mg. of radium 
salt. A silver or lead screen 1-10 mm. thick is placed over the face of the 
apparatus to absorb the soft beta rays. Over this are placed six or eight 
thicknesses of block paper to absorb the secondary rays which are produced 
when the radium rays pass through metal. The whole apparatus is then 
enveloped in thin dental rubber dam applied to the epithelioma and held in 
place by adhesive plaster. There are 4 exposures of an hour ; each may be 
given on consecutive days. The screen is then removed and three or four 
similar exposures are given with the apparatus wrapped only in rubber dam. 

Following the treatment a slight inflammatory reaction develops. A crust 
then forms which corresponds in size to the area of radium applicator. 
Under the crust which may be shed and renewed several times handling 
takes place in about six weeks from last treatment. Cutaneous epitheliomas 
of fungating type are best treated at first with unscreened radium in order 
to cut down quickly the fungating portions. In this type of lesion a half 
dozen exposures may be given in successive days with above applicator cov- 
ered with rubber daih. With the disappearance of the fungating part of 
the tumor, the base if deeply infiltrated can then be treated with screened 
radium. Another method that may be successfully used in epithelioma of 
moderate size consists in giving a single intensive exposure. One may give 
an exposure of 6 or 7 hours with 50 millegrams of radium salt screened 
with 5-10 mm. of silver. Moderate reaction takes place and recovery en- 
sues in about six weeks. For treatment of large epithehomac not less than 
50 mg. of radium salt are absolutely essential. We have treated 40 cases 
of skin cancer of all kind with 100% apparent cures. 

At the next meeting of the North Carolina Medical Society at Pinehurst, 
April, 1921, I hope to be able to report a good number of cases of cancer 
of the cervix and fundus. Also on filiroid tumor of the uterus and excessive 
flowing at and between the menstrual period. We are now working on 
six cases of Exopthalmicgoiter with radium and x-ray, which I hope can 
also be reported on favorably. 

DISCUSSION OF DR. JAMES^ PAPER 

Joseph A. Elliott, Charlotte: I would like to express my apprecia- 
tion of the exosllent results Dr. James has obtained in the treatment of 
skin cancers with radium. There is no longer any doubt but that radium 
in the hands of an expert, such as Dr. James results show him to be, is of 



74 NORTH CAROLINA MEDICAL SOCIETY 

inestimable value as a therapeutic agent. I feel, however, that with equal 
skill, xray will produce as good results as radium, in the treatment of skiti 
cancers. Where the lesion is located on the eye lid, or in the mouth, we use 
radium to advantage due to the fact that it can be placed in close proximity 
to the malignant cells. The same holds true of carcinoma of the bladder 
or prostate. Little can be expected of xray in these cases as the rays have 
to penetrate so much normal tissue before the malignant foci are reached. 
On the other hand radium can be placed in direct contact with the growth. 
Within the past few years the xray erythema dose, or skin unit, has been 
worked out so carefully by suCh men as McKee and Witherbee that one is 
no longer in doubt as to the dosage to use. Recently Kingery has worked 
out a mathematical curve showing the length of time the ray remains in the 
tissues and the rate of absorption. With this knowledge at hand it is easy 
to keep the lesion saturated, thereby obtaining the maximum effect from the 
ray at all times rather than allow the rays to be completely absorbed before 
giving subsequent treatment. To my mind this is a great step forward in 
xray therapeutics and I feel that greater results are to be hoped for as a 
result of this work. 

DOUBLE CHOKED DISCS— OPERATION, WITH RECOVERY 

OF VISION. 
Henry L. Sloan, M. D., Charlotte, N. C. 

Mrs. R. D. G., age 19, Eufala, N. C, first seen on March 16, 1920. 

Failure of vision and headaches. 

About one month ago patient began to suffer with headaches, and vision 
began to fail, and had failed so much that she had to be led into office. 
There was also nausea and vomiting, worse in the A. M., and on change 
of position — not projectile. 

When first seen one month after onset of P. I., patient was in a v-^ery 
anxious state of mind ; she seemed to feel as if some calamity were immi- 
nent. At all times she was mentally alert and answered questions prompt- 
ly. Complained much of headaches, which did not seem severe. 
P. M. H. 

For a few months before onset of P. I., patient said she suffered a great 
deal with rheumatism — which continued up to the time she came to our 
office. 
F. H. 

Of no importance. 

PHYSICAL examination 

T. p. R. 

Normal. 

General appearance good. Appetite good, but digestion poor. 

Eye findings: O. D. V. Count fingers two inches. O. S. V. Amaurotic; 
light perception absent. 

Both eyes prominent, but always thus. Pupils widely dilated and did not 
react to light. Media clear. Both discs were enormously swollen — show- 



PRACTICE OF MEDICINE 75 

ing about nine diopters of swelling with many hemorrhages, and with us- 
ual contortions of vessels in such condition. 

O. D. Ext. rectus showed paresis. 

O. S. ext. rectus paralysis with convergent squint. 

Nasal examination and xray of sinuses negative. X-ray of teeth, urin- 
alysis (repeated examinations) negative. Blood and spinal fluid Wasser- 
manns, negative. Leucocytosis — 20,000. Spinal fluid cell count 3, and un- 
der pressure, — with monometer, 26. (Normal anywhere up to 10.) Blood 
pressure, 128 — 80. 

Neurological examination : Has atoxia of both hands. Knee jerks ab- 
sent. No clonus. 

Treatment: Although rhinologic was negative, we, opened ethmoids and 
spnenoids. Negative pathological findings. However, the next day patient 
remarked that she was no longer troubled with rheumatism, and was free 
of it during her stay in hospital. 

Vision did not improve and subjective symptoms of headache and nausea 
persisted. Two days later a temporal decompression was done by Dr. Breni- 
zer. Soon all symptoms were relieved and vision began to improve and 
improved steadily until patient was dismissed from the hospital. 

An examination of eyes April 6, showed: O. D. V.r=20-.100. O. S. 
V.=20-100. 

Practically all retinal hemorrhages had been absorbed and there were only 
three diopters of swelling of both discs. Both external recti showed much 
improvement of function. Patient went home feeling fine, with useful vis- 
ion and with a good chance of much better vision as time passes. 

This is a case, probably of brain tumor; which Gushing tells us will be 
found much oftener if we only look for it. With refined methods of diag- 
nosis they were found to be much more frequent, than old statistics indi- 
cated in the records of Johns Hopkins Hospital. 

Other causes of choked discs are nephritis, syphillis, basilar meningitis, 
supperative sinusitis, and echinoccus cyst of brain, disseminated sclerosis, 
eta These could be practically all ruled out in this case. Choked disc in 
brain tumor is present in about 80 per cent of cases. 

Given a case with symptoms of headache, nausea and vomiting, we should 
make a careful examination of the visional fields. Dyschromatopsia (in- 
terlacing and inversion of the color fields) is a much earlier sign of brain 
tumor than choked dies. This sign can be easily demonstrated. In its most 
typical form, the blue field is interlaced and may become completely inver- 
ted with the red. There may be blue scotoma or a total achrom-atopsia for 
this color alone. And many other varieties conforming somewhat the type 
mentioned above. We have been taught that such perimetric findings are 
pecular to functional and hysterical states. That such color field changes 
are due to increased intracranial pressure has been shown by rapid restora- 
tion of normal color values in the fields of vision after relief of the pressure. 
So I would urge use of these examinations under such circumstances. 

Of course, in the case here reported the possibility of any helps from tests 
dependent on good vision was precluded. But they could have been done 
earlier. 



76 NORTH CAROLINA MEDICAL SOCIETY 

Given a desperate case of the character here reported, I would urge cran- 
ial decompression as an emergency measure to conserve vision. Then look 
for the cause later. This operation is not necessarily heroic or dangerous. 

In conclusion, one purpose I have reporting this case is to emphasize the 
importance of ophthalmology as an aid to general medicine. The eye is an 
outgrowth from the primary forebrain, and is very closely related to many 
pathological brain changes. We are very fortunate in having many of our 
medical men quite alive to this fact. 

Much valuable information can be had in the diagnosis of intracranial 
lesions in the earlier stages by use of ophtholmological examination, and we 
feel that it should be made use of more often in such conditions. 

Note: Patient was seen finally on June 8th, 1920. 

Vision: O. D. V.=20-40 minus 1. O. S. V.=20-70 plus 1. 

Both discs had lost all their swelling. There was slight bilateral papil- 
lary palor. Both external recti had regained normal function. In fact, pa- 
tient felt quite well. 

DIFFERENT FORMS OF FOOD ADULTERATION. 
W. M. Allen, Charlotte, N. C. 

State Chemist of North Carolina. 

Food adulteration had its origin in very early ages. Even when society 
was in a very primitive state there were knavish tricks in bartering, substitu- 
tions of bad for good and falseness of many kinds. There was not room for 
so much adulteration then for the food of the family was raised from the 
soil on which they then dwelt and was prepared for use by themselves and 
commercial frauds on a large scale had not developed. There are, however, 
records of ancient sophistications practiced by the Greek and Roman traders, 
but it was the Middle Ages that the most interesting types of these practices 
developed. 

About the first fraud alluded to in the early writings was the adulter- 
ation of opium. The test was primitive and crude. If pure it burned with 
a clear, brilliant flame; if adulterated the flame was dififerent. Its quality 
was judged by its behavior when exposed to the sun. 

In some very early writings we find frauds practiced by bakers alluded 
to. They added to bread a white earth, soft to the touch and sweet to the 
taste, w'hich was supposed to have been obtained from a hill situated near 
Naples. 

The adulteration of wine in Athens necessitated a special inspector, whose 
duty it was to detect and stop such practices. Greek history mentions Can- 
thon, who excelled in ingenious mixtures as he knew how to impart to new 
wine the flavor of aged wine. In Rome and Gaul wine was adulterated in 
the cellars with artificial color and flavor. 

In Europe generally from the eleventh century on bakers, brewers and 
vinters were frequently accused of corrupt practices. 

By the "Assize of Bread" during the reign of John the sale of bread was 
regulated in England, the regulation of the price, by limiting the profits of 
the baker so that the price of the loaf should bear a certain relation to the 



PRACTICE OF MEDICINE 77 

price of wheat. The Assize of John's reign continued in force until 1286 
when it was repealed by "The Statute of Assize." 

There were various modifications of the assizes, and they were finally 
abolished in 1815. Though preventing adulteration with foreign substan- 
ces was not the main object of the regulations, as time went on and the 
sins of the bakers accumulated, clauses with regard to the adulteration of 
bread with foreign matter were inserted and the later ones developed into 
the "English Sale of Food Act." The assize of 1582 contained the follow- 
ing: "If there be any that by false means useth to sell meal; for the first time 
he shall be grievously punished, the second time he shall lose his meal ; the 
third he shall forswear the town and so likewise the bakers that offend. 

The assize of 1634 contained stringent regulations with regard to musty 
meal. If there be any manner of person or persons, which shall, by any 
false ways or measure, sell any musty meal unto the king's subjects, either 
by mixing it deceitfully or sell any musty and corrupt meal, which may be 
to the hurt and infection of man's body, or use any false weights, or any 
deceitful ways or measures, and so deceive the king's subjects, for the first 
time he shall be grievously punished, the second he shall lose his meal, for 
the third offense he shall sufFer the judgment of the pillory, and the fourth 
time he shall forswear the town wherein he dwelleth. 

It is recorded in "Doomsday Book" that during the reign of Edward the 
Confessor that a knavish brewer was taken round the town in the cart in 
which the refuse of the place had been collected, and to that was added 
corporal punishment. 

In many towns in the sixteenth century there were "ale-tasters" whose 
duty it was to inspect the beer. For example, the Mayor of Guilford 
ordered that the brewers make a good useful ale, and that they sell none of 
it until it be tasted by "ale-tasters." The ale was not only tasted, but it 
was otherwise tested. Some of it was spilt on a wooden seat, and on the wet 
place the taster sat, attired in leather breeches. If sugar has been added, 
the taster's leather trousers would stick to the seat ; if sugar had not been ad- 
ded, the dried extract, having no adhesive property the trousers would not 
stick. In France and Germany during the Middle Ages as in England, the 
regulation of the sale of allimentary products applied almost exclusively to 
meal, drugs, wine and beer and the punishment in France was very similar 
to that of England except in France it partook more of the character of a 
religious penance. In Germany the punishment was decidedly more severe. 
All who adulterated food or drink were punished severely, with painful 
and dishonoring penalties, such as public exposure of the fraud and whip- 
ping at the gate. There are instances recorded where for adulterating 
food or drink the culprit was burnt at the stake or buried alive. 

From these extracts we see that food adulteration and laws to prevent 
same are not wholly products of modern times, but are inheritances of early 
Middle Ages, but no interest was taken in the subject during the early 
years of this country. 

About the first legislation of this nature in the United States was an act 
of Congress in 1848 to secure the purity of imported drugs. 

In about 1877 laws to prevent the sale of adulterated food were passed 



78 , NORTH CAROLINA MEDICAL SOCIETY 

in some of the States like New York, Massachusettes, Michigan and New- 
Jersey and chemists commissioned to investigate and report on the subject. 
Some most excellent work was done in those states and from time to time 
other states followed their example. 

In about 1879 a bill for Federal regulation of food in interstate commerce 
was introduced into Congress and during the years following similar bills 
were introduced but opposing interests were so strong that not until 1906, 
after the horrible exposures of the Chicago and other packing houses could 
such bill be passed-. 

During the first hundred years of the history of this country practically 
no effort was made to prevent food adulteration and the sophisticator and 
adulterator of foods had full sway. Their actions were regulated only by 
their own conscience Avhich if they ever had, became so paralized that their 
nefarious businesses were not interfered with much, and the food sold to 
the American people during that latter part of that period would have made 
a monkey blush. 

Food adulteration was not so bad in the South as it was in the North 
and consequently the Southern States were slow to pass food regulation 
laws. 

Our own good state was about the first to take such action and in 1899 
passed a law which in 1907 was redrafted and passed and with some amend- 
ments is our present food law. So far as intentional adulteration is con- 
cerned the law is effective but not so much was known at that time about 
sanitation and from a sanitary standpoint it needs revision. 

The Legislature passed a good law and made it the duty of the Depart- 
ment of Agriculture to enforce it without however providing any funds for 
the purpose. Practically the same thing followed in several of the other 
Southern States. 

The funds of the Department of Agriculture were from an inspection 
tax on fertilizers and were therefore paid in by the farmers of the State. 
The Board of Agriculture, made up of farmers, did not see fit and would 
appropriate but little from a fund paid in by one class of people for the en- 
forcement of a food law that would benefit them much less than it would 
the people who depended wholly upon bought food for their living. 

For several years less than $2,000.00 a year was spent for all purposes of 
food law enforcement while many other states were spending from $10,- 
000.00 to $40,000.00 a year for such work. 

At our solicitation since that time other inspection laws like the oil and 
gasoline laws, the linseed oil laws and the bottlers plant inspection law, 
etc., have been passed that produce revenue for the enforcement, and by 
doing the food yvork in connection with the latter fairly reasonable funds 
are available for the food work, but no funds specifically for food work are 
provided. 

But more to the subject, food is that which, taken into the body, builds 
tissue or yields energy. 

Food is adulterated : If it contains any added poisonous or other added 
deleterious ingredient which may render such articles injurious to health. 



PRACTICE OF MEDICINE 79 

If it consists in whole or in part of a filthy, decomposed or putrid animal 
or vegetable substance. 

If any substance has been mixed or packed with it, so as to reduce or 
lower or injuriously affect its quality or strength. 

If any substance has been substituted wholly or in part for the article. 

If any valuable constituent of the article has been wholly or in part ab- 
stracted. 

If it be mixed, colored, powdered, coated or stained in a manner wholly 
damage or inferiority is concealed. 

Then the effect of adulterated food on mankind is studied from two 
standpoints. First, the effect on the health ; and second, the effect on the 
wealth. A very small amount of adulteration will have a tremendous accum- 
ulative effect on either our health or our wealth. Then the adulteration of 
food comes under two general heads : 

1st. Adulterants which are harmful or deleterious and effect health, and, 

2nd, Adulterants which are fraudulent and only affect the cost. 

The first may be divided into two classes: Those things that are of 
themselves, when added to food, deleterious or which when added to food 
render the food deleterious and are added intentionally in its manufacture 
to preserve it; or to color it to improve its appearance, and those things 
which occur or get into the food incidentally in the manufacture of same, 
owing to the use of spoiled or inferior material or insanitary conditions 
under which it is manufactured or handled. 

Under division one, sub-division one are chemical preservatives and pois- 
onous coal tar and certain other mineral colors. When the food laws were 
first passed chemical preservatives such as benzoate of soda, borax, salicylic 
acid, certain sulphites and even formaldhyde were used premiscuously in 
all kinds of foods and many were colored with poisonous dyes. The object 
of the color was to deceive the purchaser. 

Inferior, and even spoiled materials, were chemically preserved, artifici- 
ally colored and flavored and sold as high class products and because of the 
flavor and color the true nature was not at all evident. 

The use of these products was doubly objectionable. It made the use 
of more or less spoiled material possible that would otherwise have been 
easily detected, and, while the amount of the preservative or color consumed 
at any one time was so small that its poisonous effect on the body was neg- 
ligible, it was enough to preserve the food and therefore to a certain extent 
interfere with the action of the digestive ferments of the body and retarted 
digestion. 

Under food law enforcement, the use of these preservatives and coal tar 
colors in food have practically disappeared, but it was not without a fight, 
and a hard fight too, for they died fighting. It was difficult to get evidence 
regarding their effect on the body that the courts would accept. Actual 
test had to be made by the Referee Board. The test was a long tedious 
process and not very satisfactory at best, but the results all taken together 
showed preservatives in food to be more or less objectionable, and the re- 
sults, while not conclusive, did aid in breaking up the practice. 

Another kind of adulterants that effect health are bacteria and products 



80 NORTH CAROLINA MEDICAL SOCIETY 

that are the results of bacterial action. They are not intentionally added 
to food, but get into it incidentally from the use of bad, decomposed mater- 
ial, or by careless or insanitary manufacture or handling. 

I shall not attempt to discuss the possible effects of bacteria on health; 
that is the field of the physician, but will in a cursory manner refer to 
ptomaines about which, however, very little is known. They are of bacter- 
ial origin and are very poisonous. Not always but for some reason they are 
sometimes formed in the decomposition of organic matter. Ptomaines are 
formed only in nitrogenous matter, and rarely in matter except of animal 
origin. 

Ptomaines are a class of arganic bases or putrefective alkaloids formed by 
the action of putrefactive bacteria on nitrogenous matter. Chemically 
speaking they are derivatives of ethers of the poly hydric alcohols. Some 
of them have been prepared synthetically. Authorities seem to differ as to 
whether they are all poisonous or not, but it is well known that most of 
them are exceedingly poisonous. But one thing that I wish to call to your 
attention is that ptomaines cannot be reliably detected chemically, that is, 
there is no chemical test for ptomaines, that can be relied upon. The only 
way to detect any of this class of poisons is to test same on a living animal. 
That may be done by either feeding the suspected specimen to the animal 
or by injection. It is our practice in the Food Laboratory to feed it to the 
animal. 

It appears that almost any animal is sensitive to ptomaines. Cats, rats 
and guinea pigs are all desirable subjects. Rats being pests that will eat al- 
most anything and fairly easy to obtain are used most, but Pussy has fared 
badly at times at our hands when we had to test for ptomaines. 

A few years ago a catch of fish were allowed to get bad before they were 
pickled at Morehead City. Ptomaines were formed in them and before 
that fact was known they were pickled, mixed and packed with a large lot 
of good fish. When they were later put on the market several people were 
made ill from eating the fish. The matter was reported in the papers. We 
immediately secured samples. Some of the fish proved to be bad. By wire 
we had the shipper trace each shipment and stop sale of same until an in- 
vestigation could be made. Samples from about forty barrels were ob- 
tained. Some of them proved to be bad while others were good ; even diff- 
erent fish from the same barrel, one would be bad and another good. The 
bad were so mixed with the good that it was impossible to separate them 
and several hundred barrels had to be condemned and sent to the fertilizer 
factory. 

We used chemical tests described in the books, as we had done before, 
but again found them unreliable. We examined them physically but after 
being pickled there appeared to be no positive difference in the appearance 
or odor by which we could tell the good from the bad. No salt fish smells 
good and if any smelt worse than any other we could not detect it, but some 
of the fish when eaten by a cat or rat would make it very sick from which, 
in some instances they died, while some of the other fish did not seem to 
affect them at all. 

The packer of the fish was unable to account for the bad fish unless they 



PRACTICE OF MEDICINE 



81 



were mixed in with good fish by the fisherman from whcm the fish were 
bought, so that they escaped detection. 

Some of you no doubt saw in the Associated Press reports within the past 
few months, references to sickness and death in several instances, from the 
eating of infected ripe olives. 

' A government report shows that a shipment of these olives were seized 
first by the Food Inspector in Wisconsin. The government alleged that 
the olives were adulterated in that they consisted in part of a filthy, de- 
composed and putrid vegetable substance. Examination by the Bureau of 
Chemistry showed that guinea pigs fed on olives from the shipment died, 
indicating the presence of toxin due to decomposition of the olives by bacter- 
ia which were later identified as Bacillus botulinus. Olives similarly in- 
fected were responsible for the death of several people within the past few 
months in Canton, Ohio; Detroit, Michigan; Brooklyn, New York; Mem- 
phis, Tennessee and elsewhere. 

Investigation showed that defective methods in processing, pickling and 
padking the ripe olives were responsible for the infection. 

The government report further states that all the ripe olives to which 
trouble has been attributed were packed in glass and that the trouble was 
probably due, for fear of breaking, to insufficient heat to sterilize the pro- 
ducts. The poison would of course develope in tin containers if they were 
not sufficiently processed, but as there is no danger of breakage in tin, a 
sufficient degree of heat is usually applied. 

In all cases of botulinus poisoning investigated, the ripe olives showed 
signs of decomposition. They had odor and taste characteristic of decom- 
position that indicated that they were not sound. In some instances even 
where death resulted, the persons who served the olives and persons who ate 
them recognized that the olives were not sound. 

Then, there appears to be no necessity for one to live in dread or fear 
of being poisoned by unconsciously eating dangerous food, or food in which 
ptomaines have formed. 

There are, however, cases where the real character of the product is hot 
evident from its physical appearance, a good example of which is a beverage 
containing ethyl and methyl alcohol. A beverage containing ethyl alcohol 
might contain a dangerous amount of methyl or wood alcohol without the 
presence of the latter being evident from its taste or odor, though the taste 
and odor of the meth}^ alcohol is quite different from that of ethyl alcohol. 
As is well remembered, only a few months ago there were a number of 
deaths from the use of methyl or wood alcohol in drinks. Wood alcohol 
is so deadly poisonous that it can't be used to any great extent as an adulter- 
ant or substitute for ethyl alcohol in beverages for it will tell its own story 
in very sad terms. However, there is another use to which it is put as an 
adulterant or substitute for ethyl alcohol, which, while objectionable, is 
not so fatal as if used in a beverage. That purpose is the use of it as a 
solvent in extracts, perfumes and lotions which, if taken internally at all, 
is in very minute quantity, not enough to tell the story at once, and this 
fact makes its use more possible for this purpose and in the long run, upon 
a whole, vastly more dangerous. 



82 NORTH CAROLINA MEDICAL SOCIETY 

Another example of a substitute which is both fraudulent and deleterious 
to health and the presence of which in food is not evident because of its 
taste or odor, is the use of saccharin as a substitute for sugar. Saccharin as 
a substitute for sugar in food is far less dangerous to health than is true in 
the case of wood alcohol, so far as immediate results are concerned, but in 
the long run it is possibly an even greater curse because its effect is not 
so evident, which makes its use vastly more possible and much harder to 
prevent. As a substitute for sugar it plays a double roll, and if permitted 
by the food laws, its use would doubtless be carried to an enormous extent 
during the present scarcity and high price of sugar. 

Saccharin is a Benzoylsulfonic imide, and while it is sweet, it has no re- 
lation to sugar at all. It is in no sense a food and supplies no energy or 
nutriment to the body when used in food. Its use as a substitute for sugar 
is not only a fraud but is more or less deleterious to health, according to the 
findings of the Referee Board, Food Inspection Decision 135, by the Secre- 
taries of the Treasury, Agriculture and Commerce and Labor of the 
United States, adopted April 26th, 1911. 

Another class of food adulteration consists of adulteration that is fraudu- 
lent only and does not affect health. It is adulteration that reduces or 
lowers the value or strength of the product without rendering same dele- 
terious to health. 

From the foregoing it is evident that food adulteration that is deleterious 
to health is of all importance, for life itself without health is hardly worth 
living. It has been said that that depends upon the "liver," and as physi- 
cians you know how important the "liver" is. 

As so much depends upon health for our happiness it is impossible to com- 
pare the importance of the two classes of food adulteration, but I do desire 
to convey to you some idea of the importance of food adulteration from an 
economic standpoint. 

It is estimated by food officials that in point of volume or frequency of 
occurrence that well above 95 per cent of the food adulteration in the Uni- 
ted States is from an economic standpoint, the object of which is to gain by 
fraud in the substitution of a cheaper, or less expensive, or less desirable pro- 
duct for one of higher price. 

If not of more importance to health and happiness of the human family, 
this class of food adulteration is vastly more voluminous than adulteration 
that is deleterious to health. It is a broader field and offers greater reward. 
Many dealers and manufacturers will accept profits from this class of adul- 
teration that ■would not knowingly sell a product that was deleterious to 
health. In fact, it is sometimes hard to make even fairly intelligent dealers 
understand that a product can be adulterated and misbranded and its sale 
absolutely illegal, when if the same product be properly branded and repre- 
sented to be what it actually is, and nothing else, that iti sale is perfectly 
legal. They say, well, if it is adulterated forbid the sale of it and I will 
throw it back on the jobber or manufacturer. That dealer may be selling 
at retail, a compound vinegar or a skim'milk cheese as vinegar or cheese, as 
the case may be, when the product as he bought it is properly branded but 
his customers never see the original package. Compound vinegar is not de- 
leterious to health but it is not vinegar and is not worth as much as vinegar. 



PRACTICE OF MEDICINE 83 

Vinegar is a product made from the juice of apples and has a delightful 
appetizing fruit flavor. Compound vinegar is made from almost any kind 
of waste sugar or starch material, like stale bread, etc. Skim milk cheese is 
a good food, rich in milk proteids, but it is not as good as cheese which is 
made from whole milk without having any of the fat removed. If sold as 
skim milk cheese the sale of such a product is all right, but it should not be 
sold as cheese. 

Corn syrup is a good food but it is not as choice as cane syrup, so a mix- 
ture of the two should not be sold as pure syrup. 

Cane syrup is a good food but it is not as choice and will not sell on the 
market for as much as maple syrup, and if it is added to maple syrup its 
presence should be made known to the purchaser. 

Nut butter and oleomargarine are good foods but you don't want to pay 
the price of creamery butter for them. 

These examples could be extended or multiplied almost indefinitely for, 
to be sure, for every high class food product there is some way of adulterat- 
ing it or of substituting fraudulently some less valuable product for it and 
so doing it that the fact is not evident on the face of it. Even bread, the 
staff of life, has been greatly misrepresented. Low grade flour from which 
it was made was bleached to appear like a high grade. 

As manufactured by modern machinery high grade flour is white and it 
is bought and sold on its color or lack of color. When a lower grade flour 
is bleached to appear like a higher grade it is misrepresented, unless the fact 
that it has been bleached is made known to the purchaser. 

The law requires flour, if bleached, to be labeled bleached, so that the 
purchaser may know that it is not necessarily high grade because it is white. 

Food officials have not had easy sailing in the development and enforce- 
ment of food laws. Every effort has been fought hard by those who profit 
by fraudulent practices in the adulteration and misbranding of food pro- 
ducts. They have able chemists and lawyers to study their work minutely to 
direct and protect their practice. 

Like the patent medicine people they are thoroughly organized and stand 
shoulder to shoulder. When you touch one you have touched all and the 
whole tribe is on you. 

In conclusion, I will add that it is to be hoped that in the near future Dr. 
Rankin and the Board of Health may secure legislation that will require 
the proper branding of drug products. 

I thank you for your attention. 

BLOOD CHEMISTRY IN NEPHRITIS. 

Dr. W. M. Copridge, Durham 

Researches in biological chemistry have wnthin the past few years added 
much to our knowledge of pathological conditions. Almost no department 
of medicine has missed the benefits of the work of such men as Folin and 
Dennis, Dakin, Meyers and others. In the diagnosis of nephritis we find we 
have been especially favored by the researches in the so called "Micro- 
Chemical" methods of blood analysis. The subject of nephritis has received 



84 NORTH CAROLINA MEDICAL SOCIETY 

new light where our knowledge of the subject has been perhaps most dis- 
astrously clouded, and that has been in the early diagnosis of the conditions. 
Formerly physicians have used, most largely, the chemical and microscopi- 
cal examination of the urine as an index to the extent of pathology in the 
kidney. The limitations of these methods have long been known. It is a 
fact that the work an organ is doing cannot be entirely interpreted by the 
evident extent of pathology in that organ. Again, the demonstrable patho- 
logy of the organ is not always in proportion to the work the organ is doing. 
McQuarrie and Whipple have shown that in proteose intoxication the renal 
function is very markedly lowered without any demonstrable anatomical 
lesions in the kidney. So we have come to realize that the interpretation of 
albumen and casts in the urine is usually that of pathology in the kidney 
but now we know that we can little judge the function of the kidney by the 
presence or absence of them. 

Since the time of Bright many attempts have been made to estimate the 
amount of work the kidney is doing, by the use of some substance that may 
be given in measured amounts and can be recovered in definite amounts in 
the urine. To this end, many substances have been used — Methylene Blue, 
lactose, salt, water and many others. Roundtree and Geraghty in 1910 in- 
troduced phenolsulphonpthalien for this purpose. Without any doubt this 
method of studying renal function has been the most generally useful and 
must be considered a great step forward in these studies. It seems that it 
is the best substance yet derived for fairly accurately determining, for the 
time, the work the kidney is doing. It does not tell us that the kidney is ex- 
creting a measured amount of the dye hour by hour and day by day over 
any considerable period. Neither does it tell us that the kidney is handling 
the substances such as urea, creotinine or uric acid, in the same proportion 
that it excretes the pthalien. So, as valuable perhaps as any excretory test 
may be, the pthalene test has its limitations. The idea of examining the 
blood for evidence of renal impairment was conceived many years ago. The 
methods used did not permit of any practical use until 1913 when Folin and 
his workers devised the comparatively simple methods now in use. The 
work of Meyers and Fine, Mosenthal, Marshall, McLean and others have 
shown the great practical value of the methods in the early diagnosis of neph- 
ritis and also of the prognosis of the disease. Generally in uncomplicated 
nephritis, the blood chemistry findings have run parallel to the phalian test 
again emphasizing the great value of the latter. In some cases, however, 
the Chemical analyses have shown that the pthalian test cannot be relied 
on for the same extent of accuracy as the chemical examination of the blood. 

In general the examination of the blood for evidence of impaired renal 
function has been concerned with the ammonia nitrogen, total nonprotein 
nitrogen, urea, uric acid and creatinine. It has been found that the latter 
three — the urea, uric acid and creatinine give more information. Studies in 
blood urea probably superceded uric acid and creatinine, it naturally being 
thought that since the bulk of the nitrogenous waste was eliminated in the 
form of urea, that in cases of impaired kidney function retention of this sub- 
stance would serve as an index to the extent of the injury. 

Marshall, by the introduction of his urease method of determining the 
urea of the blood, made It possible for this test to be done with ease in a very 
modestly equipped laboratory. McLean has called attention to the value of 



PRACTICE OF MEDICINE 85 

comparing the blood urea readings with the urea content of the urine, much 
in the same method as that of Ambard. This method seems to be very much 
to be preferred when considering the question of urea. We know that diet, 
exercises and other factors play an important role in the urea content of the 
blood. The amount of urea in the blood therefore varies through fairly 
wide limits even though the kidney may be excreting a normal amount of 
the substance. 

The part which the liver plays in the production of urea is unquestionably 
a large one, whether all of the urea is formed in the liver or not is an open 
question with the favor being on the side that the muscles and other tissues 
do form possibly a small amount of the substance. Shroder, with experi- 
ments on dogs has done much to show that the liver forms most of the urea. 
Pawlow has shown that when the liver is practically destroyed the urea in 
the urine is greatly diminished. It seems, therefore, that the activity of the 
liver must also be considered in interpretating blood urea readings. 

We have, in the Watts Hospital laboratories, felt that in certain cases 
with low blood urea readings where renal functions was definitely low, we 
have been able to ascribe such a condition to injury to the liver. One case 
in particular which seemed to carry this point, was one of bichloride poison- 
ing. About 30 grains of bichloride had been ingested about 24 hours be- 
fore the observations were made. The urine was scanty, loaded with albu- 
men and casts, with the pthalien practically zero in two hours. In such a 
cases even with so short duration we would certainly have expected blood 
urea readings considerably above normal. As a matter of fact the urea was 
decreased, being between 15 and 20 milligrams per 100 cc. of blood whereas 
the normal lies between 20 and 40 milligrams. This reduction we ascribed, 
without any direct proof, to liver injury due to the bichloride, resulting in a 
decrease in liver function coincident to the kidney injury and resulting de- 
crease in kidney function. 

In cases of toxemia of pregnancy we have found at times the same occur- 
rence. We have seen cases with very low pthalien outputs with blood urea 
figures about normal or below. Knowing as we do that liver injury is very 
often severe in these cases we have again ascribed the low blood urea reading 
to low liver function. In several cases we have felt that the blood urea es- 
timation has helped us to differentiate the cases of acute nephritis complica- 
ting pregnancy, from the cases of true violent toxemia of pregnancy. In 
this last group the urea of the blood is not markedly increased although the 
kidney function as measured by the pthalien test may be as low as 10-15% 
in 2 hours. We have noted that the outcome in such cases not so favorable 
as the cases showing low pthalien with high blood urea — showing as we be- 
lieve that the cindition in the latter cases is an acute nephritis which is pro- 
bably not complicated with liver injury. As, I have said above, these obser- 
vations have been only dinical in their nature and have been made on a 
comparatively small series of cases and therefore may be erroneous if ana- 
lyzed experimentally. Nevertheless, they have practically convinced us that 
in cases with severe liver injury the blood urea reading will very probably 
be low. We feel that in several cases of suspected toxemia of pregnancy 
the blood urea and pthalien tests have helped us to decide which cases were 
really acute general toxemia of pregnancy and those of acute nephritis com- 
plicating pregnancy. 



So NORTH CAROLINA MEDICAL SOCIETY 

In chronic nephritis and in acute uncomplicated nephritis the blood urea 
is usually increased very often to 100 or more times the normal. These cases 
usually, but not always show a corresponding decrease in the output of ptha- 
lien. A very interesting case was reported by Halsey in which the urine 
showed no albumen or casts and the patient in apparently very good condi- 
tion. Examination showed a zero pthalien output with tremendous nitrogen 
retention with death in about 3 weeks. 

The variability of the blood urea has called for the introduction of the 
estimation of the other more constant substances of the blood. Uric acid of 
the blood is derived partly from exogenous sources but also from enogenous 
sources as well. It is claimed by Chase and Meyers uric acid is the most 
difficult of any of these substances for the kidney to excrete. They report 
that in consequence of this fact uric acid is the first substance to be retained 
in case of kidney injury that it is the most valuable test in order to deter- 
mine the incipient cases of nephritis. Their observation is to the effect that 
creatinine is the easiest substance for the kidney to eliminate and accordingly 
place very high prognastic value in the creatinine estimation. A high crea- 
tinine reading being indicative of severe and probably fatal kidney injury. 

It is a well established fac(t that practically all types of nephritis are ac- 
companied by an increased hydrogen content of the blood. The retained 
products in nephritis seem in some way to depress oxidation in the tissues to 
the extent that half way product* of an acid nature are the results. Often 
this retention of acid becomes of serious import — a vicious circle being form- 
ed — the retention of acids causing more kidney damage and vici versa. It is 
therefore of importance to know the degree of acidosis. There are several 
ways in which this may be determined. The carbon dioxide content of al- 
veolar is perhaps the best index. For this determination Marriott has de- 
vised a simple method and Van Slyke has devised a more elaborate method 
in which the carbon dioxide combining power of the blood plasma is deter- 
mined. In practically all cases of nephritis these tests show somp degree of 
acidosis. A very simple and perhaps crude method of determining the de- 
gree of acids is that of Sellards in which we administer sodium Bi Carbon- 
ate in 5 grams doses — normally this amount of sodium bicarbonate will cause 
the urine to become alkaline. If after the ingestion of this amount of sub- 
stance the urine remains acid, it is indicative of an acidosis. 

The practical importance of the blood chemistry analysis is hardly to be 
overestimated. Very often cases supposed to be mild cases of nephritis will 
be found to be serious when studied by these methods. Impending uremia 
may often be prevented when it is recognized early and the patient is taken 
thoroughly in hand. 

We believe that one of the most fruitful fields for more careful study of 
kidney conditions is in pregnancy. There is no more distressing class of 
cases than those in which the pregnant woman apparently suddenly goes in 
to a state of acute toxemia. Whether the exiology of the condition lies pri- 
marily in the kidney or not it is certain that the prognosis is much better 
when the kidney condition has received attention all thru the term. With 
the function tests and blood chemistry we are enabled to fairly accurately 
ascertain the extent of kidney injury early in pregnancy and to prevent in a 
large number of cases the serious renal complications. It is certain that fre- 



PRACTICE OF MEDICINE 87 

quent blood chemistry analyses combined with the pthalien test will act as 
an excellent guide to the prophylaxis and treatment of the condition. We 
have in the past month seen a case of a pregnant woman of 3 months dura- 
tion, who according to her physician had shown no albumen in her urine 
previously, and after eating a hearty meal at night went into toxemia with 
convulsions the following day. In such a case it is quite possible that had 
facilities allowed her physician to have had kidney function and blood chem- 
istry analyses on his patient, her true condition would probably have been 
known and the proper prohylaxis adopted. Incipient or early nephritis 
is of interest to the surgeon as well as medical man. Blood chemistry analy- 
ses will often help the surgeon in his decision as to whether "the kidneys can 
stand an anesthetic." It is possible that the surgeon can materially lower his 
percentage of cases or uremia following ether or chloroform if he is assist- 
ed by blood chemistry analyses in making his decision. 

1. McQuarrie and Whipple — Journal of Experimental medicine, April 
1, 1919. Vol. XXIX No. 4 pp. 421-444. 

2. Meyers and Fine — Journal Bialogical Chemistry, 1915 Vol. XXL, 
pp. 389. 

3. Mosenthal and Lewis — Journal Am. Medical Assn., Sept 23, 1916., 
Vol. LXVII, No. 113, pp. 933. 

4. Marshall— Journal Bialogical Chemistry, 1913, Vol. XIV, page 283, 
Ibid, 1913, Vol. XV, pp. 287 and 495. 

5. McLean— Journal Am. Med. Assn., Feb. 5, 1916, Vol. LXVI, No. 
6, pp. 415. 

6. Shroder — Achiv. F. experimentelle Pathologic and Pharmakologic 15, 
364, 1882 and 19,373, 1885. 

7. E. H. Halsev— Journal Am. Med. Assn., June 10, 1916, Vol. LXVI, 
No. 24, pp. 1847. 

8. Chase and Meyers— Journal Am. Med*. Assn., Sept. 23, 1916, Vol. 
LXVII, No. 13, pp. 929. 

9. Marriott, Arch Int. Med., 1916, Vol. XVII, p. 840, Journal Am. 
Med. Assn., 1916, Vol. LXVI, p. 1594. 

10. Van Slyke — Unpublished data. 



SURGERY 



ACUTE PANCREATITIS RESEMBLING ACUTE INTESTINAL 

OBSTRUCTION REPORT OF CASES. 

Eugene B. Glenn. Asheville, N, C. 

Mr. President and Gentlemen: 

Deaver stated in 1918 that he believed it is no exaggeration to say that 
acute pancreatitis is more often unrecognized than it is diagnosed before op- 
eration, in the first place, because it is comparatively infrequent, and there 
is no sign of symptoms that can be said to be pathognomonic of the disorder. 
Generally the desperate condition of the patient makes operation imperative 
without the formality of a definite diagnosis. Also, acute pancreatitis is as- 
sociated with cholecystitis, perforating cholecystitis, perforating gastric or 
duodenal ulcer, appendicitis, etc. 

As a predisposing factor, obesity and alcoholism are some times mentioned. 
Age and sex do not seem to play a part. While somewhat more common 
between the ages of 25 and 50, it occurs at all ages. McPherdan reports a 
case 9 months old. In 91 cases analyzed at to sex, there were 59 males and 
32 females, while in Deaver's series of 15 cases, 11 were females. 

In 1889, Fitz named, defined, and classified acute primary interstitial 
pancreatitis, a disease the effects of which have been recognized since 1641. 

Douglas states that neither the character of food nor the manner of eat- 
ing, syphilis, or occupation can be regarded as predisposing causes. 

The frequency with which pancreatitis occurs in obese patients, a large 
portion of whom become rapi.dly fat, has led to the probably erroneous sug- 
gestion of a casual relationship. Robson asserts that the immediate cause of 
the various forms of pancreatitis is bacterial infection, clinical observation 
and clinical work in a great measure sustain this position. In numerous in- 
stance, the most careful bacteriologic search has failed to demonstrate the 
presence of micro-organisms even after a fatal, destructive pancreatitis. 
These notable exceptions justify us in accepting with some reservation the 
sweeping statement that pancreatitis is always an infection process. Reason- 
ing by anology, it is probably true, yet unproved. 

"A sudden acute abdominal seizure, pain overwhelming, in an apparent 
healthy, usually obese individual, accompanied by incessant vomiting, upper 
abdominal distension, a transverse resistance not easily elicited, weak pulse, 
sub-normal temperature, collapse, and sometimes cyanosis, should suggest 
acute pancreatitis." (Deaver.) 

Osier quotes Fitz and says: "Acute pancreatitis is to be suspected when 
a previously healthy person, or suf¥erer from occasional attacks of indiges- 
tion, is suddenly seized with a violent pain in the epigastrium, followed by 
vomiting and collapse, and in the course of twenty-four hours by a circum- 
scribed epigastric swelling, tympanitic or resistent, with slight elevation of 
temperature, circumscribed tenderness in the course of the pancreas, and 
tender spots throughout the abdomen, are valuable diagnostic signs." 



SURGERY 89 

Edsall, of Philadelphia, thinks that all urinary tests combined have little 
value in suspected pancreatic disease, as contrasted with careful clinical con- 
sideration of the cases. The only test that appears to him to be of any real 
value is that for Glycosuria, and this is in very many cases negative- If pos- 
itive, however, especially if there are focal abnormalities present, the re- 
sults add decidedly to the evidence in such cases. 

On account of the obstinate constipation at first, in the acute cases, it is 
hard to obtain a fair specimen of fecal contents. 

Patients in whom the extravasation of pancreatic juice has caused fat 
necrosis are least likely to recover. 

The surgery of the pancreas must be directed to providing an escape for 
the highly toxic pancreatic fluid ; in other words, the pancreas must be 
drained. 

Deaver is not always in favor of operating in a state of profound shock; 
he deems it wise to wait for a short time, in order to give the patient a 
chance to rally, and to wait for the peritoneal inflammation to localize. In 
the interim, Murph3'-Fowler-Ochsner method treatment is instituted. 

Early operation is desirable. The presence of blood fluid exudate in the 
pancreas requires incision and packing with gauze. Too free and indis- 
criminate an incision presents the danger of free hemorrhage, difficult to con- 
trol. Scarification of the peritoneum over the gland, should, however, be 
sufficient to allow gauze drainage to be brought into direct contact with the 
surface. A few blunt punctures of the pancreas are of service in providing 
free exit for the contained blood, lymph, and the obstructed secretion. 

Two routes may be chosen, the transperitoneal or the extraperitoneal, 
through a loin incision. 

One of the most troublesome post-operative effects of drainage in acute 
pancreatitis is the formation of sinuses. Irritation of the skin over which 
the discharge flows may be avoided by protecting the skin with a bland oint- 
ment. In order to limit the activity of the pancreas, a strict anti-diabetic 
diet is found useful in promoting healing. 

It is difficult to make a differential diagnosis in acute pancreatitis with 
any degree of certainty, because there are several other violent acute condi- 
tions which are so similar in their symptoms that they can probably never 
be positively excluded. The conditions most likely to be confounded are, ( 1 ) 
perforation of the posterior wall of the pyloric end of the stomach; (2) 
perforation or gangrene of the gall-bladder or duodenum. 

Cases of severe acute pancreatitis have been diagnosed as acute intestinal 
obstruction, renal colic, ectopic gestation, and, of course, appendicitis and 
gall-stone colic. 

(Ochsner) In acute pancreatitis the pain is extremely severe in the 
right upper quadrant of the abdomen. There is ihtense shock ; nausea and 
vomiting are usually present, and the patient gives the impression of being 
on the verge of dissolution. The abdominal muscles are tense, although 
Monihan found this symptom absent in some of his cases. There is usually 
a history pointing to gall-stone colic in previous milder attacks. 

If a tumor be felt, there is usually tympanitis on percussion over this sur- 
face, because the gland is located behind the duodenum. 



90 NORTH CAROLINA MEDICAL SOCIETY 

Cyanosis has been observed by Opie and others. Sugar is present in the 
urine in some cases. Egdahl gives a careful review of 107 cases in his study 
of the symptoms and diagnosis of acute pancreatitis which is well worth the 
careful consideration of the clinician. 

REPORT OF CASES. 

CASE. — Mr. E. W. C, aged 32, occupation civil engineer, weight 140 
pounds. Entered hospitatl October 23rd, 1919. Diagnosis acute intestinal ob- 
struction had been made and patient was referred for immediate operation, to 
relieve the obstruction. Two years previous he had been turned down for life 
insurance and one year previous for admission in the Navy, on account of 
sugar in the urine. He had suffered during this time with attacks of epigas- 
tric pains or colic. Two weeks previous to the attack, he had the "flu," but 
did not go to bed for two or three days at the onset. Six days before com- 
ing to the hospital, he was suddenly seized with severe cramp-like pains. 
Thought at first that it was an attack of acute indigestion. But when vomit- 
ing kept up and constipation resisted all treatment, a diagnosis of intestinal 
obstruction was made and he was sent to the hospital for immediate oppera- . 
tion for obstruction. While in the station at Asheville, on the way to the 
Meriwether Hospital, he collapsed. When he reached the Hospital, at 7 p. m. 
his temperature was 96 2-5, pulse 140, respiration 42. Last bowel movement 
was on October 18th, five days previous. Vomiting had become less frequent, 
but was regurgitant and of a dark brown or black appearance, but not sterco- 
ral. Hiccoughing was persistent, general tympany was present, although 
there was a marked localized distension of the epigastrium. The patient ex- 
pressed a sense of fullness and distension. A marked cholemia was present. 
Palpation was made diificult on account of the epigastric distension and great 
tenderness. A deep lying tumor-like mass could be felt with some difficulty, 
above the umbilicus. Urine showed large amount of sugar, small amount of 
albumen, small amount of blood, numerous granular casts, Indican normal, 
acetone positive, specific gravity 1030, reaction acid. 

A high asafoetida enema was given and a few small particles of fecal mat- 
ter and a large amount of flatus was expelled. Examination of material re- 
turned showed a few fat droplets. 

A diagnosis of acute pancreatitis was made, but on account of the profound 
shock, no operation was attempted. Patient complained of intense thirst, a 
smothering feeling, and a slight headache. He became restless, tried to get 
out of bed, developed involuntary urination, expelled Murphy drip, breathing 
became shallow, pulse very weak, and lived only 18 hours after he was ad- 
mitted to the hospital . He vomited a laarge amount of. black coffee ground 
fluid the last thirty minutes before he died. 

CASE 3. — Mr. P., age 56, weight 250 pounds, well-to-do farmer. Previous 
history negative except that he had suffered with light attacks of acute indi- 
gestion. He was a big eater, particularly at his evening meal. 

The day previous to the onset of the attack, he rode on a wagon, worked 
hard all day, ate a hearty supper, and slept well during the night. Got up in 
the morning feeling as well as usual, began dressing, and while stooping over 
tying his shoes, he was seized with the most frightful paroxysmal pains in 
the epigastrium, followed by nausea and vomiting, associated with extreme 
shock. 



SURGERY 91 

The family physician was called and a diagnosis of acute intestinal ob- 
struction was made. The pain was so severe and shock so profound, that the 
physician thought he was "going out" in spite of all he could do. He was 
brought to the Hospital 18 hours later. The vomiting was copious at first, 
of a dark green bilious character, later a dark brown, but not stercoraceous. 
Hiccough was absent. 

A high S. S. enema was given after entering the Hospital, and some parti- 
cles of fecal matter and gas were expelled. The patient had not voided since 
the onset of the attack, and catheterization showed ten ounces of urine in the 
bladder. Urine acid, specific gravity 1028, albumen positive, sugar negative, 
Indican slight, many hyaline and granular casts. 

Being positive that we were not dealing with intestinal obstruction, it was 
decided that we had a case of acute pancreatitis. It was evident that unless 
he could be reacted from the extreme condition then existing, an operation 
would be a useless procedure. There was almost a total anuria during the 
next twenty-four hours, in which time there developed a looseness of the 
bowels, with a very offensive odor, dark green in color. Examination showed 
fat in the stool. The epigastrium was very much distended. There was a 
circumscribed tenderness in the region of the pancreas, extending into the 
left loin, with tender spots about over the abdomen. 

The pulse were frequent and irregular, and almost impercc'ptib^e. The tem- 
perature, slightly elevated on admission, dropped to sub-normal, a few hours 
later rising to 101. Lowest temperature 97, highest 101. 

There was an extreme mental lethargy, followed by a low grade delirium. 
A mild jaundice appeared in the second twenty-four hours, with bile, sugar, 
and a large amount of acetone in the urine. 

His condition grew steadily worse, and he passed away in a little more 
than seventy-two hours from the time he entered the Hospital. 

Autopsy showed some free blood stained peritoneal fluid. The gland was 
enlarged, soft and succulent. It had a dark reddish-brown color. The duct 
and its ramifications contained blood and icterus fluid, the gall-bladder was 
distended, but no stones present. Several round, opaque areas of dissemi- 
nated fat necrosis were found upon the mesentery and omentum and extra- 
peritoneal fat adjunct to the pancreas. There was an acute cellular infiltra- 
tion of the connective tissue of the organ, with an extensive necrosis of the 
lobules. Bacterial examination was negative. 

CASE 3. — Mr. W., age 52, weight 230 pounds, occupation foreman. Went 
to church on Sunday morning and while on the way back home, only a short 
distance from the house, he was attacked by a sudden upper abdominal pain, 
overwhelming in character, accompanied by incessant vomiting, with upper 
abdominal distension, weak, rapid pulse, sub-normal temperature, collapse, 
and slight cyanosis. He had always been well, and this was the first time 
he had ever needed to call a physician. He gave no history of previous indi- 
gestion or epigastric pains. The family physician was called, tie did all in 
his power to relieve the man, and after he had utterly failed to move his 
bowels, check vomiting and relieve hiccoughing, he concluded he had a case 
of intestinal obstruction. 

The patient was placed on the train during the second twenty-four hours 
and brought to the Meriwether Hospital for immediate operation for obstruc- 



92 NORTH CAROLINA MEDICAL SOCIETY 

tion, A high S. S. enema with 1-2 ounce tincture of asafoetida added result- 
ed in a large, soft, brown, liquid stool and a quantity of flatus. The stool 
contained fat droplets. 

Temperature on admission was 99, pulse 124, respiration 36. Hiccough 
was continuous. There was a limitation of diaphramatic movements. There 
was deep seated epigastric pain, increased by firm point pressure, over the 
splenic area, which extended around toward the left loin. Tympany was be- 
coming general, with points of tenderness over the abdomen. The transperi- 
toneal route of operation was chosen. The entire gland was enlarged and the 
head of the pancreas contained a dirty green fluid. Areas of fat necrosis 
was disseminated throughout the mesentery and omemtum. The pus con- 
tained the bacillus coli communis. 

The abscess cavity was drained in the usual manner. The hiccoughing per- 
sisted. There developed a looseness of the bowels, with a very offensive odor. 

The urine before operation was clear amber, specific gravity 1032, acid, al- 
bumen large amount, sugar large amount, Indican medium amount, acetone 
medium amount, casts, small number of Hyaline and coarsely and finely 
granular. Day after operation urine down from 1032 to 1018, sugar and al- 
bumen about the same, Indican negative, acetone had increased to large 
amount. Cell count dropped from 21,000 to 16,000. Sugar continued to in- 
crease, albumen and casts diminished. There was a large increase of sugar 
and acetone on the 14th day. He died on the 16th day after the operation 
and the 19th day of the attack. 

Autopsy showed the gland to be swollen and the right half of head dotted 
with numerous yellowish-white spots and prominences arranged indiscretely. 
The left half had a dark reddish-brown appearance throughout. 

Diagnosis of pancreatitis was not confirmed either by operation or autopsy 
in the first case. I am of the opinion that it was a sub-acute or chronic pan- 
creatitis of about two years duration, with an acute termination, probably 
influenced by the recent "flu" infection. 

The second case was one of acute hemorrhagic pancreatitis, with profound 
shock and rapid termination. 

The third was a case of suppurative pancreatitis, although there were evi- 
dences of pancreatic hemorrhages. The suppuration did not necessarily pre- 
cede or accompany the hemorrhages. 

Osier says that intestinal obstruction or acute perforating peritonitis is 
usually suspected. He reports a case admitted to the Johns-Hopkins Hospi- 
tal illustrating the common mistake. The young man had symptoms of in- 
testinal obstruction for three or four days. The abdomen was distended, 
tender, and very painful. He says: "I saw him on admission, agreed in the 
diagnosis of probable obstruction, and ordered him to be transferred to the 
operating room. Halsted found no evidence of obstruction, but in the region 
of the pancreas and at the root of the mesentery, there was a dense, thick, 
indurate mass, and there were areas of fat-necrosis in both mesentery and 
omemtum. Oddly enough, this patient returned four years later with another 
attack, but he refused operation and his friends took him away." 



SURGERY 93 

DISCUSSION OF DR. GLEXx's PAPER 

Dr. Jas. M. Parrott, Kixstox : I wish Dr. Glenn had given us some 
details as to the condition of the teeth and tonsils, of the ears and sinuses, 
in these cases. Perhaps he will do this when he closes the discussion. 

Dr. J. W. Tankersley, Greexsboro : Dr. Glenn's paper is too inter- 
esting to go by without discussion. Personally, I have never had any exper- 
ience with acute pancreatitis, but I have seen several cases in operations on 
the gall bladder and other abdominal organs. The question of primary in- 
fection has engaged my attention, and the question is, is it a primary pan- 
creatitis or is it secondary to some infection elsewhere, as Dr. Parrott sug- 
gested, an infection of the teeth or sinuses, or, more important in my opin- 
ion, an infection of the gall bladder or other pelvic organs. There have 
been several theories advanced. It has been demonstrated that bile, if in- 
jected into the head of the pancreas, will cause acute pancreatitis. Bile as 
injected from the gall bladder does not cause it. Therefore, if the gall-blad- 
der is not functioning we have the possibility of infection. Another source 
of infection is hcemic. We all recognize that source, and I believe that to be 
the only primary source of infection in the pancreas. Another source of in- 
fection is the lymphatic. Frequently we run across these cases of pancrea- 
titis. I say frequently — they are not frequent. If we pay more attention 
to the pancreas we shall run across more cases. The cases are subacute or 
chronic, and I believe in most cases they come from infection of the gall- 
bladder and possibly from the appendix. I have seen cases of deaths which 
came from acute pancreatitis. One was an exacerbation of a chronic condi- 
tion which existed previous to a gall-bladder infection. They presented the 
typical picture previous to death which Dr. Glenn set forth. 

I was interested in Dr. Glenn's paper, I think it was excellent, and I 
would like to hear more discussion. 

Dr. Jas. M. Parrott, Kixston: We have Dr. Southgate Leigh, of 
Norfolk, and other distinguished visitors with us today, and I wish to move 
that the courtesies of the floor be extended to them. 

This motion was adopted. 

Dr. Glexn, closing the discussion: I was in hope that Dr. Leigh and 
Dr. Royster would have something to say about this paper. 

There are two things that impress me which I did not bring out in the 
paper. One is the fact that when you have complete intestinal obstruction, 
the use of the enema will always result in failure to obtain expulsion of gas. 
You must be careful to see that all of the air is out of the hose going from 
the syringe. Always in testing thoroughly for gas, have the stream of 
water running when introduced into the rectum. Another distinct differ- 
ence is in the vomiting of pancreatitis. It never becomes stercoraceous in 
pancreatitis, after a while it becomes regurgitant, some times a dark brown 
color. Another thing, too, most striking, is the profound shock, pain, and 
collapse in acute pancreatitis. 

After you have seen a few cases, you can hardly be mistaken in the diag- 
nosis. 



94 NORTH CAROLINA MEDICAL SOCIETY 

SAVING SUPPURATING INCISIONS. 
Hubert A. Royster, M. D., Raleigh, N, C. 
A plan for preserving abdominal incisions, which have suppurated deeply 
and preventing them from breaking down, has been employed in my hospital 
services for several years. The results have been so encouraging that the 
technique iS' herewith presented with confidence. Most frequently, the 
method is applicable to appendiceal incisions, but it may also be used in in- 
fected wounds of any kind. 

The fundamental question of drainage enters at once into our consider- 
ation. Some of us have come to believe in the reverse of the old motto and 
when in doubt we do not drain. The perfectly frank suppurating abdo- 
mens require an outlet; these admit of no doubt, and we drain them. But 
the cases concerning which we are in doubt rarely ever require a drain, be- 
cause the condition is mind, not convincingly infectious otherwise we would 
not be in doubt. The abdomen may be closed with safety, yet there are 
many good surgeons who continue to put in drains when they find murky 
serum in the cavity or are confronted with gangrenous appendix even when 
it is enveloped in omentum and unruptured. 

There have been three steps in the advancement of surgery. Formerly 
we operated to save life ; later we operated to save time. The economic side 
of surgery is most important. The greatest loss of time from abdominal 
operations occurs in cases that are drained, so that any method that reduces 
the confinement period to a minimum is desirable. 

Where drainage is needed it becomes a matter of great economic value to 
use stab wounds outside of the incision rather than to place a drain through 
the incisions. When this is done, in eight out of every ten cases the Avound 
is kept intact and heals perfectly, while drainage is efficient and safe. 

In some of the types referred to as doubtful in which the abdomen is 
closed, the wound suppurates, though the abdominal cavity remains free 
from infection. It is well known that the resisting power of the tissues of 
the abdominal wall is not so strong as that of the peritoneum. One is not 
surprised therefore when a leaky appendix is smeared over the open wound 
or a tight one ruptured in lifting it out, to observe a swollen and tender 
area around the incision four or five days later. As a rule the focus of this 
infection is under the aponeurosis and within the fibres of the internal ob- 
lique muscle. If the incision is closed loosely, suppuration is not so apt to re- 
sult. 

Supposing now that the wound has suppurated, as described, we will be 
apprised of its occurrence by continued pain near the incision, a possible rise 
of temperature, and, on inspecting the region an edematous, bulging area to 
one side or the other of the incision. In the McBurney incision this swollen 
area usually is seen to the outer side of the wound. (Fig. 1.) As soon as 
the condition is recognized, a small spot of skin at the most prominent part 
is injected with a local anesthetic and a bistoury plunged deeply downward 
and inward. Through this small stab the pus is evacuated. (Fig. 2.), aid- 
ed by pressure upon each side. When the small cavity is emptied a quanti- 
ty (equal in amount to the pus removed) of a ten per cent melted iodoform- 
vaseline ointment is introduced by means of glass syringe. (Fig. 3.) This 
distends the cavitv fills the Interstices and solidifies on cooling. A cold wet 



SURGERY 95 

compress is immediately applied over the whole area, and an ordinary dress- 
ing over this. As a rule, the wound is not disturbed for four days, when on 
removing the dressing the incision and the suppurating area will be found 
clean and intact. Slight pressure will cause any excess of ointment to exude 
and another cold compress may be put on. If before the fourth day a dis- 
charge be noted through or around the dressing, the wound again may be 
emptied by pressure and a second injection of the ointment made, following 
the same plan in the after-treatment as outlined above. 

The only advantage of the iodoform is its odor which counteracts that of 
the colon bacillus in the pus. The melted ointment method is not new with 
me or possibly to others. As long as twenty years ago I used it in the treat- 
ment of suppurating buboes and ischio-rectal abscesses * and have continued 
to employ and recommend it ever since with the utmost satisfaction. Other 
substances beside iodoform may be incorporated with the vaseline ; but hav- 
ing tried many different powders I still prefer iodoform. In this type of 
cases it is certainly superior to bismuth which came into vogue for other pur- 
poses much later. It is admitted that simple vaseline would be sufficient in 
many instances except for the absence of deodorizing qualities. Before in- 
troducing the ointment the wound cavity may be washed out with Dakin's 
solution or a weak dilution of hydrogen dioxide. We have not found this 
to be essential. 

DISCUSSION OF DR. ROYSTER's PAPER. 

Dr. a. G. Brenizer, Charlotte: Practically all the men in the base 
hospitals in the war had an opportunity to close a lot of wounds. Our 
practice in making the secondary sutures was to disregard practically every- 
thing but the gas bacillus, the streptococcus, and the tetanus bacillus. The 
wounds were frequently treated with wet compresses, or letting whatever 
pus formed escape through the suture holes. Without the use of Dakin's, 
without any antiseptics at all, the closings were just as successful as if treated 
with Dakin's. I do not believe with Dr. Royster that it is necessary to make 
a stab at the side of the wound, and I do not believe the ointment helps 
much. I believe that the evacuation of the pus would possibly do about as 
well. I have not had experience with the ointment and I do not know 
whether or not Dr. Royster ran parallel cases, but I would be surprised if 
the antiseptic ointment did very much good. 

Dr. T. C. Bost, Charlotte : This question of drainage is a very im- 
portant one. The late war, among other things, has taught us a lesson in 
not draining. The whole practice is swaying toward the non-drainage side 
and I am sure it is a step in the right direction, but I think the fact remains 
that when we are in doubt we should drain. It is a fact that the less experi- 
enced man wall be more in doubt when to drain. The more experienced 
men, of course, will be in doubt sometimes, and I think it is up to them to 
drain in doubtful cases. Notwithstanding the fact that drainage, if unnec- 
cessary, will produce a certain amount of harm and that in the absence of 
drainage we minimize the possibility of adhesions and wnth drainage we in- 
vite the possibility of external contamination, in these border-line cases I 



*New York Med. Record. 



96 NORTH CAROLINA MEDICAL SOCIETY 

think we shall do more harm by not draining than by draining, regardless 
of who treats them. 

Dr. J. T. BuRRUS, High Point: I rise more to a question of personal 
privilege than to discuss the paper. 

In the first place, I wish to "come before you and ask Dr. Long's and Dr. 
Royster's pardon for the somewhat vehement attack which I made upon a 
paper of a similar nature in Durham several years ago. I think that Dr. 
Long presented a paper at that time upon the question of drainage. I am 
sure that he and Dr. Royster were right at that time and that they are right 
now, and equally sure that I was wrong. However, I maintain this, and 
that was the position which I endeavored to occupy at that time, that in the 
hands of men who have had an unlimited experience — Dr. Henry Long, Dr. 
Highsmith, Dr. Royster, Dr. J. W. Long, and men who have done an im- 
mense amount of work — there is a difference in degree in the question of 
drainage. They know when to drain and the kind of serum or exudate that 
can be safely enclosed. But take the young man, who is just beginning, a 
man who has not had a large experience, and perhaps the safest thing for 
that man to do is to drain. So the difference would be in the degree of ex- 
perience that the men have had. 

I am not familiar with the method of handling wounds according to Dr. 
Royster's idea. I believe that if pus or fluid accumulates in the abdominal 
wall the only question is the question of drainage. I do not see why that 
should not come out through the first or primary incision as well as in open- 
ing up a new field. Again Dr. Royster may be right and may be a pioneer, 
and if so, when this question comes up again in six or ten years, I shall be 
very glad to come up and thank him for the teaching. It is very important 
and I think that our greatest prerogative is not to have trouble in surgical 
wounds, and I believe that we are now living in an age when we do not 
have very much trouble with them — that is, when the wounds are clean pri- 
marily. In the years 1917 and 1918 it was my privilege to do and to wit- 
ness a large number of incisions made primarily, and when we made these 
wounds and were careful with our antiseptics I do not recall a large number 
of cases wherein there was an accumulation of pus or where the wall was 
primarily infected. 

I thank you very much. 

Dr. Southgate Leigh, Norfolk, Va.: I was very much impressed 
with Dr. Royster's ingenious procedure, though I have never used it. I was 
rather surprised not to hear him speak of dichloramin-T, for it seems to us 
that that is the very best antiseptic for promoting the healing of soiled 
wounds. Our experience has been very satisfactory. I do not recall a single 
case in which the wound has failed to heal when we have sprayed it thor- 
oughly with dichloramin-T in five or ten per cent solution and then closed 
it up with the solution in the wound. We always sponge these wounds with 
bichloride, also. 

I cannot agree with the doctor that when in doubt we should not drain. 
I am very much afraid that is a dangerous doctrine. I expect the best plan 
to follow is to imagine ourselves in the place of the patient and then decide 
what we would want done. I do not believe there is a man in this room 
who would want a wound closed in his own abdomen if he were in doubt, 



SURGERY 97 

and I think that applies to all of us — those who have had considerable ex- 
perience and those who have not. Of course the reason for closing up the 
wound is to save time. In suppurating appendicitis, if you will make a trans- 
verse incision, cut the muscles at the other end, and spray the wound thor- 
oughly with dichloramin-T, you will get a good result. There will not be 
much delay in the healing on account of the small sinus. 

I hope we shall hear something about dichloramin-T and about the use 
of Dakin's solution, for they are wonderful helps in surgery. The war has 
done that much for us. Dakin's solution, made exactly in the way advised 
by Carrel and Dakin, applied practically constantly, at least every two 
hours day and night, to the wounds will hasten tremendously the healing of 
the wound. I believe that in suppurating appendix cases we are cutting 
short the hospital time by at least two weeks by the use of Dakin's solution. 

Dr. J. W. Long, Greensboro, N. C. : Dr. Royster's treatment, which 
he has presented to us so clearly and forcefully, appears to be addressed to 
the incision itself and not to the deeper parts. His method, which he de- 
scribes in his characteristic facetious style, may be paraphased as a "super- 
ficial salvage of suppurating smells." Dr. Royster merely iterates a truism 
when he says that the tissues of the incision are far less able to take care of 
infection than is the peritoneum. 

Now, as to the merits of the method described by Dr. Royster, I wish to 
say that it is a most excellent procedure. When we sew up an incision in 
the presence of infection we should by all means make provision for drain- 
age. Also, in case infection subsequently develops drainage must be es- 
tablished either by opening the incision or by making a stab wound to the 
side. I think a far better plan, is to leave the incision in such a condition 
that it will drain itself, either by approximating the edges loosely or by in- 
troducing drainage at the time of the operation. When we are dealing with 
infected tissues such as a gangrenous appendix, it is wise to drain the incision, 
whether we drain the abdomen or not. In severe infections drains should 
be placed between each two layers of the abdominal wall. By doing, this we 
avoid extensive suppuration of the abdominal incision. 

Dr. Royster's iodoform and vaseline injection is a splendid one. It is 
evidently patterned after Beck's paste and Rutherford Morrison's hip. Both 
are excellent applications for suppurating wounds. However, Moynihan 
says that they used bip in the English Army with excellent results, but grad- 
ually quit it and got just as good results. 

Dr. Royster, closing the discussion : If Dr. Brenizer will remember, I 
said I claimed no superiority for the iodoform except its smell, which gave 
rise to Dr. Long's text from the Scriptures. If you drain through the wound, 
you will have a sinus which will stay there as long as you pack a piece of 
gauze into it, and that is just as long as you want to keep the patient in bed. 
I have not only developed parallel cases, but I have tried and watched other 
methods, such as opening the incision itself and using hot packs or irrigation 
and tapes. Usually it is three weeks before these wounds heal 

In regard to Dr. Bost's question, I will leave him a beautiful little conun- 
drum : "When is a drain not a drain ? When it is a stopper." 

Dr. Burrus gives me a chance to say, "Whom the Lord loveth He chas- 
teneth." He has seen the light. The most important attitude for a medi- 



98 NORTH CAROLINA MEDICAL SOCIETY 

cal man is to feel miserable today unless he knows something he did not 
know yesterday. 

Replying to Dr. Leigh's remarks, I have not used dichloramin-T, but 
Dakin's solution and other solutions, on these wounds before closing them 
up and then found that I had occasional suppuration outside the line of the 
wound. The wound was all right, but the organisms penetrated the tis- 
sues before we could get to them with the solution. His suggestion of using 
dichloramin-T is a very favorable one, however, and I think I have in mind 
what to do to save some of these wounds from suppurating. 

When I said, "When in doubt, don't drain," I meant to imply that the 
experienced surgeon is never in doubt in the dangerous cases. You and I pro- 
bably all of us, drain the same kind of cases. But we may differ about the 
cases we do not drain. Do you tell me that a man opens an abdomen and the 
appendix is not ruptured, but the whole abdomen is filled with a murky 
serum, that he is going to drain? If he does, it is because he is afraid of a 
fetish. You do it because someone said it in a textbook or in a clinic. Now 
if you have a great big gangrenous appendix wrapped up in the omentum, 
are you going to drain it? I have seen men drain these types of cases of 
which I have been speaking, and they kept the patients in bed a long time. 
Of course if the appendix is ruptured and there is pus all over the abdomen 
you will drain. My most devoted friend, the man I have patterned after 
most in North Carolina, and the man who is chiefly responsible for my hav- 
ing come back to the State, has expressed in an alliterative fashion what I 
have tried to tell you He speaks of my method as the "superficial salvage 
of suppurating smells" May I say this much — also alliteratively ? — that 
smell is issuing from saprophytic sinuses considered by some to demand a 
cigarette; but sound surgical sense says otherwise. Dr. Long is eternally 
right about draining the incision ; but I have presented a plan for saving the 
incision without draining it. The iodoform ointment accomplishes the same 
thing and leaves the incision intact. The method is not fashioned after 
"bipp," because I used it twenty years ago. I wish to emphasize that it is 
the plan and not the material which is important ; it is economic surgery and 
not surgical fear which I am trying to impress upon you today. 

GOITER. 

Observations drawn from 150 operated cases and 71 unoperated cases. 
Addison Brenizer, M. D., Charlotte, N. C. 

I am employing the word goiter in a very loose sense, to embrace all en- 
largements of the thyroid gland. The word goiter, while counting a great 
deal, in reality denotes little. It denotes a more or less permanent enlarge- 
ment or mass over the front of the neck to the lay mind and the same to 
many of the medical mind, with the exception that the enlargement has to 
do with the thyroid gland., The word goiter, however, is a very familiar 
word and from use, good or bad, is well accepted. Though as vague per- 
haps as rheumatism in its denotative sense, still it is of value in its connative 
sense, if the pathological conditions of the thyroid gland included under this 
term be understood. 

A scheme of the pathological anatomy of the thyroid gland is necessary in 



SURGERY 99 

the diagnosis and treatment of goiter and I would formulate an outline such 
as the following. 

A Disturbances in development : ( 1 ) Absence of the thyroid gland. 
(2) Accessory thyroids, from the base of the tongue (foramen cecum) to 
the sight of the normal gland, along the tract corresponding to a thyroglos- 
sal duct and beneath the sternum and upper chest. 

B. Disturbances in metabolism: (1) Atrophies, after inflammations 
and reductions of blood supply on tying off vessels. (2) Degenerations: 
Parenchymatous, hyaline, amyloid, calcarious. 

C. Disturbances in circulation : ( 1 ) local and general venous conges- 
tions may lead to enlargements of the thyroid. The transitory swellings 
during menstruation, initial sexual excitement and pregnancy are caused by 
a congestive hyperaemia, with increase of a watery colloid. Under this 
heading come the false goiters of adolescence and pregnancy. (2) A mark- 
ed development of either arteries or veins may accompany any of the goiters 
and determine the nomenclature "vascular goiter." 

D. Inflammations: (1) Simple thyroiditis, characterized by degenera- 
tion of epithelium and cellular excrudation, not infrequently accompanies 
the various infectious diseases. (2) Visible purulent mfections are rare. 
These may spread directly from open wounds or contact with the larnyx or 
trachea or they may be hematogenous infection during, for example, typhoid 
or a pyemia. Abscesses may break outwardly or inwardly into the trachea. 
Diffuse inflammations may be followed by a destruction of glandular sub- 
stances and fibrous atrophy. Goiters are far more prone to inflame and 
break down than the normal thyroid. (3) Tubercles are found in the 
thyroid accompaning disseminated miliary tuberculosis. Larger solitary or 
multiple tubercles are occasionally observed. (4) Gummata are found 
very seldom. 

E. Regenerations: Thyroid tissue is slow to regenerate. Those devel- 
opments of reses left after operations have likely a goitrous base. The tend- 
ency of these is to degenerate. 

F. Hypertrophic enlargements: (1) These are the so called goiters 
proper, although the circumscribed forms offer no sharp differentiatior from 
tumor growths. These hypertrophies are (a) diffuse, where the enlarge- 
ment involves the whole gland or the greater part of it, and (b) nodular, 
where the enlargement is issolated and encapsulated. According as the in- 
crease in volume is due to accumulation of colloid substance in the follicles 
of the gland or to an increase of the follicles themselves, we speak of: (a) 
a colloid goiter, and (b) a parenchymatos goiter. The former type is by far 
the more frequent. The goiter accompanying the symptoms complex, known 
as Graves' disease or exopthalmic goiter, is usually a diffuse goiter of the 
parenchymatos type, differing, however, from the parenchymatos goiter in 
that the process of change in the existing follicles is more active. The folli- 
cles show the lining cells changed from cuboidal to columnar forms and sup- 
erimposed in several layers. The follicles empty of colloid, and the cells 
often form festoons into the empty spaces. These invaginations are follow- 
ed up into the follicles by the surrounding connective tissue. The intersti- 
tial tissue is very vascular and permeated with leucocytes. The picture has 



100 NORTH CAROLINA MEDICAL SOCIETY 

been compared to that of a lactating breast and it does show every sign of 
over active tissue. This process 'of change is described as hypertrophy and 
hyperplasia. These changes may take place only in certain parts of the gland 
and may spring up in old standing simple goiters giving rise to symptoms of 
thyro-toxicosis. 

G. Tumors : ( 1 ) The commonest benign tumor of the thyroid gland is 
an adenoma. This tumor is responsible for many cases of nodular goiter 
and is sometimes accompanied by a thyro-toxicosis, showing many of the 
symptoms of Graves' disease; exophthalmos is usually absent. (2) There 
are a number of varities of malignant tumors of the thyroid, interesting to 
the pathologist, but impossible to differentiate clinically. The commonest 
malignant tumor is a carcinoma of the adenomatous type. 

Cases in my series illustrating the above pathological scheme : 

A. Thyro-glossal duct — (operated.) 

B. Case of Vincent's angina, cervical adenitis, swelling and tenderness of 
the thyroid gland; rapid heart beat, marked exopthalmos; subsidence of the 
thyroid, recession of the eyeballs, marked ptosis — thyroiditis, hyperthyroid- 
ism, injury of the cervical sympathetic. 1. 

(2) Old standing goiters of enormous size showing all forms of degen- 
eration, even masses of calcarious deposit like bone. 37. 

C. ( 1 ) Enlargement of the thyroid in young girls between thirteen and 
twenty years, increase in size during menstruation usually dysmenorrhoea ; 
cystic ovaries in live years ; same type of enlargement of glands during preg- 
nancy. (55.) 

(2) Enlargement of the thyroid in a woman forty years old; gland at 
times, especially during periods, twice the size ordinarily, tense, a distinct 
bruit heard over it — vascular goiter. 1. 

D. ( 1 ) Accompanying flu, hard tender swelling of the right lobe of 
the thyroid gland, hoarseness; after several days swelling softer; right lobe 
exposed and incised, free pus — abscess of thyroid gland. 1. 

(2) During subacute state of laryngitis and bronchitis, swelling of thy- 
roid, becoming quite large, tender and fluctuating ; advised exposure and in- 
cision, refused; abscess ruptured into trachea, patient coughed up deluge of 
pus, complete recovery — abscess of thyroid gland. 1. 

Goiter with additional swelling, pain and tenderness; exposure of struma 
and incision, abundant pus — abscess of struma . 3. 

Adenitis tuberculosa, mass corresponding with right lobe and isthmus of 
thyroid! thyroidectomy, conglomerate tubercles — tubercle of thyroid. 1. 

A large lymph glands in the neck, mucous patches in the mouth, macular 
rash over the body, positive Wassermann; enlarged thyroid, pulse rate 120; 
anti-syphilitic treatment, with disappearance of thyroid enlargement and re- 
duction of pulse — thyroiditis syphilitica. 1. 

Enlarged thyroid, fast pulse, 128, exopthalmos; osteo-mylitis of tibia and 
cranial valut, positive Wassermann; anti-syphilitic treatment with disap- 
pearance of all symptoms — thyroiditis syphilitica, hyperthyroidism. 1. 



SURGERY 101 

E. Right lobe of thyroid removed for exopthalmic goiter, reappearance 
of struma of left lobe and isthmus, severe Graves' disease ; isthmus and part 
of left lobe removed — further development on goitrous base. 1. 

F. Diffuse goiter, parenchymatous and colloid. 14. 
Nodular goiter, colloid. 39. 

Diffuse nodular goiters, showing more or less marked symptoms of Graves* 
disease. 88. 

G. Adenoma, incapsulated, symptoms of thyro-toxicosis. 3. 
Carcinoma, adenomatous type. 2. 

Without plunging hopelessly beyond my depths into the subjects of re- 
ciprocal glandular actions or humoral correlations and humoral interrela- 
tions, I shall offer merely several observations which point to the fact of an 
uncommonly intimate pathological correlation or interrelation of the several 
ductless glands and which are well adapted for the complication of clinical 
pictures. 

Most of the ductless glands come into play with the thyroid ; the pituri- 
tary, the parathyroids, the thymus, the adrenals, (including the medulary 
portion and the entire chromaffin system,) the pancreas and the gonads. 

Thyroid gland: (1) Over-function and possibly dys-function causes 
Graves disease. (The thyfnus is now thought to play an important role in 
exophthalmic goiter.) (2) Underf unction or absence of function in adults 
produces myxedema; in infancy cretinism- (3) Total removal brings on 
cachexia strumapriva, resembling myxedema. (4) Thyroid extracts im- 
prove cretinism and relieve myxedema as long as it is given ; it accentuates 
hyper- thyroidism. 

Pituitary gland : (1) Over-function causes acromegaly. (2) Under- 
function causes hypophysial dystrophy. 

Parathyroid glandules : ( 1 ) Over-function is said to cause osteomalacia 
and eclampsia; proof wanting. (2) Under-f unction produces tetany in 
pregnancy. (3) Partial parathyroidectomy may be followed by tetany; 
total removal is followed by tetany and death. Parathyroid extract and 
transplantation of parathyroids is claimed to ameliorate tetany s\'mptoms, at 
least temporarily. 

Thymus gland: (1) Over-function may have to do with status thymi- 
cus and status thymo-lymphaticus. (2) Under-f unction ; the gland nor- 
mally involutes between the tenth and fifteenth years. (3) Thymectony 
has no influence on otherwise normal adults ; it has a transient retardation 
of body growth in infancy ; in some cases of exophthalmic goiter it has a 
checking influence on the progress of the disease. (4) Thymus extracts 
are questionable, probably accentuate an existing hyperthyroidism. 

Adrenal glands: (1) Over-function causes hypertonia, hyperglycema, 
glycosuria. (2) Under-function causes Addison's disease. 

The pancreas: Under-function or absence of function causes diabetes 
mellitus. 

The gonads: (1) Over-function causes temporary excessive develop- 
ment of the organism, chlorosis in females. (2) Under-function and ab- 
sence of function causes eunuchoidism. 



102 NORTH CAROLINA MEDICAL SOCIETY 

The pineal gland : Under-function causes premature developments, es- 
pecially of the genitalia. 

Gley and others observed an enlargement of the pituitary glands after ex- 
tirpation of the thyroid in young animals. The enlargement affects the 
glandular anterior lobe ; vacuoles are found in the cells. Conversely after ex- 
tirpation of a part of an adenoma of the pituitary in acromegaly an enlarge- 
ment of the thyroid was observed. The hypophysis has been occasionally 
found enlarged in myxedema; in such cases the enlargement may depend on 
strumous degeneration. On the other hand, Benda states that the glandular 
hypophysis is small in Graves disease. The statements, however, as to the 
physiological correlation between the two ductless glands do not agree. But 
of greater clinical interest are the pathological correlations between the pit- 
uitary and the thyroid. 

Thus, in endemic cretinism, not only the thyroid alone, but also the hyo- 
physis is usually strumously degenerated. Josefson reports a case of hyper- 
plasia of the hypohysis in congenital struma of the thyroid gland. Rosen- 
haupt reports a case of sarcoma of the anterior lobe of the hypophysis in 
which there was also a similar tumor of the thyroid gland. Falta has point- 
ed out frequent manifestations of hyperthyrosis in acromegaly, especially in 
the later stages, with corresponding pathalogico-anatomical alterations in the 
thyroid gland. In multiple ductless glandular «celerosis the sclerotic pro- 
cess affects almost regularly the thyroid and the hypophysis. A slight degree 
of thyroid insufficiency does not seem to be rare in hypophysial dystrophy, at 
least a mj^xedemoid puffiness of the face may be observed, especially in the 
later stages. Finally there is evidence that the hypophysis may degenerate 
in the later stages of Graves' disease, because in such cases are found char- 
acteristic fat deposits and swellings of the skin that remind one of myxedema 
while the hyperthyrosis still continues and shows a great sensitiveness to thy- 
roidine and adrenaline. 

An important diagnostic test of exopthalmic goiter is the adrenaline test 
as carried out by Goetsch. This test is dependent upon whether or not ad- 
renaline increases the blood pressure and pulse rate above ten points. It is 
a known fact that cases of exopthalmic goiter bear adrenaline poorly and 
there are many symptoms of exopthalmic goiter that point to an already in- 
crease of adrenaline in the blood. 

The case of Bortz and Thurmin of a girl seventeen years old who first 
developed normally, the menses ceased and there developed a luxuriant deep 
black beard, and a sparse mustache, hairs developed on the chest and linea- 
alba. Death occurred as the result of an intercurrent illness. An autopsy 
revealed atrophy of the ovaries, enormous enlargement of the thyroid, nor- 
mal hypophysis ; on both sides there existed a super renal tumor rich in blood 
vessels that had apparently developed from the cortex (hypernephroma.) 

R. Mueller in mentioning the secondary sexual characters in which an im- 
mediate dependence upon the sexual glands is shown, lists the skeleton, the 
muscular system, the skin appendages, such as combs, horns, beard, etc., gives 
the swelling of the thyroid gland a prominent place. 

Well known is the swelling of the thyroid gland in the premenstrual per- 
iod, the struma ante-menstrualis, as pointed out by Heidenhain. The sup- 
rarenal cortex and the hypophysis also increase in size before rut and the 



SURGERY 103 

premenstrual period. The mammary glands often swell slightly and may 
rarely, even in virgins, secrete colostrum. The nipples show an increased 
erectibilit>' and are painful. All these changes occur as well during preg- 
nancy. 

It has been known since antiquity there has been an increase in volume of 
the thyroid gland during pregnancy. 

Falta reported a case of castration in a man for tuberculosis, where among 
other symptoms a goiter developed which later receded. 

Usually in castrates and eunuchoidism the thyroid gland is of less volume. 
Rapid improvements in eunuchoidism have been reported after treatment 
with thyroid extracts. Apert mentions a case complicated with cryptorchid- 
ism in which after one years' treatment with thyroid extract, the penis had 
distinctly grown, the testicles had lowered, and the weight had increased 
fifty pounds. Also Parhan and Mihailesko report a similar case in a four- 
teen j^ear old youth with left sided inguinal cryptorchidism and obesity ; un- 
der thyroid. extract the genitals took on a rapid development. 

Handmann found the thyroid glaftd enlarged twenty-four times in forty- 
four casaes of chlorosis, three times with distinct Graves' symptoms. 

O. Marburg reported a case of a girl nine years old, who during eight 
months' time became obese, excessive especially on the breasts and abdomen. 
Autopsy showed a complex tumor of the pineal gland consisting of tissue of 
the pineal gland, the ependyma, the choroid plexus, and of glia, there was 
a colloid ctruma of the thyroid. In another case Neuman, occuring later in 
life, there was a persistent thymus and the formation of a goiter. 

There are a number of suggestive points in the relation of the genital and 
sexual organs and the thyroid glands. In the king crab the thyroid opens di- 
rectly into the uterus. The false goiters of adolescence and pregnancy are 
suggestive. Cases with so called goiters of adolescence usually menstruate 
late ; I have found in eight cases out of fifty-five cystic ovaries ; three of my 
cases of exopthalmic goiter had already been operated on for large ovarian 
cysts and one case operated on for exopthalmic goiter was later operated 
for an enormous cyst. Lampe, using the Abderhalden reaction, found in the 
sera of exopthalmic goiter patients, ferments against the ovaries, thyroid 
and thymus. This fact would point to some defect in ovarian secretion. I 
take it that the thyroid is stimulated to over-activity or reciprocally compen- 
sates an under-activity of the ovaries during the developmenal period and 
pregnancy. 

These so-called goiters of adolescense amounting to nothing more patho- 
logically than an enlargement of the gland, with increased watery colloid, 
represent a hypothyroidism while reciprocating the ovaries and usually dis- 
appear with maturity. Accompaning their disappearance there is usually 
relief of dysmenorrhoea and extreme general nervousness during the men- 
trual period. 

In long standing cases of exopthalmic goiter there is occasional atrophy of 
the entire genitalia and of even the breasts. I have never seen a well devel- 
oped, long standing case give birth to a child. Some one has said that a test 
of pure exopthalmic goiter is the fact that the woman could bear a child. 
(Halsted.) 



104 NORTH CAROLINA MEDICAL SOCIETY 

So far as I have been able to ascertain, and this point is a difficult one to 
find out, I should say that the majority of early cases of exopthalmic goiter 
and the cases of goiters of adolescents were more hyper-sexual than hypo- 
sexual. Thomas says: "Nearly every married woman with whom I have 
discussed the matter has admitted some sort of incompatibility with her hus- 
band and since it almost always appears during the active sexual life, I 
strongly suspect a distinct relationship." On the other hand, I believe long- 
standing and out-spoken cases of expothalmic goiter to be hypo-sexual. 

Briefly, the presence of a goiter is diagnosed by these simple signs: (1) 
An enlargement over the front of the neck, more often asymetrical than 
symetrical and of an extremely variable volume. (2) The covering skin is 
normal and does not ordinarily adhere to the growth. The superficial veins 
are usually considerably dilated. (3) The mass is movable in the depth, 
freely from side to side, but slightly from above downward. It moves up 
and down with the trachea on swallowing. (4) The consistence of the 
mass varies with its anatomical structure. Except in cancer, the surface is 
regularly smooth or smooth and thrown into bosses and the consistence soft 
elastic; cysts are fluctuating. (5) Respiratory troubles, such as dysponea, 
hoarseness, and aphonia, due to interference with the trachea and the recur- 
rent laryngeal nerve. (6) Dysphagia, from compression of the esophagus. 
(7) Cyanosis, from pressure on veins. The internal jugular vein and car- 
atoid artery are pushed outward and backward and are very rarely troubled. 

Indications for operation: (1) Cosmetic. (2) Relief of pressure on 
trachea, esophagus, nerves and blood vessels. (3) Relief of hyperthyroid- 
ism and thyrotoxicosis, noted in twenty to twenty-five percent of simple 
goiters. (4) Prophylaxis for the preceding. 

Dangers of thyroidectomy : ( More on paper than in reality ) . ( 1 ) Anes- 
thesia. (2) Hemorrhage. (3) Shock. (4) Infection. (5) Recur- 
rent laryngeal nerve injury. (6) Injury to parathyroid glandules. (7) 
Air embolism. (8) Incision of trachea or collapse of trachea. 

In fact that most of the large goiters are enucleated from the gland itself 
and the gland left behind protecting the deeper structures of the neck, and 
even in thyroidectomy the posterior capsule and a shaving of the gland are 
left behind, eliminates most of the dangers enumerated above. 

Symptoms of Graves disease : 

A. Major symptoms: (1) Tachycardia. (2) Exopthalmos. (3) 
Goiter. 

B. Minor symptoms: (1) Tremor. (2) Muscular weakness. (3) 
Nervous excitability. (4) Mental depression. (5) Vertigo. (6) Eye 
signs, a dissociation between movements of the eye balls and upper lids (von 
Graefe) ; b — widening of lid slits (Dalrymple) ; c— protrusion of eye balls; 
d — insufficiency of convergence (Moebius) ; infrequency and incompleteness 
in winking (Stelwag). (7) -Paroxysmal dyspnoea (Bryson), asthma. (8) 
Intermittent sweating, diarrhea or vomiting. (9) Gravity of the disease 
increased by mental and physical exhaustion; by thyroid extract and to a 
less extent by iodine (therapeutic test), by adrenaline (Goetsch's test). 
(10) Emaciation and anemia. (11) Leucopenia, with increased lympho- 
cytosis. (12) Oedema of lids, later of feet. (13) Discoloration of skin, 
pigmentation, urticaria. 



SURGERY 



105 



There is the closest analogy between the syndrome of Graves' disease and 
the eifort syndrome. In France I was able to observe practically all transi- 
tions between a mild effort syndrome and well marked cases of Graves dis- 
ease. 

Indications for operation : ( 1 ) In all out-spoken cases of Graves' dis- 
ease of at least one year's duration. (2) In all milder cases after the fail- 
ure of medical treatment. 

Surgical procedures: (1) Application of cold to the thyroid gland. (2) 
X-ray and radium exposures over the thyroid and enlarged thymus — danger 
of injury to the parathyroids and tetany. (3) Injections of boiling water 
into small areas of the gland (Porter). (4) Ligation of thyroid vessels 
(temporary and transient relief). (5) Thyroidectomy, partial, except in 
malignant disease. (6) Thymectomy in Graves' disease. (7) Trans- 
plantation of parathyroids (Halsted). 

Series of cases: 

Operated 150 

Not operated 71 

Operations 

Enucleation of nodular goiters (colloid) 39 

Enucleation of adenoma (thyro-toxicosis) 3 

Exposure, incision, and drainage (abscess) 2 

Excision of conglomerate tubercles l 1 

Ligation of superior thyroid vessels 2 

Thyhoidectomy-partial (simple goiter, thyro-toxicosis 16 

Thyroidectomy, lobe and isthmus (Graves disease) 83 

Thyroidectomy, total (adeno-carcinoma) 2 

. 150 

Clinical cases: 

Cases too mild or too severe for surgery 16 

Goiters of adolescence 52 

Goiters of pregnancy 3 

71 

Total cases 221 

Deaths in first 28 cases 4 

Deaths in 108 cases 

Deaths in last 12 cases 2 

The markedl}' reduced mortality has come about, not so much through an 
improved dexterity and speed in operating as in better judgment in selecting 
and preparing the cases for operation. 

A case of exopthalmic goiter is not cured by operation alone and if not 
followed up and lociked after and prohibited the resumption of former noxi, 
will cure with difficulty and may even relapse. 

For a successful outcome with an exopthalmic goiter patient, it cannot be 
over-stressed that the patient be clearly understood before the operation, 



106 NORTH CAROLINA MEDICAL SOCIETY 

carefully prepared under rest, with an ice bag on the throat and heart, and 
cold bathing done under the quietest and gentlest conditions. The time 
chosen for operation should be when the patient is at her best possible and 
not worst possible. It should be explained to the patient herself that the 
operation alone will not cure, but that she can expect great benefit, if not 
a cure, if after the operation she observe certain strict rules, principally rest, 
mental and physical, avoiding excitement of all kinds, and the adoption of a 
very simple life, free from cares and burdens. 

Two of my four deaths were from exhaustion due to prolonged operation 
with hemorrhage and shock. I feel that I should be able to save these two 
cases at present. The other two deaths were due to an increased hyperthy- 
roidism and consequent thyrotoxicosis, and w^ere likely unavoidable, certainly 
at that time. During five hours' time,, following the operation on one case, 
the pulse rate increased to beyond a possible count, the temperature rose to 

107 degrees and the patient died under what was no far different from the 
symptoms of an acidosis. 

Crile recently claims that there is ten per cent increase of metrabolism for 
each degree of temperature, and conversely, ten per cent decrease in meta- 
bolism for each degree of reduction of temperature. He says, therefore, 
that he has reduced the metabolism from toxicosis by reducing the tempera- 
ture by ice packs, ice on a rubber sheet fanned by an electric fan. I, how- 
ever, doubt that temperature alone can be used as a guide of metabolism, and 
certainly not of metabolism in hyperthyroidism and thyrotoxicosis, because, 
the most marked cases of hyperthyroidism frequently show little or no hyper- 
thermia. These deaths may be due to exhaustion of the vasomotor center 
through the thyrotoxicosis, with a concomitant effect on the heat center. 

These deaths may be due likewise, in part at least, to a lymphatism. It 
is known that, occasion is given for temporary or a permanent lymphatism 
by affections of the ductless glands. The characteristic blood picture of both 
status lymphaticus and hyperthyroidism is a relative increase of the meno- 
nuclear elements, a relative or absolute reduction of the neutrophilic leu- 
cocytes and eventually a hypereosinophilia. 

According to Wiesel and Hedinger there is regularly associated with the 
characteristic symptoms of status lymphaticus a lessened development of the 
chromaffine tissue. The medullary substance of the suprarenals is essenti- 
ally lessened and also the paraganglia are ill developed. 

It is possible that the giving off of the mononuclear cells of the blood is 
increased by hyperplasia of the lymphatic apparatus, and, on the other hand, 
we must assume an enormous trophic influence is exerted on the production 
of the neuthophilic elements of the bone marrow, this influence proceding 
from the chromafiine tissue by mediation of the sympathetic. It is very pos- 
sible that a like anomaly of constitution is the cause of sudden death in hy- 
perthyroidism as w^ell as in status lymphaticus. Thus, if the chromafiine 
tissue is lessened and not capable of a great functional breadth, it may, if 
especial demands are made on it, as by the effects of a narcosis or operation, 
suddenly give out. Such individuals either with status lymphaticus or hy- 
perthyroidism, as Eppinger and Hess mention, not rarely show symptoms of 
relatively increased vagal tonus, such as inclinations to sweats and anomalies 
of pulse and respiration. The slight functional breadth of the chromafiine 



SURGERY 107 

tissues is especially important for the fate of such individuals. On the other 
hand, it must be kept in mind that mononucleosis is a symptom with many 
m_eanings and in itself speaks little for the diagnosis of status lymphaticus 
and much less for the diagnosis of hyperthyroidism. 

It is certainly true that in the preparation for operation of cases of hyper- 
thyroidism that the application of cold locally and cold bathing have a very 
appreciable effect in quieting the patient and reducing the pulse rate. It is 
to be hoped that Crile's idea is correct and that Crile's ice packs may aid in 
warding off death in these occasional cases of markedly increased hyperthy- 
roidism and thyrotoxicosis following operation. For if these cases can be 
protected in this way, thyroid surgery, so far as loss of life is concerned, is 
made as safe as the common run of operations. 

DISCUSSION OF DR. BERNIZER^S PAPER 

Dr. J. B. Cranmer, Wilmington : I should like to ask Dr. Brenizer 
what he thinks of the medical treatment of goiter, the Forchheimer treat- 
ment, — quinine and ergotol, and in what kind of cases this may be used ? 

Dr. Bernizer: In preparing cases- for operation they go through almost 
the Forchheimer treatment. They are given five grains of quinine three 
times a day ; and an ice bag is placed on the throat. They may get better, 
but they do not hold the betterment. These cases are chronic. A few cases 
respond to medical treatment, but I doubt if there is any real medical treat- 
ment outside of rest or an icebag on the throat. I do not believe the thyroid 
gland is the whole story, but only a part of the chain which has to be broken 
by the removal of the thyroid gland. Remember, when you are treating 
cases by the medical method your mortality is about sixteen per cent, while 
the surgical mortality is about three per cent. Therefore, by subjecting 
these cases to surgery you might save thirteen per cent. While the cures are 
likely not over seventy per cent, the cures in medicine are not over thirty 
per cent. I am speaking now of Graves' disease. Mild cases might respond 
to the rest cure, but it is mighty hard to subject the patient to sufficient rest 
cure to do much good. 

Dr. Cranmer: Personally, I am of the opinion that this is a surgical 
disease, but I wished to have Dr. Brenizer's opinion in the matter. 

INGUINAL HERNIA. 

Dr. J. T. BuRRUs, High Point 

The inguinal region is one of interest to the surgeon because of the fre- 
quency of hernia and the necessity for its radical cure. The writer wishes 
to report two hundred operations for the radical cure of inguinal hernia. 

The anatomy with which we are most concerned lies within the Hessel- 
back triangle, which is bounded internally by the rectus abdominus muscles, 
externally by the deep epigastric artery and inferiorly by puparts ligament. 

The ilio-inguinal nerve lies directly under the fascia of the external ob- 
lique. Care must be exercised that this nerve is not divided or traumertized. 
This nerve has much to do with vitalizing the tissue with which we are con- 
cerned. The test of any operation for hernia is that the parts will be secure- 
ly held and that the opening will be permanently closed in a way that no 
other^ tissue will be destroyed and that the patient will be able to comforta- 
bly discharge his duties unhampered. 



108 NORTH CAROLINA MEDICAL SOCIETY 

In umbilical and incisional hernia, openings that can be totally obliterated 
all are doing an imbrication operation, thus building a firm and secure wall, 
and in many cases a wall more secure than nature constructed in the first 
place. 

In operating inguinal hernia the question of the spermatic cord has been 
uppermost in the minds of the surgeons. Many have written often and at 
length on transplanting the cord ; another list has condemned this, adhering 
to Macewin's idea — not to transplant the cord, but to place it in the notch 
as securely as possible, obliterating the canal with the conjoined tendon and 
puparts ligament anterior to the cord and plugging the opening in the inter- 
nal ring with the sack. 

Again, a good deal has been said about the amount of pressure that could 
be placed on or around the cord without injury to the testicle, a goodly num- 
ber doing the Bessini operation, bringing the tissue about the cord as closely 
as possible. Others doing the same operation seem to have no concern as to 
how loosely the cord lies in its new canal. 

In the summer of 1917 the writer was assigned chief of surgical service in 
a United States Army Base Hospital. In the early fall of this year an op- 
portunity was presented to observe a large number of men who, as j'ou know, 
went into service with hernia. In the early fall these men became unfit for 
duty owing to the combat drills and other tests of physical fitness. A real 
opportunity to try out the different operations for the cure of this condition 
presented itself. ' 

The first ten cases were operated according to Bessini operation ; eight 
cases were operated according to Macewin method; eleven cases after the 
Furgerson method. These cases were kept in bed twenty-one days, then al- 
lowed to walk some each day in the wards, gradually increasing their exer- 
cise and retained in the hospital six weeks. At the end of this time they were 
returned to duty. The day following their arrival with their organization, 
full duty was assigned them and the test given was the ability to withstand 
as much as the man that had been hard at it every day. 

Two (2) Bessini cases returned, two (2) Macewin cases returned, one 
( 1 ) Furgerson case returned to hospital with a recurrence of hernia. This 
(a very large percentage of recurrences) was not satisfactory to the chief of 
the service. The idea was to build a wall as securely as possible, through 
which the cord could emerge without injury to the testicle and at the same 
time hold. The writer began the following method, and, so far as I know, 
no recurrences were reported. 

At first the tissues were not sutured as closely about the cord as later, the 
cases being later observed closely to see that the testicle was net injured. 

Operation: (Fig. 1) Incision Sj/z to 4 inches long parallel with and two 
inches above puparts ligament, skin superficial and deep fascia divided. The 
fascia was dissected from external oblique, exposing a very broad field, 35^ 
to 5 inch incision through external oblique at the dividing fibres. Here it is 
necessary to lift up the fascia exposing the ilio inguinal nerve, care being 
taken not to injure the nerve. Fibres of external oblique divided the length 
of skin incision. The outer layers of external oblique picked up with hema- 
stats and sharp dissection to bottom of puparts ligament. Two hemastats 
placed on internal fibres of the divided external oblique. By sharp dissec- 




Fig. 1 




Fig. 2 




Fig. 3 




Fig. 4 



/ 


r^ 




/ 




- L 




" ' ''^"\ 











Fig. 5 




Fig. 6 




Fig. 7 



> 



'^- t;: 




wi 



Fig. 8 




Fig. 9 




Fig. 10 



SURGERY 109 

tion this flap was carried free internal to the conjoined tendon. This ex- 
poses the canal in its entire length with the cord and its coverings. (Fig. 
2) The cord lifted from canal b}' blunt dissection is freed. A tape is passed 
under cord for the purpose of easily lifting the cord to either side. The 
coverings of cord are divided, sack located and lifted free from vas and cord 
dissecting it free to internal ring. (Fig. 3) The sack opened and a through 
and through suture passed through sack, which is ligated as high up as pos- 
sible. The sack is now cut, which allows the stump to recede in the abdom- 
inal cavity. (Fig. 4) The cord held external until the lower sutures are 
placed. (Sutures used Chromic Gut No. 3). The internal flap or the 
divided external oblique is lifted up, exposing the conjoined tendon. From 
the under surface of the sheath the suture is carried around a goodly bundle 
of this fascia, the conjoined tendon thence to the bottom of puparts ligament, 
grasping the ligament w^hich is now pleated on itself. (Fig. 5) The sutures 
are placed in this way until the internal ring is reached, usually requiring 
four of five sutures. These sutures are now tied, which brings the cord 
from the internal ring at right angles. (Fig. 6) The internal flap is now 
brought external to the first row of sutures and sutured to puparts exter- 
nally and the fascia lata thus overlapping the first line of sutures. This 
builds a pillow under the cord and obliterates the canal above the internal 
ring or the cord. (Fig. 7) The internal layers of the external oblique are 
placed under the external flap and sutured with interrupted cat-gut sutures. 
(Fig. 8) The external flap is now placed over this line of sutures and se- 
curely sutured over the internal flap. These sutures are placed very close 
to the cord. (Fig. 9) The deep fascia closed over the cord, which has been 
transplanted directly under deep superficial fascia and skin. (Fig. 10) Skin 
incision closed with silk-worm gut sutures. 

I now present the lantern slides that will show you the steps in the oper- 
ation. 

1. Skin incision. 

2. Incision and dissection of facia of external oblique. 

3. Separation of sack. 

4. Position of first line of sutures below cord. 

5. Position of sutures of overlapping flap. 

6. Position of sutures in flaps above cord. 

7. Conjoined suturing of flaps and position of cord. 

8. Sutures line over cord. 

9. Operation completed. ' 

SOME PROBLEMS MET WITH IN GALL-BLADDER 

SURGERY. 
Dr. J. W. Tankersley, Wilmington, N. C. 

In reviewing 15 years' experience with gall-bladder operations and fol- 
lowing their ultimate outcome I have been struck by the number of compli- 
cations and difficulties so frequently encountered. Mayo in 4,000 operations 
on the gall-bladder says he has encountered complications in two-thirds of 
his cases. This has led to a closer anatomical study of the gall-bladder and 
it is quite frequent that variations from the normal are noted. In the first 
place the gall-bladder is described as a pear-shaped organ lying in the fossa 
vesicalis. This is partly true of normal gall-bladders but in practically every 



110 NORTH CAROLINA MEDICAL SOCIETY 

pathological gall-bladder there is quite a depression, amounting in most cases 
to a distinct pouch, at the under surface of the bladder just before it termi- 
nates in the cystic duct. This is a frequent source or receptacle for a large 
embedded stone and frequently presents an added difficulty in freeing and 
clamping the cystic duct in cholesystectomy. Again anomolies in develop- 
ment and formation of the cystic, hepatic and common ducts are frequently 
found. The hepatics may join much lower down than normal, I have found 
in one case the cystic entering into the right hepatic, the right and left hep- 
atic joining just below the entrance of the cystic. Again the cystic may be 
long and pass over the hepatic or around it before joining to form the com- 
mon. You can readily see the importance of understanding the possible 
conditions to be met with in ligating the cystic duct as a mistake in ligating 
here cannot be easily rectified. 

In an enlarged empyemic gall-bladder with adhesions to the pylorus duo- 
denum and transverse colon the typical splitting of peritoneum, grasping of 
duct and artery separately, is attended with much care and difficulty. In ad- 
dition if we should have duct obstruction with its comcomitant jaundice the 
difficulties are at once magnified by the slow but aggravating oozing of 
blood due to the delayed coagulation time and possibly heamic changes. To 
correct or lessen this oozing I have been in the habit of injecting blood ser- 
um intravenously preliminary to operation in all cases of jaundice. Another 
possible source of hemorrhage is from slipping of a ligature on the cystic 
duct or injury to the portal vein. On three occasions, I have seen distress- 
ing hemorrhage, twice from injury to the portal circulation, and once from 
ligature slipping on the cystic artery. Of course, we would only look for 
this in those cases of extensive inflammatory conditions, where dissection is 
difficult. These difficulties have to be avoided by double tying and more 
careful freeing of the duct and artery before ligating. In my mind the next 
most frequent difficulty is in removing stones from the ducts. I believe there 
is a frequent recurrence of trouble post-operative due to a failure to properly 
palpate and remove stones. We are told to pass a probe through the gall- 
bladder or divided end of the cystic duct and so on down the duodenum. 
Personally this has never been an easy matter to me and I have frequently 
noticed others stop after a vain attempt and remark that there were no 
stones in it anyway. To successfully palpate and detect small stones is not 
so easy when we consider the number of hardened, inflamed glands at the 
junction and along the duct that might be mistaken for stones and the 
infiltrated condition of the ducts themselves. Occasionally we find the duct 
obstructed with a stone too large to work back but there are extremely few 
cases where I have had to open the duct to relieve the obstruction. If stones 
large enough to go through the duct and obstruct the intestines surely we 
should be able to get them out without cutting the duct. Such cases have 
been reported. I believe most cases of stone obstruction occurs at the junc- 
tion of the cystic and hepatic or in the diverticulum of Vater. Where the 
obstruction occurs high up it is the exception that you cannot milk it back 
into the divided ends or opened gall-bladder, or if it occurs in the lower end 
open through the duodenum and deliver the stone by divulsion of the orifice, 
closing the duodenum afterwards. This gives a good drainage as nature 
intended it, via naturalis. This method was suggested to me by my friend 
and teacher. Dr. J. W. Long, several years ago and I have found it very 



SURGERY 111 

satisfactory. Critics may argue here that there is more opportunity of in- 
juring the pancreatic duct or allowing bile and infected material to enter the 
duct. Personally I have never had this trouble and will leave that discussion 
to any that have had more experience with this method than I. The prob- 
lem of pancreatitis complicating gall-bladder disease, I believe is too fre- 
quently overlooked but that is in the nature of a complication. However, 
I wish to add that the only two deaths I have encountered in the last four 
years in gall-bladder surgery were due to this complication. Next to diffi- 
culty in removing stones is injury to the ducts. Of course, this would occur 
only after removal of the bladder. It is very easy to say deliver the gall- 
bladder into the wound by traction, separate the peritoneum, grasp the duct 
with forceps, but in those large inflammatory conditions this is easier said 
than done and with much experience in gall-bladder surgery any of us will 
acknowledge how easy it is in this condition to grasp, cut or stitch the hepa- 
tic or common duct during this operation. I know of no more tedious or un- 
satisfactory operation than repairing an injured or severed common duct 
weeks or months afterward. Should this cut be recognized at once it may 
be properly repaired over a small rubber tube or if not completely severed 
rubber tube inserted and allow^ed to close spontaneously. This difficulty is 
well illustrated in the following case : 

Mrs. C. H. S., married, several children, had suffered for years with 
symptoms indicating gall-bladder trouble and was operated on several 
months previously. Entered the hospital in April, 1919, intensely jaundiced. 
Had been jaundiced about two months, gradually growing more intense. 
Blood examination negative, urine almost black with bile. Patient still able 
to be up and about the house but slowly going down hill. We thought 
possible obstruction was due to large stone, operation was certainly indica- 
ted. April 3rd, she was removed to operating room and under general an- 
esthesia following condition was found : 

Extensive inflammatory condition, adhesions, to abdominal wall, stom- 
ach, duodenum and transverse colon. Gall-bladder had been removed. Ad- 
hesions were dense in gall-bladder fossa. After freeing them duct was 
found to be completely obliterated by contracted inflammatory tissue except 
about one inch entering the duodenum. After freeing duct it was found 
so friable that even with delicate handling it promptly broke up under for- 
ceps. After vainly trying to obtain sufficient duct to insert tube and make 
an artificial tube it was found impracticable and I decided to anastamose 
duct to duodenum. In this case unfortunately the hepatics joined low down 
and I had to do the anastamosis at the junction of the two hepatics. This 
was finally accomplished with difficulty. Five days after she had a profuse 
hemorrhage from somewhere inside the wound which was stopped by pack- 
ing and from that on she made an uninterrupted recovery. Jaundice 
promptly cleared up and at the last report she was doing well. 

In regard to injury of the liver this will occur only from carelessness and 
usually where you have used metal retractors. The liver should be pulled 
forward only by the hands of an assistant. Personally I have never seen a 
primary cancer of the gall-bladder, only those from metastasis and here I 
believe the patient should be best let alone. On two occasions I have seen 
rupture of the gall-bladder several months after drainage with severe peri- 



112 NORTH CAROLINA MEDICAL SOCIETY 

tonitis. In both cases the patients were saved by free drainage of the abdo- 
men and removal of the gall-bladder. In both cases the patients were ad- 
vised to have gall-bladder removed at a later operation but they took mat- 
ters into their own hands. 

TREATMENT OF INFECTED BONE CAVATIES 

Drs. D. W. & Ernest S. Bulluck and R. H. Davis 

Wilmington^ N. C. 

Infected bone cavaties are healed with great difficulty. The tendency is 
toward chronicity. The process of repair seems limited and the result is 
often disappointing. Regardless of the cause the essential condition is the 
same — a chronic fistula of the bone with associated infection. 

The pathology is that of osteomyelitis. The abcess may be simple or there 
may be an involucrum and sequestrum. Such cavaties are covered with gran- 
ulations and discharge by sinuses for long periods. Sargent ( 1 ) reports 
such a case of sixteen years duration, and those existing for several years are 
familiar to all. 

The formation of new bone is not necessary for recovery, and it is diffi- 
cult to understand why bone, a connective tissue, does not replace breeches 
in its continuity with the same promptness that union follows fracture. It 
is suggested by White (2) that incomplete restitution results from lessened 
vascularity, due to the duration of the reparative process, osteosclerotic 
changes progressively denser, thicker and less vascular, limiting prolifer- 
ation. Such conditions as a rule are not found and there is little osteoscler- 
osis. Sargent believes that the fibrous tissue has reached full maturity be- 
fore the cavity is obliterated. As this tissue shows elsewhere great capacity 
for reproduction, and as the lesion ultimately heals when the fibrous tissue 
is even more mature, this view does not seem tenable. The proposition of 
Martin (3) that this inactivity of the connective tissue, "may result from 
environmental conditions, such as the desiccation and irritation of the granu- 
lations by air, contact with dressings, solutions, surface bacteria and dirt," 
seem insufficient. The same conditions surround the breeches in all tissue, 
yet they heal more promptly. A more plausible explanation of this tardy 
healing seems to follow a consideration of the tissue in question. While 
the bone marrow does have its origin in the embryonic mesoblast, in com- 
mon with other fibrous tissues; it's confinement in the bone cavity, and it's 
special function there, are not without effect on its primary characteristics. 
Thus, it becomes more cellular than fibrous, more mitotic, but the newly 
formed cells are discharged into the blood stream — having made no fibers. 
Differences in moisture, consistency, color and in bacterial resistance serve 
further to show that qualities common to areolar tissue are not necessarily 
to be expected in bone marrow. The marrow only incompletely fills the 
meduallary space. A cavity partly filled has reached the normal limit of its 
compactness. Further healing is dependent upon sterilization from within 
and closure from without. This closure takes place in a manner not gener- 
ally recognized. The granulations covering the cavity do not increase in 
thickness until the mouth of the cavity is reached, then protude from the 
opening, become mushroomed above it, until by piling on at the edges it 
becomes blended with the surrounding tissues. The healing it seems to us 



SURGERY 113 

depends upon relative sterility of the cavity, and the closure of the opening 
is accomplished by adherence of overlying fibrous tissues, generally the peri- 
mysium of adjacent muscles or their tendon sheaths. The sealing takes 
place at the edges of the cavity where the covering is attached by plastic 
adhesions to the vascular layer of the periosteum. At first the attachment 
is incomplete and is only completed after such organisms as remain in the 
cavity become latent. This fibrous door thickens by growing into the cavity 
until the level of the endosteum is reached, where it blends with the vascu- 
lar layer of that membrane. Thus, a fibrous plug is made, that fits into the 
mouth of the cavity, and to wiiich later the bone marrow is lightly attached. 
The fibrous plug may retain its character for years but is finally ossified. 

Assuming that the mechanism of recovery is as here stated, we can readily 
understand why these cavities opening at the inner side of the tibia are the 
most difficult in which to effect a cure. We have to deal with a perforation 
in the cortex that the bone itself cannot obliterate. To clean such a cavity 
and pack it with gauze for drainage, hasmostasis, and to insure the skin re- 
maining open until the cavity has closed by granulation from the bottom of 
this newly made wound, seems to be a misdirected effort, for in so doing 
the overlying tissues that would have served to bridge the mouth of the 
cavity are pushed aside and so held until they become fixed in the new posi- 
tion. The bone is incapable of producing the necessary granulation tissue 
and of nourishing it while the gap is being repaired. The result is that re- 
covery is difficult, delayed and sometimes impossible. The exposed and de- 
nuded bone undergoes destructive changes that further complicates the pro- 
cess of healing. If the old method is reversed and the overlying tissues so 
closed as to favor their approximation to the borders of the cavity, the re- 
sult will be much better. The bone is well covered and bathed in the cus- 
tomary fluids. Drainage and irrigation through a single small tube is suffi- 
cient. 

We have to treat an infection of the bone and a hole in its cortex, to clean 
the cavity and to close it. The infected surface should have its lining re- 
moved in the most careful and S3'stematic manner, until every focus of os- 
teitis and all necrotic tissue has been removed and the cavity converted into 
an open gutter. Mechanical perfection is necessary to success; a tiny morsel 
0^ tissue foreign body, or area of osteitis, may defeat the whole effort. 
Scrapings after a cavity has been most carefully treated will reveal organ- 
isms. Experience with bone grafts has shown that such organisms 
may remain dormant for long periods and then regain their virulence, and 
that a cavity may heal despite the presence of a very attenuated infection. 
Antiseptics are not without value. The one per cer^t solution of Formalin 
used by Ashurst (4) seems too weak, its action transitory and superficial. 
Phenol is efficacious but it leaves the cavity lined with a layer of devitilized 
tissue. Mosetig-Moorhof used the hot air blast, but question has arisen as 
to the sterility of such air and whether at 100 degrees Centigrade this air 
may not be injurious to the bone. To test this method Delbet curetted 
cavities so treated and made cultures from the particles removed. The cul- 
tures were alwaj's positive. • If he used Tincture of Iodine instead of hot air 
the cultures were negative. For this and obvious reasons Iodine is the anti- 
septic of choice and should be freely applied, after the cavity has been me- 



114 NORTH CAROLINA MEDICAL SOCIETY 

chanically cleaned. This work should be done under Esmarch's anaemia. 
If impossible to do this hemorrhage may be controlled by the usual means. 
In some instances — Brodies abscess and haemsetogenous osteomyelitis, — this 
cleaning, with collapse of the soft parts is sufficient to effect a cure. (5). 
The cavities infected with the pyogenic cocci show less tendency to heal. 

Plugging the cavity with such pastes as have been advocated by Beck, 
Neuber, Mosetig-Moorhof, or the Bipp (6) recently used by the English 
has not been very successful, the good results accorded each particular prep- 
aration being the reports of its originator. The cavities cannot be sterilized 
and the paste becomes infected and is discharged. The experiments of Sil- 
bermark (7) seem to rationalize these preparations, but he injected sterile 
cavities in normal bone which is hardly a parallel condition. With each 
however the soft parts are to be closed over the paste and thus a natural 
approximation of the parts is accomplished, which is certainly better than 
propping the wound open. 

The disadvantage of a "foreign body" was obviated by Schede's method 
of allowing the defect to fill with blood. This is practical in sterile cavi- 
ties (Bancroft 8), but bone fistul^e are infected. Dorst has shown that the 
susceptibility is increased 40 fold for the Staphyloccus if a hsematoma is 
present. Skin sutured over a collection of blood will not heal satisfactorily, 
even if there is no infection. A bone cavity filled with "something" is not 
necessary for recovery. It need only be sterile and covered by fibrous tissue. 
In this connection attention is called to a recent report by Albee (9) in 
which he claims "that an efficient and trustworthy stimulus to osteogenesis 
has been found in Triple Calcium Phosphate." A single injection of one 
c.c. of a five per cent solution being sufficient to reduce the duration of treat- 
ment twenty-six per cent in experimental fracture. Such an agent might 
be applicable to bone cavities and by its action so stimulate the bone that 
the bony tissue would share more activity in the reparative process. 

The most rational method it seems to us, is to carefully clean the cavity 
in the manner indicated, replace the soft parts in such a manner that they 
will rest in gentle contact with the effected surface of the bone. The wound 
is closed except for a small tube that leads to the cavity. The cavity is ir- 
rigated with Daken's solution using the Carrell technique for bacterial con- 
trol. After about two weeks the discharges are practically sterile and the 
tube is slowly withdrawn over a period lasting about two weeks. If the 
soft tissues could not be approximated to the bone at the first operation, a 
secondary one is done after the wound has been sterilized. At this time the 
types of tissue are approximated and held by suture. The gist of the treat- 
ment rests in the cleaning of the cavity, the control of infection with Da- 
kin's solution and the approximation of the adjacent fibrous tissue to the 
mouth of the cavity. 

BIBLIOGRAPHY 

1. Sargent, P.: XXXII, Ann. Surg. Phila. 1919, p. 83. 

2. White, J. Renfrew: Chr. Traumatic Osteomyelitis, Ann. Surg. 
Phila. 1919. 

3. Martin, Walton: The Treatment of Bone Cavities, Ann. Surg. 
Phila. 1920, LXXI, 47. 



SURGERY 115 

4. Ashurst, A. P. C. : Indications for the Iodoform Wax Bone — Fill- 
ing of Mosetig— Moorhof, Ann. Surg. Phila., 1917, LXV, 227. 

5. Cheyne & Burghard: Manual of Surgical Treatment, Vol. Ill, n. 
182. 

6. Beck Jour. A. M. A., March 14, 1908. 

7. Silbermark: Deut. Zeitschr fur Chir., 1904, LXXV, p. 290. 

8. Bier: Med. Klin., I, 1905, p. 6. 

9. Albee, Fred H., Studies in Bone Growth, Ann. Surg. Phila., 1920, 
LXXI, 32. 

CLOSURE OF BELLY WALL BASED ON THE HEALING 
POWER OF TISSUE. 

Henry F. Long, M. D., F. A. C. S., Statesville, N. C. 

"In making an incision in the abdominal wall the anatomical layers com- 
posing this wall should be considered, for if they are not the closing of the 
cavity after the intra-abdominal operation has been completed may not be 
satisfactory and may result in a weakened point in the wall which may 
presently develop into a hernia, and this may be many times more serious 
an affliction to the patient than the condition for which the operation was 
undertaken."' This is a truth and an admonition coming from that great 
surgical philosopher, A. J. Oschner, and this is the first key that unlocks the 
difficulty to a successful belly closure. We must not stop here, however, 
but after reaching the first point, which is a thorough and complete knowl- 
edge of the anatomy of the belly-wall, we must take up each layer separately 
and individually and study how it heals and above everythmg else how long 
it takes each layer to form a safe and complete union, in other words the 
healing time of each tissue involved. Before we study the various layers 
concerned in an abdominal incision I want to lay down this dictum — that 
we believe that only connective tissue heals to any degree of stability quick- 
ly, and that the readiness and firmness with which any particular layer heals 
depends entirely on the available connective tissue present, and I think that 
I will be able to show you that this is correct from a biological, histological, 
pathological and clinical standpoint. It is a general biologic law that the 
lower the organism the greater are its regenerative powers and the stronger 
its hold on life, for example, the ameba consisting of only one cell simply 
splits and we have two, the ordinary earth worm cut in twain goes on living 
as if nothing had happened, some of the lower organisms can even be turned 
wrong side out and live right on, reptiles continue to grow till death while 
man and the higher animals cease to grow at a certain age and so on ad 
infinitum, the lower the organism in the scale of life the greater the regener- 
ative and reproductive power and the greater its ability to live and carry 
on these functions under unfavorable conditions. This same principle ap- 
plies to tissues as well as to organisms, that is the more embryonic and sim- 
ple a tissue the greater its power to regenerate and live, the less vulnerable 
it is and the quicker it overcomes insults. I would say that the two ex- 
tremes of tissue are represented by connective tissue as the lowest developed 
and least specialized, and nervous and muscular tissue as the highest type. 
Connective tissue is essentially a supportive tissue and has no specialized 



116 NORTH CAROLINA MEDICAL SOCIETY 

function. Muscular and nervous tissue are highly specialized and differen- 
tiated and have special function to perform, these characteristics are devel- 
oped at the expense of their regenerative power. Connective tissue will 
grow in a test tube entirely separated from the rest of the organism. Car- 
rell has carried a piece continuously over a period of twenty-eight months 
and the cells were shown under the microscope to have actively multiplied 
for two years. This shows conclusively that connective tissue has regener- 
ative and reproductive powers far ahead of the others and that it will grow 
and its cells multiply under conditions adverse to cell life. Please keep this 
in mind, as the method of closure 1 shall describe is based on this fact and 
clinical experience. 

We will take as an example the incision in the lower midline. Here we 
encounter from without inward, first the skin, then the fascia and going 
through the linea alba we expose the sheaths of the recti muscles and lastly 
the peritoneum. The layers then that we have to consider are the periton- 
eum, aponeurosis, the sheath of each rectus, the fascia and the skin. 

Now let us see what the peritoneum is, how it heals and the time of heal- 
ing. The peritoneum is a thin shiny membrane covering the abdominal 
viscera and lining the abdominal cavity. It is composed of connective tis- 
sue on the "wrong side" and covered by a single layer of endothelium on 
the smooth side. This structure is a "simon-pure" example of connective 
tissue as the endothelial cells themselves are derived from the same embryo- 
nic layer as connective tissue, (mesoderm.) Every one knows how readily 
and firmly peritoneum stick together when irritated and placed in apposi- 
tion. This is clearly shown in the form of adhesions following inflammatory 
conditions in the belly. The process by which this takes place is as follows — 
"When two laj'ers of serous membrane come to lie permanently and practi- 
cally immovable upon each other there is a tendency to fusion between them, 
the endothelium covering the apposed surfaces disappearing and its place 
being taken by connective tissue." (Piersol's Anatomy.) This is caused 
by the two surfaces along the line of contact throwing out liquor sanguinis 
which rapidly separates into fibrin and serum, the fibrin forming a tempor- 
ary cement and binding the two surfaces together. After this takes place 
new connective tissues and new blood vessels are rapidly formed uniting the 
two surfaces solidly. "The rapidity with which this preliminary aggluti- 
nation occurs is well illustrated by the case reported by Oliver in which, 
after five hours, a sutured intestinal wall had formed a water tight joint." 
(Coplin's Pathology.) 

Next let us consider the muscles. Muscular tissue is a highly specialized 
tissue with special functions to perform which are developed at the expense 
of its regenerative powers and does not take any part in the immediate heal- 
ing of wounds. Muscles do not heal to any degree of stability, but can be 
trained to lie in certain positions. The pathologists tell us that repair of 
an incised wound of muscular tissue takes place entirely by granulation and 
scar tissue formed from the fibroblasts adjoining the incision, and that the 
muscular tissue itself makes only a feeble effort at regeneration. 

Fascia and aponeurosis tend to heal slowly although they are of connec- 
tive tissue origin. The reason for this is that these tissues are compact and 



SURGERY 117 

rather poorly supplied with blood causing the exudation of fibrin and the 
formation of new tissue to be rather prolonged. These layers however, 
make a very strong union when properly coapted. 

Fat heals lightly if at all. It is poorly supplied with blood, its resistance 
is exceedingly limited, hence it breaks down easily and regenerates poorly. 

Lastly let us consider the skin. Histologically the skin is composed of 
stratified squamous epithelium which is supported underneath by a very 
generous supply of connective tissue. In this tissue lie the blood vessels, 
nerves and lymphatics of the skin. The rapidity with which skin heals is 
a well known fact. This truth gave rise to the old adage "that wounds heal 
too quickly." Every surgeon has seen wounds that looked perfectly healthy 
from the outside, the skin having healed beautifully, which on further ex- 
amination showed that the bottom layers had not healed at all, and that 
deep down in the tissues below the skin pus was present. In the healing of 
a skin incision the epithelium takes a minor part, although it covers the re- 
sulting scar the real tissue that is holding together and giving strength to 
the wound is the dense white connective tissue below, the chief part played 
by the epithelial covering being to prevent a weepy surface. The conclu- 
sion to be drawn from this is that the portion of the skin that really heals 
and gives strength to the incision is the connective tissue base. We take ad- 
vantage of this as 3^ou will see later on. 

Before describing the technique let us summarize just a little so as to see 
the significance of what we have been over. 

First — Only connective tissue heals rapidly and gives immediate solidari- 
ty to the union. 

Second — Peritoneum, being connective tissue, is a rapid and solid healer. 
Third — Muscles heal very slowly and slightly, but may be trained to lie 
in certain positions. 

Fourth — Aponeurosis forms -a stout union, but is a little slow. 
Fifth — Fat is a very poor healer. 

Sixth — Skin is a rapid and safe healer, only the connective tissue base 
heals immediately and firmly. 

The technique of our closure is as follows and is based on the above find- 
ings. In describing the technique we will presume that the incision has 
been made and the various layers exposed. Now we begin by loosening up 
the peritoneum on the opposite side of the incision so as to have a flap to 
pull up between the recti muscles. We use an interrupted suture of catgut 
going through first the rectus muscle, say on the left side, then through the 
peritoneum of the. same side well back from the margin, then taking a liberal 
bite in the peritoneum on the opposite side well back from the margin (mat- 
tress fashion) then back through the peritoneum on the same side and out 
through the rectus muscle. This is continued all the way up until the in- 
cision is closed and the result is that you have two layers of peritoneum 
(rapid healer) brought up between the recti muscles (slow healer). The 
next step is to bring together the sheaths of the recti muscles and the apon- 
eurosis, this is done in such fashion with an interrupted silk worm gut 
suture as to make a surface union instead of an edge to edge (lap over). We 
make no effort to close the fat, but our next attention is directed to the skin. 



118 NORTH CAROLINA MEDICAL SOCIETY 

With a straight Hagedorn needle armed with horse hair we close the skin 
with a mattress suture so as to give a broad surface union avoiding the edge 
to edge coaptation. This same principle applies to the McBurney incision, 
to the right and left rectus incision, to the Camera incision, also the incision 
in the upper right quadrant usually made for operations on the gall-bladder. 
I have carried this principle on and in all operations for ventral hernia I 
use the peritoneum and skin, rapid healers, to make the contracted and re- 
tracted muscles come together and stay together. I have carried it on to 
inguinal hernia in the following manner — when I have dissected out the sac, 
which is peritoneum, I at once drop it into hot saline solution and when I 
am ready to close up I sandwich it between Poupart's ligament and the 
conjoined tendon of the internal oblique and transversalis muscles thus glu- 
ing them together. I have also used this same principle in the correction of 
ceacum mobile by pulling up the ligament of the ceacum and anchoring it 
in the incision. 

The writer has been closing in this manner for about eight years and if 
I had all of them to do over again I would not change my method; and 
only the finding of something better will cause me to change in the future. 

DISCUSSION OF DR. LONG's PAPER 

Dr. E. M. Summerell, China Grove : We have all heard Dr. Long's 
paper, and I trust that we have all most thoroughly enjoyed it, the more es- 
pecially since it presents to our view an extensive vista of relief for suffer- 
ing humanity. It should be a source of great satisfaction to us, if not of an 
equal amount of pride, that the author is a North Carolinian and a mem- 
ber of our Society. 

One criticism I have to offer, and that is that it is too brief, but possibly 
the doctor's excuse lies in the same line as Sam Weller's, that the chief 
secret of successful writing lies in leaving the reader to wish that there were 
more of it. 

Hernia is one of the chief opprobia of the surgical profession. It is 
either congential or acquired. As acquired it is due to mechanical violence, 
which, of course, includes surgical procedure. Every opening of the abdom- 
inal wall demands at the hands of the surgeon his most particular care and 
attention to prevent the occurrence or recurrence of a subsequent profusion 
of the visceral contents. It is proposed in this paper to show us a plan, a 
simple one, by which this object can best be attained. The method Dr. 
Long has most clearly indicated. Now, let us consider the why of this. On 
what scientific basis are the statements of Dr. Long grounded? To my 
mind, the reason for the truth of his conclusions depends upon the recogni- 
tion of certain simple anatomical, histological and pathological facts. Ana- 
tomically, we have three membranes in the human body: dermal, serous, 
and mucous. Histologically, these membranes all h!ave certain qualities in 
common, to only one of which I shall call your attention today. Pathologi- 
cally, we shall have drawn our conclusions. 

The one simple condition common to all of these membranes is the great 
quantity of lymphatics found in all of them. More than that, these mem- 
branes all possess more lymphatics than any other tissues in the body. The 
importance of the contents of these lymphatics — the lymph — in the process 



SURGERY 119 

of repair can not be over-estimated. It is histologically known that these 
vessels, whether saccular or vascular, are lined with a most delicate endothe- 
lium, the component cells of which, when irritated, become clearly individu- 
alized. And not only so, but stomata appear between adjoining cells, facil- 
itating the escape of the vascular contents. There has been demonstrated 
in the fluid both fibrinogen and fibrinoplastin. In the presence of irritation 
the capacity of the cellular contents to undergo great proliferation is vastly 
enhanced. It is known that the progeny of the proliferation of these lymph- 
atic cells is the chief, if not the only, source of the connective tissue so nec- 
essary for repair. I suppose that you will all agree that the firmness and 
solidity of the union of any incision depends upon the firmness and amount 
of the connective tissue therein developed. 

In the plan that Dr. Long has shown us so clearly and lucidly, he makes 
an effort to reinforce the incision by securing the production of as large an 
amount of connective tissue as possible in the scar. To do this, he secures 
material with as great capacity for producing tissue as possible. This he 
obtains in situ. As he tells us, he uses the redundancy of the peritoneum, 
which happens to be the richest of the three membranes I have mentioned 
in the quantity of lymphatics. As a first step, he laps one margin of the 
peritoneal incision considerably over the other, and unites the two layers 
firmly with through and through sutures. Any free margin he carries up 
further into the incision and unites to convenient tissue, thereby reinforcing 
and strengthening the whole depth of the wound. By this simple technique 
of Dr. Long's the strength of the scar is much increased and the incidence 
of subsequent hernial protrusion correspondingly diminished. 

But there is another membrane he calls upon to add its quota to the se- 
curity against hernial protrusion — the skin. This is done by mattressing 
the deepest layers (those fullest of lymphatics), the consequent irritation of 
which furnishes further reinforcement and strength to the scar. 

In conclusion, I trust that you will all agree with me that the facts nar- 
rated in Dr. Long's paper constitute a distinct and marked^I might say an 
epochal — advance in the surgery of the belly wall. 

HYPERTHROPIC STENOSIS OF THE PYLORUS. 
Dr. E. T. Dickinson, Wilson 

After talking with a number of surgeons and pediatritians on the subject 
of congenital hypertrophy of the pylorus, and learning of the decidedly un- 
equal experiences of these men with this trouble, I decided that a discussion 
here might prove interesting to us and profitable to many little ones yet un- 
born. 

As the subject is barely mentioned in text-books except of the most recent 
issue, it is likely that most general practitioners entirely overlook this mala- 
dy of the infant, or too long mistake it for a little indigestion. For a decade 
or more the writer never suspected a case, then after gaining some knowl- 
edge of its existence as a pathological and surgical condition, he found these 
cases not so frequently, to-be-sure, as appendicitis and cesarean section, but 
of sufficient frequency to prove decidedly interesting. 

I am merely calling attention to the existence of this trouble, and to the 
salient diagnostic points leading to its differentiation from the common 



120 NORTH CAROLINA MEDICAL SOCIETY 

forms of indigestion and the transient abnormal functions of the stomach 
and pylorus. My experience does not lead me to boast of any particular 
method of treatment, having been ultimately unsuccessful with the few 
cases treated. This fact should not discourage hope for discussion, as I un- 
derstand the usual salvage is about fifty per cent, of the operative cases. My 
cases have unfortunately not been properly operative because of having been 
brought too near the grave before operation was allowed. It is to the best 
interest of all concerned that the profession and the public be informed on 
the point of necessity of early recognition and proper treatment, before the 
infant has lost the vitality necessary for the effort. 

I feel sure these cases occur in the practice of most practitioners who treat 
mothers and their infants more often than is generally recognized, because 
several loomed up in my practice very soon after I had learned of its exist- 
ence, as did also in the practice of my partner, and because I seldom see one 
or hear of one from other clientiels. 

The sj'mptoms of this malady are so distinct in cases so developed as to 
need operative treatment that there can hardly be a doubt in the mind of 
the practitioner, even after a perfunctory examination. 

The infant does not grow or loses weight in proportion to the thicken- 
ing of the sphincter muscle of the pylorus and the consequent closure of the 
pyloric orifice. His appetite is good and he takes food in a normal way, 
and retains it a variable length of time. 

Sooner or later he vomits in a rather characteristic way, the contents be- 
ing forced in a stream for several inches from the mouth, called eruptive or 
projectile vomiting. 

At frequent intervals before vomiting occurs the outline of the stomach 
may be noted on the abdominal wall and the peristaltic waves can be plainly 
seen. 

After the vomiting careful palpation of the abdomen in the region of the 
pylorus will often reveal a distinct marble-like tumor which is fairly mov- 
able. 

A few drachms of bismuth subnitrate given in milk followed by x-ray 
examination will give a working knowledge of the degree of stenosis. 

Even in cases of complete stenosis the stools may be of sufficient volume 
and frequency to satisfy the mother or the nurse, but proper examination 
will detect a marked deficiency, and the color and consistency will be far 
from normal, being dark, tarry and tough, or consisting almost entirely of 
bile, or of bile and mucus. 

Treatment of these little cases should be well directed by a physician 
who knows much more of the pathology than the mother or nurse could 
possibly be impressed with. Left to the imagination of the loving mother 
and sympathizing friends these infants drift too far into starvation and the 
vicious circle of malnutrition. 

Certainly some cases of partial stenosis recover. These cases show a 
stream of bismuth passing the pylorus very soon or immediately after the 
meal has been given. They should have bismuth and antispasmodics as thera- 
peutic measures and a carefully regulated diet of milk, either mother's milk 
or modified milk as may be found to suit the individual case. Systematic gas- 
tric lavage is also instituted early and persisted in until recovery has taken 
place or more radical measures have become evident. 



SURGERY 121 

Operation should not be delayed until it is dangerous on account of ex- 
cessive starvation. Two operations are advocated. Posterior gastroenter- 
ostom}' which was the first operative procedure in these cases is still done and 
advocated by some. The Rammstedt or the Webber-Rammstedt operation 
seems to be the favorite of most operators at the present time. 

In this procedure the abdomen is opened through the right rectus above 
the umbilicus. The tumor is delivered and while held firmly between the 
thumb and the forefinger of the left hand, an incision is made into the tu- 
mor in the line of the axis of the gut, extending the full length of the swell- 
ing. This incision is carefully deepened until the m.ucous membrane begins 
to bulge into it. With scissors the muscle is gently separated from the 
mucous membrane and the incision stretched open so that the mucous mem- 
brane is exposed for a width of an inch or more. If the stomach be distended 
slightly at this time with air it can readily be seen to pass freely through the 
pyloric opening. Or if a small stomach tube has been left in the stomach 
after the lavage it can be readily passed through. 

DISCUSSION OF DR. DICKINSON^S PAPER 

Dr. 1. W. Faison^ Charlotte: I am no surgeon, by any means, but 
I do have something to do with pyloric stenosis. Diagnosis 
can be made pretty easily with the x-ray and bismuth, but 
if you use your head, you do not need either. When these little fellows 
swell up and you see repeated perstaltic waves, j-ou can easily recognize 
the condition. An operation is needed, though a few of them may get well 
without it, but too few get well to think of taking a chance without it. They 
recover rapidly. The principle is the same, that the muscle is cut through 
on the anterior portion of the stomach to the mucous membrane. One man 
would dissect the serous coat of the stomach and suture it over the cut mem- 
brane. Others stitch the omentum over the cut surface. I have one baby 
in the hospital now, four months old, who weighed eight or nine pounds 
when he was born and weighed seven pounds when he was operated on. He 
vomited almost everything. The trouble with these babies is that they are 
not turned over to somebody soon enough. That is too often the case, and 
it is too bad that the regular medical men will hold these little fellows un- 
til they begin to see the budding wings and then want to shift the respon- 
sibility. The operation was beautifully done, successfully done, scientifical- 
ly done. The baby's temperature went down at once, though it has been 
to \O\y2 since. We began feeding him within half an hour. If you had 
seen that baby last Monday and saw him today, you would doubt that it 
was the same baby. Every case, as Dr. Deaver says about appendicitis, be- 
longs to the surgeon and not to the doctors. When these little fellows get 
<5ick they belong to the pediatrician and not to the doctors. 

DISCUSSION of dr. dickinson's paper 
Dr. J. Buren Sidbury, Wilmington: I wish to bring out a few 
points in the symptoms of these little fellows. First, and most important, 
it seems to me, is the age of the patient. If a child is having projectile 
vomiting for the first time, at ten months of age he has not pyloric stenosis. 
Usually the vomiting begins from birth and is projectile in character. The 
baby may have nothing in its stools except meconium, he is usually consti- 
pated. 



122 NORTH CAROLINA MEDICAL SOCIETY 

In describing the wave that is found in this condition, it starts on the 
right side, travelling somewhat like a rubber ball across the median line to 
the left, rhythmical in character and wave-like. Some times it goes in the 
opposite direction, at which time the child vomifs. In regard to the tumor, 
that is one of the least valuable signs. At autopsy I have seen recently two 
cases, which died at nine and twelve months of age of other conditions. The 
tumor, the thickening of the pylorus, was still present. There is no tendency 
of these fibres to reunite and cause the symptoms if all the muscle fibres are 
divided. 

In regard to the technique of the operation, there is one addition, so far 
as I know. Two of Dr. Bowne's cases at Babies Hospital suturing of per- 
itoneum over the cut surface of pylorus which were operated on in the last 
four months died of hemorrhage. They were autopsied, showing that the 
only cause of death was hemorrhage. To relieve this, he has advocated 
suturing over the cut surface a layer of the peritoneum which will avoid 
hemorrhage. A very small hemorrhage may cause the loss of life in these lit- 
tle fellows. He advocates that this procedure be adopted by the surgeon as 
the means of preventing this secondary hemorrhage. 

In the routine of determining whether or not a child has pyloric stenosis, 
two or three things would be done before the child is turned over to the 
surgeon. First, the stomach should be washed out ; second, he should be 
given water to see the gastric wave; third, is the retention. Three hours 
after feeding the stomach should be washed out to see how much of the food 
is retained. In a normal baby at that age nothing should be left in the stom- 
ach at all after three hours. This procedure will give you some definite 
idea of the functioning capacity of the pylorus. The stomach content is 
not bile-stained. If there is any regurgitation of bile the possibility of 
duodeneal obstruction of some kind should be considered, rather than the 
possibility of plyoric stenosis. I agree with Dr. Faison in regard to the x-ray. 
The less these little fellows are manipulated the better. The simple watch- 
ing for the gastric wave, the determination of the amount of food passing 
through the pylorus or the amount of retentions, will give you more infor- 
mation than all the x-ray men. 

There is one point which I do not think has been brought out, and that 
is that when a child has lost one-third of his body weight that is the danger 
signal. Patients who come to operation before they have lost one-third of 
the original body weight are likely to have a favorable outcome of the oper- 
ation. While patients who have lost more than one-third will not do so well. 
See that the child does not lose more than one-third of his body weight. Be- 
yond that is the danger period. These cases, like any other cases of maras- 
mus and malnutrition, are feeding cases. The child is still a problem after 
the operation, and may be a difficult feeding case all its life. The feeding 
is a problem for the pediatrician. As Dr. Faison has said, feed them early 
and increase gradually until the child is able to take care of the food that 
you give. One most important point is this, these children need breast milk. 
That will do more for them than any other thing except the surgeon. With- 
out a skilled surgeon and without breast milk the child's chances for life 
are very, very uncertain. 



SURGERY 123 

Dr. Dickinson, closing the discussion: I want to say that I am very 
grateful for the liberal discussion of this paper, because this subject is in its 
infancy and I do not feel that the treatment will be successful until the pro- 
cedure is far in advance of the present. No treatment is successful when 
there is a fifty per cent mortality, and there is no method at present of deal- 
ing with this congenital stenosis of the pylorus that gives better hope than 
fifty per cent. 

"END RESULTS OF ONE HUNDRED CASES OF CANCER 

OF UTERUS" 
Dr. J. A. Williams, M. D., B. S., F. A. C. S., Greensboro 

I am not going to take up your time giving you statistics in regard to 
Cancer of the Uterus. We all know that thousands are dying every year 
from cancer, having its incipiency either in the cervix or body of the uter- 
us. Of the one hundred cases in this report, seventy per cent were diagnos- 
ed early and a complete hysterectomy followed. Ten of these had a re- 
currence within three years and finally died. Two others had cancer of the 
liver two or three years later. Thirty were living two years later and in 
good health. Twenty were in good health five years after operation. Eight 
were living and in good health eight 3'ears after operation. 

The above cases were in the earliest stages, the thirty remaining were ad- 
vanced cases bordening on what we would consider the border line operable 
and unoperable cases. 

I used Percy cautery on four of these for fifty minutes and in twelve or 
fourteen days did a complete hysterectomy on three. Of these all but two 
had recurrence within six months and died. On died of hemorrhage four 
days after cauterization, due to slough, before we had a chance to reopen 
and do a hysterectomy. One living six months after, with mass in pelvis 
but no indication of recurrence in vaginal mucus membrane. 

Six cases proved to be epithelioma of cervix and by wide dissection of 
vaginal mucos and abdominal hj'sterectomy, all of these are living from 
two to four years. 

The twenty left were unoperable, three were simply cauterized to stop 
hemorrhage. The rest were advised to use raduim but not being able, eight 
went home to be treated as best they could by family physicians. Nine 
others went to various places and used six to twelve treatments of radium 
at different periods. Two died in four months after return, two in six 
months. Two others in eight months and one other in one year. The other 
two, so far as I can see, radium has had no effect on, as there are large 
masses involving rectum and bladder, though they are still living. The 
radium stayed the disease perhaps but otherwise, I can see no results. 

(conclusions) 

I — That radium or Percy cautery may help stay the growth for a while 
but no permanent results. 

II — That until the physicians examine their patients at intervals after 
child birth and keep tab on the irritation from laceration and from abortion 
and get the patient to be operated on early, there is no hope. 



124 NORTH CAROLINA MEDICAL SOCIETY 

in — The public at large and especially the women must be educated to 
this fact and demand the exam'ination earh-. 

IV — That the great responsibility of this educational work rests on the 
family physician. Then and not until then will we see a decrease death 
rate from cancer of the uterus. 

V — That my belief is, that if radium proves a curative of cancer, it must 
be used in the earliest stages of the disease and then not get any better re- 
sults than the old teaching of dissecting operations, as it has been proven 
that radium is only effective in cancer of the cervix. I would prefer opera- 
tive procedure until they prove more to my satisfaction than the present, 
the efficiency of radium treatment. 

SUBPHRENIC ABSCESS. 
George Wm. Pressley, M. D., F. A. C. S., Charlotte, N. C. 

A subphrenic abscess is a collection of pus in contact with some portion 
of the under surface of the diaphragm. It is then not a subhepatic, or a 
perirenal or a liver abscess. 

Fortunately it is a rare condition but at the same time it is a very serious 
one when it does occur. The man with very large surgical practice will see 
about two cases in a year ; with very good practice about one a year ; the 
average surgeon one in two years. This rarity of the condition tends to 
catch us unprepared and we lose valuable time in making the diagnosis, in 
fact we make our diagnosis in not a few cases afterwards. 

The disease only dates back to 1845 w^hen Barlow had a few words to 
say about it. No one paid any attention to him for thirty odd years when 
Volkman operated on a case and it was not till 1880 that a clean-cut diagno- 
sis was made before operation when Von Leyden wrote his epoch-making 
paper. Since then we have known much about it, in fact much more than 
we have practiced perhaps. 

We have two main classes of cases ; post-operative and pre-operative. 
These can be divided into acute and insidious. The acute are usually rup? 
ture cases, the insidious are post-operative. 

Barnard in the British Medical Journal, No. 1, 1908, gives us a very de- 
tailed description of the anatomy of the under surface of the diaphragm 
which is very helpful in explaining the pathology of this abscess. The cru- 
cial arrangement of the hepatic ligaments divides the inferior surface of the 
diaphragm into four compartments right and left anterior and right and 
left posterior. These four spaces are lined with peritoneum. The two 
anterior spaces are large while the posterior are small. Then we have two 
spaces, a right and left uncovered by peritoneum. On the right this extra- 
peritoneal space is in the folds of the coronary ligament, while on the left 
it encloses the upper pole of the kidney. This arrangement serves admir- 
ably when all is well but in the presence of infection, like the pockets in the 
knee-joint, only more so, it adds immensely to the gravity of the situation. 
Further we remember that there is a depression in the superior surface of 
the liver called the cardiac depression but which serves as the touch hole or 



SURGERY • 125 

Starting point for this infection. As a general rule the abscess does not 
break through the falciform ligament and so remain right or left as the 
case may be whether intra or extra peritoneal. Most are right sided, in 
fact, we rarely see the left-sided kind. 

Causes are as follows: 

1. Rupture of hollow viscus as stomach, duodenum, appendix, gall-blad- 
der or esophagus. 

2. Suppuration in adjacent organs as infection of spleen, liver, kidney, 
lungs or pleura. 

3. Infected ribs, vertebra or abscess of the thoracic wall along the line of 
the diaphragm. 

4. Trauma, hematoma, foreign bodies as bullets, shreds of clothing or 
empyema drainage tube. 

5. Metastasis of local infection as carbuncle, felon or tonsil. 

6. Localization of general infection as in lagrippe. 

The right-sided abscess is usually of appendiceal, gastric, duodeneal or 
hepatic origin. 

The left-sided splenic, renal, gastric or esophageal. 

The germ most usually found is the colon bacillus, next the streptoccus, 
in some cases the pus is sterile at time of operation especially if long delayed 
the orginal focus having been removed. 

Quite a few cases give a history of amebic dysentery but no ameboid or- 
ganism can be found. 

In 1204 cases from the literature and private communications we have 
the following: 

Due to appendix 322 

stomach 280 

gall-bladder, liver 181 

duodenum 82 

spleen 45 

t. b. abdomen ' 29 

pancreas 28 

trauma 26 

female genitalia 17 

kidney 7 

pleura 6 

general peritonitis 4 

costal 4 

focal infection 3 

undetermined 75 

96 loosely stated as mostly appendix, next liver and gall-bladder, few 
stomach, duodenum, kidney, liver abscess, trauma and undetermined. In 
129 recent cases, 100 recovered, 22.5% mortality 

In 890 cases previous to 1910, 30% of the operated cases died. 



126 ' NORTH CAROLINA MEDICAL SOCIETY 

The three operative routes gave the following: 
Abdominal 214 cases,, 36% mortality. 
Transpleuro-diaphragmatic 201 cases, 33% mortality. 
Lumbar 47 cases, 23% mortality. 
In 990 cases, 739 were intraperitoneal, 151 extraperitoneal. 

CLINICAL HISTORY 

Onset sudden or may be insidious. 

If sudden the patient is seriously ill with upper abdominal pain, nausea, 
vomiting, pain hard to control andl vague as to exact location ; may be epigas- 
tric, then diffuse abdominal, in the back, then chest or shoulder, or subclav- 
icular, this last being fairly characteristic. Temperature may be subnormal 
for first few hours then up to 102. Chilly feeling in back and in some cases 
early cough and expectoration. Tenderness delayed several hours to sev- 
eral days, under costal margin on right side, epigastric or in chest or back 
or loins. Maybe absent in some cases throughout illness. Hiccough may 
be very troublesome. If insidious, the patient does not improve after oper- 
ation for some suppurative abdominal condition. Anorexia, coated tongue 
in spite of regular bowels movement. Slight temperature, 99 to 101, short- 
ness of breath on least exertion, cough, dyspnea, sallow complexion, pinched 
facies, visible alae nasi movements with respiration, chills and sweats, 
wound doing well, every thing all right except the patient 

TERMINATIONS ^ 

1. Pus may become encapsulated. Very rare. 

2. May rupture into bronchus. Pus coughed up. 
3. Rupture into alimentary tract. 

4. Rupture into pericardium. 

5. Point at unbilicus or in the loin. 

Mortality depends on time of operation, if too early you miss the pus, if 
too late you miss the patient. 

Average operative mortality 35 to 50%. 

After acute cases patient may improve week or more, temperature and 
pulse to normal, some appetite, able to be up some with quart pus in sub- 
phrenic space. 

DIAGNOSIS 

The diagnosis is most frequently made by exclusion. 

If you have a patient with some serious suppurative upper abdominal 
condition that you cannot possibly locate at all an3avhere, the chances are 
that the patient has a subphenric abscess. 

The temperature is not especially significant, may be high or normal. 

Morning normal is the rule in many cases. Late in the disease the tem- 
perature is of course pyemic in type. 

Pulse usually out of proportion to temperature elevation. In many cases 
however, the pulse will be normal, at least for the first half of the day. 



SURGERY 127 

Pain is severe and early in the rupture cases, may be slight and late in the 
post-operative cases. In both instances it is variable as to location, may be 
diffuse abdominal in the morning, thoracic in the afternoon, then in the 
back or loins. The supracavicular pain is said to be fairly characteristic. 

Tenderness is more or less conspicious by its absence. 

Leucocyte count always high, 18 to 40 thousand. One of the most help- 
ful signs. 

X-ray shows a high riaphragm more or less fixed, low liver line and fre- 
quently fluid shadow in the pleura. 

Physical signs are triangular line of upper liver — border dullness, reach- 
ing its highest point in the mid — or anterior axillary line; epigastric dull- 
ness in sitting posture which disappears on lying down ; lateral excursion of 
the costal margin on affected side. In long standing cases there may be 
bulging of chest or abdominal wall or in the back. 

Aspirating needle is the proof of the pudding if positive, if negative of no 
value. Needle should be of large caliber, at least three inches long. It 
should be put in deep in center of dullness and bulging if any and suction 
kept on all the time, watch for air or serum but if these appear in the bar- 
rel push on. 

COMPLICATIONS 

Liver abscess, the most common and most frequent cause of death, pleuri- 
sy with serous or purulent exudate occurs in about one-third the cases. Per- 
icarditis which may be serous or suppurative in character. Pulmonary ab- 
scess and septic pneumonia may be seen in many cases. 

TREATMENT 

The treatment is obvious, early free drainage. Do not pay much atten- 
tion to the original focus. 

Burke in Anals of Surgery, Oct. 1918, advises anterior incisions in 
all cases with counter drain if needed. Others recommend resection of 9th 
or 10th ribs. Possibly better both ribs and push up the diaphragm or the 
pleura can be opened in two stages or immediately by suturing the upper 
edge of the cut plura to the diaphragm and packing behind the proposed 
opening in the diaphragm. Use large tubular drains follow up extension if 
to pleura, lung or loin. If to liver the case is hopeless. 

NOTE — I am greatly indebted to the surgeons who answered the ques- 
tionaire sent out and thank them very heartily for their replies. 

ASCARIASIS AS A SURGICAL COMPLICATION 
Henry Norris, M. D., Rutherfordton, N. C. 

You are all. no doubt, so familiar with the life history of the Ascarsis 
Lumbricoides that I shall not attempt to describe it as I merely wish in this 
brief paper to call your attention to the apparently very serious symptoms 
which may be caused by these worms after surgical operations. 

I am sure that many of the surgeons here present will agree with me that 
it is an exceedingly rare thing to ever palpate a living worm in the intestine 
during the course of a laparotomy. In only one abdomen have I ever en- 



128 NORTH CAROLINA MEDICAL SOCIETY 

countered a worm which was moving. In this case, a colored woman, whom 
I operated upon for some minor pelvic condition, through a median abdom- 
inal incision, I reached over to draw up the cecum and have a look at the 
appendix, and to my surprise felt something wiggling under my fingers. I 
brought up a loop of the ileum and could plainly see and feel within it the 
outline of a round worm ; placing a lap pad about the gut, I made a small 
.incision into it and drew out a worm fourteen inches long, which was very 
much alive. The nick in the bowel was closed and the appendix was then 
removed. 

The reason that we do not feel living worms while doing abdominal op- 
erations is because they are narcotized by the ether. Probably many of 
them recover from ether as does the patient, while undoubtedly numbers ot 
them are killed by the anaesthetic. It is to the latter group that I wish to 
call your attention. 

In September, 1908, E. S., Male, age 12 years, was admitted to the Ruth- 
erford Hospital with a diagnosis of acute appendicitis, which was concurred 
in, immediate operation was advised, and performed. The appendix was 
found to be acutely inflamed, gangrenous near the tip and contained two 
concretions. The abdomen was closed in our routine manner and for forty- 
eight hours the post-operative condition of the patient was all that could be 
desired. His temperature then shot up to 103, pulse 140, respirations 28. 
His abdomen was slightly distended, but was not rigid, peristalsis was of 
very poor quality and the boy looked desperately ill. His tongue was very 
dry and his breath was peculiarly offensive. His wound was examined and 
found to be clean. A white cell count showed a slight leukocytosis. He com- 
plained of feeling very nauseated, but for several hours did not vomit, he 
then brought up a large dead round worm, twelve inches long. By the 
next morning his symptoms had returned to normal and his convalescence 
was entirely uneventful, except for the passage of two small worms follow- 
ing the administration of Santonin and Calomel. Since this case, we have 
had eighteen or twenty similar ones and are able to recognize the symptoms 
described above as due to the presence of a dead worm or worms, either in 
the stomach or small intestine. In the former location the symptoms are 
always more severe and patient appears more ill. The breath has an al- 
most death-like odor. Pain has not been complained of by those patients 
who vomited the worms, but in cases in which the lubricoides were expelled 
from the bowel, cramp-like pains were experienced in the neighborhood of 
the umbilicus. 

The symptoms are rather suggestive of peritonitis, except for the fact 
that there is no pain, peristalsis does not cease, abdomen does not become 
rigid and there is no vomiting until the ejection of the worm. A number 
of years ago I saw a post-mortem made upon a man aged about forty, who 
died with a clinical diagnosis of acute catarrhal jaundice following pneumo- 
nia. A large round worm had entered the common bowel duct and com- 
pletely occluded it. 

In those cases which we have in the Hospital a sufficient length of tirne 
before operation, routine examination of the stools prevents what is a dis- 
tinctly alarming, and I believe, not uncommon surgical complication. 



SURGERY 129 

THE SURGEON AND ROENTGENOLOGY. 

Dr. R. H. Lafferty, Charlotte, N. C. 

To saj- the roentgengram and its accurate interpretation is practically in- 
dispensable to the surgeon is today a trite remark. It is universally recog- 
nized. The great war did much toward giving it its rightful place and the 
great dependence that both surgeons and clinicians place upon it is shown 
by the number of x-ray illustrations we find in our best journals and see at 
various medical ;iieetings. While in so brief a time it is impossible to enu- 
merate the many uses, it may not be amiss to mention a few and illustrate 
some of them. 

The localization of foreign bodies reached its climax during the war, but 
in cival practice it is of great assistance. All can recall how we used to probe 
and probe for a bullet and then stop and wonder where it was. In deter- 
mining fractures and dislocations and in ascertaining the position of the 
bones we have such a well recognized and ready help in time of trouble that 
it is hardly necessary to mention it. Then in determining the nature of a 
bone lesion it may often save us much useless worry and occasionally the 
patient a useless operation. 

Over and over again the x-ray has been of service to the surgeon and in- 
ternist in locating pus pockets, which had not been reached by a needle and 
in determining the presence of fluid in the lung ; also in a study of the con- 
dition of the sinuses and antra. 

When we turn our attention to abdominal lesions no one diagnositic 
procedure, unless it be Dr. Deaver's "diagnostic scapel" can equal the 
roentgen ray in importance. While the gall stone is not located readily, it 
is at times demonstrated and more often indicated by surrounding condi- 
tions. 

The kidney calculus, ureteral or bladder stones can easily be located and 
we have not infrequently seen patients who might have saved an appendix 
and lost a kidney stone had the roentgen ray been emploj^ed before the op- 
eration. The location of many pathological conditions of the alimentary 
tract and surrounding organs, the presence of adhesions and of many chron- 
ic appendices may be shown. To stop here to discuss what constitutes 
roentgenologically a pathological appendix would consume too much time — 
sufHce to say that every appendix that is visualized is not pathological. 

The barium meal (the priority of the use of which, has been clearly 
shown (1) was not German, but A-merican) marked an epoch in the field 
of x-ray diagnosis. The advent of the pneumoperitineum marks another. 
By the injection of gas into the peritoneal cavit}^ one may show clearly all the 
softer tissues, as the heart is seen embedded in normal lung tissue one may 
locate tumor masses and adhesions, differentiate between an abscess above or 
below the diaphragm and ascertain other conditions that we have longed to 
know. It has not, as vet, come into very general use and no bad results 
have been reported. Stew-art of N. Y. (2) and OrndofE (3) of Chicago 
have no bad effects to report in over 200 cases. No one has yet seen enough 
cases to have become expert in interpretation, but it offers to us a new and 
very inviting field of study. 



130 NORTH CAROLINA MEDICAL SOCIETY 

Finally in the field of therapuesis the x-ray comes as an important ally to 
the surgeon. Following the removal of every malignant or suspicious 
growth the x-ray should be applied. It will undoubtedly lessen recurrences 
and make your work more successful. 

In conclusion I might say that it is the desire of the roentgenologist to 
serve the surgeon and clinician in diagnosing cases and in becoming as 
thorough as possible in examining a case. He has no desire to usurp their 
position in clinical study and in treating or advising the patient. I might 
venture to prophesy that in ten years from now there will, be thousands of 
unused x-ray machines sitting around in doctors' and dentists' offices just 
as there were, and probably still are, static machines by the hundreds. The 
busy doctor will decide that he has no time for the work and interpretation 
of the plates. 

REFERENCES 

1. Am Journal of Roent., Vol. 2, No. 5, page 692. 

2. Am. Journal of Roent., Vol. 6, No. 11, page 533. 

3. The Journal of Roent., Vol. 2, No. 3. 

A TROUBLESOME COMPLICATION OF GONORRHOEA 

ITS TREATMENT. 

Hamilton W. McKay, M. D., of the Crowell Urological Clinic, 

Charlotte, N. C, Former Major M. C, U. S. A. 

Like the poor, gonorrhoea with its manifold complications and far 
reaching results will always present a problem worthy of careful considera- 
tion and study. 

Even though we are living in an age of turmoil and unrest, of unions 
and strikes, it would be difficult to convince the genito-urinary surgeons 
that the gonococcus is a member of any union or will submit to an eight 
hour law. The never ceasing labors of this much dispised organism is re- 
sponsible for much of the income of the specialist whose labors are confined 
to the genito-urinary tract whether he be known as urologist, genito-urinary 
surgeon or venereal specialist. 

By the assembling of four million of our young men we, who are inter- 
ested in the study of venereal diseases, had ample opportunity for study of 
one the foremost medical problems of the present day. In my opinion if the 
moblization of our army has taught any great lesson about the control and 
treatment of venereal diseases it is in brief, that we must put aside false 
modesty, secrecy, and prudery. Why should physicians whisper about 
Florida's 15.63% venereal rate or Vermont's 1.2% venereal rate? They 
should consider these conditions just as any contagious or infectious disease 
should be studied and proper steps taken to remedy the same. Venereals 
must be both spoken of and treated as infected members of society, each 
case being a law unto itself. 

Since 1917 splendid work has been done to bring these diseases before 
the profession in a way w^hich is both beneficial to patient and doctor, and I 
am thoroughly convinced that we cannot successfully treat the above unless 



SURGERY 131 

we are interested enough to give sufficient time, thought, and study to the 
pathology in each individual case. With out present knowledge of patholo- 
gy which the gonococcus produces we should not have fixed in our minds 
any routine or standard method of treatment for the so-called specific ureth- 
ritis but we should think in terms of a pus producing organism which has 
invaded a part or the whole of the seminal tract. In the ambulatory patient 
we are very often dealing not with a specific urethritis but with a urethro- 
vesiculitis and often an epididymitis. 

A familiar character to all of us is the unfortunate worshiper with his 
syringe and pet injection with the usual instructions to shoot until all am- 
munition is exhausted while the gonococcus is retreating to the posterior 
urethra, seminal vesicles, and thence to the epididymis where he can safely 
"dig in" for the winter. Once securely entrenched in one of his favorite 
habitats he little fears the barrage of drugs which are usually thrown upon 
him. 

The gonococcus having suddenly and safely arrived in some portion of the 
epididymis it produces the most painful and troublesome complication of 
gonorrhoea, the symptoms of which are too well known and classic to enu- 
merate in this discussion but if the treatment of this condition is an index 
to the pathology produced surely few of us have given the latter serious 
consideration or study. 

A few points of interest in the pathology incident to gonococcal infection 
of the epididymis may not be amiss, first, the infection is both proliferative 
and destructive; second, abscess formation in some part of the epididymis 
is not the exception, but the rule ; third, the tunica vaginalis is generally in- 
flamed and is the seat of acute inflammatory hydrocele ; fourth, in case of 
long standing the pathology is very similar to that seen in gonococcal infec- 
tions of the fallopian tube. 

While the surgical treatment of gonorrhoeal epididymitis is now gener- 
ally accepted the usual treatment is palliative and expectant rather than 
surgical as was intimated in the early part of this paper. Rest in bed, the ap- 
plication of heat and cold, guiacol and ichthyol are too well known to discuss 
here. 

In our army in France epididymitis was frequently a complication of gon- 
orrhoea. In my opinion, more frequent than in civil life for two reasons, — 
first, because many were inducted into the army through the draft with 
chronic gonorrhoea who after long hikes with full pack would suddenly go 
down with acute epididymitis ; and an extension of the infection from an old 
infected vessicle. I should like to term this class gonorrhoeal carriers. Sec- 
ond, soldiers who contracted acute gonorrhoea were required to perform 
the arduous duties of a soldier which kept the urethra and perineum muscles 
in motion, a prominent, predisposing factor of posterior urethritis. 

The surgical treatment which was so acceptable and practicable for the 
military surgeon was epididymotomy. The object of this paper is not to 
bring you anything new but to commend this operation to you as worthy 
of trial and advocate it in selected cases of gonorrhoeal epididymitis, both 
acute and recurrent. This operation will insure a shorter convalesence 
(from three to five days in hospital) than the expectant treatment, with im- 
mediate relief of pain. 



132 NORTH CAROLINA MEDICAL SOCIETY 

A slight modification of the operation described by Hagner of Washing- 
ton, D. C, gives splendid results. The testis is held firm and rotated on its 
upper pole ; an incision one-half to t\yo inches in length is made down to the 
tunica vaginalis ; the scrotal contents, having been delivered, the tunica vagi- 
nalis is opened and the contents of the accompanying inflammatory hydrocele 
is evacuated. The epididymis is now in plain view. It is examined and at 
some selected point is opened with catract knife. A Hagedorne needle is 
introduced and the point of suppuration sought for. Drainage, of prefer- 
ence, is instituted. The incision is enclosed in the usual manner, silk worm 
gut sutures are better left long, as in repair of the perineum, collodion dress- 
ing applied with suspensory or adhesive shelf as support. 

CONCLUSIONS 

1. Epididymotomy is the logical treatment in the majority of cases of 
gonococcal infection of the epididymis, because this operation is based on 
pathological findings which are essentially surgical. 

2. By the immediate relief of the severe pain the patient is rendered 
comfortable and convalescent is much shorter than in cases which are treated 
locally. 

3. A very small per cent recur, while the surgeon has the advantage 
of being able to treat the posterior urethra almost immediately after oper- 
ation. 

4. By the relief of tension in the early stage of the infection the prospect 
of sterility is minimized. 

5. Early operation (within the first three or four days after the present- 
ing symptoms) will afford the best results. 

6. In recurrent infections of the epididymis you not only can remove a 
troublesome focus but in epididymotomy we have a valuable asset in pre- 
venting sectual neurasthenia. 

DISCUSSION OF DR. MCKAY's PAPER 

Dr. Addison G. Brenizer^ Charlotte: This paper was very pains- 
takingly prepared and a very good paper, but on a subject about which I do 
not know much. I failed to understand something that Dr. McKay said 
about presenting the testicle and using the Hagedorn needle. The paper 
was most excellent and I would be glad if he would explain more clearly. 

Dr. McKay^ closing the discussion: This operation can be done in one 
of two ways. In Dr. Hagner's original operation he opens the tunica vag- 
inalis and exposes the whole epididymis. Usually you can locate the point 
of suppuration. This point is then opened preferably with a cataract knife. 
Often the abscess is very small. The largest I have seen I suppose would 
contain about half a dram of pus. 

The other method is simple. A small incision is made through the cap- 
sule of the epididymis, a hagedorn needle is introduced and the point of 
suppuration sought for. 

I appreciate Dr. Brenizer's discussion of the paper very much. While I 
am on my feet I would like to mention that Dr. Vincent, of Tampa, Flori- 
da, who has a very skilled method, simply injects novocain and uses the 



SURGERY 133 

cautery. He failed to explain satisfactorily to me how to use the cautery, 
to evacuate the inflammatory hydrocele, but said it was an easy matter to 
empty the hydrocele after opening the epididymis. The inflammatory 
hydrocele causes much of the pain. In fulminating cases, produced by the 
gonococcus, we practically always have a hydrocele. 



Gynecology and Ob^etrics 

The meeting was called to order at 10 :00 o'clock A. M., April 21st, 1920. 
by the Chairman, Dr. J. M. Manning, Durham, N. C. 

The section on gynecology and obstetrics will please come to order. I 
was very much in hopes that we would have a larger audience here on ac- 
count of those who have prepared papers, including myself. The first paper 
to be presented in this section is "Some Phases of Obstetrics," by the 
Chairman, Dr. Manning, and I will ask Dr. B. L. Long to take the chair 
for a short while. 

SOME PHASES OF OBSTETRICS. 

Dr. J. M. Manning, Durham, N. C. 

It is said that Hippocrates, the great Grecian doctor, after finishing his 
wonderful work on the Practice of Medicine, proclaimed to the ancient 
world that "he had written every thing that was known about medicine or 
ever would be known." 

The first part of this statement we can admit ; but the wonderful develop- 
ment and the great scientific discoveries that have been made since the days 
of the ancient writer prove the falsity of his prophecies, except perhaps in 
the field of obstetrics, because a child's advent into the world is the same 
now as it was then. 

As chairman of this section I invited a specialist to prepare a paper on 
obstetrics for this meeting, thinking perhaps that he might furnish some- 
thing out of the ordinary, but he respectfully declined ; saying that he had 
nothing new about which to write. So I shall undertake, with some mis- 
givings it is true, to present a few thoughts which have come to the writer 
during a period of thirty-five years spent in the general practice of medicine. 

In so doing I am painfully aware of the fact that my experience in the 
practice of obstetrics is similar more or less to every other practitioner in 
the society, and I do not presume, nor can I say anything on this subject, 
which will furnish one spark of information to any of you. 

Since Adam and Eve were sojourners in the garden of Eden and were 
not ashamed of the scantiness of their dress until Eve tempted did eat of the 
apple and passed it on to our distinguished ancestor, practical obstetrics be- 
gan in the world and has been peculiarly active in all ages and among all 
people, civilized and uncivilized, jew and gentile, cannibal and cocanut 
twirler ever since. It is true that there are a few notable exceptions to the 
general rule, for we are told that Eve the mother of all had no mother her- 
self, but the Lord God caused Adam to fall in a deep sleep, and from one 
of his ribs made woman. In the year Anno Domini 1920, Adam's lost rib is 
the most important part of his anatomical frame, for this rib is gaining much 
distinction in the industrial and political world, and when the suffragist 
amendment becomes a law this rib will become a shining mark for the poli- 
tician's gun-fire. 

There is another gentlemen who took a distinguished part in the activi- 
ties of life in his generation and in whose honor and in commemoration of 
the manner of his coming the medical profession has christened that oper- 



GYNECOLOGY AND OBSTETRICS 135 

ation, which in this year of surgical progress is becoming more and more 
popular and less and less dangerous to the mother and child, commonly 
known as Caesaran section, on which our friend, Doctor Woodard, will 
speak today. 

So far as we are informed the remainder of the citizenship of the earth 
has been ushered into life in the usual way. It is not my purpose to impose 
on your patience a text-book dissertation on obstetrics, but to those who 
through lack of experience have not had the opportunity to develop any 
methods of their own, I respectfully refer them to such distinguished au- 
thors as Hirst, Williams, and Wright, who have so forcefully given detail- 
ed procedures in the management of cases of labor — before, during and 
after parturition. I might say this, it is well, when engaged to care for a 
pregnant woman, and subsequently to attend her in confinement, if a primi- 
porae, especially, to see that her pelvic measurements are sufficient to nor- 
mally give birth to a child at full term. I would suggest that her diet be 
somewhat restricted as to the ingestion of red meats, and that she take a 
fair amount of out-door exercise and that her emunctives be kept in a 
healthy condition. Urinary analysis should be made at intervals of two or 
three weeks after the first half of gestation, and oftener if found necessary. 
If these preliminaries are satisfactory to the accoucheur there is abundant 
assurance that there will probably be a normal labor, but unfortunately 
for the medical attendant and likewise the patient there will be no positive 
assurance there will not be some serious emergency to arise at the time of 
parturition which will greatly disturb the doctor's composure of mind and 
at the same time throw the family of the patient into violent consternation. 
For instance, there may follow delivery a concealed hemorrhage with no 
outward evidences of such a serious complication. The patient complains 
of blindness, her face is blanched, her respiration is difficult and gives other 
evidences of a rapid disintregration. In an emergency like this the accouch- 
eur begins to perspire and as the condition grows more serious the more 
active his sweat glands, until his face is bathed in a profuse perspiration. He 
realizes he must do something and do it quickly and he has no time to re- 
call what obstetrical authors may suggest as the proper procedure. He must 
check this flow of blood or else see his patient fade away like a flower under 
the burning rays of a July sun. 

The writer has had several experiences of this nature and so has every 
other doctor who has done much obstetrical work. Let me say to the young 
members of the profession in emergencies of this kind, don't lose you head, 
for the family of the patient will do this for you. Look wise no matter 
how agitated you may be on the inside, don't let this disturbance come to 
the surface. Never lose confidence in yourself. The important thing to 
remember in concealed hemorrhage is to empty, with your hand, the uterus 
of its blood clots so that this organ can normally contract and check the 
bleeding. Administer hypodermically ergot or pituitrin. Give stimulants, 
enteroclysis, or hypodermoclysis of normal saline solution, and last but not 
least hold your hand over the uterus until you know beyond a doubt that 
this organ is well contracted ; then perhaps the mentally and physically ex- 
hausted accoucher can rest from his labors with the consciousness that the 



136 NORTH CAROLINA MEDICAL SOCIETY 

life of his patient has been saved and his reputation, for there is no death in 
the community so sad and so ruinous to the hopes and aspirations of the 
doctor as that of a woman in confinement. 

Picture, if you please, this scene — a country home, a woman in confine- 
ment a lone doctor with no trained assistance, and no available medical 
help, and an emergency as I have described — then this other scene in con- 
trast: — a city physician (the man who writes learned text-books on obste- 
trics) a hospital, or a private home, two or three trained nurses, a medical 
assistant, everything to be used about the patient previously sterilized. His 
gown and gloves and his assistants' paraphernalia carefully prepared and at 
the conclusion of the ceremony an obstetrical fee that would make the 
country doctor smile the balance of his natural life. This is a striking con- 
trast, but yet it is absolutely true. What experience has the latter with the 
former and how can he better overcome difficulties. 

There is still another complication we sometimes meet in obstetrical 
work. 

PUERPERAL ECLAMPSIA 

The learned authors tell us that this condition follows a deficiency of 
urinary execretion, or rather a failure of the kidneys, and other execretory 
organs to properly eliminate the excrementitious products of the system. 
Toxaemia of pregnancy is a pathological condition produced by pregnancy, 
and which is generally relieved after the termination of parturition. The 
symptoms which generally appear during the second half of pregnancy are 
edemas of the extremities ; urinalysis shows albumen, casts both white and 
red corpuscles. Unless this condition is relieved by treatment — medical, 
dietetic, and otherwise eclampsia is apt to follow. 

Albuminuria in the early months of gestation, is indicative of either 
chronic or acute nephritis and is not necessarily followed by eclampsia, but 
this condition occurring in the seventh, eighth or ninth months of gestation 
is usually due to a general toxaemia associated with toxsemic kidneys. Under 
these conditions we may fear convulsions at the end ot gestation because 
the system is poisoned by toxins resulting from imperfect elimination due 
to defects in the functioning of the intestines, liver, and kidneys. 

The health of an individual is precarious at best : — He may be well today 
and sick tomorrow. We are often called to see a patient suffering with 
headache, high fever, coated tongue. We tell him that he has a bilious at- 
tack for lack of a better name. We give him calomel at night to be follow- 
ed by a dose of epsom salts in the morning. The next day he is well. This 
man had an intestinal toxaemia, which has been relieved by flushing the 
sewer pipes and eliminating the poisons he has developed within himself, 
either through the ingestion of food, or defective tissue metabolism induced 
by the improper functioning of the organs of secretion and elimination. 
This equilibrium of health appears to be more easily disturbed during preg- 
nancy than at other times. It is the disturbance of the balance between the 
production of toxins and their elimination. This condition in the pregnant 
woman is more serious because she must eliminate the poisons accumulated 
by herself as well as those of the growing fetus in utero and it is this condi- 
tion that is followed by eclampsia. As a remedy I would suggest an abund- 
ance of epsom salts. Clean out the intestinal tract, eliminate thoroughly 
day by day. 



GYNECOLOGY AND OBSTETRICS 137 

I might go on if time permitted and tell of other serious emergencies that 
might arise in the practice of midwiferj^ that would jolt the doctor, the pa- 
tient, and the family but what is the use. The older practitioners have seen 
them all and the younger graduates of medicine as he pursues his weary way 
will in time meet them on the roadside. It will be up to him to make the 
most of them. 

In conclusion, let me say that the life of the country obstetrician is a hard 
one, Hlled with doubts and uncertainties, headaches and heartaches. His 
reward will not be in dollars and cents, for the surgeon in one hour's work 
will receive many times the obstetric fee, but in the consciousness that he 
has done what he could to alleviate the pains of a woman in travail. 

Dr. B. F. Long: Is there any discussion of this paper? 

Dr. Manning, taking the chair: Now, gentlemen, is it the disposi 
tion of the members here today to discuss these papers as they are read or 
wait until all papers are read, which is not many, and have the general dis- 
cussion afterwards? If the chairman doesn't hear a motion to the contrary, 
we will have the papers read first and the discussions later, because they are 
all correlated subjects. No objection, so ordered. 

CONCERNING THE DISEASES OF THE CERVIX UTERI. 
Dr. Foy Roberson, Durham 

Many interesting papers have been written on csserean section, uterine 
suspension, perineorrhaphy and other g>^necologic problems, but very little 
has been written concerning that part of the internal genitalia of the female 
which bears the brunt of most gynecological pathology. I refer to the cervi- 
cal portion of the uterus. Indeed the cervix is the portal of entrance of prac- 
tically all pelvic diseases. 

From the time the young girl enters the age of puberty until she has passed 
the menopause, the cervix is constantly in danger of succumbing to any 
of the pathologic conditions of which it is susceptible, and these are many. 
In passing, I will mention some of the most common ; congenital cervical 
atresia, partial stenosis from acute antiflexion, atresia due to scar tissue, lac- 
erations with subsequent hypertrophy, erosions and eversions of the cervical 
mucosa, endo-cervicitic, cystic degeneration, cervical polypi, chancre of the 
cervix, tuberculosis of the cervix and finally that most malignant of condi- 
tions, cancer of the cervix uteri. It will be observed many of the above con- 
ditions have their origin in childbirth or the venereal infections. Personal- 
ly, I believe that cancer of the cervix is always due to either the results of 
childbirth or infection of some source. I have never seen a cancer of the 
cervix without a previous history of one or the other or both of these condi- 
tions. In other words, I have never seen a cancer of the cervix without a 
history of either laceration or endocervicitis. It therefore behooves us as 
medical men and surgeons to give more consideration to this part of the fe- 
male anatomy in order that women may be saved from some of the dangers 
of developing malignant disease, also that they may be saved much un- 
necessary suffering. There is probably no more annoying condition than for 
a woman to be constantly troubled with a foul irritating leucorrhea which 
is practically always present in any cervical disease. Again it is not infre- 
quent that menrorrhagia has its direct origin in some pathological condition 



138 NORTH CAROLINA MEDICAL SOCIETY 

of the cervix. Not only may leucorrhea and hemorrhage be present, but 
sooner or later the individual becomes intensely nervous and complains of 
backache, loss of appetite, loss of weight, and ill health in general and finally 
if the condition is not relieved, there is great probability of the development 
of carcinoma as a result of a thing that was previously benign. Even at 
childbirth, a woman may bleed to death as a result of a laceration of the 
cervix opening into the uterine artery, and quite frequently puerperal septic 
infection enters through a lacerated cervix. 

What then is to be done in order that such cases may be prevented from 
occurring or that they may be relieved after they do occur? First of all, the 
medical profession should do everything possible to co-operate with the 
campaign now being waged against venereal infection. I am sure that great 
good can be accomplished in this way toward preventing the specific diseases 
of the cervix. I also think that every woman who is^delivered in a hospital 
or under such conditions that would justify such a procedure, should have 
a careful inspection of the cervix after delivery and should laceration be 
proven it should be repaired immediately. In this way we may possibly pre- 
vent a subsequent development of hypertrophy of the cervix with its accom- 
panying erosions and leucorrhea, and possibly at the same time forestall an 
impending puerperal septic infection with its deadly results. 

I feel, too, that quite frequently the physician or surgeon fails to examine 
carefully the cervix in the ordinary gynecological examinations thereby 
overlooking important pathology, probably because he gives his entire at- 
tention either to the perineum or to the uterus, tubes and ovaries. And even 
when disease of the cervix is known to exist as well as disease of other 
female generative organs, it seems to me that too frequently we are not will- 
ing to spend the necessary time in giving it the attention it really needs. 
Probably a beautiful hysterectomy or perineorrhaphy is done and the dis- 
eased cervix is left behind to cause the usual train of symptoms and possibly 
to develop later into carcinoma. I have seen carcimona develop in two 
patients who had never borne children. In one a bilateral salpingo-ospho- 
rectomy had been done for tubo-ovarian disease and the other had a supra- 
vaginal hysterectomy for pelvic inflammatory disease. In all probability the 
carcimona in these cases was produced by the constant irritation of a leu- 
corrhea of long standing which had its origin in an infected cervix which 
was most likely a specific infection to begin with. I believe that if the cer- 
vical mucosa in these cases had been destroyed at the time of operation by 
the electric cautery or by excision, that malignant disease would never have 
developed and that these patients would have been saved much suffering 
before it did develop. 

It has been my custom for several years in doing partial hysterectomies to 
first destroy the disease of the cervix with the electric cautery. True, it is a 
little troublesome and time consuming, but it is certainly time well spent 
and productive of much good, for the patient is practically always relieved 
of a troublesome leucorrhea and I have never seen cancer develop in such 
cases. 

Last year at the State Medical Meeting, Dr. Heineberg of Philadelphia 
read before this section a most interesting and instructive paper on the medi- 
cal treatment of the disease of the cervix uteri as a preparatory procedure to 



GYNECOLOGY AND OBSTETRICS 139 

either amputation of the cervix or trachelorrhaphy- He showed that much 
could be accomplished in treating the hypertrophied cervices with lacerations, 
erosions and eversions by medical treatment. In about 50% of his cases, 
he was able to relieve the condition entirely by medical treatment. The 
other 50% required amputation or trachelorrhaphy, but always in a more 
modified degree than when no treatment had preceded operation. His treat- 
ment consisted in first cleaning away the secretion with a weak alkaline solu- 
tion, and then the application of silver nitrate solution. The silver was 
first used in 50% strength and later decreased to 10% strength. He also 
brought out in his paper that trachelorrhaphy was always to be preferred to 
amputation in women who are still in the child bearing period since about 
50^ of the women who became pregnant after amputation of the cervix 
aborted. 

I do not think there is any place for the curette in treating these condi- 
tions. It probably does much more harm than good. I mention this because 
1 know that quite frequently a curettage is done for leucorrhea. The 
treatment should be either medicinal applications or operative such as am- 
putation, trachelorrhaphy, or the electric cautery. 

Let me say finally that I believe all women as they approach the mena- 
, pause should have thorough pelvic examinations made and that any existing 
disease of the cervix should receive proper attention. In this w^ay many 
cases of cancer may be prevented. 

TO SUMMARIZE 

1. Diseases of the cervix uteri are many and are frequently present. 

2. It should be routine in gynecological examinations to make a thorough 
examination of the cervix, and the treatment proper should be given. 

3. Wherever such disease is found to exist and supra-vaginal hysterec- 
tomy is indicated, the cervical mucosa should either be exercised or destroyed 

4. Medical applications are splendid, especially preparatory to opeartion, 
and frequently they m?.ke operation unnecessary. 

CESAREAN SECTION IN ECLAMPSIA. 
C. A. WooDARD^ Wilson, N. C. 

Eclampsia always constitutes a condition of emergency. It is a culmina- 
tion o'f the effects of toxic influences that at the time of the seizure have al- 
ready been poisoning the system for weeks or months. Throughout the 
pregnancy the patient may show symptoms of the disease which give ample 
warning of the danger to be encountered, or the explosion may come wholly 
unannounced, as instanced by a case of mine, which manifested no symptoms 
— no swelling, no headache, no eye symptoms, passed a negative physical 
examination and exhibited a normal urine as late as 24 hours before the 
attack. 

The toxins, whatever their origin, not only circulate in the blood but at- 
tack the various organs of the body, notably the liver, the kidneys, the bram 
and the lungs. The liver presents the most interesting pathology. At 
autopsy there are found spots of necrosis — hemorrhagic and anemic — there 
may be cloudy swelling or even general autolysis. The picture is sugges- 



140 NORTH CAROLINA MEDICAL SOCIETY 

tive of that of acute yellow atrophy of chloroform poisoning. The brain 
shows oedematous areas and anemic spots with occasional hemorrhages and 
areas of softening. The kidneys show varying degrees of nephritis, the par- 
enchymatous type predominating as a rule. The lungs are congested and 
At times oedematous with thrombi and emboli here and there. The pneu- 
monia that sometimes intervenes is a complication and not a part of the dis- 
ease per se. The oedema is the clinical manifestation most evident in some 
cases. 

One cannot examine these organs without wondering how the patient 
lived with so much destructive pathology, for of course it is inconceivable 
that these necrotic areas and degenerative changes could have developed 
after the convulsion. And such pathological changes explain why the con- 
dition is still so resistent to treatment and enables one to understand why 
even the most reputable methods of eliminative treatment fail in a certain 
percentage of cases to check the progress of the disease. The toxins destroy 
the tissues of vital organs, and as in the instance of the brain, enter into 
combination with the cells, so that the elimination of the toxins from the 
blood only gets rid of a part of the poison and leaves the patient still suffer- 
ing from the damage already done to the cells. 

It is interesting that the disease displays a variation in the predominance 
of involvement of the several organs, the symptoms giving a clue to the 
particular type according to the degree of involvement; that is, one case 
will show a predominating kidney involvement revealed by the urinary 
findings, another will show by the nervous and mental symptoms that the 
nervous system is the seat of the greatest amount of damage, another that 
the lungs are attacked as evidenced by the symptoms and signs of pulmonary 
oedema, still another will be jaundiced revealing severe disease of the liver. 
All these organs are involved, but in varying degrees in different cases. 
These points are of importance in management of the individual cases. 

As to the treatment of these cases, it is pretty generally agreed that the 
uterus should be emptied as soon as possible, though Stroganoff's expectant 
method has its advocates, especially for cases so situated as not to have ac- 
cess to surgical treatment. 

In cases in which labor is well under way and dilation of the cervix is 
sufficiently advanced version or the application of forceps is rational surgery, 
but if the eclamptic seizure takes place before labor begins when the cervix 
is not dilated, or if the passages are contracted or any other obstruction ex- 
ists to prevent easy instrumental delivery, and the patient is not infected, I 
think Ceasarean section is indicated. 

The operation is simple and is attended with less shock in this class of 
cases than version or the use of forceps, and certainly the child has a much 
better chance for being delivered alive. Anaesthetics are uhjectioiiable, but 
it requires little more for a section than for a version or instrumental de- 
livery. Indeed it often takes less time for a section, and if morphine and 
hyoscine are administered before beginning the (ipe.-atica, one is able to get 
through with very little anjEsthetic. The amount of traumatism in Cesa- 
rean section is less in many cases, and if the operation is performed with 
reasonable dispatch it is attended with very little additional shock. 

Several types of operation have been devised, as the extraperitoneal and 



GYNECOLOGY AND OBSTETRICS 141 

the Porro operation for septic cases, but in the purely eclamptic cases that 
have not been examined too much the simple transperitoneal operation is 
most suitable. 

The usual preparations are made for an emergency abdominal operation 
and the bladder is emptied. An incision is made from a couple of inches 
above the umbilicus to three or four below, the uterus is delivered or not as 
the operator may prefer. If the uterus is delivered a towel should be spread 
over the abdominal wound to protect the intestines or prevent contamina- 
tion with the uterine contents. It sometimes facilitates matters to clamp 
the skin together with forceps behind the uterus. An incision is made 
through the uterus from the fundus down the mid-line for from four to 
six inches, the child is delivered, the cord divided between clamps, the pla- 
centa delivered and the uterus wiped out with gauze. Pituitrin may be 
administered hypodermically before the uterine incision is made but usually 
the uterus contracts sufficiently without it. An assistant's hands around 
the cervix controls bleeding until the wound is closed. 

The closure of the uterine wound is an important step in the operation, 
as indifferent closure may allow insecure healing and predispose to rupture 
in subsequent labors. It is essential to coapt the sides of the wound snugly 
and to draw the sutures taut. Various methods of suture are used. My 
preference is for closure with three layers of running sutures, using No. 2 
chromic catgut for the deep layers and No. 1 for the peritoneal layer. The 
first includes the deeper half of the muscle down to the mucosa, the next 
takes in the rest of the muscle layer up to the peritoneum and the third 
brings together the peritoneal layer. It is important that the sutures be ac- 
curately applied and that the knots be tied securely, and that the peritoneum 
be coapted perfectly to prevent adhesions. Occasionally an interrupted 
stitch here and there will be necessary to prevent ooze. The omentum 
should be drawn down behind the uterus, and the abdominal wall closed in 
the usual way. 

The post operative treatment is the usual after abdominal operations plus 
the eliminative treatment for the eclampsia — morphine and hyoscine for 
the nervous manifestations, purgatives and diuretics to induce elimination 
and alkalies to overcome acidosis. In some cases phlebotomy is a most valu- 
able aid. I do not care for sweating as it makes the patient restless^ and 
likely does as much harm in this way as it does good by the small amount of 
toxic matter eliminated. 

I do not wish to be judged as advocating Csesarean section as a routine 
in eclamptic cases, but in selected cases I am of the opinion that it is a treat- 
ment of choice, for it frees the child from the hazard of delivery and is at- 
tended with less shock and traumatism to the mother. 

OVARIAN TUMORS. 

Dr. John B. Nicholson, Worthington 

During 16 years of surgery and general practice, perhaps the gynecological 
thing that has come to me most frequently, except minor conditions such as 
lacerations, etc., has been ovarian tumors. This, while a condition that 
yields readily to surgical procedure, is distressing, when encountered in ig- 



142 NORTH CAROLINA MEDICAL SOCIETY 

norant whites and negroes. Frequently have I had patients, sufferers for 
years, brought to me in extremis because of ignorance and prejudice. 

About ten years ago a negro woman, 42 years of age, enormously dis- 
tended, came to me, she could hardly breathe. She had waited eighteen 
months for the delivery of a child. Upon opening the abdomen we found 
a large cyst-adenoma, (multi-locular glandular cyst). This growth was 
very adherent to the parietal peritoneum. This is a large and common va- 
riety of ovarian cysts. These cyst masses are filled with a gelatinous stuff, 
which at times leaks and spreads over the intestines, giving the appearance 
of malignancy. There was no leakage in this particular case. It is well 
however, to say when rupture of this type of cyst does take place that the 
cells inside the cyst continue to secrete this gelatinous material in large 
quantities- The cyst should be removed and as much of the gelatinous 
material as possible. Nothing can be accomplished by washing out the ab- 
dominal cavity. 

Dermoid cysts of the ovary have been rare to me. We have had only 
two. One a large cyst of the left ovary in a white woman, 45 years of 
age; this cyst contained hair, in large quantities, very long and could be 
combed, some teeth and sebaceous material. The other dermoid was of the 
right ovary in a white girl, 15 years of age. This contained a small 
amount of hair and much sebaceous material. Both of these cysts were 
above the average in size. In children and young girls these tumors are at 
times extremely malignant, recur rapidly and terminate fatally; these are 
teritoma. Dermoids also leak and a remarkable case has been described 
in which so much sebaceous material had leaked into the abdominal cavity 
that the abdomen pitted like soft clay. Quite a number of cases have been 
reported in which, when the surgeon opened the belly, the peritoneum was 
found covered with nodules, from which grew tufts of hair. These "epithe- 
lial weeds", as they are called, differ from cancer nodules, in that they do 
not invade the underlying tissues. 

We have seen one fibroid ovary. This operation was not done for the 
ovarian condition but for the removal of what was thought to be a large 
fibroid uterus. This fibroid uterus proved to be a very large malarial spleen, 
(twelve and a half pounds) which had descended and was resting on and 
adherent to the uterus. The spleen was removed, also the fibroid ovary, 
whi(5h was not very large but about the size of an orange. The patient is 
living. This operation was done fourteen years ago so there was nothing 
sarcomatous about this fibroid ovary. These fibroid tumors undergo degen- 
erative changes as do uterine fibroids, they become cystic and calcify- They 
are found in the young and the old. 

We have never seen a sarcoma of the ovary, unless the dermoid cyst in 
the girl fifteen years of age proved to be one. This removal was done such 
a short time ago that I am unable to say as to its malignancy. I have no 
pathologic report on this growth. Bland Sutton has collected one hundred 
cases of cystic ovaries in girls fifteen years and under. Of this series forty- 
one were simple cysts, thirty-eight simple dermoids and twenty-one sarco- 
mas. This is perhaps too small a percentage. He says that sarcoma does oc- 
cur more often, as it does in other paired organs. 

Papillomatous cysts are not so rare, but are very puzzling the first time 



GYNECOLOGY AND OBSTETRICS 143 

one encounters this type of growth. The first impression is, that the thing 
is malignant, that all to be done is close the abdominal cavity because while 
in the early stages the papillomatous processes are confined inside the cyst 
wall, the cyst wall soon ruptures and tumor resembles a huge cauli-flower, 
with the warts spreading out over the entire peritoneum. Hydro-peritoneum 
is also present, due to peritoneal irritation. This is a hopeless picture. 
However, the removal of the growth, in most instances, can be done with 
good results. One case recorded by Pye Smith, at Guy's Hospital, London, 
a woman was tapped 299 times between August 18th, 1884 and April, 1894. 
She came for the three hundredth tap and died. The post-mortem showed 
a papilloma of both ovaries, which could have been relieved by operative 
interference. On the other hand these tumors will sometimes attain an 
enormous size without bursting. 

We' have never encountered a carcinoma of the ovary. These growths 
are secondary to cancer of the gastro-intestinal' tract or gall-bladder. So 
these are metastatic or implantation cancers. The cancer cells invade the 
adjacent tissues and become grafted on to the cystic ovary. The primary 
focus should, of course, be looked for whenever we encounter a growth of 
the ovary with carcinomatous appearance. 

Cysts of the broad ligament. We remember quite a large one, as large 
as a medium size watemelon. These cysts are found between the anterior 
and posterior folds of the broad ligaments and contain simple fluid. They 
can be enucleated easily, care being taken to avoid injury to the uterus. At 
times much oozing hemorrhage attends this operation, then it is best treated 
by marsupialization. 

It is known now that hydatid cysts, slow effusion of blood, tuberculous 
exudates, and ovarian cysts sometimes will become enclosed in a fibrous tis- 
sue capsule formed by the exudate from the peritoneum, which their pres- 
ence excites. These are known as Spurious Capsules and are often mislead- 
ing, however, we can remember that true ovarian cysts always project from, 
never inside, the broad ligament. 

Cystic growths are pedunculated usually and sometimes undergo axial 
rotation, producing symptoms analagous to strangulation of the intestines, 
minus foecal vomiting and this may even take place confusing us in the di- 
agnosis. When cysts suddenly enlarge and give symptoms of axial rotation, 
if no rotation be found on opening the abdomen, then we usually have free 
intra-cystic bleeding. 

Sometimes when opening the abdomen the cyst is found to be suppurating. 
It is hard to understand this rare condition, since the cyst is air tight. We 
know that the chief sources of infection are the tubes, intestines, vermiform 
appendix, tapping and puncture by foreign bodies. Bland Sutton reports a 
suppurating cyst due to puncture by a fish bone through the rectum. The 
cyst was behind the uterus and adherent to the rectum. The blood stream 
is also undoubtedly a source of infection in systemic diseases, as is evidenced 
by reported cases of suppurating cysts, due to the typhoid bacillus. This 
organism has been isolated from such cysts in many instances. 



144 NORTH CAROLINA MEDICAL SOCIETY 

"THE TERMINATION OF PREGNANCY FOR THERAPEU- 
TIC REASONS." 
Dr. F. Webb Griffith, Asheville, N. C. 

In this brief paper I shall not discuss those cases where the uterus is emp- 
tied for an inevitable abortion, missed abortion or dead foetus, but only that 
group of cases where the pregnancy is terminated before term out of con- 
sideration for the health or life of the mother. Criminal abortion, whether 
done to avoid disgrace or simply to limit the size of a family we all con- 
demn. Still more severely do we condemn the physician who violates the 
confidence and trust placed in him by the state, by doing a curettement 
under the deceptive diagnosis of "endometritrus" or "dysmenorrhea" when 
in reality he is knowingly doing a criminal operation. When a curette- 
ment at the patient's home is discouraged by the profession and when all 
scrapings obtained at the hospital are examined routinely by the hospital 
pathologist, such practice will automatically cease. There comes occasion- 
ally to every physician and frequently to those of us who do gynecology, 
the necessity for deciding whether or not the life of the foetus should be 
sacrificed in the interest of the mother. During the four years from Janu- 
ary, 1916 to January, 1920, my records show that pregnancy was termi- 
nated before the viability of the child in twenty-five cases. An analysis of 
these cases I shall use as the basis for this paper. In every case there was 
at least ohe and usually two consultants who kindly shared the responsibili- 
ty with me. In eleven of these patients the indication was pulmonary tuber- 
culosis. 

In a health resort like Asheville it is not surprising that pulmonary tu- 
berculosis should head the list of causes for therapeutic abortion. Just what 
is sufficient indication to justify emptying the uterus in a tuberculous patient 
is still a much mooted question. You will see one patient who has appar- 
ently only a slight lesion, and that well arrested, pass through pregnancy 
nicely, and then after labor rapidly go to pieces, either by a flaring up of 
the pulmonary lesion or by a general miliary tuberculosis. On the other 
hand one with an advanced lesion can occasionally go through without ap- 
parently doing much damage. I believe we are perfectly justified in these 
cases, in giving certain amount of weight to the wishes of the patients 
themselves. Where a woman has two or three children we are not quite 
as much justified in taking a chance with her health and possibly her life by 
allowing pregnancy to continue as we would in a childless couple anxious 
for offspring, especially if they are willing to accept the risk after it has 
been fully explained to them. 

Some of my good friends, whose opinions upon pulmonary tuberculosis 
carry great weight, maintain that we are not justified in terminating preg- 
nancy more than once upon the same patient. They tell their patients that 
pregnancy has been terminated in the interest of their health or life, but 
should they become pregnant again they do so at their own risk and must 
go to full term and bear the consequences. That attitude I cannot quite 
understand, for, if it is the duty of the medical advisor to safeguard them 
the first time why not the second time? That is like saying to a patient, 
who has by indiscreetly getting wet or chilled developed pneumonia, that 
all medical skill would be used to save him this time, but that should he 



GYNECOLOGY AND OBSTETRICS 145 

commit the same indiscretion again he must suffer the consequences without 
the help or alleviation the physician might be able to give. To me the more 
rational procedure would be to say to the patient that should she become 
pregnant again, we will terminate pregnancy, only however, upon the con- 
dition that we be allowed to go a step further and sterilize her. Some of 
these patients are young and while at the time not in shape to go through 
a pregnancy, yet it is possible that a few years later they may be so improved 
as to be perfectly justified in taking the risk. In such cases instead of domg 
the usual ligation and cutting of the tubes, it would be wiser to employ 
some of the methods which aim at temporary sterilization. 

The technic described by Carey Culbertson in 1917, appeals to me more 
than any other I have seen. It consists of a high abdominal incision, start- 
ing just beneath the umbilicus and extending downward. The uterus is 
caught with uterine forceps and brought backward toward the promontory 
of the sacrum. The left round ligament is then caught about 6 cm. from 
the uterine horn and lifted up. A forceps is then passed through the "clear 
space" of the broad ligament from before backwards and the fimbriated ex- 
tremity of the left tube brought into the anterior cul-de-sac and stitched 
with a fine catgut suture. The right tube is then treated the same way. 
Beginning at the point where the left round ligament passes into the left 
inguinal canal the round ligament is stitched with continuous catgut to the 
anterior parietal peritoneum down its entire length to its junction with the 
fundus. The same is done on the opposite side. A fold of the anterior par- 
ietal peritoneum is now brought across the fundus from one round liga- 
ment to the other. 

This procedure leaves the tubes patent and opening into a small cul-de- 
sac completely shut off from the rest of the abdominal cavity. Culbertson 
performed this operation thirty-one times, but unfortunately has not yet 
had occasion to "unsterilize" any of the patients. So that while it is very 
pretty theoretically it may not work out so nicely in practice. However, it 
gives the patient hope that some day she might be in shape to become preg- 
nant and she does not have that mental depression which sometimes follows 
when a woman realizes that she is permanently and irreparably sterile. 

For the pernicious vomiting of pregnancy, operation was done eight 
times. These cases were all given treatment by their family physician be- 
fore being brought to the hospital and in some cases where the condition 
was not too desperate on admission treatment was continued in the hospital. 
We have been guided entirely by what seemed to be the condition of the 
patient rather than by the estimation of the nitrogen output as advocated 
by Williams. When the patient is anxious for a child and will give her 
full cooperation in the treatment it is surprising what can be accomplished, 
even in the most desperate cases. When, however, the patient strenuously 
objects to the discomfort and treatment and to any further increase of the 
family the physician has a most difficult task. If he has not the cooperation 
of the patient and the moral support of the husband to make at least a rea- 
sonable fight, he should drop out of the case. 

Caesarean section, placenta prsevia or the toxemia of pregnancy after the 
seventh month are not considered because they do not decrease, but rather 
increase the chances of the child and therefore do not come in the scope of 



146 NORTH CAROLINA MEDICAL SOCIETY 

this paper. However, in one case of pre-eclamptic toxemia the child, al- 
though born alive, died within twenty-four hours. The one case of eclamp- 
sia which was at the six and one-half month was seen in consultation at a 
hotel twenty miles away. The patient had been having convulsions for 
twelve hours, numbering in all about twenty. As it was out of the question 
to move her to the hospital, a room was hastily prepared and a vaginal 
caesarean section done, after which she had only one slight convulsion and 
made an uneventful recovery. 

In only one case have I had to empty the uterus for a pyelitis, and that 
was in a woman about five months pregnant. As a rule, passage of a renal 
catheter and washing out the pelvis of the kidney suffices either to relieve 
the condition or to tide over the patient until after labor. In this case, how- 
ever, the patient was admitted to the hospital in such a desperate condition 
that it was obvious radical treatment was urgently indicated. In one case 
the uterus was emptied about the third month, for a progressive exophthal- 
mic goiter. Following this patient was kept at rest until her symptoms im- 
proved and then a thyroidectomy was done. In one case a five weeks preg- 
nancy was terminated in a patient who had a short time previously been 
through two major operations and had also had a rather severe hem- 
orrhage from a gastric ulcer. 

The last case of my series was a most interesting one. A girl aged four- 
teen was brought to me with the history that for several months she had not 
menstruated. Examination showed a general fullness of the lower abdomen 
but no definite enlargement of the uterus could be outlined. Further ex- 
amination showed what appeared to be a complete atresia of the vagina. 
More careful search under an anaeesthetic revealed a small opening into the 
vagina just large enough to admit the smallest sized probe. Upon enlarg- 
ing the opening into the vagina a haematocolpos was encountered. After 
cleaning out the blood clots the uterus was then felt to be enlarged. I nat- 
urally concluded that we had also a haematometra, so I thoroughly dilated 
the cervix and upon starting to remove the supposed clots from the uterus 
I was surprised to find a pregnancy approximately three months. It was 
then too late to do anything but proceed and empty the uterus. 

In conclusion I again wish to emphasize the great responsibility which 
these cases place upon the medical profession. We should call in as con- 
sultants, those who are especially fitted to pass upon the disease for which 
curettement is proposed. In that way the family physician and the gynecol- 
ogist will be restrained from rushing into an operation for insufficient rea- 
sons, or on the other hand, what is equally as culpable, will not allow a 
patient to drag along, day after day or week after week, until irreparable 
damage has been done. 

DISCUSSION 

Dr. Moir S. Martin, Mt. Airy, N. C. : This is an interesting series 
of papers. The paper that I am especially interested in is the one on Cesa- 
rean section by Dr. Woodard. The points in our work that I would espec- 
ially like to call your attention to are: First, in regard to the anaesthetic. 
In eclamptic cases the anaesthetic is a very important consideration. In our 
work we use exclusively Gas and Oxygen. Of course in the majority of 
cases the patient is given one-fourth grain of morphine and then it is some- 



GYNECOLOGY AND OBSTETRICS 147 

thing like thirty minutes to an hour before the operation is started. This 
might cause some criticism because some of our best men contend that we 
should not use opium in any form. Personally, we have used it and have 
never seen any bad results following it. By this method your patient prac- 
tically wakes up on the table, that is, if not too deeply unconscious from the 
toxaemia, in other words, comes out from under the anaesthesia and you have 
no bad results following your operation as you would in ether or chloro- 
form. Gas and Oxygen in our opinion is the ideal anaesthetic in these 
cases. 

The second point, is the administration of soda and glucose solution by 
the Murphy drip after the operation as a post-operative procedure, with 
elevated bed or the Fowler position. This has been very satisfactory in our 
work; at least we feel that it has helped us to overcome the toxaemia in 
these cases. Those of us who have tried the alkaline solution in this class 
of cases know that it is of benefit, as to how it does it that is another ques- 
tion. 

Dr. Lawrence, Winston-Salem, N. C-: In 1916 I read a paper be- 
fore this Association on diseases of the cervix and vagina, and tried to point 
out some of the dangers in these cases as a result of manipulation and oper- 
ation. If we study the cytology of carcinoma of the cervix and vagina we 
find that the cancer cell is a displaced epithelial cell. We start with the 
normal epithelial cell, and as a result of irritation proliferation takes place 
and goes on to the extent of breaking down the basement membrane and dis- 
placing itself in the connective tissue when it becomes a cancer cell. This 
is very simple pathology ; but the average text book on pathology is about 
six or seven hundred pages, and when one begins to read the pathology of 
cancer he soon becomes disgusted with it and puts the book back on the shelf. 

McCarthyof the Mayo clinic has made the study of cancer quite simple, 
and one who has read his works has been enlightened along that line. 

In cancer of the cervix, I thoroughly agree with the paper that was read 
on the etiology of it; that it is due to trauma, and the trauma may be pro- 
duced in many ways, chief among which of course, is childbirth. Next we 
may mention instrumentation et caetera, and an effort on the part of the 
cells to repair the damage causes them to multiply in many numbers, and 
for want of a better place than their normal location, they break down the 
surrounding tissues and grow wild. Recently I have seen two very interest- 
ing cases of carcinoma of the cervix that interested me very much. Both 
of them happened to be in colored women, and they both happened to be 
young women, one thirty-one and the other twenty-nine years of age. They 
both had cancer of the cervix, both had had pelvic inflammatory disease. 
One was operated on in Durham by a colored doctor and the other was 
operated on in Winston-Salem by a colored doctor. I do not know what 
was done in either case. I saw them about one year after their operations 
and the cancer at that time was extensive, involving the cervix and vagina 
and extending out into the broad ligaments on either side. I think there 
is no doubt that these cases were caused by- trauma aided by infection and 
should teach us a lesson in treating gynecological cases; that is we should 
not handle the cervix or tissues any more than is absolutely necessary in 
treating diseases of these parts. We should repair lacerations of the cervix 



148 NORTH CAROLINA MEDICAL SOCIETY 

and vagina at the time they occur in cases of obstetrics, if they can be done, 
and it can be done in a hospital and in a majority of the cases in private 
practice. There are cases, of course, remote from hospitals that cannot be 
properly treated in these cases, I think they should be sent in as soon as pos- 
sible or proper aid be given them at the earliest possible moment — that is 
as soon after labor as possible. In repairing the cervix and vagina one should 
be extremely careful to see that he does not turn in epithelial tissues in do- 
ing the plastic work, in other words all tissues should be proximated evenly 
and well. 

Now all of us that do general surgery have complicated obstetric cases 
sent to us for treatment; while I was intern in a hospital we had sixteen 
vaginal caesarean sections and I do not remember how many abdominal sec- 
tions. Since I have been out I have done something like twenty vaginal 
caesarean sections, and about ten abdominal csesarean sections. I could not 
give you the exact figures as to the number of cases or results obtained with- 
out referring to my cases, but in general the results have been highly satis- 
factory. In cases of eclampsia and placenta praennia I invariably do a Caesa- 
rean section provided there is not sufficient dilatation and a pelvis that will 
permit delivery by vagina. It is the most rapid and appears to be the most 
rational way of delivering the woman. Every surgeon has a particular 
technic of his own and if he gets good results from that technic it is the 
thing for him to do. For instance, in regard to anaesthetics — in most cases 
you do not give much anaesthetic, but I make it a rule if there is a com- 
petent doctor around and especially an older man I ask him to give chloro- 
form because it requires very little, it is most satisfactory in these cases, and 
in my experience I have never seen bad results following its use. 

After the operation I simply put them to bed and keep them warm, give 
them plenty of fluids in the form of salt solution, glucose and soda solution 
and treat the symptoms as they arise. In the last three cases I have had in 
the past five months all three mothers and the children and even the father 
have lived. 

Dr. Woodard: Once in a while we see something as dramatic in medi- 
cine as surgery. These cases of toxemia of pregnancy start out with 
symptoms due to the pathology of the pregnancy, but owing to the inability 
to retain food later develop a starvation acidosis and this added affliction 
may even dominate the picture. It is in this type that the soda and sugar 
solution produces the most brilliant results. 

I may mention a case typical of the class. The patient had been treated 
by the usual methods but had steadily grown worse until her condition had 
become so critical that she was sent to the hospital to have the pregnancy 
terminated. However, the administration of the soda and sugar solution 
by the Murphy drip produced immediate improvement and the patient had 
no more toxic symptoms, but passed on through an uneventful convales- 
cence to a normal pregnancy and continued so to full term. 

With regard to the anaesthesia in eclampsia, of course, this is one of the 
most important points in the management of these cases. The ideal would 
be to get along without a general anaesthetic using only local as suggested 
by Dr. Roberson. But, as Dr. Lawrence has indicated, these patients gen- 
erally come to you after having had several convulsions and are often coma- 



GYNECOLOGY AND OBSTETRICS 149 

tose, and, therefore, require very little anaesthetic. Usually the cases we see 
have had morphine ; just a little ansesthetic to get them on the edge of nar- 
cosis and you are able to proceed with the operation. 

As I mentioned before, some of these cases have a predominating liver 
involvement; in these one would avoid chloroform. In a case showing be- 
ginning pulmonary cedema one would avoid ether. In a case showing pre- 
dominating kidney involvement one would prefer to use neither one, yet in 
the majority of these cases the amount required is so small that I feel that 
the objection to their use is more theoretical than practical. 

Dr. F. Webb Griffith^ closing discussion: Dr. Roberson asked one or 
two questions. 

One of them was — what are the indications for the termination of preg- 
nancy in tuberculosis. Personally, I don't have to decide that, for in Ashe- 
ville we have a whole host of lung men who can decide it for us. However, 
in a general way there are two groups of cases, those who are far advanced 
with tuberculosis and where it is obvious that tremendous damage will be 
done if pregnancy continues to full term ; the other group where the lesion 
in the lung is so slight that to allow pregnancy to proceed to full term the 
patient is deprived of the excellent chance she would otherwise have in get- 
ting over her tuberculosis. .1 recall a case where a curettement was done 
and the condition of the mother immediately greatly improved. She soon 
became pregnant again and her physician, a most competent specialist in 
pulmonary diseases, felt that he could not give his sanction for a second 
curettement. Patient went to full term, gave birth to a healthy child and 
died shortly afterwards. That brings up a fine moral question — Is it better 
to prolong the life of the mother for a few months or even a year or two 
and sacrifice the child, or should a short time of the mother's life be sacri- 
ficed in order that a child may have its chance to live out its normal life? 
Frankly I do not know how to decide such questions. The very hardest 
cases to decide are those early cases of pulmonary tuberculosis where the 
patient has every hope of getting well if she is not pulled down by a pro- 
longed pregnancy. So that by doing a curettement you give her the one 
chance in her life to be well and probably in a few years she can have healthy 
children. These are the cases where the lung men must decide and not the 
surgeon. In the toxemia of pregnancy if you have in association with you 
two level headed physicians I believe they can usually decide pretty well 
when the patient is getting to the danger point. 

I have enjoyed Dr. Roberson's paper very much and am glad to see that 
we are getting more and more away from what has been described as "Gyne- 
cological tinkering." Local application and tampons have a very valuable 
place, but I know of nothing which is more overdone than such treatments. 
You recall that the outer part of the cervix is lined by many layers of 
epithelium and the blood vessels underneath give to these layers a bluish tint. 
Now the inner lining of the cervix has only one layer of epithelium and the 
blood vessels showing through appear red. So that when there is a bilateral 
tear the physician frequently sees this red everted inner lining and calls it 
ulceration. He will apply silver nitrate or some other caustic which will 
cause a proliferation of epithelium and he then consideres the ulceration 
cured. After a time these proliferated cells desquamate and the condition 



150 NORTH CAROLINA MEDICAL SOCIETY 

recurs. The patient is then given another course of treatment and the same 
cycle will be kept up as long as the patient will stand for it. Just as Dr. 
Roberson has pointed out either these patients need nothing at all done or 
else they need radical treatment such as repair or amputation of the cervix. 

As to cancer of the womb there are two types, the squamous-celled and 
the adeno-carcinomata. I have never seen a case of the former except where 
there has been some trauma to the cervix, such as instrumental dilation at 
pregnancy. After doing a hysterectomy I think it is an excellent procedure 
to cup out the mucous membrane of the cervix for in so doing you can get a 
better closure and will prevent a subsequent leucorrhea. While this cupping 
by removing the glandular element of the cervix would theoretically pre- 
vent adeno-carcinomata it obviously could not prevent squamous-celled can- 
cers. 

The paper on csesarean section has been very interesting. In a great ma- 
jority of cases the decision for or against Csesarean section is entirely the 
question of the child. If you have a dead foetus or if pregnancy must be 
terminated before the child is viable, Caesarean section is practically always 
contra indicated. Very often vaginal Caesarean section should be done in 
preference to the abdominal, but after all is said the method should be chosen 
which gives the greatest safety to the child without correspondingly greater 
danger to the mother. 



EYE, EAR, NOSE AND THROAT 

WHAT CONSTITUTES GOOD TONSIL SURGERY. 
John W. MacConnell, M. D., Davidson, N. C. 

What constitutes good tonsil surgery? This question is propounded in 
no cynical mood, nor in criticism of any colleague's work, neither have I 
any new or startling method of my own to put before the Society. My 
idea in this discussion is to arrive at some basic facts in connection with ton- 
sil surgery as it is generally done, and as we would like to do it, two condi- 
tions which are not at all times similar. The proposition of tonsil surgery 
in its simplest analysis is only that of removing two vestigial glands in the 
right and left faucial regions, on account of their diseased condition. 

The operation is not a new one — rather the reverse, for it is one of the 
oldest operations in surgery. The early Greek and Roman surgeons divul- 
sed the tonsils, tearing it out with a hook or with the finger nail, both of 
which practices are still in use and some operators make a great deal of their 
work of finger dissection and speak of it with some show of originality, 
whereas both Hippocrates and Celsus advised the method, the former as 
early as 460 B. C 

Tonsil enucleation is difficult because of the location of the tonsil, which 
is rather deep in the throat and surrounded by prominent structures and 
the operation is complicated by the free bleeding and salivary secretions 
accompanying any surgical procedure in these parts. To overcome the diffi- 
culty of operating in a narrow space, at a fair depth, various instruments 
have been designed, many of them freakish in appearance, some utterly 
void of any mechanical attraction or convenience, but designed frequently 
by one who was lacking in manual dexterity, and who had tried to over- 
come his awkwardness with an instrument of many twists and turns. I 
was interested in counting the number of instruments listed for tonsil sur- 
gery in one of our recent catalogues. There were advertised in one cata- 
logue alone 122 instruments for removing faucial tonsils, surely a travesty 
on surgical skill. 

Good tonsil surgery consists in removing the tonsil in its capsule entirely, 
without injuring adjoining structures, particularly the faucial pillars and 
the musculature of the pharyngeal region. This being the proposition, it 
is wise to acquaint ourselves with the surrounding tissues to avoid injuring 
any, and to remember the anatomy of the parts. The tonsil is embryonic 
tissue, developed in three lobes, which sometimes remain, but generally 
only two lobes can be made out in an adult tonsil. These are the two 
lower lobes, the superior lobe being found only on deep inspection of the 
supra-tonsilar fossa. The plica-triangularis is an operculum of tissue cover- 
ing the upper part of the tonsil in its embryonic development, then splitting 
into an anterior fold the plica-pretonsillaris which runs down to the base 
of the tongue, and a posterior fold — the plicainfra-tonsillaris, the two folds 
with the base of the tongue forming the fossa-triangularis. This is the region 
in which we work and all these tissues are to be respected, and should re- 
main uninjured in a tonsil enucleation. 

The tonsil rests in this area surrounded by a distinct fibrous capsule. Its 
size and shape vary, but the surrounding structures are constant, though 



152 NORTH CAROLINA MEDICAL SOCIETY 

they may be distorted by adhesions and frequent inflammations. The blood 
supply is chiefly from the tonsillar branch of the facial artery — which 
branch breaks up into smaller vessels at it enters the tonsil, and these fol- 
low the trabeculae of the capsule as it is infolded in the lymphoid tissue. 
In tonsils chronically inflamed, there is often developed a plexus of veins 
much larger than the normal, and which give great trouble in post-opera- 
tive oozing without there being a specific bleeding point to ligate. The 
facial artery may take an upward swing where it passes beneath the tonsil 
and it is a possibility that it may be injured by a sweep of the knife in the 
deeper tissues — the writer has never seen this accident. The lower part 
of the tonsil may be supplied from a branch of the lingual and the posterior 
superior part by the palatine branch of the ascending pharyngeal. I have 
seen this latter condition a number of times as I am sure all of you have, 
and it shows as a rapid spurter in the upper segment of the tonsillar fossa. 

Good tonsil surgery — should be as surgery in any other part of the body — 
that is it should rest upon proper respect for tissue, a proper acquaintance 
with the parts, every vestige of tonsil should be removed, no other tissue 
should be removed, and a proper hemostasis should be maintained both dur- 
ing and after the operation. Tonsillotomy, slitting of crypts, and the gal- 
vano-cautery have no place in good tonsil surgery. If the case needs remov- 
al of tonsils — they should be removed — just as an offending gland or tumor 
would be removed in any other part of the body. To do this there is only 
one true surgical operation and that is the enucleation with knife or scissors 
of the entire tonsil and its capsule, leaving the pillars undamaged, ligating 
any bleeding points before finishing with the patient. Whether a snare is 
used at the latter part of the operation is a matter of no particular import- 
ance, though most of us do so, for the lower border of the tonsil is not well 
defined and runs down sometimes to a point as thin as a shaving, and the 
snare will follow the line of demarkation down very successfully. The' 
operation mentioned will remove all tonsils not a group of selected cases 
and the writer considers it the only true surgery of the tonsil. Finger dis- 
sections and the Sluder operation will be a success in a certain percentage of 
cases, but the writer does not think that it is wise to select several different 
methods of tonsil enucleation when one operation can be perfected which 
will successfully remove any and every tonsil. The operation outlined is 
equally good whether the patient is under local or general anaesthesia, and 
whether it is a child or an adult. The writer uses novocaine for all cases 
of local anaesthesia and ether for general anaesthetic. Results are as good 
under local as under general anaesthesia, though naturally we can work 
more rapidly and easily under the local. Some of my colleagues inject a 
small amount of adrenalin-novocaine solution into the anterior pillar even 
when ether is used and, while not strictly a good surgical procedure it has 
advantages for the prevention of capillary oozing during the operation, 
shortens the time, and if the operator is experienced, as my colleagues are, 
the same respect for tissue will be maintained whether there is oozing or 
not. In the hands of some, the procedure is not wise, for the operator is 
more daring when the tissues do not bleed and frequently goes deeper than 
he thinks and has secondary hemorrhage when the effect of the adrenalin 
wears off. 

I am advocating no particular type of knife or scissors. Just a good sharp 



EYE, EAR, NOSE AND THROAT 153 

instrument introduced under the anterior pillar of the tonsil where it is not 
adherent, then sweeping the knife around the tonsil going well up under 
the frenum of the plica, for if the upper lobe is well separated the operation 
is half done. Traction towards the median line enables one to strip the ton- 
sil down to its inferior pole which may be divided with the knife or snare. 
Retraction of the anterior pillar forward allows inspection, then any bleed- 
ing points are caught and ligated, or twisted until the fossa is dry. Especi- 
•4lly should the fossa be dry before the patient leaves the table or operating 
chair. At no other time will the patient be under such good control, and 
if they are taken in the operating room later to have something dene to 
stop any hemorrhage, however slight, they have lost the necessary confi- 
dence, and are fearful that some accident might have occurred. 

Hemorrhage is the bugbear of most tonsil operators and is not altogether 
a fanciful danger for severe hemorrhage does sometimes take place, and any 
man who does a sufficient number of cases will have some which will bleed. 
My own routine is to give the calcium salts the day before the operation in 
large doses, and I am confident I have had less capillary oozing or venous 
hemorrhage since that time. In my experience I have had four hemorrhages 
which were severe, though in a retrospective view they do not appear as 
alarming to me as they did at the time. One was an operation to remove 
stumps from a previous tonsilotomy of another surgeon some years before. 
I was operating in a strange hospital without any of my own instruments 
and did a scalpel dissection in which I may have wounded the pillars and 
the bleeding kept up until the blood pressure was lowered enough to make 
the flow stop. The second was on a case of known hemophilia, when I was 
more daring and less experienced than now, and the bleeding kept up a 
couple of days, then ceased and the ultimate results were excellent. The 
third was a middle aged man with a case of pyorrhea — which cases have 
always seemed to bleed more than others. This oozing kept up for twenty- 
four hours and the patient was severely shocked before it corrected itselt 
The fourth was in a choreic young girl, at the age of puberty — was second- 
ary in character — lasted twelve hours — was due to a small piece of tonsil 
left under the plica in the upper fossa and as the patient was removed to 
her home before the bleeding commenced I found myself handicapped by 
not having proper assistance. In a hospital her case should have been 
easily controlled. 

I mention these cases to show that I have not yet reached my ideal in ton- 
sil surgery. My work in examining college students for the last thirteen 
years and two and a half years of army service in examining the throats of 
thousands of men has given me a fair index as to now tonsil surgery is gen- 
erally done over the United States, for I never look into a throat which has 
had an operation that I do not ask, who operated and how long since. I 
beg you to notice that I make no comment on the character of the work to 
the patient and I think we should always be careful in our remarks to the 
laity upon the result of any operation for such misunderstanding can be 
avoided thereby. The errors noticed might be summed up as follows: 

First, failure to remove the entire tonsil. There is no question that if 
the tonsil is entirely enucleated it does not return but if part is left, it may 
continue to hypertrophy and the former condition be unremedied. 



l54 NORTH CAROLINA MEDICAL SOCIETY 

Second, removal of a part of the constrictor muscle of the pharynx. This 
muscle is sometimes rather adherent to the capsule and if many of the mus- 
cle fibres are removed a hardened scar results and the patient will complain 
of a feeling of tightness in the throat which is uncomfortable. 

Third, injury to the pillars, by the knife or snare, and in occasional cases, 
part of the velum palati has been removed and the uvula as well leaving a 
distorted pharynx. _ 

Fourth, some general surgeons who remove tonsils are frightened by the 
blood, which is more than occurs in many abdominal operations and they 
seek to prevent it by suturing the pillars which is always bad practice, for 
if any vestige of tonsil remains it will be deeply embedded and give trouble 
certainly, and the sewing of the pillars together causes undue tightness ot 
the pharynx. If at any time it becomes necessary to suture the pillars to 
prevent hemorrhage the sutures should be removed early and an elevator 
passed between them, separating them permanently. 

Conclusions: There is a great improvement in the tonsil surgery of the 
past few years, but there is the tendency to experiment upon different types 
of instruments and operations rather than adopting a simple surgical techni- 
que and perfecting that operation which will suit all cases. 

2. Though some continental surgeons hold that tonsillotomy is an opera- 
tion of choice, our experience in America is that the entire tonsil should be 
removed in its capsule and that if the operation is thoroughly done no injur- 
ious consequences ever follow, and that such consequences are due to imper- 
fect surgery and not to the tonsil operation per se. 

Dr. J. B. Greene^ Asheville, N. C. : I wish to express my apprecia- 
tion of Dr. McConnell's excellent paper. 

It pleased me, particularly, that the dissection of the tonsil is advised 
rather than the Sluder method. I am of the opinion that the latter method 
is losing somewhat its former popularity. 

The doctor speaks of venous hemorrhage from the tonsillar fossa after 
operation. It has seemed to me that such bleeding is practically always ar- 
terial, though at times the artery is difficult to locate. 

In reference to the administration of Calcium Salts prior to operations, I 
would like to state that I have little faith in such medication since the use 
of this drug some years ago in a case in which I particularly desired immuni- 
ty from troublesome bleeding, was followed by most annoying hemorrhage. 
Since that time I have not used Calcium lactate, and have had little post- 
operative bleeding. 

In reference to the use of adrenalin chloride in our local anaesthesia solu- 
tions, I am in the habit of using eight drops of the one to one thousand solu- 
tion for the removal of both tonsils. I realize that some operators refrain 
from the use of adrenalin chloride for the fear of early secondary bleeding. 
This has been a rare symptom in my experience. 

Dr. J. P. Matheson, Charlotte, N. C. : "I think the Society should 
express their appreciation to Dr. McConnell for such a timely paper, and 
such a thorough discussion of the subject. I would like to mention one or 
two things that I consider important in tonsil surgery. 

To make tonsil surgery easy, as well as effective and to do the least 



EYE^ EAR, NOSE AND THROAT 155 

amount of traumatism to the patient's throat, it is necessary to have a first 
class aniESthetist, and I prefer one who is constantly giving ether for tonsil 
work, and who at the same time can act as your first assistant. This makes 
the operation much quicker, much safer, and often with very much less 
traumatism to the patient's throat. Second, in local work, I prefer to do 
these in my office, and keep them there for three hours afterwards, and then 
send them to the hospital. In this way you save considerable time, your pa- 
tient has very much less excitement, and in case of hemorrhage or other 
complication, you have easy access to your patient, and can give your imme- 
diate personal attention. If at the end of three hours there is no sign of 
tonsil bleeding, you can feel very comfortable. Usually hemorrhages of the 
tonsil after local begin to show very soon after the operation, or at the end 
of about two hours, and in having your patient present on a comfortable 
couch saves a considerable amount of time, annoyance, and excitement 
should it become necessary to stop a hemorrhage. 

CONSERVATISM IN TREATING FOCI OF INFECTION. 
By J. G. Murphy, M. D. Wilmington. 

When I promised our late co-worker and friend, Dr. E. Reid Russell, at 
the close of the Pinehurst Meeting to write a paper to present at this time, 
I had in mind writing on "Astigmatic Corrections," and results we get 
from same, but I have been so impressed in my practice during the year 
with the importance of the subject I am bringing to you that I thought 
this would be of more practical value and especially so if it brings out a dis- 
cussion. That would be worth more to us than the paper itself. Of course 
any doctor is obsolete and behind the times who does not believe in foci of 
infection, and not only believes in them but practices hunting for them in 
his daily work. While I am writing this beginning of my paper, there is 
under my care a patient who came in recently with a disturbance of vision, 
and on examination I found him to have a lens opacity. He was too young 
for a senile cataract so I began to look for a cause for a visual disturbance 
of this type and I found the antrum under the affected eye to be full of pus- 
This was drained and in ten days he was relieved of symptoms that were 
present before, and his vision is improving. 

Now, do not think that I am coming to you to write on the hackneyed 
subject of simply clearing up foci of infection for that is an idiom in surgi- 
cal practice today, but what I do wish to emphasize is this, that the focus 
of infection may be far remote from the organ giving the symptoms, and 
about which we have been consulted and in our zeal for the patient, and by 
our lack of knowledge of the proper mode of treatment of the focus as locat- 
ed by us in our examination we are apt to suggest a line of treatment, which 
will probably be carried out by the specialist to whom we send him, because 
of the fact that we suggest that such should be done. Would it not be bet- 
ter if we would send the patient to the specialist to whom his focus belongs, 
and ask that they decide on the best means of relieving a condition which we 
have found to exist. Possibly by the process of elimination we have located 
the focus producing existing symptoms in our field of specialty. The one to 
whom we send the patient is better fitted to pass on these conditions than the 
Ophthalmologist or Oto-laryngologist. I can make myself clearer in cor- 
recting these errors we have made by sighting some cases which have un- 



156 NORTH CAROLINA MEDICAL SOCIETY 

doubtedly come into the practice of every specialist here present, for instance, 
we have myriads of symptoms and on examination find that the focus caus- 
ing these symptoms is in the teeth, and we, using a degree of positive authori- 
ty, tell the patient they must have their teeth extracted, and our advice is 
likewise carried out, and our patient becomes a victim of our ignorance. We 
have assumed to pass on a subject which should be decided by the dentist. 
You can see our mistake because the doctor to whom he goes thinks we have 
some reason for our positive advice, when in reality we are only asking to 
remove the focus of infection. The specialist to whom he is sent might be 
a dentist who prefers, and according to his practice does more easily relieve 
by treatment, than by the more drastic means of extraction. 

There is no harm in taking out the appendix as a possible source of in- 
fection, nor is there any harm caused by removing tonsils. These organs 
have no functions, but do not advise removing the teeth unless you are com- 
petent to make such a diagnosis. 

THE RELATION OF PUBLIC HEALTH WORK TO THE BUSI- 
NESS INTEREST OF THE EYE, EAR, NOSE AND THROAT 
SPECIALISTS OF NORTH CAROLINA. 

G. M. Cooper, M. D., Director, Medical Inspection of Schools^ 
State Board of Health, Raleigh 

Mr. Chairman and Gentlemen : 

When I was awarded the courtesy by your Chairman, Dr. Banner, of 
having a part in this program, after several days consideration of the matter 
I decided to accept the generous invitation extended to me, and chose 
for consideration the above subject. It is my purpose to discuss this question 
briefly, frankly, and impersonally. In order to keep our perspective clear 
and because he has expressed so definitely and concisely my own conception 
of the work of the physician individually and as a class, I am quoting the 
following paragraph from a recent presidential address before the American 
Neurological Association by Dr. James H. McBride, of California: 

"It is an important truth that nothing stands alone in this world, not 
even a medical association. We go up or down together. We are here 
today not solely because we are physicians, but also for the reason that 
society created us as a profession because it needed us, and we are therefore 
always serving its purpose. Our most private work is really a social and 
public work, so that in all we do we are going on the errands of society. 
Each one of us is an essential part of this moving human order that keeps 
society together and holds humanity to its sober task. 

"In this period of industrial and social reconstruction, when all interests 
are becoming intertwined, when human interspaces grow smaller, and new 
relations create problems that change our views of life and society, it is 
necessary that the medical profession also make certain readjustments and 
that it annex human interests to its older activities, if its members are to 
maintain its fine traditions and keep step with social progress." 

Something like ten years ago, when the real progressive sections woke up 
to the importance of enforcing compulsory vaccination against smallpox as 
the only means of combatting that disease, and when the wide-awake school 



EYE, EAR, NOSE AND THROAT 157 

boards of these same sections began to enforce the requirement of vaccina- 
tion before pupils should be admitted to the public schools, considerable ap- 
prehension spread throughout the length and breadth of the State on the 
part of a great number of physicians, many of whom openly expressed the 
fear that the activities of the health department in the control of smallpox 
was going to make serious inroads into the income of the private physicians, 
and that by paying for this vaccination service by the day and to a single 
health officer in each county or city, instead of farming it out on the basis 
of private fees, strenuous opposition developed as the perusal of the litera- 
ture of that day will afiord abundant proof. This attitude is looked upon 
today as ridiculous and the private physicians still have work to do. 

About five years ago, when the State Board of Health began its first 
systematic effort at the control of typhoid fever, one of the methods used, 
especially for its educational value, was the ofifer of voluntary free vaccina- 
tion against this disease. Here again we were met by the same cry that the 
State Board of Health is encroaching in the field of private practice, and 
that the physician's income is placed in jeopardy. The fear and apprehen- 
sion was so wide-spread here that it became necessary for the Secretary of 
the State Board of Health to discuss this matter formally at the meeting of 
the State Medical Society as late as April, 1917. Today that attitude on 
the part of these physicians appears just as ridiculous or even more so than 
the fury against public vaccination against smallpox. The physicians are 
still doing business and making more money than they ever have in their 
lives. 

There are today in North Carolina 836,000 school children enrolled in 
the school census of the State. From accurate facts that cannot possibly be 
disputed there are not less than 125,000 of those children needing operations 
for removal of diseased tonsils and adenoids so badly that their parents, 
their teachers and their neighbors will readily assert this fact. Many thou- 
sands more of them have defective vision, latent and incipient tuberculosis, 
defective hearing and other easily preventable defects, to say nothing of the 
75% of this great total who have dental defects. Thus you see today, right 
this minute, in North Carolina there are 125,000 children that need this 
operation. They need it badly. The number is being each day augmented 
by the new recruits of children coming six years of age entering school. 
There are at the other end of the line passing out of school on into adult life 
others who are carrying their handicaps, as I have done, all their lives for 
the lack of this operation. Thus you see if the specialists in North Carolina 
who have license to practice medicine and have hung out as specialists, both 
part-time, full-time, or what not, were to begin operating on these children, 
supposing that they were presented for the service, each man of you would 
have to operate on 1475 children before the end of the year to clear up what 
is enrolled in the schools today. This estimate is lower by at least 5% than 
has ever been published by any responsible agency in the United States, a 
recent writer in the Saturday Evening Post giving a 25% higher estimate 
for the country at large than this. 

Now, what are the real facts concerning these operations? It is this: 
Less than 1 % of these children under the system that has been in vogue in 
North Carolina up to and including the present, on the part of the special- 



158 NORTH CAROLINA MEDICAL SOCIETY 

ists and the public generally, will ever even consult a specialist. Less than 
10% of them will ever even consult a general practitioner. Why? Be- 
cause they have never been convinced of the necessity for such remedial 
treatment and because of the morbid fear of the word operation and all that 
it implies. This applies to the people who have the money as well as in- 
digents. 

The only concern the State Board of Health has in this matter is to con- 
vince the people of the necessity for these operations so that every effort pos- 
sible may be made in order that they have it done for the benefit of the next 
generation of men and women of North Carolina. The work that the State 
Board of Health has been doing is to make a mighty effort to arouse wide- 
spread interest as to the necessity for the operation. We have found every- 
where that the first thing that had to be combatted was that it is not a 
scheme to.make money for doctors. 

The one reason that medical inspection of schools as practiced in a routine 
manner in the United States has been productive of so little real good has 
been that when a child is examined in school by a medical inspector or nurse 
and a note sent to the parent advising that the child is not physically normal 
and urging that a physician be consulted, ninety-nine out of every hundred 
of them throw the card in the fire with the comment that "this is just afford- 
ing jobs for doctors who cannot make a living, and for old maid nurses; 
and then it is being done chiefly in the interest of doctors who want to get 
the children to treat." Consequently, when we take it absolutely out of 
the field of commercialism and center our whole efforts on the operation, 
only beneficient results may be expected to follow. To do this without 
classification of childrn according to social or financial standing, race, color 
or creed, we are finding a much better comprehension of what the opera- 
tion means. And what it means, when this sentiment is crystalized and 
universally accepted by all the people in North Carolina, to the business in- 
terests of every specialist practically a one-eyed man or a fool could readily 
see. 

Again the best time to do these operations and the time that we urge upon 
everybody is in the pre-school age immediately preceding the starting of the 
child to school. It is a common practice now to hold children out of school, 
as a rule, until the beginning of their seventh year, and very wisely so I 
think. Therefore, we urge upon the people the necessity of having these 
operations done during this period — from five to seven years of age, — when 
possible. That naturally places this in the hands of their private practi- 
tioners and private specialists, because school physicians have nothing to do 
with the children until they are enrolled in school. You can see there the 
enormous business benefits to the specialists wherever this advice is accepted 
and put into practice. 

In conclusion, I may state that the prime reason for the existence of a de- 
partment of medical inspection of schools of the State Board of Health is 
(1) to find defective children and get them treated; (2) to convince the 
parents and guardians and teachers of the children from Cherokee to Curri- 
tuck of the necessity for the correction of remedial physical defects as early 
as possible; (3) it is our aim and intention to work in the utmost harmony 
with the medical profession, especially the specialists of North Carolina, 



EYE^ EAR^ NOSE AND THROAT 159 

and with the teaching profession and school authorities in the attainment of 
this idea. Your assistance is needed and will be appreciated now and in 
the future as in the past. 

Wm. S. Jordan : 
Mr. Chairman : 

"I had not intended having anything to say in regard to this matter, but 
I must object to the suggestion that the chief objection to doing this work 
in this way is because it deprives the doctors of fees that ought to be paid. 
There are plenty of doctors who would be willing to do any number of de- 
serving cases for no fee at all and too without being known in the transac- 
tion for that matter. I feel that it is unbecoming to seek the cooperation 
of the profession by holding out the benefits of the advertising received. If 
it is a good thing to do the doctors ought to be glad to render the service 
and keep their personalities in the background. If there were no other ob- 
jections to the method this one is enough to place it outside the proprieties 
of practice. As a matter of curiosity it would be interesting to know how 
many of those engaged in this work would do it so enthusiastically or at all 
if they felt they were to be deprived of the advertising they receive thereby." 

Question : — Dr. Louis N. West and Dr. H. M. Bonner. 

"How are operators selected to do clinical work for the North Carolina 
State Board of Health ?" 

Answer: — Dr. G. M. Cooper. 

"I can best answer that question by giving a recent illustration in the 
matter of selecting operators for a clinic to be held in Duplin County within 
a few days. The nurse was instructed there while making her survey 
throughout the county to ascertain from the parent of each child requesting 
3n operation, and also from the various physicians practicing in the county, 
who their choice of an operator would be if it was a private matter. The 
result was that the choice was about equally divided in different portions of 
the county between one Wilmington specialist, one Goldsboro specialist, 
and one Raleigh specialist. Therefore, I have arranged a three-day clinic, 
conducted one day at a time by each of these three specialists. The depart- 
ment has made every effort to be absolutely fair to all reputable specialists 
practicing in different sections of the State. We have tried to be just as 
fair as if the selections were made in private practice." 

THE COMPARATIVE VALUE OF ROENTGENOGRAPHY 
AND TRANSILLUMINATION IN DIAGNOSIS OF DISEASES 
OF THE FRONTAL AND MAXILLARY SINUSES, WITH 
DESCRIPTION OF AUTHOR'S METHOD OF 
ORBITO-PALATOBUCCAL ROUTE OF TRANS- 
ILLUMINATING THE MAXILLARY SINUS. 

H. H. Briggs 
Roentgenography and transillumination offer valuable objective evidence 
of the condition of the superficial nasal accessory sinuses. Which of the 
two is more valuable is debatable, depending upon the anatomical relation- 
ship, the modus operandi, and upon how much the observer has studied the 
various methods of each while comparing his diagnosis with his surgical 



160 NORTH CAROLINA MEDICAL SOCIETY 

findings. The one method supplements, frequently corroborates, and oc- 
casionally refutes the findings of the other. If they did more they would 
together form the sine qua non of sinus diagnosis, and their findings would 
be pathognomonic. If taken jointly, and in connection with other symptoms 
and signs, they often prove to be determining factors in establishing a diag- 
nosis, and frequently suggest the proper therapeutic procedure. All agree 
that the roentgenogram better outlines the sinus, and offers definite limits 
to guide the operator. It alone furnishes positive evidence of absence of a 
frontal sinus, the shadow of which by transillumination might indicate an 
infected sinus. On the other hand, the rays making the plate must pass 
through the head, the greater part of which is foreign to the parts we wish 
x-rayed. Consequently there may be in the plate misleading shadows caused 
by many parts within the cranium posterior to the sinuses. On the other 
hand the translucency of a sinus is little interfered with by extraneous parts 
except by slight variations of thickness in the bony walls and overlying soft 
tissues. Transillumination requires less skill, is quickly and inexpensively 
done by the clinician himself, while the roentgenogram, correctly made, is 
the product of a rather highly specialized, and, therefore, expensive techni- 
cian, requiring careful interpretation by either the technician, or preferably 
the clinician. It is just as essential for every clinician to be able to inter- 
pret the roentgenogram — altho he may not have made it — as it is for him 
to perceive the translucency of the sinus by the electric light. Every sinus 
plate reveals details to the interpreter which no one can fully describe to 
him, and to operate from another's findings is like striking where someone 
points. 

Roentgenography: It is not intended to describe here the technique of 
making sinus plates other than to discuss the two usual positions of exposure, 
namely, the nose-chin, and nose-forehead positions of the plate, and to de- 
scribe the special advantage of each in exposing the frontal and maxillary 
sinuses. In either position the axis of the tube should be parallel with the 
plate, and the principal rays should pass through the special part to be radio- 
graphed at right angles to the plate. Authorities agree that a soft tube with 
intensifying screen and a moderate amount of milliamperage are best adapted 
for the deep penetration and detail demanded in sinus roentgenography. 
(Waters and Weldron (1) American Journal of Roentgenology, February 
1915, VII, Number 4, page 633.) For the sake of correct detail the part 
to be exposed should be placed as close to the plate as possible. At the same 
time consideration must be given to the density of the tissues through which 
the rays must pass before entering the sinus which is to be x-rayed, and to 
fulfill these conditions the position approximating the nose-chin position of 
the plate is most admirably adapted for the maxillary sinus. The base of 
the skull offers two prominences of bone of considerable resistance ; viz : the 
lesser wings of the sphenoid, and to a much greater degree the petrous por- 
tions of the temporals. It is, therefore, desirable to select a position that 
will allow the projection of these parts to fall on the plate outside the pro- 
jection of the sinus which is to be x-rayed. 

In the nose-chin position the projection of the lesser wings of the sphe- 
noid bisects the orbits horizontally, and are seen as narrow curved lines 
passing outward and upward through the orbit, and the petrous portions 
are superimposed on the upper incisors, and therefore, just below the shadow 



EYE^ EAR, XOSE AXD THROAT 161 

of the antrum. The exact position of the plate with reference to the nose 
and chin depends upon the type of face. In the average physiognomy the 
tip of the nose should be about one centimeter from the plate; one with 
prominent nose and receding chin should rest with nose on plate, or perhaps 
pressed deeply against the latter, while the opposite type of dish-face may 
require the nose lifted one or two centimeters from the plate. In the nose- 
chin position rays passing through the maxillary sinus first pass through the 
middle fossa of the skull above the petrous processes of the temporal, and 
below the lesser wings of the sphenoid. Projected within the shadow of 
the maxillary sinus, and near the nasal wall may frequently be seen the 
foramina, altording exit for the optic and the three divisions of the fifth 
nerves, especially the foramina rotunda, and ovalia lying more latterly, and 
being the more easily outlined in the normal sinus. 

The nose-forehead position is ill suited for the maxillary sinus, as in it 
the petrous processes are projected across the antrum often with such density 
of shadow as to completely obscure the details, mislead the interpreter, and 
simulate a pathological condition of the sinuses. This position is perhaps 
the befier routine method fur the frunf.l sinus, especially if an exact out- 
line of the upper limits of the sinus is desired, and provided that the prin- 
cipal rays are directed from a position sufficiently forward to bring the lesser 
wings of the sphenoid below the supercilliary ridge. It is not so well adapted 
for the outline of the orbital extensions of the frontals, and the anterior 
ethmoid cells as is the nose-chin position, because of the shadows of the lesser 
wings of the sphenoid, and the base of the anterior fossa. 

Transillumination : The value of transillumination depends on the inter- 
ference which the pathological contents and thickened mucosa of a diseased 
sinus offers to transmitted light. A perceptible interference to light is 
shown by uncontaminated mucus, and more by normal mucous membrane ; 
and when the latter becomes swollen and hyperemic, and the sinus filled 
with mucopus and detritus, especially in chronic infection, a high degree of 
illumination becomes necessary for translucency. Since we are concerned 
with the light-interference caused by the diseased processes in the sinus 
cavity alone, it is highly iinportant that the light, before entering and after 
passing out of, the cavity, should encounter as little interference from ex- 
traneous bone and soft tissue as possible, and to this end the essayist wishes 
to describe a method of transilluminating the maxillary sinus which he has 
used with gratifying results for eleven years, viz: "An orbito-palatobuccal 
route of transillumination." The advantages claimed over the palato-facial, 
or Heryng method are : 

(1) The light passes through less extraneous (to the sinus) tissue. 

(2) It passes through opposite instead of adjacent sides of the sinus, and, 
therefore, penetrates deeper into the cavity. 

(3) It takes less time. 

(4) It is more cleanly. 

Author's Method : The patient is placed on a high stool in a dark room, 
requested to tilt the head backward, and open the mouth. The cheek is 
retracted with a tongue depressor so as to bring into view not only the hard 
palate, but that part of the floor of the antrum in the buccal cavitj- outside 
and above the molars. 



162 NORTH CAROLINA MEDICAL SOCIETY 

The light is placed against the lower lid above the infraorbital notch, 
pushed inward, and pointed downward until the infraorbital is well passed, 
when an area of pink will be seen on that part of the roof of the mouth and 
buccal wall on either side of the alveolar process corresponding to the floor 
of the antrum. 

That the extraneous tissue in this orbito-palatobuccal method are less 
extensive, and offer less resistance to the light than in the Heryng method 
is evident after comparing the thickness of the antral walls in the valuable 
data given by Davis in his classic monograph (2) : "Nassal Accessory Sin- 
uses." (Ann. of Rhi., Otol., & Lar., Sept., 1918), as follows: "The orbital 
wall is a thin plate of bone from 0.5 to 1.5 mm., and the facial from 2 to 5 
mm.," or 3 to 4 times as thick as the orbital wall. Thus the light passes 
through only one-third as much bone, and far less soft tissue in entering the 
antrum through the orbit in the author's method, as it does in its exit from 
the antrum through the facial wall in the Heryng method. In each case 
the light passes through the roof of the mouth. In the new method there 
is the added advantage of being able to observe the translucency outside of 
and above the molars, as well as in the roof of the mouth ; in fact the entire 
floor of the sinus where pathological conditions are most usually found is 
outlined and transilluminated. 

Route of Transmitted Light Through Antrum : The popular fallacy in 
the palato-facial method of Heryng is the presumption that the light passes 
directly through the antrum. As a matter of fact, the greater part passes 
first through the floor of the nostril into the nasal cavity, then through the 
lateral nasal wall into the antrum and through the upper inner and anterior 
corner of the antrum, escaping entirely any localized pathological condition 
of the sinus lying over the roots of the teeth and outer antral wall, which 
is the most frequent site of pathology, especially when the infection is of 
dental origin. Apropos this is the following quotation from Logan Turner, 
"Accessory Nasal Sinuses, 1910": "With the exception of a very small por- 
tion of the outer edge of the palatal plate of the superior maxilla close to 
the alveolar margin the roof of the mouth forms the floor of the nose, and 
has no part in the formation of the floor of the antrum, this wall being 
formed by the alveolar process which bears the teeth. The typical floor is 
over the molars, and the posterior portion of the second premolar, and in all 
stages of development is in close relation to the teeth, there being always 
a bony covering over their roots." A further quotation from Turner will 
help to remind one how far, laterally, the inferior fosas of the nose extend: 
"In an antrum of average dimensions the outer border of this latter 
(canine) ridge indicates externally the line of union between the facial and 
nasal walls of the cavity." Quoting further: "When the lamp is placed 
in the mouth some of the luminous rays enter the maxillary sinus directly, 
while the remainder pass into the nasal cavities, and thus reach the antra 
through their nasal walls." It is very evident, therefore, that when (as 
frequently happens) a septal spur or an enlarged inferior turbinate or some 
other abnormal condition fills the inferior fossa, transillumination by the 
old method is very materially interfered with, and its interpretation ren- 
dered faulty. 



PEDIATRICS 



THE IMPORTANCE OF LUMBAR PUNCTURE IN INTRA- 
CRANIAL HEMORRHAGE OF THE NEW-BORN. 
REPORT OF A CASE WITH RECOVERY. 

Dr. J. BUREN SlDBURY^ WiLMINGTON, N. C. 

Intra-cranial hemorrhage of the New-Born is not an uncommon occur- 
rence. On the contrary, it is much more common than any of us know, due 
to difficulties in its recognition in some cases. At times it is not only very 
difficult of recognition but even impossible to make an absolutely certain 
diagnosis, antemortem. It may occur in any type of delivery. The most 
usual history is that following a prolonged labor, with or without instru- 
ments. It may occur, however, in the so called normal labors and not in- 
frequently does it happen to the premature baby. Two such cases have oc- 
curred in my practice in the last three years. 

This condition was first properly interpreted by Sarah McNutt ( 1 ) in 
1885. It was brought more into prominence some twenty-five or thirty 
years later by Little. That the majority of these cases are born dead or die 
soon after birth we do not wonder at. However, there are a certain num- 
ber who do survive. Of the total mortality under one year of age 30% is 
due to Congenital disease of which syphilis ranks first and this condition 
not far behind. 

Etiology: The cause of this condition may be divided into two general 
heads. First, Spontaneous or hemorrhage due to a general condition as 
Hemorrhagic Neonatorum. 

Second, and most common cause is Traumatic. Under this bead the most 
common causes are: (1) prolonged, tedious or hard labor, with or without 
instruments; (2) precipitate labor with injury to the child's head; (3) in- 
judicious use of Pituitary Extract; (4) breech extraction of the after-com- 
ing head; (5) premature babies have very fragile blood vessels which are 
not strong enough to undergo the amount of pressure necessary even in a 
normal delivery, hence their predisposition to this condition. 

It is unquestionably true that a large majority of the infantile cerebral 
paralyses occur either in first born children or in those who have been born 
after prolonged, dry, hard labors. That prolonged, hard labor is a most 
important factor in the production of this condition, I think, goes without 
question. The early intelligent application of the forceps will reduce the 
length of labor, thereby reduce the length of time the head has to undergo 
this pressure. Other things being equal and the mother's condition good, is 
it not wiser to cut down the period of labor and not wait until the mother 
is exhausted and the foetal heart is imperceptible before offering help? 

Pathology: If we think for a moment how delicate the brain tissue and 
the capillaries of the new-born must be we wonder why more cases do not 
occur. The bleeding may occur any place in the cranial cavity, in the vessels 
of the duramater, in the piamater, in the arachnoid membranes, in the brain 
tissue or ventricles. It may be small and punctate or it may be diffuse and 
cover one or more hemispheres, forming a clot of varying size and thickenss 
It may even occupy a third or fourth of the cranial cavity, in which event it 



164 NORTH CAROLINA MEDICAL SOCIETY 

will cause compression of the brain substance and back pressure of the venous 
circulation, and, in turn, may rupture other capillaries. If the clot covers 
any other area than the motor area we may get no symptoms at the begin- 
ning, but later a condition of imbecility or epilepsy may develop with no 
other signs. The location more than the amount is likely to give rise to 
symptoms. We may have quite a large hemorrhage in the so called silent 
area without giving symptoms at the time of bleeding. A small hemorrhage 
in the motor area is more apt to give rise to symptoms. Hemorrhage at 
the base of the brain may give rise to symptoms not unlike meningitis, due 
to basilar irritation. 

How long the blood stays in a fluid state or how long it takes the blood 
to clot is not definitely known but we do know that it does not clot so 
readily as it does on the outside of the body. When a lumbar puncture is 
done on some of these cases as much as two ounces of fluid blood which 
clots readily in the test-tube has been obtained. When you get that much 
pure blood on lumbar puncture I do not think that it can with fairness be 
attributed to a contaminated puncture. This happened in the one case 
which I am reporting with recovery. In this case I obtained two ounces of 
pure blood on lumbar puncture one hour after the first convulsion and five 
days after delivery. 

Mouno (3) reports a series of forty autopsies on infants dying within a 
few days of birth, in which he found ten cases of rupture of the tentorium 
and five of the falx cerebri. In all of these cases death was due to hemorrh- 
age following the rupture, though the diagnosis was made first at the autop- 
sy table. This emphasizes the frequency of the condition as well the in- 
frequency of its recognition. 

Green (4) reports two cases diagnosed before autopsy, one died on the 
third day the other on the seventh, the latter showing a negative spinal 
fluid. Both of these cases showed much fluid blood with small clots on the 
surface of the hemispheres. Each of these cases gave a history of nursing 
well and appearing normal for two and three days respectively at the end of 
which time "they refused to nurse, had a feeble cry, developed a peculiar 
pallor and facial edema." Neither of these cases had any of the typical 
signs of compression. 

Thrombosis is not an infrequent finding and in some cases would seem 
to be the only explanation of the symptoms shown. 

Symptoms: To have a new born baby nurse all right for two or three 
days and then refuse to nurse, become pale and listless, with intermittent 
periods or crying spells followed by stupor and perhaps convulsions or 
twitchings of one or more muscle groups should make you think of a hem- 
orrhage and especially so if the mother had a hard or instrumental delivery. 
Convulsions following an instrumental delivery should make us suspect this 
condition always. The following are the signs to bear in mind : Convul- 
sions or twitchings of one or more extremities, bulging fontanel (not a con- 
stant sign), nystagmus, strabismus which is more or less constant, increased 
reflexes which may be more marked on one side, stiff neck and a Kernig's 
sign may be present if the irritation is confined more to the base of the brain. 
The pulse is strong, full and at times slow. The respirations are irregular, 
they may be superficial and rapid or they may be slow and deep or may even 
similate Cheynes-Stokes. 



PEDIATRICS 165 

While any or all of these signs may be present in any one case, there are 
other cases which show none of these signs as was shown by the two autopsy 
cases reported by Green (4). I wish to emphasize that there is no harder 
diagnosis in medicine to make, with certainty, than some of these cases 
which show none of the typical signs. Any obscure illness of the new-born 
which can not be satisfactorially explained any other way should make us 
think of hemorrhage or thrombosis, especially if there was a difficult labor. 
The extreme type is seen in the Spastic Diplegias. 

It must be born in mind that all symptoms may be entirely absent at 
birth, and so far as the mother knows, the baby has been perfectly well un- 
til about eight or ten months of age the mother brings the baby to the office 
because she does not think the baby has been developing as a baby of his age 
should. He does not sit up, does not grasp objects or show the proper in- 
terest in his surrroundings. On physical examination, nothing definite is 
usually found and the doctor tells the mother to go home and stop worrying 
about the child for he will be all right or he will "out grow it." A more 
careful examination will probably show that this child has an increased 
spinal pressure of 10 to 20 mm mercury, not infrequently signs in the eyes 
denoting intracranial pressure as papalitis or distended and engorged veins. 

There is another or older type which may come to the doctor about the 
age of puberty, either a few years older or few years younger, because they 
have "peculiar spells." He may have epileptic seizures with or without 
the loss of consciousness or he is unmanageable, incorrigable. These are some 
of the latest signs of hemorrhage of the brain in the new-born. Whether 
we have symptoms in early infancy depends upon first, the location, whether 
it is in the motor or the silent area; second, the size of the hemorrhage. I 
think every one will agree that there must be cases of birth hemorrjiage 
which do not give any symptoms and which get entirely w^ell. Dr. Free- 
man (5) refers to a case which had all of the signs of hemorrhage and com- 
pression for which he advised an operation. The parents refused operation 
and nothing was done and the child made a complete recovery. No Lumbar 
puncture was done. This was a fortunate outcome, which, in my mind, 
represents a very small percent of these cases. The risk of following this 
as a routine is apparent. 

Diagnosis: In every case of suspected intracranial hemorrhage a Lumbar 
Puncture should be done. It will help in three ways. Letting off the 
spinal fluid will relieve the intracranial pressure and stop the convulsions. 
It will make the child more comfortable in every way. Secondly, it may 
cure the patient. Third, it will be an aid to diagnosis. If pure blood is 
obtained by lumbar puncture in amount more than could be explained by 
"contaminated puncture" or if the blood flows as freely at the end as at the 
beginning we are fair in assuming that there was free blood in the spinal 
canal. The use of the spinal mercurial manometer will enable you to tell 
with certainty the exact intracranial pressure. The normal intracranial 
pressure of an infant is 2 to 5 mm mercury. The majority of these cases 
will show an intracranial pressure of from five to twent>^-five millimeters of 
mercury. 

The findings in the spinal fluid are not constant. The spinal fluid may 
be almost pure blood, and may be as much as two ounces in quantity. There 



166 ■ NORTH CAROLINA MEDICAL SOCIETY 

is an admixture of spinal fluid with the blood and you may get three or 
more ounces in all. The spinal fluid may show no abnormalities, or it may 
show only a few red cells with some broken down red cells. In some cases 
you get an amber colored spinal fluid with hematin pigment. This I have 
seen in two cases. 

Case report. Case 1. E. C. R., ag-e 5 days, male, the result of the first 
pregnancy, birth weight 6 Ibs.^ full term abnormal delivery. The mother 
had eclampsia and just before delivery had one or two convulsions. The 
labor was induced and took about fourteen hours. The labor was hard and 
tedious and was terminated by the use of forceps with difficulty. The moth- 
er's condition was so serious at the last that the life of the child was not 
considered, for it seemed that the mother was surely going to die. At de- 
livery the cord was around the neck twice and it was with difficulty that that 
child was made to breathe. On physical examination the child was poorly 
nourished and weak. He had a double cephalhematoma with two or three 
forceps marks on the head. He had to be fed with the medicine dropper for 
he would not nurse. Nothing unusual happened until the fifth day after 
delivery when, at 3 P. M., the child had his first convulsion which was gen- 
eral and lasted about five minutes. The other similar convulsions occurred 
in the next hour. At 9 P. M. the child showed a bulging fontanel, a peculiar 
pallor and a double internal strabismus. His knee jerks were active and 
equal, and there was no Kemig's sign and no stiff neck. A lumbar puncture 
was done and three cubic centimeters of fluid was obtained of which two 
c. c. was pure blood. The spinal pressure reading was 15 mm. mercury. 
The baby had a very good night, had no convulsions and nursed the mother 
the next morning and continued to nurse her for 10 months. A lumbar punc- 
ture was repeated each day for 4 successive days at which time the fluid 
became clear and the pressure normal. He had an uneventful recovery and 
at 12 months weighed 22 pounds. His mental and physical development has 
been normal. He is now 20 months old and is normal in every way. 

Case No. 2. 0. V., aged 3 yrs. 5 mos., female, the result of the fourth 
pregnancy, the mother had one miscarriage at three months, two other 
children living and well. The child was delivered of a breech presentation 
with difficulty in delivering the after-coming head. Mother was in labor 
from Wednesday 11 A. M. till Thursday 9 P. M. Twenty-four hours after 
delivery the baby began having general convulsions at frequent intervals 
continuing for 48 hours, having probably thirty or forty convulsions in that 
time. For the first eight months of the baby's life she practically slept 
very little, cried a great deal of the time. The child never nursed, was fed 
modified milk with the spoon at first and when it would take the nipple at 
three weeks of age it was started on the bottle. The feeding history was 
not a rational one and may have accounted for some of the sleeplessness 
and crying. Physical examination showed an undernourished and under- 
developed child, color fairly good^ muscles soft and flabby. The child was 
unable to sit or stand up, could use her legs and they were not stiff but 
made no eff"ort to use them in walking. Her present weight is 20 lbs. 9 oz.^ 
her birth weight is unknown but she was an average size baby. Measure- 
ments: height 33 in., circ. of head ISVs in., chest 19 in., abdomen 17 V2 in., 
right calf 6 in., left calf 5%. She cut her first tooth at 8 mos.. has twenty 
now in good condition. She understands what is said to her but can say 




Case I. E. C. R. Age 12 mos., wt. 22 lbs. A perfect baby. 



PEDIATRICS 167 

only one or two syllables. Her blood count and urine were normal. Spine 
puncture showed 10 mm. Mercury pressure, while the fluid gave a negative 
wassermann and a normal cell count. The retinal veins were engorged and 
distended. There was no choked disc. 

Case 3. N. M., male, 3 yrs., the result of the second pregnancy, the first 
pregnancy resulting in craniotomy of child before he could be delivered, two 
other living children well and healthy. All labors are hard and long, with 
instruments. Chief complaint is stiffness of the legs and in ability to stand 
alone or to walk without assistance. He was bom at term, birth weight 
9% lbs., nursed his mother eight months then fed mixed diet. He sat up at 
7 mos., talked at 18 mos., cut his first tooth at 8 mos., walked first at 19 
mos., but never very well, and less well now than he was 6 months ago. 
Physical examination shows a well nourished child, good color, muscles firm 
with those of the lower extremity unusually firm. His knee jerks are very 
active and equal. Eyes pupils equal and react to light and accommodation, 
the disc is blurred and the veins distended and tortuous. He has a positive 
Kemig's sign on both legs and a very active patella reflex. His gait is that 
of a spastic diplegia. Measurements: height 38% in., circ. of head 20 ^/^ 
in., chest 22 in., circum. of calves and thighs equal, weight 36 lbs. Spinal 
pressure was 20 mm. mercury, cell count normal, wassermann negative. 

Case 4. M. D., aged 7 days, girl, premature, 7 mos., result of the second 
pregnancy which followed eleven months after the first. The labor was 
normal and the baby did very well, nursed well and had a pink color and 
cried vigorously. On the fifth day the baby refused to nurse, had one or 
two slight convulsions, became quite pale and stupid, but at times would 
cry out. On examination the fontanel was tense, there was a double Ker- 
nig's sign, no stiffness of the neck. Lumbar puncture gave an amber fluid 
which registered 8 mm. mercury. On examination there were some broken 
down red cells and twenty red blood cells, in tact, to each cubic millimeter. 
The child died the following day, no autopsy obtained. 

Case 5. J. L. W., aged 17 yrs., male, result of the first pregnancy, mother 
was in labor three days, instruments used. At end of forty-eight hours the 
baby began to have convulsions and three or four convulsions each day for 
the first month. There are three brothers and two sisters living and well. 
Past history, he had diarrhoea his second summer, has had jaundice twice, 
no other illnesses. He has always been an unmanageable child, will not 
work at one position more than two or three days. He has escaped from an 
institution for the Feeble Minded three different times. He frequently goes 
away from home three and four weeks at the time, sleeps in the woods and 
either begs food or eats barks or roots and shrubs. When asked why he 
does this he gives a simple grin and says because he wants to run away. On 
physical examination he looks like a mental defective, his eyes are. dull and 
vacant in their expression, has a thick skin and coarse, dry hair. He is well 
nourished and has an unusually large nose. His temp., pulse and respira- 
tions are normal. His blood pressure is 105 systolic and 50 diastolic. His 
height is 67 in., weight 111 lbs. His spinal fluid gave a negative cell count 
and negatvie Nogouchi reaction, the wassermann on blood and spinal fluid 
was negative and his spinal pressure was 18mm. mercury. His optic disc 
was pale and retinal veins were distended and tortuous. 



168 NORTH CAROLINA MEDICAL SOCIETY 

TREATMENT. In all cases of suspected birth hemorrhage a lumbar 
puncture should be done for daignostic as well as for therapeutic purposes. 
Repeated daily lumbar punctures until the spinal fluid is clear of blood is 
indicated in these cases with the use of the Spinal Mercurial Manometer to 
register the intracranial pressure each time. By this means you can deter- 
mine whether the pressure has been reduced to normal as well as draining 
off as much blood as may come by this route. After having done this, if 
there are any focal signs, such as twitching of any group of muscles or eye 
signs, as pappalitis or marked venous engorgement of the retinal veins a 
decompression operation should be considered and a surgeon called. Though 
I feel that it is wiser to call a surgeon with the first symptom that he may 
better be able to advise as to the advisability of operation. The question of 
an operation is an important one and if it is going to be done should be 
done early, before the clot organizes, if we expect the best results. Up to 
1914, only 17 decompression operations had been reported for this condition. 
Of this number 7 recovered, four of these were operated on by Gushing 
while others he operated on died. 

Aspiration of the subdural space by puncture through the coronal suture 
at the lateral angle of the anterior fontanel has been done by Henschen (6) 
with good results. Giles (7) has reported one case cured by aspiration of 
the subdural space or, as he called it, "Decompression Cranial Puncture. 

More recently Dr. William Sharpe (11) of New York has operated on a 
number of these cases and his results are as follows: Of twenty-seven 
cases treated by (11) Dr. Sharpe, "nine had a cranial operation, four had 
lumbar puncture drainage, while the others did not have a definite increase 
of the intracranial pressure — so "latent" types — and recovered life without 
operation or repeated spinal drainage. Five of these cases died, three fol- 
lowing the operation. Unless the intracranial pressure is very high in these 
newborn cases they should be given the opportunity of recovering life and 
the greatest ultimate normality by repeated spinal drainage." 

The advisability of an operation in these cases is a difficult one and will 
have to be decided on the individual merits in the case. We know that 
cases have recovered with only a lumbar puncture. Up to the present time 
four cases have been reported cured by Lumbar Puncture. Brady (8) reports 
three cases treated in this way with two complete recoveries. In 1916 
Green (9) reported one case cured by Lumbar Puncture, and in the same year 
Lippman (10) reports another case. 

The importance of the early recognition of this condition can not be em- 
phasized too strongly. In the beginning, if an operation should be done, it 
should be done immediately if the best results are to be obtained. A Lum- 
bar Puncture should be done on every case. It will not only relieve symp- 
toms, but it may even cure the patient. The Spinal Mercurial Manometer 
will accurately determine the intra cranial pressure. 

Aside from the medical aspect, it is of economic value to the State that 
these little fellows get a square deal at birth. The world is too full of 
imbeciles, idiots, spastic diplegias, paralytics, epileptics and other less de- 
fectives who are occupying our institutions as well as ai'e in our best fami- 
ilies, who would probably have been normal, valuable citizens had they been 
given a "square deal" at birth. Might Cesaerean section not be substituted 



PEDIATRICS 169 

for high forceps and the length of labor not be cut down by eariy intelligent 
application of the forceps, when the mother's condition will warrant it ? 

BIBLIOGRAPHY. 

(1) Green. Boston Med. & Surgical Jr. Vol. CLXXII, No. 19, 1914. 

(2) B. Sochs. J. A. M. A., Vol. XLVII, No. 19. 

(3) Mouno. Archives Mensuelles D'Obste'trique et de Gynecologie. Aor., 
1915. 

(4) Green. Boston Med. & Surg. Jr., Vol. CLXX, No. 18. 

(5) Freeman, Rowland G.. New York. 

(6) Henschen. Verhandt. Deutsch. Gesellsch f. Chir. 1912, Vol. 41, 271. 

(7) Giles. Rev. Mens, de gyn., Vol. VII, P. 465-74. 

(8) Brady, J. M. J. A. M. A., Vo. LXXI, Aug 3, 1918. 

(9) Green. Boston Med. & Surg. Jr., 174,947, Jan. 29, 1916 

(10) Lippman. N. Y. Med. Jr., 103, 263. Feb. 5, 1916. 

(11) Sharpe, William. New York. 

(12) Meara & Taylor. Arch. Ped., Nov., 1909. 

(13) Currier, Andrew F. Med. News, Aug. 3, 1901. 

(14) Sochs, B. J. A. M. A., Nov 10, 1906. 

(15) Davis, E. P. W. B. Saunders Co., 1911, p. 483. 

(16) Wai-wick, M. Am. J. Med. Sc, 158, 95, July, 1919. 

(17) Vescher, A. L. Cor Bl. F. Schweiz Aerzte 49; 230. Feb. 22, 1919. Ab. 
72, Apr. 19, 1919. 

(18) Haynes Royals. N. Y. C. 

DISCUSSION OF DR. SIDBURY^S PAPER 

Dr. a. S. Hoot^ Raleigh : I think this is one of the most valuable con- 
tributions to pediatrics that we have had in a good many years. I was very 
glad indeed to see that Dr. William Sharp, of New York, who has done 
more brain surgery on children than anyone else in this country, has, in a 
recent article, given Dr. Sidbury credit for this method, and all of us, par- 
ticularly the obstetrician and the pediatrician, should be more keenly on the 
lookout for the symptoms of early intra and extra-dural hemorrhages. 

Another thing, too, I think a great many of these cases that come to us in 
later infancy with evidence of having sustained birth injury have not had a 
hard labor or an instrumental delivery. A good many of these birth injuries 
come to us with a history of having had a normal delivery. Any of these 
cases that show the symptoms that Dr. Sidbury has pointed out ought to 
have a lumbar puncture performed upon them, the diagnosis made, and the 
treatment carried out as suggested. 

*FOCAL HEMORRHAGIC ENCEPHALITIS. 

(Report of a Case with Transfusion) 
Aldert Smedes Root, B. S., M. D., Raleigh, N. C. 

Much has been written within the past two years upon a disease to which 
the various names "Encephalitis Lethargica," ''Influenzal Encephalitis," 
"Epidemic Encephalitis," "Epidemic Somnolence," et cetera, have been 
applied. 



170 NORTH CAROLINA MEDICAL SOCIETY 

None of these terms seem appropriate. In case of "Encephalitis Letharg- 
ica," as Bassoe (1) points out, — it is the patient and not the disease to 
which "lethargica" refers. "Influenzal Encephalitis" suggests an etiology 
which has not yet been proven. "Epidemic Encephalitis" and "Epidemic 
Somnolence" are not definitely applicable, — for the malady may not prove 
at all times to be epidemic in its occurrence. 

Of those cases which have come to necropsy, — the pathology is constant — 
consisting of small hemorrhagic foci in the midbrain, — hence the term 
"Focal Hemorrhagic Encephalitis" seems a more correct one than any of 
those which have been mentioned. 

The etiology of focal hemorrhagic encephalitis has not been definitely de- 
termined. Its coincident occurrence with influenza in both past and present 
epidemics, has led most writers upon the subject to accept a definite relation- 
ship between the two diseases, — if separate diseases they be. The general 
concensus of opinion is, that focal hemorrhagic encephalitis is either a form 
of influenza specifically affecting the brain, or that the toxins resulting from 
influenza produce the lesions at a time subsequent to the acute attack, or that 
an organism or virus different from that of influenza is the causative agent. 

In the latter case, it is pointed out, many of these patients have recently 
suffered from influenza so that their resistence is lowered, consequently 
they are rendered more susceptible to the organism or virus causing enceph- 
alitis. This would explain the coincident occurrence of the two diseases. 

The preliminary report of Lowe and Strauss (2) indicates that the dis- 
ease is caused by a filterable organism resembling that described by Flexner 
and Noguchi in poliomyelitis. These they observed, when smears from the 
mucus membrane of the nasopharynx of fatal cases were stained with Giem- 
sas solution- The authors were able to transmit the disease to monkeys and 
rabbits by innoculating them with Berkfeld filtrates of nasopharyngeal 
washings. 

Von Wiesner (3) of Vienna, announced that he isolated a globoid 
diplococcus from a case of encephalitis and reproduced the disease in a 
monkey by innoculating the animal subdurally with nervous tissue from a 
fatal case. 

Cleland and Campbell claim they have successfully conveyd the virus of 
the disease to the sheep, the calf and the horse. 

Mcintosh (4) of London, innoculated a monkey with material from fatal 
cases which died with the symptoms of focal hemorrhagic encephalitis. 

Flexner and other investigators have failed to find an organism in the 
cerebro-spinal fluid or in the brain, nor have they obtained any definite re- 
sults from innoculating monkeys with preparations of emulsified brain and 
cord substances from individuals dying from the disease. 

Flexner (5) in the March 27th, 1920, Journal of the American Medical 
Association, writes as follows: 

"It is still too soon to say whether or not we are now at the threshold of 
the clearing up, by way of animal experiment, of the etiology and mode of 
communication of this menacing disease, as was accomplished so recently, 
and also by animal experiment, in the case of poliomyelitis. It is to be 
sincerely hoped that we are. But at this moment, and while waiting for 



PEDIATRICS 171 

the ultimate and convincing experimental results, one need entertain no 
doubt of the infectious and communicable nature of lethargic encephalitis.". 

The pathology of focal hemorrhagic encephalitis is more or less constant. 
The lesions consist chiefly of perivascular hemorrhages and infiltration of 
the walls of small vessels with lymphocytes and plasma cells, — occurring for 
the most part in the midbrain, — the pons, peduncles, the basal nucleii, the 
aqueduct of sylvius, the floor of the fourth ventrical and the optic thalmus. 
Less frequently the medulla and the white substance of the spinal cord are 
affected. There is but little necrosis or tissue destruction 

Of the cases reported by Neal (6), Tucker (7), Bassoe (8), Heiman 
(9), Crookshank (10) and Barker, Cross and Irwin (11), a total of 138, 
86 were males and 52 females. The ages were between 3 months and 55 
years. 

Symptoms: Many of the cases of focal hemorrhagic encephalitis reported 
have not been preceded by an attack of influenza, — although a larger num- 
ber have been, — an average duration of two weeks intervening between in- 
fluenza and the onset of encephalitis. 

The latter is manifested by a progressively increasing lethargy' and 
asthenia, — frequently associated with cranial nerve palsies. This triad of 
symptoms was first observed by French and English writers. The palsies, 
however, are present in not more than 25% of cases. Slight fever is present 
• — 100 degrees F. to 102 degrees F., and constipation is the rule. Headache 
and diplopia are frequent symptoms in older children. The patella re- 
flexes may be increased or diminished, — more frequently the latter. Rigidi- 
ty of body and muscular tremors have been noted in a number of cases. 
Signs of menigeal irritation, however, are usually lacking. (Brudzinski's 
and Kernig's). Vomiting frequently occurs in the early stages. While 
usually gradual, the onset may be sudden, being ushered in by a convulsion. 
Slight optic neuritis may be present, — but not choked disk. 

The most characteristic symptom is a disturbance of general conscious- 
ness. There is first noticed mental apathy and drowsiness which becomes 
day by day more pronounced until a state of coma is reached from which 
the patient can be aroused but into which he soon falls again. The im- 
mobility of features gives a peculiarly expressionless face. This comatose 
state may last for several days, weeks, or months, when the patient either 
gradually improves until entirely recovered, or recovers physically but is 
left mentally defective, or death takes place. 

The muscles paralyzed are more frequently those enervated by branches 
of the 7th and 3rd cranial nerves, resulting in facial palsy or ptosis and 
opthalmoplegia — external or internal (positive and bulbar nucleii.) These 
palsies usually clear up entirely within two or three months' time, — if the 
patient survives. 

Laboratory Findings: There is present a moderate lencocytosis. Blood 
cultures are negative. The cerebro-spinal fluid is clear and under slight, 
sometimes considerable, pressure. The cell count is, as a rule, low in cases 
seen late, 5 to 25, but higher in those seen at the beginning of the disease, 
sometimes reaching one hundred. The cells are largely mononuclears. Al- 
bumen and globulin are increased, and reduction in Fehling's is normal. 



172 NORTH CAROLINA MEDICAL SOCIETY 

Barker, Cross and Irwin (12), attaching much importance to the exami- 
nation of the cerebro-spinal fluid, make this statement: "In our experience 
a cell count in the cerebro-spinal fluid of from 10 to 100 small mononuclears 
along with a positive globulin reaction with negative Wassermann and neg- 
ative bacteriological smears and cultures is, at the time of an epidemic of 
encephalitis, strong corroborative evidence of the existence of the disease in 
a patient in whom the process is for any other reason suspected to exist." 

Prognosis: The mortality according to the English Government Report 
is about 20%, and this figure seems also to express fairly accurately the mor- 
tality in this country from the cases thus far reported. 

The course of the disease is within wide limits, varying from a few days 
to several months. In a majority of cases, the course is protracted to 5 or 
6 weeks or longer. 

There is not enough data to form an opinion as to the percentage of pa- 
tients who are left mentally defective. Two of Heiman's nine cases in 
children, whose ages fell between 4 months and 13^ years, became im- 
becilic. The treatment of the disease has been purely symptomatic. 

The foregoing is a brief resume of the focal hemorrhagic encephalitis as 
described by various authors up to the present time. The chief object of 
this paper is to call attention to the striking result which the writer obtained 
by transfusing a 15 month old infant who was suffering from the disease, 
and for this reason the case will be reported somewhat in detail. 

Baby A., female, age 15 months, was seen first August 16th, 1919. The 
other two children born to the parents were living and well. The mother 
has had no miscarriages. There was no tuberculosis in the family, nor any 
exposure to it. The baby had not had influenza, nor any other disorder 
prior to the present one. She was born at term, — labor having been nor- 
mal, the birth weight being 8 pounds. She had always been well and strong 
up to the present illness, and had developed as the normal baby should. She 
sat up without support at 6 months of age, stood alone at 9 months, and 
said 2 or 3 words at 13 months. She had been nursed every 3 hours from 
birth (7 feedings), and recently had been having an ounce of whole cow's 
milk after each nursing. 

The present illness dated back 4 weeks, at which time the baby seemed to 
be sleeping more than usual. No particular concern was felt over this un- 
til the somnolence increased to such a degree that at the end of a week she 
only aroused for her nursings and would immediately lapse into the coma- 
tose state. She had remained in this condition up to the present time. There 
had been little if any fever, no tremors or paralyses. She was obstinately 
constipated. 

Physical Examination: Weight 16^ pounds; height 30^ inches; cir- 
cumference of head 18 inches; of the chest 16 inches. Color very pale and 
skin waxy in appearance. Muscles flabby. Patella reflexes not obtained. 
Anterior fontanella 2^x1^4 c.m. Eyes: negative, — no ocular paralyses. 
Mouth : tongue heavily coated, corners of mouth excoriated from drooling 
of saliva, six incisor teeth present. Ear drums: Negative. Physical ex- 
amination of the throat, thorax, abdomen, liver, spleen, genitals and ex- 
tremities, negative. Temperature normal. Blood: Red blood cells 
2,600,000. Hb. 35%, White blood cells 5,000; Urine: Amber, acid, sp. 



PEDIATRICS 173 

gr. 1010. Albumen: Faint trace. Sugar: Negative. Diacetic acid, neg- 
ative. Microscopic: 5 or 6 w. b. c. per field (low power), no casts. 

Lumbar puncture was performed and 3 c. c. of clear fluid removed under 
normal pressure. It contained two to five cells. Albumen: trace; Sugar 
trace by Benedict's test. 

The baby was observed for two days. It was with difficulty that she 
could be aroused from the deep stupor. While undergoing a lumbar punc- 
ture she lay with expressionless lace and closed eyes, the only evidence of 
pain being shown by slight twisting of the body. On account of the marked 
degree of anaemia, it was decided to transfuse her. 

On 8-19-19, 60 c. c. of blood, obtained from the mother, in 7 c. c. of 
2^% citric acid solution was introduced into the superior longitudinal 
sinus. This blood was previously tested against that of the infant and vice 
versa for hemolysis. After transfusion, the lips and fingernails became pink 
and she nursed vigorously an hour later. 

On 8-20-19, the day following the transfusion, the red cell count was 
3,000,000 Hb. 43% and white blood cells 6,500. When seen this morning 
she was sitting up in bed fingering toys. Her general appearance was very 
much better. For several hours at a time during the day she was wide 
awake, would grasp objects placed into her hand and make cooing sounds. 
Her diet was regulated and she was sent home. 

On 9-1-19, twelve days later, she was seen again. She did not seem 
drowsy, but evinced little interest in anything. She did not follow objects 
or sounds. Her physical condition was distinctly improved. The mother 
says she is drowsy at infrequent intervals, and does not sleep much more 
than she did before she became ill. 

On 9-13-19, twelve days later, and twenty-five days from the time of 
transfusion, symptoms relating to the nervous system were noted and had 
developed rather suddenly on the previous day: — continuous spasmodic 
twitching of the muscles of the left side of the face and right arm. Mouth 
was held open and coarse tremor of tongue present and constant drooling 
of saliva from corners of mouth. At frequent intervals gutteral sounds 
were uttered. The lower extremities were unaffected. The weight was 17 
pounds 2 ounces. Red blood cells 3,000,000; Hb. 50% ; white blood cells 
7,000. 

9-22-19, Tremors of face and arm were less marked. Dermatitis of face 

from constant drooling. Baby does not notice objects or sounds. Hb. 55%. 

10-11-19, Weight 18 pounds. Physical and mental condition improved. 

Tremors less marked. She notices objects, takes watch in her hand and 

reaches for mother. She cannot stand alone. 

10-28-19, tremors have entirely disappeared. No further mental improve- 
ment. She sits with mouth open and vacant expression. Cannot stand 
alone. 

1-8-20, physical condition improved, appetite good, bowels regular. No 
tremors. No improvement in mental condition. 

Summary: We have an infant 15 months of age, who, for 3 weeks, had 
been in a state of profound somnolence, with no evidence of improvement 
either physically or mentally taking place as time went on. She was trans- 



174 NORTH CAROLINA MEDICAL SOCIETY 

fused with blood from her mother (who had not had influenza), and a 
striking improvement followed almost immediately, so that within a short 
period of time she came out of the comatose state into which she had been 
for so many days. Her appetite returned, she gained in weight, the blood 
picture rapidly improved and the obstinate constipation was overcome. 

All indications at the present time point towards the child's being men- 
tally defective. Whether or not there will be a restoration of, or improve- 
ment in, the mental faculties, — it is impossible to say. It is, however, hard 
to disassociate the rapid and sudden betterment in the child's physical con- 
dition from the effects of the transfusion. 

201 N. Wilmington Street. 

*Submitted for publication April 21st, 1920. 

*Read before the Pediatric Section of the North Carolina Medical Socie- 
ty, held in Charlotte, N. C, April 21st, 1920. 

REFERENCES. 

(1) Bassoe, Peter: Epidemic Encephalitis (nona), Jour, Am. Med. Assn. 
1919. 72:677. 

(2) Loewe and Strauss: Etiology of Epidemic (Lethargic) Encephalitis: 
Preliminary note, Jour. Am. Med. Assn., 1919. 73:1056. 

(3) Von Wiesner, R. Wien, Klin, Wchnsehr. 1917, 30:933. 

(4) Forty-eighth Annual Report of the Local Government Board, 1918- 

1919. Medical Supplement, London, 1919, p. 76. 

(5) Flexner, Simon: Lethargic Encephalitis: History, Pathologic and 
Clinical Features, and Epidemiology in Brief, Jour. Am. Med. Assn., 

1920, 74:865. 

(6) Nea'l, Josephine B.: Lethargic Encephalitis, Arch. Neurol, and Psych., 
1919. 2:271. 

(7) Tucker, B. R.: Epidemic Encephalitis Lethargica, or Epidemic Som- 
nolence or Epidemic Cerebritis, with Report of Cases and Two Necrop- 
sies, Jour. Am. Med. Assn., 1919. 72:1448. 

(8) Bassoe, P.: Epidemic Encephalitis (nona). Jour. Am. Med. Assn., 
1919. 72:971. 

(9) Heiman, H.: Post-influenzal Encephalitis, Am. Jour. Dis. Ch., 1919. 
18:83. 

(10) Crookshank, F. G.: Brit. Med.' Jour., 1918. 2:489. 

(11) Barker, Cross and Irwin: Am. Jour. Med. Science. 1920. CLIX: 157. 

(12) Barker, Cross and Irwin: Am. Jour. Med. Science, 1920. CLIX: 337. 

DISCUSSION OF DR. ROOT^S PAPER. 

Dr. I. W. Faison, Charlotte: That is a splendid paper of Dr. Root's, 
and he deserves a great deal of credit for handling it as he did. 

I just rise to ask one question. There is one phase of the matter into 
which I would like to go a little further. I would like to ask him to ex- 
plain the transfusion, what he expected from it and why did he give it? 

Dr. J. BuREN SiDBURY, WiLMiNGTON: There is one point that I 
noticed in a few of the cases that I have seen in the hospital. I do not 



PEDIATRICS 175 

think it has any significance in regard to the therapy at all, but most of the 
cases have an initial onset of temperature to 102 or 103. Then the temper- 
ature comes down and stays at an absolute level. It ocmes down to 98 and 
stays there. The temperature is absolutely level unless some complication 
arises. I do not think that it has any significance, but I wish to cite it as a 
point that I have noted. 

Dr. Root^ closing the discussion: I gave the transfusion on account of 
the extreme degree of anemia in this case. I merely hoped to carry the child 
further along, until the disease ran its course. Just how the transfusion 
produced the marked change in the baby's condition I do not know. I did 
not speculate on that in my paper. It may have operated in several ways — 
possibly through the introduction of anti-bodies. Possibly the course of the 
disease was at an end, but that seems improbable on account of the sudden 
betterment which took place immediately after transfusing. 

ACIDOSIS. 
Dr. L. W. Elias, Asheville 

A year ago, an intelligent, well equipped North Carolina practitioner 
was questioned regarding Acidosis in his part of the State. Replying he 
asked, "what is it?" In the belief that his case was not an isolated one, 
this paper was written. In further apology let it be stated that it is entirely 
immaterial to the writer whether Acidosis is called a disease, a symptom a 
symptom-complex, or what not. This is cheerfully left to individual prefer- 
ence. For the sake of clearness, statements will be made rather dogmatically. 

Three points are considered: (1st) Attention is called to a clinical con- 
dition, the recognition of which is fairly recent. (2nd), is considered its 
diagnostic features, and, (3rd) is a discussion of the measures employed for 
relief. 

Acidosis exists when acid is increased in the human system, and the base 
reserve is decreased. 

All body fluids and tissues are kept in a slightly alkaline condition. This 
reaction is most carefully guarded. When the metabolism of food or the 
breaking down of tissue liberates acids, the alkaline stabilizers are worked 
constantly to prevent a disturbance of the normal alkaline reaction.^ The 
means employed are oxidation of acid products into carbon dioxide, which 
latter is eliminated through the lungs- Some acid is thrown out bodily 
through the kidneys; more is eliminated through the kidneys after first being 
neutralized by the body bases. These bases consist of sodium, potasium, 
magnesia, calcium, and amonia. The amonia on its way to form urea is 
diverted to neutralize acid. This is Nature's normal method of maintain- 
ing a constant alkaline reaction in the body. If acid is introduced into the 
body, or develops in excess, then an increased demand is made upon the 
bases of the body, and the body begins to lose its base reserve. If this is con- 
tinued, there is of necessity a decrease of that alkalinity of the tissues, which 
is absolutely essential to the proper maintenance of life and body activity. 
An acid condition of body fluid is never reached, but as acid accumulates 
and base is exhausted, in attempting to neutralize the acid, a less alkaline 
condition is approached. This condition we speak of as Acidosis. 



176 NORTH CAROLINA MEDICAL SOCIETY 

The manifestation of Acidosis will be considered in a moment. But 
first arises the question what causes this disturbance of normal function to 
such an extent that the body is no longer able to maintain its usual alkalini- 
ty ? This is a problem 3'et almost wholly to be worked out. We know that 
with pneumonia and numerous other diseases, we may have acidosis. We 
know that with summer diarrhoea we frequently have it. Here, a loss of 
water from the body is probably one of the factors, acting by reducing kid- 
ney elimination. We may also have it in chloroform and ether anesthesia, 
and in a number of other conditions. The exact way in which these dis- 
eases and conditions operate to produce Acidosis is very imperfectly under- 
stood, or not understood at all. 

Besides the above, we have the condition of Acidosis coming on apparently 
out of a clear sky, when we are absolutely unable to find any cause what- 
ever. It is to this type that I wish to call particular attention, as it is this 
type which is not so well recognized, and, by some of even the best men, its 
very existence is denied. And yet the symptom-complex is distinct enough 
so that when stated those who have never noticed it before will probably 
recall some cases, or at any rate will observe them within the near future. 
For this condition is not rare, and once one has his attention called to it, he 
is sure to meet cases in his practice. 

To illustrate this condition, take a typical case. A little two-year old, 
who is a well developed, carefully fed, normal child, apparently in the best 
of health, and with no past history bearing on the case. Suddenly he begins 
to vomit without rhyme or reason. He seems languid and dull, and on being 
disturbed is irritable. He vomits, usually only on taking food or water. 
Thirst is pronounced. The skin slightly flushed, and he seems to have fever, 
but the thermometer shows but a slight elevation, usually not above 100 or 
101 degrees. There may be a few stools of fairly normal appearance. The 
breath has an odor suggestive of chloroform. The urine gives a strongly 
acid reaction to litmus. The breathing, which is one of the most important 
diagnostic points, is the deep "air-hunger" type rather than rapid. In the 
case just mentioned, this may be so slight that it is not noticed. When it is 
present in a pronounced degree, the patient has reached an advanced stage 
of acidosis, and the condition is grave indeed. A careful physical examina- 
tion of ears, throat, chest, abdomen, skin, blood and urine fails to reveal any- 
thing that might suggest a cause of the trouble. And when one who has had 
a number of cases, finds such a condition, and careful examination reveals 
no cause for it, he says the patient has Acidosis. And because the outcome 
in any particular case is almost more uncertain than anything in medicine, 
the doctor is guarded in his prognosis. 

The symptoms enumerated above may vary in degree. Vomiting may be 
excessive, or absent. The listlessness slight or amount almost to coma. The 
odor of the breath slight or heavy, pervading the entire room. The thirst in- 
tense or moderate, etc. But the above picture is fairly characteristic of the 
average case. 

This condition may right itself without help, presumably because what- 
ever produced the trouble ceases to operate, and the system has not suffered 



PEDIATRICS 177 

sufficient damage to prevent readjustment of itself unaided. On the other 
hand, the condition may grow worse, and the dullness increasing the urine 
remaining persistently acid in spite of large doses of sodium bicarbonate, 
many times the amount which in health would render the urine alkaline. 
The dyspnoea becomes pronounced, and death supervenes quietly, or sud- 
denly, with the patient apparently in a state, of profound exhaustion. Death 
usually occurs in from twenty-four hours to four or five days. 

Diagnosis: The diagnosis is made by the nausea and vomiting and thirst, 
with disturbed respiration of the "air-hunger" type, with listlessness, or 
stupor. Confirming the diagnosis is the persistently acid urine after large 
doses of alkali. In the light of repeated clinical experience the above con- 
ditions, without any cause which the most careful examination will reveal, 
justify a diagnosis of Acidosis. 

The symptoms may all be so slight that one is in doubt as to whether or 
not he is dealing with Acidosis, and it may take careful watching to decide. 
However, valuable time need not be lost, since one of the important means 
of treatment is also a most important measure for diagnosis. This is the ad- 
ministration of sodium bicarbonate. In doubtful cases give one-half drachm 
of soda in one-half oz. of water every hour. In the average baby 30 grains 
will render the urine alkaline. If after two or three doses the urine still 
remains acid, we are justified in calling the case Acidosis. 

Treatment: Once the diagnosis is made, most energetic measures should 
be instituted, for, as above stated, no one can say which case will resist, and 
which yield easily to, treatment. So we dilute the acids with water, which 
also assists the kidneys to eliminate acids. We further combat the acid, and 
at the same time restore lost base, by giving sodium bicarbonate, preferably 
in large doses given at short intervals; at least Yx dram every hour. If this 
is given in sufficient amount, we check the condition, possibly bringing it to 
a standstill. The acid is being neutralized, the depleted base reserve is be- 
ing replenished. But in many cases this is not sufficient, and without carbo- 
hydrate the patient will slip back into his former condition, and go pro- 
gressively bad. Hence carbo-hydrate is imperative. If it must be injected 
into the body, it is given in the form of glucose, a 5% to 10% solution. 
When vomiting has subsided the starches are used. At times they act in re- 
lieving nausea. 

Our treatment then, consists of water, sodium, bicarbonate and carohy- 
drate. These are not given consecutively, but in practice they are given 
more or less simultaneously, either by mouth or Murphy drip or possibly 
by the skin, in the vein, or in the peritomeal cavity. 

Large amounts of water are needed, and where vomiting is excessive and 
the bowels irritable, the intra-peritoneal route presents the most satisfactory 
way of introducing it into the body, giving 150 to 400 c. c, with or without 
5% of glucose and with or without 2% of sodium bicarbonate. This is 
repeated in 4 to 6 hours. The veins also are used for the soda and glucose. 
But, except in the presence of great abdominal extension, the peritoneum 
should be used for the solution, since the large amounts needed, if given in 
the vein, would throw too great a strain upon the circulation. 

Conclusions: 1. Acidosis is a condition caused by an increase of acid, 
and a loss of the base reserve of the system. 



178 NORTH CAROLINA MEDICAL SOCIETY 

2. This may follow disease, or other known abnormal conditions. 

3. There are cases, by no means rare, where the symptoms of Acidosis 
are preceded and accompanied by nothing discoverable, which might be con- 
sidered as a cause. 

4. The treatment consists in getting into the system large amounts of 
sodium bicarbonate, carbohydrates and water, in every way possible, and as 
quickly as possible. 

Dr. a. S. Root, Raleigh : I was very much interested to note how Dr. 
Elias was going to differentiate between cyclic vomiting and acidosis. I 
have not yet found any one who has been able to discuss that to my satis- 
faction. I think that we are all somewhat mixed up on acidosis. Dr. Dunn, 
of Boston, considers cyclic vomiting, or recurrent vomiting, as a form of 
acidosis. Dr. Howland, of Johns Hopkins, considers a case to have acidosis 
where the hydrogen-ion concentration of the blood is increased and the CO 
tension of the aveolar air is decreased. That is the border line that he draws, 
but it is impossible, in a practical way, to make that distinction. Clinically, 
Dr. Howland considers cases that have hypnoea as cases of acidosis. These 
cases of recurrent vomiting alwaj^s have diacetic acid in the urine, and I am 
not at all sure that this is an accompaniment of cyclic vomiting, or whether 
it is the result of starvation, because in a majority of these cases you do not 
find diacetic acid in the urine when the vomiting begins, but you will always 
find it the day afterwards. 

Dr. I. W. Faison^ Charlotte: This is a subject that has been forced 
on me during the last six months by two very close and very interesting 
cases. I wish to mention first what Dr. Root had to say as to cyclic vomit- 
ing. It would look as if the cause of all these conditions is the sheet anchor, 
or what you mean by acidosis. We know that a child can have acidosis f ram 
too frequent bowel movements, acidosis from constipation as the cause, also 
that it can come from any type of infection. Another cause brought out at 
the Southern Medical Association meeting at Asheville, which interested 
me much, by Dr. McGuire Newton, of Richmond, was that four cases of 
cyclic vomiting had a cause behind it of an organic appendix. I had one of 
the same type, which was operated, and so far the cyclic vomiting has not 
reoccurred. It is well to consider that, it is well to go into the appendix be- 
fore you go by a case of cyclic vomiting. Starvation, continued vomiting, 
or diarrhea following these acute attacks of cyclic vomiting, the cause be- 
hind which is the lockup of an organic appendix. 

Now, as to Dr. Elias' paper, which is pretty thorough, we can look back 
and try to make the diagnosis from the history of the first few days prior to 
the attack. The child is put on the train, is traveling for a day or two, his 
diet changed, and on the second day he has acidosis. Now, what was the 
cause ? Taking away the carbohydrates and putting him on eggs and milk. 
The protein diet is the cause of the acidosis. It does come on suddenly, they 
do vomit, they suffer for water and air. The picture is distressing, it is 
awful to look at. There is no more distressing condition, to my mind, than 
this one of puerperal eclampsia. First we hear the patient beg for water 
and beg for rest. It tries a man's soul. 

As to the treatment, I cannot say much, for I have only five minutes. I 
have had peculiar things come up in that line. I had a patient in this same 



PEDIATRICS 1 79 

condition, awful hyperpraea and thirst. She had been treated by no less 
great man than Dr. Barker of Hopkins, so I asked her what Dr. Barker 
did for her. She told me that he gave her soda, and I did exactly what he 
had done. Less than twenty-four hours afterwards I ran across Dr. Barker 
and told him what I had been doing, that I had been giving her soda, as she 
said he did. He said that they had quit soda as a curative, that it would not 
cure acidosis. It is well enough to give it, it does not hurt. If you have a 
baby you have to rely on the stomach to take it. Do not get his rectum dis- 
turbed. So far as curing, it is not worth anything. The remedy is glucose, 
dextrose. I came in close conference with Dr. Howland in consultation 
over the other case. He said, "Do not give soda unless he will retain it. If 
he vomits do not put anything of any nature in his stomach. Put six ounces 
of ten per cent glucose dextrose in the rectum every six hours and wait. If 
that does not cure him, he will not be cured." I got a Murphy drip at once, 
put the catheter well up into the colon and took about one and one-half 
hours to give him six ounces by the drip method. The hj'perpnoea began to 
give way, the stomach relieved, the child began to take water, and we gave 
him water, and after twelve hours of absolute tie-up of the kidneys he passed 
water. When that happened I felt absolutely sure that the child would get 
well, and he did get well. It is the fats especially and the proteins that pro- 
duce the greater majority of these cases. There is an excess of fat or pro- 
tein metabolism. The metabolism of the child was so changed that this con- 
dition was killing him. Therefore, change that and put in the sugar. For 
daj's and days this child had no fats or proteins of any description, but kept 
on sugar and corbohydrates. So, in the handling and treatment of acidosis, 
soda will hold them for a day or so, but it does not cure. 

There are no authorities for me in medicine — there are consultants and 
advisors — they may and do change their minds. 

Dr- Horace M. Barker, Lumbrton: As to the point which Dr. 
Faison brought out regarding the protein side of it, I have found in a num- 
ber of cases that these cases that periodically have a spell of acidosis, cyclic 
vomiting, etc., do show in a number of cases a marked idiosyncrasy. In fact, 
I have one case now that has a marked idiosyncrasy to onions. By eliminat- 
ing that one protein, that case has gotten on splendidly. The eliminating of 
the protein is one of the many factors. 

Dr. J. Buren Sidbury, Wilmington, N. C. : I think that Dr. Faison's 
talk emphasizes the fact that until you have a specific therapy you have a 
multitude of therapies. The three points that Dr. Elias brings out, first, all 
the water the child can take by mouth ; second, hypodermoclysis or intra- 
peritoneal injection of normal saline or dextrose and soda ; thirdly, soda 
bicarbonate to the point of neutralizing the urine. As much as two thousand 
c. c. of fluid in twenty-four hours should be administered if possible. 

Food is of secondary importance and should be delt with accordingly. 
This is a condition which is going to do its work in a short while and if the 
child does not get any food it will be better than attempting to give food 
which may aggravate the condition. 

Dr. Elias, closing the discussion: I am exceedingly grateful to you all fo:- 
this illuminating discussion. It brings out the state of mind in which th^ 
profession is at present. There is no uniformity of opinion here, neither i*" 



180 NORTH CAROLINA MEDICAL SOCIETY 

there in the mind of any individual doctor. There must be a multitude of 
causes. I recently lost a case that had for two weeks previously had a dram 
of soda every day. The mother was giving it for some little skin eruption. 
The child had had very careful diet, with no variation of any sort, but the 
soda was not worth a cent. On the other hand, there is a doctor at home 
who has two children who have had two attacks each, and he attributed it to 
eating tod large an amount of crackers. There was no indigestion, but they 
had a marked attack of acidosis. There are dozens of other cases, and they 
violate every theory that you can formulate. There is no theory that is sat- 
isfactory. I have been recently up to the Surgeon General's library and to 
Baltimore and other places, and you can find as many theories as there are 
doctors. There is no uniformity as to the causes nor as to the treatment. 
Some say it is due to colloids, some say that is all poppycock. There is ab- 
solutely no uniiormity, but one thing that I want to emphasize is that this 
condition must be recognized. I think it is high time that we are recognizing 
this thing and not waiting for the hypertony, which they say is the only diag- 
nostic point. When a child gets to that point he is mighty sick, and there are 
very few chances for the average case, in my limited experience. Learn to 
recognize these cases before they reach that stage. Early recongition is the 
important thing. 

I think everybody is agreed that there is a loss of bases. When that is lost 
we are bound to have a disturbance of the system. It is largely theoretical, 
but it is theoretically accurate to give something to restore this lost base, and 
we do get relief in some cases. 

Now, as to the way of giving water, the intra-peritoneal injection is the 
ideal thing. You can inject it into the abdomen, giving all the way from 150 
to 300 c. c. of normal salt solution. You can put glucose into it, and it can 
not be rejected. So give the water. If you give it into the vein you will 
overwhelm the circulatory system. Give it in the abdomen and it is soaked 
right up. Take a needle and inject it just below the navel. It is practically 
impossible for the intestine to puncture. You can repeat it every four to six 
hours, and if you observe proper asepsis you can give it with practically no 
danger whatever. 

The discussion as to whether a person has acidosis or cyclic vomiting does 
not mean a thing, to my mind. It does not count for a thing. There is no 
way yet of deciding. But there is a clear cut condition of which babies are 
dying, and that is acidosis. It comes on out of a clear sky, they vomit, are 
restless and dull, and the babies die. There are three things today to give 
them — soda, which helps for a short time, water, and dextrose, and then 
you are doing the whole thing at once. 

INFECTION OF THE NEW BORN. 
Dr. Yates W. Faison, Charlotte^ N. C. 

Not only must the new born infant combat diseases particularly encount- 
ered at this early stage of life, but he must also fight diseases that commonly 
effect other children. 

We usually think of the young baby as being immune to the common con- 
tagious diseases, but we know that they do occur. 



PEDIATRICS 181 

Scarlet Fever has been reported in a new born infant — Diptheria is rather 
uncommon in young infants, but all infants are susceptible from birth ex- 
cept those whose mothers have immunity. Uusually infants under 2 months 
of age are immune to Measles, but here again it seems that only those in- 
fants are immune whose mothers have had the disease. 

Measles has been reported as soon as sixteen days of age. 

Whooping Cough has been reported as early as the fourth day with dis- 
tinct whooping by the eighth day. 

Besides these, the infant may suffer from any of the common infectious 
diseases — Influenza, Typhoid Fever, Pneumonia, etc. 

Again we see various infectious conditions caused by the various pyogenic 
organisms — I will only mention ophthalmia neonatorum, tetanus, and 
pemphigus neonatorum, as they are usually, considered separately. 

In some of these infectious conditions, there is only a localized external 
inflammation, more often ending in abscess formation. 

Omphalitis, or inflammation of the umbilicus and surrounding cellular 
tissues is probably the most common — Occurs any time until the umbilicus 
has cicatrized — Usually terminating in abscess formation. 

Erysipelas may be a complication of the inflammation about the umbilicus 
or may start from any abrasion of the skin at any part of the body — Usu- 
ally spreads widely — Generally involves only the superficial tissues, but 
may involve the deeper tissues and cause diffuse suppuration. The symptoms 
are very severe and usually terminates fatally. 

Multiple superficial abscesses may occur. 

Sometimes one or more of the internal organs are affected, without ex- 
ternal manifestations. We might include in this type the umbilical arteritis 
and phlebitis cases. 

The arteritis occurs much more frequently than the phlebitis. The um- 
bilicus may show nothing abnormal, but on pressure pus may be expelled 
from the vessels. The vessels may be involved only a short distance or 
may reach all the way to the liver. The arteritis is complicated by the usual 
lesions of a pyemic infection, the phlebitis is usually accompanied by intersti- 
tial changes in liver or multiple liver abscesses. The patients usually show- 
• ing jaundice. 

Pneumonia is not at all uncommon in the new born. Usually of the 
broncho type, the processes appearing more often in the upper than in the 
lower lobes. The symptoms are often obscure and the physical signs indefi- 
nite. There is found at autopsy some involvent of the lungs in most of the 
fatal cases of pyogenic infection. 

Peritonitis is a common complication of an umbilical arteritis or erysipelas 
in fact it is one of the most common complications of pyemic infection and 
very often the cause of death. It may be local or general. 

Meningitis also occurs as an acute purulent process, associated with meni- 
geal hemorrhages, acute encephalitis, and multiple abscesses in the cortex. A 
positive diagnosis can generally be made by lumbar puncture. 

Acute suppuration of joints may occur early or late. The smaller joints 
are more frequently involved than the larger ones, but any joint in the body 



182 NORTH CAROLINA MEDICAL SOCIETY 

may be attacked. The organism most often found is the gonococcus, next 
the streptococcus. 

Pyelitis has been found in the new born. 

A case was reported where the appendix was successfully removed twelve 
hours after birth. And finally there occurs cases of general infection, true 
septicemia or pyemia, associated with multiple abscesses in the viscera, joints, 
or cellular tissues. This is a particularly common manifestation of infection 
of the new born, and it is to this type that the term "Infectious Disease of 
the new born," is commonly applied. I will consider this condition in more 
detail and then report a case. Infection occurs when micro-organisms are 
brought to any portal of entry, which is open in a new born child whose 
resistance is too weak to prevent their entrance. Dunn thinks that the most 
important factor in the occurrence of the infection in the new born is the re- 
latively open condition of certain portals of entry, particularly the umbilical 
wound. He thinks that if the low general resistance of those infants was 
such a big factor, infections would be relatively much more common. 

The organisms may enter through abrasions of the skin or mucus mem- 
brane, the mouth, lungs, or umbilicus, the last one being by far the most 
common one. The stump of the cord is undergoing a necrotic disintegration 
thrombi are found in the umbilical veins which may easily become infected 
and then break down into purulent material. This material may then enter 
the circulation and produce a general infection. All these processes may go 
on without any lesion being noted at the umbilicus. The infection may take 
place before or after the separation of the cord. 

The infection may come in rare cases from the vaginal secretions or the 
mother's milk. Although it has been shown that in the great proportion of 
cases the milk of a mother suffering from septicemia contains pyogenic 
organisms, still the taking of these into the stomach is not likely to infect the 
infant. Other sources of inocculation are unclean hands of nurse or physi- 
cian, improper care of umbilicus, dirty bath water and dirty clothing. 

In rare instances septic infection may be transferred directly from an in- 
fected mother to the fetus through the placental circulation. 

The micro-organisms chiefly concerned in these infections are the common 
pyogenic bacteria, staphylococcus anreus and streptococcus. Next in impor- 
tance comes the gonococcus and pneumococcus. 

The clinical manifestations are many and varied. The three most com- 
mon symptoms are fever, jaundice, and hemorrhages. 

There is usually a sudden rise of temperature followed by an irregular 
septic temperature. After a period of such fever, the temperature in some 
cases becomes normal or even remains permanently sub-normal. 

Jaundice may or may not be present. In the severe cases it is intense. It 
is not of the complete obstruction type, but bile is found in both urine and 
stools. Hemorrhages are common and may be the cause of death. They may 
come from the umbilicus, intestine, or any mucus membrane- Purpura is 
the most common hemorrhagic manifestation. 

Nervous symptoms are generally present. Prostration is generally mark- 
ed and extreme exhaustion may come on rapidly. These symptoms vary 
from restlessness or apathy to convulsions or stupor. 



PEDIATRICS 183 

The pulse is rapid and weak. Diarrhea is frequent — vomiting is less com- 
mon. Wasting is usually present and rapid. In addition there are symptoms 
and signs due to the various forms of local inflammation — localized abscess- 
es, peritonitis, meningitis, pneumonia and erysipelas — these may be so pro- 
nounced that they obscure the more serious general infection. On physical 
examination the liver is usually found enlarged — the portal of entry may or 
may not be found — the umbilicus may or may not be inflamed, the umbilical 
depression may be filled with pus, or pus may be made to exude by pressure 
about the umbilicus. 

The blood examination usually shows a marked lencocytosis. Only by a 
blood culture can the diagnosis of a general infection be definitely proven. 

The prognosis is always bad, even in the mildest forms — and the severest 
types almost alwaj's die. It is probable that practically all cases, in which 
there is a general sepsis or any important visceral lesion, die. Only patients 
with localized inflammation, such as those of joints or skin, are likely to re- 
cover. A few cases of apparent umbilical infection recover, but it is probable 
that in these cases the septic process never become general. Death may occur 
within a few days or may be delayed for a longer period. 

Pyogenic infection of the new born, just as puerperal fever in the mother, 
is preventable. This is shown by the great diminution in its occurrence 
since the introduction of aseptic methods into obstetric practice. In the vast 
majority of cases this disease is due to the carelessness of an attendant, the 
physician, the nurse, or the patient. — Clean clothes, clean hands and clean 
surroundings for the baby are essential. The umbilical wound should be 
treated like any clean wound — dressed with sterile dry dressings and every 
thing that comes in contact with the wound should be sterile. 

Unfortunately our treatment is limited. Mostly symptomatic. Wherever 
there is localized suppuration, incision, evacuation and drainage should be 
done. 

The childs general nutrition should receive careful attention by closely 
directing the details of nursing and feeding. An autogenous vaccine can be 
tried where it has been possible to isolate the infecting organisms — but as yet 
no favorable reports on its use have been made. I believe that transfusion 
in these cases offers us the best hope of benefit, as it has proved in puerperal 
sepsis in the mother. I will now report a case. 

This baby was brought to me on January 28th when he was two weeks 
old. Father living and well except for occasional attacks of supposedly gas- 
tric ulcer. Absolutely denies buetic infection. Two older children living 
and well. No history of tuberculosis on either side. The mother on the 
second day after this child was born began a rapidly rising temperature, 
which turned out to be a streptococcic puerperal infection, from which she 
died in a few days- The delivery was normal in every respect and directed 
by a careful physician and nurse. The child appeared and acted in a normal 
manner — weiq;hed eight and one-half pounds. Navel cared for in usual 
way. Was given boiled water for twenty-four hours, then put to mother's 
breast. After third day was put on artificial feeding (Dryco Dried Milk, 
I believe) because of the mother's febrile attack and lack of milk in breasts. 
One or two other foods were tried during the next two weeks — due to in- 
fant's "apparent inabilitj^" to digest them. 



184 NORTH CAROLINA MEDICAL SOCIETY 

On the fifth day there appeared a swelling in the first phalanx of fourth 
finger of left hand. The swelling was symmetrical, reddened and tense. At- 
tained the size of a hazel nut. Absolutely no temperature or other symp- 
toms. The following day a like swelling appeared around and including 
apparently the left elbow — exactly the same characteristics and symptoms 
except the baby resented having the left arm moved. Cord came off on the 
seventh day and appeared normal. In three days both swellings began to 
decrease in size. The color became a dusky red, as if the tumors contained 
old blood. They became reduced about one-third in size and remained so 
up to the time I saw the baby. 

Five days after the first swelling on finger was noticed, the scrotum was 
found to be swollen and rapidly attained the size of a large orange. On 
the same day a like tumor appeared over the right clavicle, about the inner 
third, about the size of an egg. Both swellings had the same appearance 
as previous ones, first tense, pinkish, oedenatous, then lessening in tense- 
ness and becoming a dark red color and reduction of one-third to one-half 
original size. The baby had not yet shown a bit of fever. Temperature 
ranged from 98.5° to 99.5° rectal. 

No other symptoms developed except the feeding had not progressed very 
satisfactorily. The baby had lost only about one pound since birth. I saw 
the baby on the fourth day after the swellings in the scrotum and over the 
right clavicle appeared. 

He was well developed, color good, did not look as if he had lost but very 
little weight — weighed seven and one-half pounds — cried lustily, but took his 
food very slowly. Did not look like a sick baby. Head, eyes, mouth and 
throat negative. Heart and lungs normal. Abdomen soft. No tenderness 
or rigidity. No masses. Umbilicus showed no redness or induration, slight- 
ly moist masses could be expressed from umbilical vessels — liver palable about 
three cm. below costal border. Spleen not palable — lower extremities nega- 
tive. Anus negative. Glands in groins and axilla palable. Skin clear. There 
was a swelling directly over the middle of the right clavicle about the size 
of a half lemon — slightly reddened, tense, with a very slight sense of fluctu- 
ation. It looked very similar to an angio neurotic oedena swelling. 

There was a like swelling over the left elbow, spindle shaped, extending 
for an inch above and below. Seemed to give pain on motion. There was 
also a swelling over the first phalanx of fourth finger on left hand — here the 
color was a darkened red as if old blood was under the surface — more fluctu- 
ation than the others. 

The fourth swelling was in the scrotum which was about the size of an 
orange of a dark red color like the finger, tense, but showing slight fluctu- 
ation. Rectal temperature 99°- Pulse 140. Respirations 30. Urine nega- 
tive except for slight trace of albumen. Stools were light yellow — full 
of undigested food — some mucus — four to six dkily- Blood — white blood 
count — 65,000 — smear showed Polynuclears 64%. Mono nuclears 36% — 
no normal cells. 

The diagnoses suggested were Pyogenic Infection, Sj^philis, Tuberculous 
Infection and a Hemorrhagic condition. 

As three of the four swellings had occurred over or about the bones, x-rays 
were taken, which showed the swellings not in the bone but in the soft tis- 



PEDIATRICS 185 

sues. So here we had an infant whose mother had just died with a strepti- 
coccic puerperal infection, not sick looking but fairly well nourished, with 
swellings appearing at intervals over different parts of the body, with none of 
the ordinary symptoms of a pj^ogenic infection as high temperature, prostra- 
tion and wasting — in fact he had shown no temperature, but had a white 
count of 65000. 

I decided to puncture these swellings and see what they contained. The 
swelling over the clavicle was selected and at first obtained nothing, but on 
pushing the needle deep in, thick, old pus was drained up into the syringe — 
in turn each swelling was punctured and each one contained pus. A bacteri- 
ological examination of this pus showed a pure culture of streptococci — im- 
mediately each swelling was incised, evacuated and drained — it was surpris- 
ing to see the amount of pus — the tunica vaginalis on either side was filled 
— at least two ounces was drained from the elbow. 

The baby was put on a weak cow's milk mixture to which Dextri Maltose 
was added in two days. It was taken well and the stools began to look more 
normal a once. By some misunderstanding the autogenous vaccine ordered 
was never completed. The second day after entrance another abscess ap- 
peared over the sixth rib, left side, anteriorly, which was immediately 
drained. 

On this day the baby began to run its first temperature — 100°-100>4 
rectal. The third and fourth day passed without any new development ex- 
cept for the fact that the baby seemed to be brighter and improving. All the 
wounds were draining only slightly and looked as if they were healing. The 
chances at this point looked bright for recovery. But on the morning of the 
fifth day the temperature was runnin^^ between 102°-103". The baby 
was restless, looked sicker. Physical examination revealed two things. A 
rather indistinct swelling was barely to be made out at the edge of the liver 
in about the nipple line — no jaundice. Also the abdomen had become a little 
spastic and distended and seemed tender. The symptoms became rapidly 
more severe. The child became prostrated — would take no nourishment — 
circulation collapsed requiring repeated stimulation. The abdomen became 
extremelv distended, hard and spastic, especially over the upper portion. 
Temperature 104°-106°. The baby died that night. The baby had un- 
doubtedly developed a peritonitis, with possibly a liver abscess. Autopsy 
was denied. 

This was a pyogenic infection of the new born, probably pyemic in type. 
The portal of entry was obscure. At first showing only manifestations of 
suppuration in the cellular tissues, with one joint involved with none of the 
common severe symptoms, then a period of apparent convalescence after the 
incision of the abscesses, and finally a sudden appearance of a visceral lesion, 
certainly peritonitis and possibly liver abscess, with sudden death in twenty- 
four hours. The question of the portal entry is of some interest. No abras- 
ion of skin or mucus membrane was ever found. Although we know that 
when no other point is to be found the umbilicus is probably the source 
whether or not there is any sign of inflammation — yet in this case it might be 
a question — since the infecting micro-organism was the same in both 
mother and baby and as her infection showed up so soon as the second day, 
it is not inconceivable that the bacteria was present at time of delivery and 
was ingested. Again, as the baby was nursed three or four days after the 



186 NORTH CAROLINA MEDICAL SOCIETY 

sepsis Started in the mother, it could be one of the rarer cases where the 
bacteria entered through the milk. 

The course of the case was some what out of the ordinary — ordinarily it 
would be hard to conceive of a new born infant, with an infection of this de- 
gree and accumulation of so much pus, never running any fever except at the 
terminal stage. And 1 shall be frank to say when I first saw the baby, the 
explanation of the different swellings was puzzling. Again, it seems strange 
that the absorption, which must have undoubtedly been going on in the pres- 
ence of so much pus and for at least two weeks, did not show more general 
symptoms — there was no primary reaction of fever and then falling to sub- 
normal because of overwhelmed resistance. 

Another point brought out by this case is, that we must keep in mind that 
every infection of the new born, no matter how slight or mild a degree, must 
be considered a serious condition. I almost made the mistake of letting the 
father return home on the fourth day after I saw the baby; yet in twenty- 
four hours the baby was practically dead from a complicating visceral lesion. 
Always give a guarded opinion. And finally I wish to enter a plea for more 
careful and closer watching of the new born baby. We see it too often that 
the physician considers his duty done when he has seen the delivery through, 
tied the cord, and turned it over to some attendant to be bathed and clothed. 
He almost forgets the little stranger unless someone calls his attention to 
something that they consider abnormal. The baby should be watched as care- 
fully as the mother, yet usually she receives most of his attention. He should 
give detailed instructions as to the care and nursing, and then follow up and 
see that these instructions are carried out. 

Dr. L. W. Elias, Asheville: This is a very interesting paper, and 
brings up a good many things to think about I wonder if the doctor thinks 
that opening up those abscesses had anything to do with the rapid increase in 
temperature. I wonder if he thinks an aspiration would have had any less 
effect. 

Certainly, the doctor's suggestion in regard to the care of the baby should 
be most heartily commended. 

Dr. Yates W. Faison, closing the discussion : That question was con- 
sidered, and the surgeon overruled us and decided to open up freely and 
drain. It was considered. The point has been brought up in discussion about 
this case before that probably opening these abscesses and letting them drain 
gave the child resistance enough to cause the temperature. It did not go 
down and then come up again. 

SIMPLIFIED INFANT FEEDING AND THE BREAST 
A RATIONAL FEEDING PROGRAM FOR THE FIRST YEAR 

OF LIFE 
Frank Howard Richardson, M. D. 
Assistant Pediatrist, and Chief of Children's Clinic 
Brooklyn Hospital, Brooklyn, N. Y. 
Read before the Pediatric Section of the Medical Society of the State of 
North Carolina, at the Sixty-Seventh Annual Meeting, held 
at Charlotte, N. C, April 21, 1920. 
Infant feeding, whether simplified or complicated, as a subject for discus- 
sion before a Pediatric Section, is something to be approached with caution. 



PEDIATRICS 187 

The changes have been rung upon it so often and in so many different keys, 
that one feels like treading lightly and asking for a special dispensation for 
discussing it. And yet I think that no one will deny that Infant Feeding 
needs simplifying, if there is any subject within the whole broad scope of 
modern Medicine that does. There are perhaps a number of reasons for 
this. First, Pediatrics, along with a number of other subjects in the medical 
curriculum that are of greater age as recognized specialists, is considered a 
minor in our medical schools, and is crowded out of the students' time and 
interest by other supposedly more important subjects. And yet Pediatrics 
is the only branch of the whole array that deals with the well organisms 
and the only specialty that must be practiced by every general practitioner. 
Secondly; As a result of this comparison of a large and important subject 
into such small compass, the professor and instructors are inclined to em- 
phasize the striking cases, of a sort less commonly encountered, rather than 
to dwell upon those far commoner and hence (to them) less interesting 
problems of everyday occurrences, and especially these concerned with in- 
fant feeding. 

Thirdly: The subject of Infant Feeding itself is one that has given rise 
to most acrimonious debate, due to honest divergence of opinion on the part 
of widely differing schools of thought. 

Fourthly: This difference of opinion as to what constitutes a satisfactory 
system for the feeding of infants has been able to persist as it has, because of 
the relatively wide limits of tolerance possessed by different infants, and by 
the same infant at different times, for the most widely differing articles of 
diet. We have each of us but to consult his very recent memory, in order 
to recall some perfect specimen of babyhood, that has arrived at this condi- 
tion on feeding that we would have said must surely have led to speedy 
marasmus — explicable on no other grounds than those of the tremendously 
wide limits of food tolerance possessed by some babies. 

Fifthly: The fact that such widely differing schools of thought could 
each of them point to a highly satisfying and successful series of cases, has 
led each group to believe that it had fairly well solved the problem of infant 
feeding. It has also caused each group to doubt the possibility of attaining 
the equally successful series of cases claimed by the proponents of some 
entirely different set of principles. All have perhaps failed to put proper em- 
phasis upon the fact that a great body of babies, fed according to any old 
methods or to no methods at all, were worrying along perhaps almost as 
well as some of these special series had been doing. They had been studying 
especially the sick baby, with his greatly narrowed limits of food tolerance 
due to the food injury that he had sustained; and had failed to attempt to 
formulate, from the experiences of this large mass of carelessly fed but fair- 
ly healthy, well babies, a simple method that could be readily taught the 
average student, graduate or undergraduate, and by him passed on to the 
average mother or nurse. In other words, the student has been taught a 
complicated method of feeding, desirable enough perhaps in special cases of 
food injury, but by no means essential for the great mass of well babies. Ac- 
cordingly, he has been well-nigh helpless, in the face of the demand of his 
mother's instructions for the feeding of their well children, because he has 
never been taught a simple system which simple folk, with a well baby, will 
take the time and trouble to follow out. 



188 NORTH CAROLINA MEDICAL SOCIETY 

The result of this lack of a definite routine procedure for use in the case 
of the average well child, such as can readily be taught to and learned by 
the average medical student, and by him translated into simple instruction* 
for the average mother or nurse to carry out from day to day, can be seen 
all about us. We know that many otherwise able and conscientious physi- 
cians never attempt to interfere in the management of the well babies of 
their families. They regularly allow some elderly female of the species to 
prove herself more deadly than the medical male, by using her experiences 
of a generation ago to decide proportions, dilutions, quantities, and feeding 
intervals, — after first using her superior judgment for instructing the young 
mother when to take her baby off the breast. Others, when appealed to, turn 
with a sigh of relief, to the proprietary foods, which never fail to promise 
most flattering results, — and every so often, let us be frank enough to ad- 
mit, achieve them. Many babies, we know, with the broad limits of toler- 
ance that we have spoken of, survive this catch-as-catch-can process. Many 
more succumb, to swell the frightful mortality figures that we have come 
to feel are unavoidable with artificially fed infants. 

While granting that we must individualize, even with our well babies, 
just as we individualize with our typhoids or with our appendectomies, it 
must be that we can standardize and teach infant feeding, just as we stand- 
ardize and teach typhoid therapy and surgical technique. It seems not 
too much to ask that the outlining of general principles should precede 
rules for specialization to meet individual conditions. 

I have been brought to believe, from a brief survey of my own brief ex- 
perience, that a large proportion of the cases that are referred, or drift, to 
the man doing pediatrics exclusively, whether in private practice or in hospi- 
tal work, are feeding cases that could have been handled perfectly well by 
the family physician. He has failed, from the lack of a definite technique to 
apply, in his infant feeding cases, similar to the routine procedures which 
he is wont to apply in other situations. In other words, the pediatrist is 
achieving much of his reputation as the result of his successes with easy 
feeding cases, instead of being compelled as he should be to tax his best skill 
and ingenuity over the difficult ones alone. If this be true, then there is a 
serious flaw somewhere in the program of medical education today. For the 
future welfare of the race is in the hands, not of the pediatrist, who, in the 
very nature of the case, sees comparatively few of the whole infant popula- 
tion ; but of the family doctor, who, sooner or later, sees the vast majority 
of them at least once in their lives. But it is to the pediatrist that the fami- 
ly practitioner, when in the embryo stage represented by the medical student, 
looks for his instruction in this most important matter. If we fail him (and 
my memorv of the instruction given me during my undergraduate years 
leads me to think that we are failing him), can we blame him when he al- 
lows that more plausible teacher, the detail man from the proprietary food 
concern, to usurp the seat in the teaching chair that has been so inadequately 
filled? And yet, hand in hand with this admitted unfamilarity with the 
intricacies of infant feeding, on the part of the great majority of the medi- 
cal profession, goes a most amazing readiness to wean babies for the most 
trivial and inadequate of reasons. When one has struggled as desperately 
as every man in this section has done, many a time and oft, over the artifi- 
cial ailmentation of a puzzling case, one is simply awe-struck at the sang- 



PEDIATRICS 189 

froid with which babies are taken off the breast, every day, for acuses so 
trifling as to be laughable, were not the results apt to be so serious and even 
tragic. "The baby doesn't get enough milk." "I never have been able to 
nurse my babies-" "My milk is blue and watery — I know it doesn't nourish 
the baby." "My baby didn't gain this week." "My milk poisons the baby" 
or any one of a dozen other such statements, that should mean nothing more 
radical than an inquiry by the physician into the state of nursing affairs, and 
some simple adjustment or explanation, ushers in the change from nature's 
feeding, which works so well that no one needs to understand it, to bottle- 
feeding, which is admittedly but the poorest of substitutes, and is but 
wretchedly understood by the best. As often as not it is the grandmother, 
the aunt, or the nurse, who blithely crosses this Rubicon, with never a qualm 
over future hazards, and never a regret over bridges burned behind. One 
can hardly imagine a shipwrecked sailor's pushing away his life-preserver, 
or a mountain climbers tossing away his hobnailed boots ; and yet either of 
these would be taking a far less serious risk than is thus imposed upon the 
infant whose breast alimentation is thus discontinued for these absolutely 
inadequate and avoidable reasons. 

The first step that I would urge in the simplifying of Infant Feeding, 
then, would consist in keeping every baby on the breast. I grant you at 
once that such a dictum as this, solemnly enunciated without further ampli- 
fication, would constitute an insult to your intelligence, and an admission of 
my ignorance of the state of medical knowledge today. I should not have 
the effrontery to urge upon any body of physicians, — much less upon a group 
of men engaged as you are wholly with the problems of infancy and child- 
hood, — the already universally acknowledged superiority of breast feeding 
over the best of artificial feeding. This has been so generally conceded, and 
the literature has been piled so high with reports, experiences, statistics, and 
conclusions, to this effect, that it would be a waste of time to try to find any- 
one who would oppose what has come to be considered almost an axiom of 
pediatrics practice. What I do want to stress today, however, is the dispari- 
ty existing between our theory and our practice, in this regard. What I do 
want to plead for today, is the realization, first upon the part of the indi- 
vidual practitioner and through him upon the individual mother, that what 
both know and concede to be true in the great mass of cases, is in all proba- 
bility true in the individual case that they are considering, and whose wean- 
ing they are proposing. No one ever claims that bottle feeding in the ab- 
stract is better than breast feeding. It is only when we urge a mother to 
keep her own baby on the breast, even at the expense of some pains and 
effort on her part and ours, that we meet with any opposition to the con- 
tinuance of breast feeding. And we certainly do meet with it; then, as 
everyone of you will, I know testify with me. 

I personally am firmly convinced of what is by no means universally con- 
ceded or recognized, — namely, that practically every mother can succeed in 
nursing her own child. I say "practically" advisedly, in the face of the testi- 
mony of the textbooks, which are fond of citing cases of congenital or ac- 
quired intolerance on the part of certain infants toward its mother's milk. 
I am willing to go a step farther, and concede that probably each man here 
can call to mind one or more cases in his own experience in which every 
effort to keep a baby on its mother's milk failed ignominiously. And yet, to 



190 NORTH CAROLINA MEDICAL SOCIETY 

Strike a quick percentage, what tiny fraction of a percent is represented in 
the practice of any one who recalls such a case or two of so called toxicity 
as compared with the total number of babies he has seen. We have all of 
us heard or read of the existence of two-headed calves ; and yet we do not 
ordinarily construct our stanchions so as to accommodate these rare freaks 
of nature. 

Mind, I do not claim that every mother, or anywhere near every mother, 
can carry her baby through the nine months that we set aside for lactation, 
without help. But I do say that, given a realization on the part of the 
mother and of her medical attendant of the truth in her particular case of 
what both recognize to be true in the vast majority of cases, — and every man 
who wishes it can reduce his panel of exclusively bottle-fed babies almost 
to the irreducible minimum supplied by motherless babies, and babies that 
have been weaned three or four weeks before he sees them. And, if we are 
to credit the results of Moore, of Portland, Oregon, as set forth in his fas- 
cinating paper in the Archives of Pediatrics for December of last year, even 
this minimum may prove not to be an irreducible one, after all, for he re- 
cords one case of re-establishment of breast feeding after 8 weeks of wean- 
ing, and another after 11. 

Granted, then, that mother and physician are in accord and resolved to 
do their best to keep the baby on the breast. What can we do to help them ? 
In view of the universally admitted superiority of breast feeding, it is rather 
surprising that we can find so little, relatively speaking, of real practical 
help, in the text-books or in the literature, to aid us in this task. The task 
is a two-fold one ; first, the maintenance of lactation, and secondly, the ad- 
justment of the milk to the baby or of the baby to the milk. In comparison 
with the volumes and reams devoted to the intricacies of artificial feeding, 
the space given to the problems connected with the far commoner class of 
breast feeding, seems almost negligible. I want to outline the regimen that 
has been found most successful here, emphasizing with it details which are 
perhaps the most important feature in the management. In a word, this 
consists in the inauguration of what is variously known as auxiliary, com- 
plementary, or supplementary feeding. 

By whatever name we call it, let it be distinctly understood that what is 
meant is ofFering the baby a bottle, with a formula appropriate to its age, 
weight, and general condition, after every breast feeding^ and letting him 
take as much or as little of it as he will. What is not meant is alternate 
breast and bottle feeding ; for reasons that will be dealt with in a moment. 
He may be kept anywhere from five to thirty (or in rare instances more) 
minutes on the breast; until he shows, in short, by his restlessness and the 
tossing about of his head, that he has about exhausted the possibilities of the 
one breast. He is then allowed to swing over to the bottle, previously heated 
and in readiness, and permitted to take as much as he will of the comple- 
mentary feeding. It is probably well within the bounds of truth to say, 
(grandmothers to the contrary nothwithstanding) that a reasonably well 
baby never overeats, if given a food of the proper strength. "Colic," so- 
called, from this cause, can far more often than is realized, be proved to be 
nothing but hunger, by allowing the child to take even more of the food 
than he has already taken. Even that infallible argument, "Why, doctor, 
I know it's colic; he just draws his little legs up on his stomach when he 



PEDIATRICS 191 

cries," will_ fail of effect, when the mother sees the "colicky" baby fall 
asleep just as soon as he is allowed to be the judge of his own capacity. In 
other words we are quite safe in allowing the baby in this way to tell us 
how much too little breast milk he is getting. 

The following ideas should gradually be inculcated in the mind of the 
mother. It is especially useful, in this connection, to give a small slip or 
folder, preferably typed or printed in simple language, embodying these 
points: 

1. That she should get away from the baby at least once in the twenty- 
four hours, — for the sake of both individuals. 

2. That she should get enough sleep ; eight hours representing a mini- 
mum rather than a maximum. 

3. That worry is a great milk reducer. If the doctor can keep up the 
baby's weight and satisfy his appetite with complementary feeding, and give 
the mother confident assurance of ultimate success he can generally obviate 
the untoward influence of worry. 

4. That she may eat whatever she pleases, within ordinary bounds of 
reason, provided it does not cause indigestion on her part. The baby will 
not be affected by what she eats. 

5. That excessive amounts of milk, cocoa, beer, or even water, do not 
necessarily, or even usually, aid in improving either the quality or the quanti- 
ty of milk produced. That such excesses, on the contrary, usually in the end 
do harm, by spoiling the good appetite so necessary to lactation, if not ac- 
tually upsetting the digestion. 

6. That, in general terms, the same regimen that produces health and 
strength and bodily well-being, produces milk. 

7. That no special diet can greatly modify the chemical constituents of 
the milk. The best opinion today is emphatically agreed on this. Further, 
some authorities believe that quantity alone can be altered, — that the quality 
is, in an overwhelming majority of cases, always good. 

8. That a laboratory test of the character of the milk is never of any 
practical use. The only test that is worth while is the practical test as to 
its efifect on the baby. If he is hungry, or is failing to gain, he should have 
complementary feedings until the breast supply becomes adequate, as shown 
by these two criteria. 

9. That the milk never disappears suddenly, beyond recall, — say within 
twenty-four or forty-eight hours. Such an apparent vanishing of lactation 
is always evanescent, if complementary feeding is instituted promptly. The 
temporary diminution of the milk secretion can in this way always be made 
up for, the baby be tided over, and an enforced weaning be done away with. 

10. That the care of the nipples is a most important phase of the periods 
of later gestation and lactation. It should begin a month or two before the 
birth of the baby, in the case of a mother who has depressed nipples. Gentle 
manipulation for a few minutes daily will make these easy for the baby to 
manage. Cleanliness, hardening by the application of one-half strength 
alcohol, and protection by the employment of inch-square bits of sterile 
waxed paper, are important aids in keeping the nipples fit. Bismuth and 
caster oil, equal parts, may be used for incipient cracking. Many women 



192 ^ NORTH CAROLINA MEDICAL SOCIETY 

find that their nipples will not stand the wear and tear incident to nursing 
a child on both breasts at each feeding. Nursing on alternate breasts is usu- 
ally advisable. However, as early milk is thin and watery, as compared 
with later milk, which is richer, or strippings, which are very high in fat, 
we may 'if we wish diminish the fat content of what we are offering the 
baby by allowing him a shorter period at each of the two breasts at one 
feeding. As he fails thus to empty the breasts completely, however, we must 
be on the lookout, in such cases, for a reduction in the milk supply, 

11. That we know of but two galactagogues. One is the stimulation of 
the infant suckling at the nipple. The other is the complete emptying of the 
breast at each nursing. These can be temporarily stimulated; the first, by 
the breast pump and nipple massage, the second, by the breast pump and 
manual stripping of the breast, preferably after the manner described by 
Moore of Portland in the December Archives of Pediatrics. But the best 
agency of all is the one that combines the two, — namely, the nursing baby. 

12. That milk is like the manna that the Lord provided for the children 
of Israel, — it cannot be stored up in the breast nor saved there for future 
use. A thorough understanding of this act will do away with that bane of 
the doctor who is trying to improve a breast supply, — namely, the alternate 
feeding of breast and bottle, (supplementary feeding proper). This is very 
frequently indulged in on the mistaken supposition on the part of the mother 
or her friends that there is not enough milk for all the feedings, and that 
in this way it can be eked out. Lacteal glands, like muscle tissue, work the 
better the more they are called upon to perform, within physiological limits. 
The surest way in which to dry up a breast supply, is thus to skip several 
feedings a day. 

There seems to be no reasonable doubt that a moderate amount of breast 
milk does "take the curse off" the bottle feeding. Whether it be a question 
of carrying over antibodies from the mother to the baby, or whether it be a 
question of vitamines, or whatever the cause may be, we know that the child 
on complementary feedings shares much of the good fortune of the entirely 
breast fed infant. Then too, after weeks, or perhaps even months, the 
breast may begin to function to such an extent as to render further artificial 
feeding unnecessary, either temporarily or until weaning time. Such a solu- 
tion as this, of a feeding problem, never offers itself unasked, in the case of 
the entirely bottle fed baby! 

A fair degree of familiarity on the part of the attending physician with 
some comparatively simple form of infant feeding procedure to employ for 
his complementary feeding, is of course, necessary. Surely, however, this is 
not too much to ask of any man who is dealing as extensively with women 
and children, as is the general practitioner. 

And so, back we come, or around we come, after all, to the favorite topic 
of pediatricians, Infant Feeding. The practitioners (and they are not few) 
who refuse to admit that there is such a speciality as pediatrics, taunt us 
with the gibe that every pediatric meeting, whatever its announced topic, 
either starts out or ends up with a fuse over infant feeding. If a personal 
experience is allowable, I must confess that after some years in hospital and 
clinic work with children, it was still with fear and trembling that I ap- 
proached an ordinary feeding case ; and it was still a good deal a matter of 



PEDIATRICS 193 

chance what feeding mixture such a new case would receive at my hands. 
I felt convinced that the old, complicated methods on which pediatrically 
speaking, I had been brought up, were somehow wrong; and yet I did not 
know what was right. My feeling of dissatisfaction with the old stuff may 
perhaps best be expressed by an illustration from life. If the operation of a 
trolley car were such a delicate, complicated matter that no one but an Edi- 
son could compass it ; and you needed fifty trolley cars to handle the traffic 
of your city; then you will agree with me that the trolley car, as a means of 
handling your traction needs, would fail as a working, practical proposition. 
For there are not available Edisons enough to go round. Similarly, if it 
takes a Holt, a Morse, or a Kerley, to feed j^our baby and mine, Mrs. Jones's 
and jVlrs Brown's, then infant feeding, as taught today in the east at least, 
is a failure. But we know that it is by no means as rare an occurrence as 
we could wish, to have a mother bring back to us, after two or three months' 
absence, a big fat baby that we have failed to make gain on the most scienti- 
fic formulae, with the triumphant remark, "Oh, Doctor, see what Blank's 
Food did for my baby." Not pleasant, is it? Nor yet, as sometimes has 
happened to the best of us, to have Grandma's mixtures preferred by an 
ungrateful child to our elaborate formulae. Such occurrences compel seri- 
ous consideration. 

Some time ago my attention was called to what was to me an interesting 
attempt to join in the holy bonds of matrimony two systems hitherto con- 
sidered hopelessly unmarriageable, — namely, the percentage and the caloric 
ideas of infant feeding. I believe that Dennett, in his book Infant Feeding 
and even more in the teaching in his Seminary at the New York Post Grad- 
uate Hospital, has done more than anyone else in the east to popularize this 
union in a workable technique. In every marriage, each party to the contract 
•contributes elements that the other lacks, to make up a complete unit. In 
this marriage of the percentage with the caloric, — of the east with the west, 
— of the Bostonese with Chicagoese, if yau can conceive of such a union be- 
tween such incompatibles — we shall rely upon the so called percentage 
method to tell us zvhat to give the baby; and upon the so called caloric 
theory, or method, to tell us how ?nuch to give. But, in order to fulfill the 
requirements that vi^e set for ourselves in naming this investigation, we must 
produce something that is really simplified, — it must be, not a head-splitting 
arithmetical jumble of proteins, carbohydrates, fats, and calories, but a sim- 
ple, straightforward rule-of-thumb working svstem, — simple enough to be 
workable for him who runs to read and to apply. 

The part in our scheme that the percentage method is to play, then is to 
determine how best to make our mixture digestible, — a matter that the 
caloric method, so called, never attempted to help us with. This simple 
point Chapin, for instance, absolutely disregards, in his diatribes against 
calories, in which he attempts to reduce the whole idea to the ridiculous by 
suggesting that we furnish the necessary calories to the youngest in the form 
of coal oil. 

Without getting ourselves into the usual arithmetical tangle by comparing 
the percentages of the three food elements in human milk and in cows milk, 
let us recognize that there are three elements, any one of which may under 
certain conditions give us trouble in adapting the milk of the cow to the 



194 NORTH CAROLINA MEDICAL SOCIETY 

Stomach of the human, — namely, fat, sugar, and protein; disregarding the 
salts, about which we know as yet so painfully little. Let us dispose of the 
danger due to the fat, by reducing it to a very low amount, — which will be 
the case if we dilute ordinary cow's milk with twice as much water; i. e., 
give one-third milk and two-thirds water. This same process will reduce 
the harmful potentialities of the sugar to an even greater degree by reduc- 
ing it so far that we shall have later actually to add some sugar to our mix- 
ture in order to have enough to approximate it to the human norm. The 
protein can be disposed of even more simply, — by subjecting the diluted milk 
to a boiling process for three minutes, which completely breaks up the curd 
when acted upon by the stomach juices, as has been conclusively demonstrat- 
ed by Brenneman of Chicago in his classic work on boiling milk. That the 
protein of the milk is "the cause of many of the nutritional disorders en- 
countered in infancy" is categorically denied by Grulee, of Chicago, in his 
"Infant Feeding," (page 167 sec. — . ) He is sure that the so called "case 
in curds" are irritant only mechanically; and that this source of trouble is 
eliminated by boiling. The only possible objection to this, that it may cause 
scurvy in time, is done away with absolutely by the feeding of orange juice. 
If, then, we agree to start any child that comes to us on a mixture of one 
part cow's milk and two parts water, boiled together for three minutes, 
with no sugar added, we shall at least be giving a mixture that can do him 
no harm. For our fat is diluted far below that in human milk, our sugar 
is almost absent, and our casein, the protein constituent, has- been rendered 
harmless by boiling, so that it will form a finely divided curd when it meets 
with the digestive juices of the infant's stomach. Any possible ill effect of 
the boiled milk we shall eliminate by feeding him a little orange juice once 
or twice a day. But this, if we start with 10 ounces of milk and 20 of water, 
will probably be insufficient. We can prove this by multiplying 10, the 
number of ounces of milk by 20, the number of calories in an ounce of milk, 
— the water, of course, having no caloric value. That is, our initial formula 
which we agree is digestible, is worth 200 digestible calories, if you will. 
While it is much better, by all o'dds, to give too little of a digestible food 
than to give any amount of an indigestible one, still we must eventually 
come up to his digestive requirements, best measured in calories, if we are 
to look for a gain. But how are we to ascertain what this caloric need is? 
By multiplying the number of pounds the baby weighs, say 10 pounds, by 
50, which is an average calculation of the requirements of the average child 
per pound per day, we shall arrive at the number of calories that we must 
eventually give our baby in assimilable form, if we are to get him to thrive 
and gain weight ; in this case, 500. Starting, then, with our trial or initial 
formula of 10 ounces milk and 20 ounces water, we may gradually strength 
en this until we have brought it up to the number of calories (in this case, 
500) that we have determined upon as a normal daily feeding for our baby, 
■eventually. Our strengthening must be in terms of two factors only, how- 
■ever; namely, milk (with its 20 calories to the ounce) and sugar, (with its 
30 calories to the level tablespoonful). 5 level tablespoonfuls, or 150 cal- 
ories, may be taken more or less arbitrarily as the total sugar content at 
which to aim. It is probably better borne in the form of dextri-maltose than 
in that of either cane sugar or milk sugar. In order to decide how many 
ounces of milk we shall eventually want to give our baby, we may subtract 



PEDIATRICS 195 

150, the number of calories to be contributed b_v our five level tablespoon- 
fuls of sugar, from the total number of calories previously determined upon 
(by multiplying the number of pounds the baby weighs, by 50, his daily re- 
quirement per pound.) This total, divided by 20, (the number of calories 
in each ounce of milk), gives the amount of milk needed. 

This leaves us nothing to determine, but the amount of water to be used 
in the final total feeding. In order to do this, we shall simply have to de- 
termine the total bulk to be given the baby in the course of the day, which 
will be the number of bottles to be given, times the number of ounces in each 
bottle, determined by any rule that you have been using in the past. A gen- 
eral average might be represented by 7 feedings (which gives bottles enough 
for a feeding every three hours during the day, and one night feeding) times 
3, 4, 5, 6, or 7, the number of ounces per bottle, according to the age of the 
child. This bulk must be furnished by the water plus the milk, as the sugar 
goes into solution. As the number of ounces of milk required has previously 
been determined, we need only add water to bring up the total to the total 
bulk desired. 

Now we need not, nay must not, aspire to reach this desired haven of the 
optimum number of calories at a bound. Grant that our baby may, and 
probably will, be hungry, long before we have advanced him from the — 10 
oz. milk — 20 oz. water — on which we started him, to the optimum formula 
that we have decided he must ultimately reach. But we are, all of us, com- 
mitted to the principle of making haste slowly, in feeding babies ; and at 
least we do away with the formerly commonly accepted 24-hour starvation 
period. The hungry baby worries the mother with his crying ; but the child 
that worries the doctor is the baby that has no appetite. 

Leaving all theory aside, the practice is this. Start virtually every baby 
on a mixture of 10 ounces milk and 20 ounces water, boiled together for 
three minutes, with no sugar added. The caloric value of this is 10x20, or 
200. Experience will tell you when it is safe and advisable either to give a 
stronger mixture or a greater bulk at the start, for this trial formula, as we 
may call it. With this weak strength and small amount, the preliminary 
starvation period that we used all to insist upon has been found quite un- 
necessary and hence a loss of valuable time, in most straight feeding cases. 
Add an ounce of milk a day. The caloric value increases thus 20 a day. 
Add a level^tablespoonful of sugar (preferably in the form of a malt sugar), 
every few days, in place of the increase in the milk, computing the value of 
the food on those days by adding thirty calories for each level tablespoonful 
of sugar added, instead of the twenty that would have been added by the ad- 
dition of an ounce of milk. 5 level tablespoons make a good average quanti- 
ty. In order to determine whether water should be increased, left as it is, 
or decreased, we must know how much bulk we want our baby to have in 
the twenty-four hours. This is easily arrived at, by multiplying the num- 
ber of feedings (say 6 or 7) by the number of ounces he is to get at each 
feeding (which averages an ounce per month, — more in the early months, 
of course, and less in the later.) The difference between this total, and the 
number of ounces of milk, will represent the amount of water needed. — as 
the sugar, of course, dissolves, and so occupies no bulk. Before long, add the 
juice of half an orange to each day's dietary. 



196 NORTH CAROLINA MEDICAL SOCIETY 

The question of the best interval at which to feed is a point which is 
variously settled by different schools. My own custom has been largely the 
result of the method described by the homely phrase "cut and try." The 
two-hour interval I use only in the case of prematures; and the two-and-a- 
half, only as a step or half-way step in the course of changing from the two- 
hour interval on which a baby may be when he comes in, to the three-hour 
interval at which I always prefer to start. As soon as the baby is doing per- 
fectly well on this, — by which we understand that he is being fed at 6 a. m., 
9 a.m., 1 a.m. and 3, 6 and 10 p.m., and once during the night, — and seems 
satisfied to wait from one feeding to another, and occasionally sleeps 
till well along toward morning, I advise the mother to dispense with the 
night feeding, by giving first water when the baby wakes and cries and then 
omitting both nursing and water. This is the routine for babies that are not 
seen at birth ; those cases that are, do not have any night feeding at all, be- 
ing given warm water at two o'clock a. m. or later if they wake, which they 
soon cease to do. As early as the end of the first month, I suggest to the 
mother that she will probably find it easier for both the baby and herself if 
she can change over to the four-hour interval. If the idea appeals to her, I 
have her allow the baby to go as long as he will from feeding to feeding, — 
three and a half hours if he will not go four, — for about a week. Before 
the end of that time, a well-fed baby is usually established on the four-hour 
schedule. The same free and easy method is used at three or four months, 
if the baby is satisfied and the mother cares to try, with regard to omitting 
the 10 p. m. feeding. These changes are so much easier for the mother, and 
involve so much less handling of the baby, that they are usually easy to per- 
suade the mother to try for. It is hardly worth insisting upon, however, 
and especially is contra-indicated if the baby is hungry, and ready for the 
bottle at the end of the three hour interval. The baby's own hungry inclina- 
tions can here be safely relied on and show us his needs if we will study him 
carefully. 

A most valuable adjunct to employ at times in the management of difficult 
cases is that much talked of agent, dry milk. Like most other proprietary 
preparations, it has its very definite dangers in its likelihood to become a very 
intolerant master, as soon as it gains in the minds of the laity the place that 
we are apt carelessly to help it to attain. In the child who has suffered a 
"food injury," it is often a most valuable aid, with the lowered fat content 
that at least one brand offers, and the apparently increased adaptability con- 
ferred by the heating process. Especially if one had reason to doubt either 
the intelligence or the zeal of the one who is to prepare the complementary 
food, is this an efficient and valuable ally. If caloric value is given as 16 
calories to the level tablespoonful (leveled, that is, with a knife). 

A word as to the management of prematures, in order to cover the various 
phases of the feeding of the first year of life. It is coming more and more 
to be realized that it is a waste of time, — nay, of human life, — even to at- 
tempt the feeding of the premature infant with anything other than human 
breast milk, either whole or diluted. Strengths and intervals may well be 
left to the individual feeding the individual case. I am firmly persuaded 
that the obtaining of the tiny amount of breast milk needed for the first days 
and weeks of the life of the premature, is by no means the difficult or im- 
possible matter that we are apt, offhand, to consider it. That community 



PEDIATRICS 197 

must be a tiny one, indeed, in which there is at any one time but one nursing 
baby. And it should be most rare, indeed, to fail to find a mother who, if 
the need were fully and carefully explained to her, would be glad to spare 
for the starving baby of her neighbor the few drops necessary to save its life, 
from the bounteous table that nature has set for her own more fortunate 
child. In the larger community it is easier; in the hospital, comparatively 
simple. Cooperation between the obstetricians and the pediatricians has in 
more than one instance resulted in the establishment of some central agency, 
at which the parents of the infants whose need for human milk is urgent, 
can be put in touch with the mother who is willing to supply, on a financial 
basis, a stated amount of breast milk per day. A more interesting bit of 
hospital wire pulling has been the feeding of the premature, by means of a 
pipette or Breck feeder, on a diluted breast milk expressed from a mother 
in the maternity ward, while the supply of its own mother was started by 
placing to her breast a needy baby from the pediatric ward, who greatly 
benefits by the operation, until the premature can get his supply direct by 
nursing at his own mother's breast. 

Weaning is a procedure which entails no suffering on the part either of 
mother or of child, since the brutal old custom of abrupt weaning was done 
away with. At about the sixth month, or thereabout, the mother is told to 
precede each breast feeding with a tablespoonful or two of a cereal. As 
soon thereafter as one wishes, the vegetables may be added, one by one, as 
baked potato with milk, spinach, carrots, mashed peas and beans. As these 
additional articles are judiciously used to expand the baby's dietary, he will 
naturally become less and less dependent upon the breast milk, which, to- 
ward the end of the nursing period, he will be using more as a drink than 
as a sole dependence for nourishment. Milk, either diluted, and without 
sugar, or straight, may be added as desired. In this way, the change from 
breast feeding to general diet is made so gradually as to be almost impercep- 
tible. It is only fair, in this connection, to mention the paper in which 
Morse, of Boston, sums up very fairly his objections to this procedure, and 
his reasons for adhering more strictly to the older custom of introducing 
these articles of diet considerably later. The change can be made quite as 
gradually from the four hour feeding intervals to the more conventional 
hours of meal times. The 6 o'clock feeding becomes a 7 o'clock breakfast 
with cereal (without sugar), milk, orange juice, and bread. The 10 o'clock 
feeding becomes the pre-nap lunch of crackers and milk. The two o'clock 
feeding is easily recognized in the after-nap dinner, with the addition of 
baked potato and milk, one other vegetabl, bread or toast or zwieback, and 
a simple pudding. The six o'clock feeding is less deeply camouflaged, ap- 
pearing as supper, with Graham or Wheatsworth crackers and milk, and 
stewed fruit. The omission of eggs in any form, and of the elaborately pre- 
pared beef broth or scraped beef, is intentional. The value of the former 
is more than problematical ; the labor^ spent on the latter is out of all pro- 
portion to its value, which has undoubtedly been greatly exaggerated. 

SUMMARY 

Infant Feeding, as taught until yesterday in the schools, needs simplifying 
and needs it acutely. 

2. The first step in simplifying, and the most important for the welfare 



198 NORTH CAROLINA MEDICAL SOCIETY 

of the race tomorrow, is the maintenance of breast feeding, partial or com- 
plete, in the vast majority of our babies, 

3. Such a statement alone is inadequate. Proof of the assertion, as well 
as help to the mother in accomplishing it, are needed. This consists in the 
"adjustment," as I like to call it, of the breast to the baby, or the baby to 
the breast. 

4. I have attempted to show how any man may keep that wonderful 
ally, old Gradma Nature, on his side, — and in many cases, take all the 
credit while he allows her to do most or all of the work. 

5. To do this, requires a reasonable familiarity with some reasonably 
simple form of Infant Feeding procedure, for use in connection with the 
breast feeding, at some time during the period of lactation. I have tried to 
formulate the simplest that I have yet found. 

6. A useful servant, but one that must be watched lest he assume the 
mastership, is some form of dry milk. 

7. The successful care of any respectable proportion of prematures pre- 
supposes the employment of breast milk in all cases. 

8. Breast milk is not the rare thing we like to consider it, — we can get 
it for the premature, if we go after it hard enough. 

9. Weaning is a gradual affair, — as such it may be accomplished abso- 
lutely without disagreeable effect upon either mother or child, if it be be- 
gun early enough. 

1 0. References. 

Ladies and Gentlemen, I have tried to give you my articles of faith with 
regard to the management of the feeding of the ordinary baby — or one that 
approximates the ordinary. (For no mother will ever admit that her baby 
could be classed as ordinary, by the dullest imagination). Endless variations 
from the average may be made, to suit the individual baby, and to increase 
its flexibility in the hands of the individual infant feeder. A necessary part 
of the technique, in actual practice, that I have not attempted to bring 
out, consists in the rendering of frequent reports and the maintaining of 
constant touch between mother and doctor. This is absolutely essential, for 
checking up results, to see if directions are being carried out, and to detect 
and correct errors arising from a misunderstanding of directions. (In my 
own case, this is covered by the morning telephone consultation hour, at 
which time mothers are encouraged to telephone in reports and questions, 
with absolute freedom.) 

Some such skeleton technique, flexibly and humanly applied, that may 
easily be taught to any man who has to deal with babies, will carry perhaps 
95% of our babies safely through the first, or critical year of life. If this 
is true, and I believe that a large number of men might easily be found 
whose experience will confirm it, we may reasonably leave the remaining 
5% or less to be discussed in some more highly technical treatise than 1 have 
attempted here. 

REFERENCES 

1. C. Ulysses Moore, Arch. Pediatrics, Jan-, 1920. 

2. Roger H. Dennett, Simplified Infant Feeding 



PEDIATRICS 199 

3. Chapin, H. D., Do Calories Measure the Value of Food? J. A. M. 
A., 27 Dec, 1919, v. 73, No. 26. 

4. Brenneman. Am. J. Dis. Ch., 1911 I 341. 

5. Ibrahim. Monatschrift f. Kinderheilkunde, 1911, x 55. 

6. Grulee. Infant Feeding. 

7. Holt and Howland. Diseases of Childhood, 1918. 

8. Hill and Gerstley. Clinical Lectures on Infant Feeding. 

9. Rubner, M., and Heubner, O. Die Naturliche Ernahrung eines 
Sauglinges. Zettscrift f. Biologie, 1898, neue Folge XVIII, pp. 1-55. 
(First ref. in lit. to Cal Fdg of Inf.) 

10. Hill, Lewis Webb. Review of Methods of Infant Feeding. Bost 
on Med. Jour., April, 1920. 

11. Talbot, Fritz. Arch. Fed., 1910, XXVII, 440. 

12. Morse, Robert Levett. Jama, 28 Feb., v. 74, No. 9. 

13. Love, J. D., J. A. M. A., 19 Dec, 1919, (Abstract.) 

SIMPLIFIED INFANT FEEDING. 
Dr. Frank Howard Richardson, Brooklyn^ N. Y. 

EXHIBIT NO. 40. 

Dr. J. R. Ashe: We have all enjoyed this very instructive paper of Dr. 
Richardson's. I find that a great many mothers who are feeding infants 
need help. Most of these mothers, if we do supplement their feeding they 
are perfectly able to nurse a baby for several months. 

I find so many babies four and five months old, whose mother's milk is 
just beginning to fail, you can't make it take the bottle. She does get a 
little in its mouth by the spoon. I have had so many to act that way. I 
have made it a rule to try to start the babies out on bottles when two or 
three months old, whether they need it or not. 

Dr. B. L. Smith : My only rule in feeding babies is the time. Laying 
aside the quantity etc., the only rule I insist, if a child takes his food at six 
in the morning I want him to take it at 6 the next morning, etc. The most 
important part of feeding is fixing the food to suit the baby. I have been 
using in the past two years the dried milk as supplementary food to the 
breast. I found that the most easily prepared — one advantage it has over 
the condensed milk is that the child will not wean itself from the breast on 
account of the sweetness of the milk. I do not feed it as a food, except as 
supplementary food, or in emergency cases. 

Dr. Richardson's paper was hard to discuss, but you can bring out a few 
things. I always give the bottle after the breast. I found that if you put 
the babies on water that that is sufficient to keep them up with the bottle, 
and they will at anytime adopt the bottle of milk in place of the breast, that 
is if you have them acquainted with the bottle. 

L. T. RoYSTER, Norfolk, Va. : I have very little to say. I have never 
taken a baby of^ of mother's breast because the milk did not agree with it. 
I have not seen a case like that yet. Anyone that attempts to take babies off 
of the breast because it has colic, had better stick to the ills we have and not 



200 NORTH CAROLINA MEDICAL SOCIETY 

rush to others. I have never taken a baby off of mother's breast and I see no 
reason for it at all. The use of the terms complementary and supplement- 
ary are rather confusing, some use supplementary as adding to the mother's 
feeding. I always use supplementary, if I can possibly do so feeling that one 
dram of mother's milk at each nursing is far better than no dram. 

The other principle is, if we alternate the feeding, the mother's milk will 
dry up very quickly. The breast pump is the last thing on earth to use. 
The nurse can be taught to nurse the mothers, as well as the milkman to 
milk the cow. I never use a breast pump if I can avoid it. The mothers 
can nurse the milk out of their breast if taught by the nurses. A baby sud- 
denly weaned from a mother's breast by the death or illness of the mother, 
if it is a healthy baby it should present practically no difficult in feeding. We 
must know what takes place in the stomach or intestines. I was fortunate 
enough to study in New York, and in those days we had to figure down to 
the minutest percentage. That day has passed. Now we realize that any 
of those foods may cause indigestion. I will say that that is very frequently 
the case — fats and sugar — whether mixed with milk or not and where the 
rules are laid down by the manufacturer — unfortunately too many of us let 
the manufacturer be our teachers. Personally I never used any of the dry 
preparations. I do use mixture of Dextrine and Maltrose, but it is too lax- 
ative, and therefore we have not gotten to that point. If we start any child 
that is healthy on milk formula, disregard its weight for ten days or two 
weeks to be sure we have not any symptoms of indigestion. I have never 
used a dram of condensed milk in my whole 25 years experience, nor have I 
ever used dry milk except in traveling. However we can obviate the imper- 
fect supply by the boiling process, and by giving orange juice. 

The question I do want to speak on is the question of premature baby. 
He is talking on the stand-point of well equipped muscles and I agree with 
him. Unfortunately in my experience, I am ashamed to say that I have not 
the experience in Hospital feeding I w^ould like to have. A great many of 
these cases occur in private homes on the outside of town. Perhaps three 
times out of five in my premature work, I am unable to get breast milk, 
therefore we have to resort to something else. I don't know how many of 
you saw an article I wrote in Medical Clinics about two years ago. I have 
found a valuable aid — you have to be with people that are not as intelligent 
as you would like to have them. I have raised some of my babies on whey, 
and when they have gotten whole whey instead of skimmed whey, when a 
child digests that you can slip off to a simple formula of whole whey. I use 
that exclusively in my practice. I think, there are times when you have got 
to eliminate the feeding. The vast majority of babies can be fed success- 
fully on home milk. When you have regulated the fat and sugar and in- 
creased them both gradually then you have almost always prevented your 
difficult feeding cases. 

Dr. G. S. Mitchenor, Edenton, N. C. : I wHs mighty glad to hear Dr. 
Royster say he had never taken a baby away from the mother's breast. In 
Eastern Carolina I find quite often where the mother has taken a baby away 
from her breast saying she did not think her milk agreed. The mid-wufe 
and the mother are responsible. I have recently had sonie very embarassing 
experiences and went into a home — the mother was giving this infant — 



PEDIATRICS 201 

five months old syrup of quinine. The child had not been born when we 
passed our last malaria. Some women in the neighborhood told her about 
it. We have got to educate our mid-wives because they have it in for us. 

I agree with the doctor that a dram of milk, 60 drops is better than none 
at all, but if we have a mother who cannot give the child the necessary 
amount is it better that we let the child get as much milk on the three or 
four feedings and supplement that with cow milk, or would it be better to 
let that child have only one or two feedings a day? 

Dr. Faison. Take away infant feeding. We would nearly have to go 
out of business. I am of the opinion that this treatment ought to begin be- 
fore the baby is born. Get this woman in a condition to take care of her 
baby — to have her nipples treated. 

Another thing I want to say, and I hope these nurses will tell the others 
what I say about it — that is you nurses are with a woman in confinement 
and with her a month, if that woman don't give a plenty of milk within 
30 days you are a mighty sorry nurse, and so sorry that you ought to be kept 
out of the profession. God didn't put that breast on a woman to lie around 
and do nothing. With the proper massage and proper treatment she will 
give the sufficient amount of milk. If you take care of that breast and that 
nipple dampened with boracic acid and keep that nipple thoroughly wet and 
if the woman is well the breast will give the milk. If you don't do it it is 
your fault, and I want 3'ou to feel that responsibility. 

You ought not to let your patient have sore nipples and if you don't have 
sore nipples you ought not to have a sore breast. The doctor that has a 
patient with sore breasts ought to quit the busmess. The doctor is there 
during the child's birth and hands the baby over to the nurse and it is 
good-bye. All of these things which Dr. Richardson said I agree with. A 
baby should have at least an ounce of good milk for every pound he weighs. 
With that view he will sure gain. A woman does not bring babies into this 
world for the purpose of being troubled with them — they don't want to do 
that, if so thev would turn it over to the doctor and put it in the hands of 
the nurse saying, "I am not going to nurse it." Such a woman as that is 
not fit to be called a mother. The trouble now is to get the women to have 
the babies. Rich society women have something else to do, they don't want 
to go through nine months and have a baby. The poor people say they are 
too poor, they can't have babies. If you take the poor people out of the 
country with their birth-rate, how long will it be before we would not have 
any people? Our birth-rate in North Carolina stands higher than any other 
State in the Union. I was at a house three times in my life when a baby was 
born and when the 13th baby was born I beean to feel sorry for the fellow. 
I says "why don't you quit it?" He says "Doctor I am poor and that is 
the onlv thing that comes to me on credit." 

I am going to ask Dr. Richardson a question on supplementary feeding — 
if that baby don't get but a dram it is worth more than all the medicine. 
The supplcmentar^' feeding should be given after the nursing. The Pepsin 
and stuff is not worth all the salt in the water. I have in my lifetime dis- 
agreed with Dr. Moore and Dr. Royster both of them, put it down that 
all of the mother's milk will agree with the children, but I have never been 
able to get away from the fact that it did hurt. I have come to the con- 



202 NORTH CAROLINA MEDICAL SOCIETY 

elusion in the years of experience that Faglestein and his crowd brought 
the best news in the world when they state that protien did not hurt. When 
you have a child that fat and sugar hurt you have your protein that you 
can go on and make him go on or live on. It is hard sometimes to get the 
babies to nurse, the mother's get discouraged. When they do that, I beg 
them to get a nurse and let the mother leave home and I tell the nurse, 
"If you don't get that baby to eat in three or four daysj I will have you 
discharged." These nurses are great institutions, outside of the hospital 
they are hardly worth a cent to us today. It will take four hours on the 
'phone to get a nurse as long as they can get around the hospital and talk 
about the boys and dress and primp up, they will not go in the private 
homes. You nurses ought to go on a strike and act like humanitarians — 
we need you and we need the babies. 

I agree with Dr. Richardson when the babies are crying with colic, they 
are crying because they don't get enough to eat. I had a baby in the hos- 
pital that I operated on and he was crying, I said, "What is the matter?" 
She said, "he had the colic." I said, "Bring me that four ounces of food I 
had fixed up for him." I gave it to him and he went to sleep immediately. 
Let them hollow and cry, they will grow by that. I agree entirely with 
Dr. Royster on the pump business, I think that is bad. If you get the milk 
out of the breast it will secrete, it has to come out, that is really the only 
way that will make a breast well. If that baby don't take it out it ought to 
be gotten out. If that mother will take her breast in her hand and press 
it, it will come out. We all agree that mother's milk is the ideal milk for 
a baby. I am glad to hear these men sit down on dry milk, it don't do for 
me. It is a commercial failure — everybody in town you ask them what 
they are doing, and they say, "I don't know anything about it." We have 
too good a milk here to send to New York, Europe, Asia and Africa and 
buy milk in tin cans that is dry. I have seen the condensed milk do some 
good, but with the proper bathing and proper treatment and a mother that 
is willing to keep her mind quiet, and play the piano and sing will give 
milk and plenty of it. 

Dr. Richardson, closing discussion: I want to thank Dr. Royster for 
that suggestion of his about the extra bottle. I have mothers to ask me 
about that, they say it says to give the baby one bottle a day. A mother 
rolls over all during the night and nurses her baby — she should not do that, 
as she has to have the rest. If you want a mother to have a chance, ask 
her to let the baby go 4 or A^A hours a day. That youngster does need the 
extra bottle, in order to get him used to using it. I think the best way 
would be to give the bottle just before nursing when he is hungry — but 
never give it in place of the breast. 

Dr. Smith pointed out the importance of being punctual. I think this 
is fine, especially in the beginning. It makes a mother get up in the morn- 
ing. I don't believe you can take care of a baby if you are going to sleep 
all the morning. I realized that, after I had some of my own, that taking 
care of babies was some work. One of them is getting up early in the morn- 
ing. I don't 'insist on waking the baby up at tick of the clock, but most of 
the babies will wake up pretty close to the time. I don't do the alarm clock 
talking that I used to, but. I think the baby will get along about as well. 



PEDIATRICS 203 

I want to thank Dr. Smith for bringing out the point that I didn't bring 
out — I never give the bottle before the breast, if you do that baby will not 
do much toward nursing the breast. I tried to dodge the question of com- 
plementary and supplementary. The alternate feeding is a curse to the 
mother. As soon as she starts to alternate feeding, her milk is going to dry 
up. I must confess that I don't know a great deal about bringing up ba- 
bies in small communities. I would like to ask you if anyone of you will 
try in the next year in your own community and see if you can't get some 
woman with a nursing baby, to give a mother of a premature baby a little 
bit of her milk after her baby is through. Explain to her that the whole 
medical profession thinks that that would be the means of saving Mrs. 
Jones' baby. 

Dr. Faison : They do that here in Charlotte, and are glad to do it. 

Dr. Richardson: That could be done if we use what personality the 
Lord has given us. I used to want to look old — I have found that the older 
people don't look down upon us because of our y^uth. They believe what 
you say if you will say it firmly. I am confident that the mothers are nurs- 
ing babies now more just because the doctors are urging it. 

So often it is hard for me to get mothers to believe they have enough of 
breast milk. I always ask them to let me see their breast and they take it 
and push it and no milk comes. Dr. Moore describes a method that any 
mother could learn. 

First, your implements are ball and thumb and ball of first finger; with 
these grasp the breast way back — he says as though you were going to pinch, 
come down aim at it — don't come anywhere getting together. The third 
movement is pull down. You will get a stream of milk from the breast, 
when the breast pump will only bring a little. You will try two or three 
times, the mother will scream out because it hurts if you do it quickly, but 
you must try it slowly — it is one of the best demonstrations I know of to 
show a mother that she has milk. I thought you folks down here were so 
up to date that you would not have much use for extra feeding. I have a 
man in my ward, who is my Senior, he said, "If four or five percent of mv 
babies don't do well on breast feeding I take them off." That man passed 
through the stage of thinking he could not feed babies artificially, but now 
he can do that, but he has not learned to carry over from the mother's 
breast whatever there is in breast milk to make the best baby in after life, 
the best standard individually. If that is true that woman is way back of 
grandmother who sticks to breast feeding. I think if Ave will let old grand- 
ma nature do the trick for us, because she will if we keep the baby on com- 
plementary feeding. 

Chairman: I want to express to Dr. Richardson the thanks of this 
section for bringing us his message. Your paper has been most cordially 
accepted and we appreciate it. 

LARYNGEAL STENOSIS 
L. T. RoYSTER, M. D., Norfolk, Va. 
Laryngeal stenosis is one of the most tragic situations known to medicine ; 
its relief by intubation is as satisfactory as it is dramatic. There are a num- 
ber of causes of difficult or obstructed breathing, resembling, to the casual 



204 NORTH CAROLINA MEDICAL SOCIETY 

observer, very closely the clinical picture of laryngeal stenosis, and from 
which this condition must often be differentiated. Those most frequently 
encountered are: post or retro-pharyngeal abscess, peritonsillar abscess, 
foreign body in the larynx or trachea and edema of the glottis. The diag- 
nosis from retro-pharyngeal abscess is especially important, since in the 
latter condition the separation of the jaws by the mouth gag is often fol- 
lowed by immediate death. 

This paper will deal entirely with membranous croup or laryngeal diph- 
theria, and its treatment by means of the intubation tube. There are four 
conditions which may call for intubation: 

1. Catarrhal or spasmodic croup; 

2. Influenzal croup ; 

3. Membranous croup or laryngeal diphtheria; 

4. Edema of the glottis. 

1. Catarrhal or spasmodic croup usually comes on at night, most often 
near midnight ; is usually accompanied by a high-pitched, ringing, harsh 
metallic cough. It comes on suddenly as a rule and ends as abruptly as it 
appears, with the approach of day. It has a tendency to recur for three 
successive nights, but during the day is generally unnoticeable. There are 
some children who are "subject" to this form of croup, having it with every 
slight cold or with any sudden variation in weather, or after over-eating, 
in which instance it takes the place of digestive up-set. Unfortunately, 
catarrhal croup does not invariably clear up during the day, but may persist 
and produce a continued hoarseness and stenosis, which is so severe as to 
require intubation. I have never seen an instance of this, but it is said 
by many excellent observers to occur. The nearest approach to it 
which has come to my attention, was in a case of measles. This 
child required the closest attention for about ten days, during which 
it was thought, from hour to hour, that an intubation might be required. 
During the past winter this child developed influenza during the conva- 
lescence from chickenpox. She again developed a severe stenosis. 

2. Influenzal Croup. This condition, though observed many years 
ago, has come into prominence during the recent epidemic of influenza, 
particularly through the writings of Lynah, of New York. He mentions 
several types, which it is not necessary to describe here. These cases occur 
during an attack of influenza, and develop quite suddenly. If intubation 
is needed, it is needed very early in the course of the croup. They are 
frequently intermittent and are very spasmodic. They may be so severe 
one minute as to almost call for immediatae intubation, while the next 
minute the patient may be resting quite comfortably. Some of these cases, 
however, pursue the usual course of laryngeal diphtheria, and gradually 
increase in severity, but in a much shorter time than in diphtheretic croup, 
and finally require intubation. 

There is only one method of diagnosis, and that is by means of the 
laryngo-tracheoscope. This cannot well be used except in a hospital espe- 
cially equipped ; and as far as treatment is concerned, matters little beyond 
the necessity for the exhibition of the antitoxin. I am quite sure that one 
or more of my cases of the past winter was of this type, though I have no 



PEDIATRICS 205 

way of proving it. One of these cases developed quite suddenly about 
midnight in a child which had had a severe cold for several days. By ten 
o'clock the next morning it needed intubation. This child died of bi- 
lateral pneumonia at 10 P. M. the same night. 

3. Laryngeal diphtheria. There are two forms of this condition, primary 
and secondary. 

Primary laryngeal diphtheria is, as its name implies, of primary laryngeal 
origin; that is, not following or secondary to a faucial infection. There 
is no visible membrane, and a positive culture is rarely obtainable, because 
of the difficulty of getting into the larynx with an applicator. This diag- 
nosis, therefore, must rest entirely on the symptomatology and clinical course 
of the disease. This form comes on gradually, irrespective of the time of 
day or night; the child is only slightly hoarse at first, but this hoarseness 
gradually increases in severity in the course of one to three or four days 
until labored respiration sets in with marked retraction of supra-sternal 
and epigastric space, as well as the intercostal spaces. Finally, marked 
cyanosis occurs, which gives way to an ashy appearance which immediately 
precedes death from suffocation. This is the course of untreated cases. 
This type is rarely as septic as the faucial or the mixed cases. The reason 
for this is that the larynx is poorly supplied with lymphatics. We should 
never be fooled by the absence of jfaucial membrane, and should never wait 
for a positive culture, when dealing with this tj'pe. 

Secondary cases are those which follow or are secondary to a faucial in- 
fection, or are concurrent with such an infection. They are apt to be 
very septic, and require most energetic treatment in order to save them- 

4. Edema of the glottis may develop in the course of any disease, espe- 
cially, acute nephritis, or arachitii bronchitis (Jackson), or from food idio- 
syncrasy, such as egg albumin. This edema may be severe enough to re- 
quire intubation. 

Incidence of laryngeal diphtheria. In this vicinity (Norfolk, Va.), as a 
rule the largest number of cases occur from January 1st to April 1st, and 
the number of cases is rarely in proportion to the number of cases of diph- 
theria in the community at the time. This year the conditions have 
changed, and I had performed ten intubations before Christmas (four 
since). During twenty years of private practice I have averaged about 
ten each winter. By far the larger number of cases occur among the poorer 
people, but a fair number occur among the well-to-do. 

Responsibility. In a large number of cases the parents rarely think the 
child has anything more than a severe cold for several days, a physician 
often being called when the child is breathing with great difficulty and is 
quite cyanosed. But this is by no means always the case. Physicians 
themselves have a large share in the responsibility in death from membran- 
ous croup. More cases have come to my attention in which the physician 
failed to recognize the condition than those in which he was called too late. 
Physicians are not careful enough in treating sore throats. It is absolutely 
essential to take a culture of every throat which shows a patch, regardless 
of its size or location, and not say that a child has a tonsillitis merely from 
inspection. In almost every case of secondary laryngeal diphtheria which 
has come to me for treatment, the physician has assumed that he was deal- 



206 NORTH CAROLINA MEDICAL SOCIETY 

ing with a tonsillitis, without ever having taken a culture. As for the 
primary laryngeal cases, there is only one absolutely safe rule to follow; 
every case of croup which comes on during the day, and every case which 
comes on at night, and which does not clear up during the day, should 
have antitoxin. If this rule were followed, intubation would rarely be 
performed. 

Age of occurrence. The vast majority of cases of membranous croup 
come on between the first and fourth years; occasionally, however, one sees 
a nursing infant which has to be intubated. My youngest case occurred 
during the past winter, when I intubated a 2-months' old nursing infant; 
which was well advanced in labored breathing, having been stenosed for 
three days. This infant coughed up strips of membrane, which, however, 
showed no diphtheria bacilli on culture. The child did poorly all through 
the tube period (6 days) and died of pneumonia eight hours after extuba- 
tion. 

Indication for operation. By far the larger number of cases which 
come to the operator for intubation come late in the course of the disease 
— many of them so late that it is with difficulty they are saved at all. A 
number are not saved because of needless delay in intubating. When the 
supra-sternal and epigastric spaces are retracting, showing that the child 
is laboring for breath, and bringing into play the accessory muscles of 
respiration, and the pulse is becoming rapid, intubation should be per- 
formed without delay. When the intercostal spaces are retracting with 
inspiration the child is in imminent danger, and when there is a cyanosis 
the case is desperate indeed. The danger in these cases is rarely from the 
septic condition, but rather from the strain that labored respiration puts 
on a heart whose muscle fibers are already affected by a disease which has 
a special predilection for this particular muscle. The longer the stenosis 
lasts without relief, the more rapid and thready the pulse becomes, and 
the more hazardous the convalescent period, with consequent death in 
many cases after the stenosis has been relieved by a tube. 

It is far better to intubate early — even unnecessarily — than to wait too 
long. Extubation, as a rule, is performed on the fifth or sixth day. Not 
infrequently the tube must be replaced within a half hour, while occasion- 
ally it is expelled by coughing at about the right time without needing re- 
intubation. 

The operation. When urgently needed, the more expeditiously the in- 
tubation is done, the better for the child, since, while introducing the tube, 
there is necessarily a short period during which all air is shut off. Perfect 
success in this operation can only be obtained by one with considerable ex- 
perience. I was much amused when asked once by a physician if I did not 
think it was better to do a tracheotomy than to make eight or ten attempts 
at an intubation. The reply was, that any one who had to make so many 
efforts was not sufficiently skilled to attempt it at all. As a rule, from 
the time the gag is placed in the mouth to the time the tube is in place, the 
obturator withdrawn, and the gag removed, should require about ten sec- 
onds. Rarely should it be necessary to make a second attempt. 

Dr. Joseph O'Dwyer, the inventor of the tube, always required his 



PEDIATRICS . 207 

Students to intubate one hundred times on the cadaver before attempting 
the operation on a living child. 

Extubation is far more difficult than intubation. It is particularly 
difficult when it must be done to relieve a stopped tube. When removing 
tube at expiratiori of the needed time of its stay, we may take our time and 
be deliberate. 

The instrument. There is only one type of tube, introducer and ex- 
tubator which is perfectly adapted to this work, and that is the O'Dwyer 
type, made only by George Ermold in New York. There have been many 
imitations, but there is only one genuine. In the selection of a tube it is 
essential to choose the right size ; not so small that it will be easily coughed 
up, aiKi not so large that it will over-stretch the larynx, and thereby cause 
irreparable injury. This error may also result in the child's having to 
wear a tube for a long period, if not indefinitely. 

The care of cases. No class of case holds the operator on duty more 
closely than do intubation cases. He must never be so far away that he 
cannot be reached within a few minutes. These cases are essentially hos- 
pital cases, and require the service of a nurse especially trained. Now that 
the city of Norfolk has a Contagious Hospital, with proper facilities for 
handling intubation work, I require all such cases to be transferred to the 
hospital, although I must say that I have done some of my best work in 
this line, not only in the private homes of the poorer classes, with and with- 
out a nurse, but even many miles in the country, where I saw the patient 
only at the time of intubation. In one of these cases the tube was coughed 
up in an accommodating manner four or five days later, I eventually re- 
ceiving it by mail. 

Dr. Ruff: In connection with this paper I want to mention a condition 
he did not touch on a new disease. Dr. Jackson, at the American Medical 
Association called attention to what he called Peanut Bronchitis, due to 
getting a portion of the peanut kernels in the lung, which caused an in- 
tense irritation to the bronchi and lungs. That was the first time it was 
described. He said he had had many cases of it. At that meeting one of 
the biggest men in London was present — a Nose and Throat Specialist — 
and he had never heard of this condition, but Dr. Jackson has had many 
of these cases. Unless that peanut kernel is removed the patient is going 
to die. I sent a case to Dr. Jackson and he removed it, and the child got 
well. 

Dr. Daniels, Goldsboro : I was very much interested in that paper. I 
have been practicing Ear, Nose and Throat about seven years, but the 
fourth year of my work it fell to my lot to do intubation. It was some- 
thing I knew nothing about doing. I had to make several attempts to 
introduce the tube. The Doctor said you should introduce 100 on the 
dead body before you undertake it on living persons. Last j^ear I read 
a paper on that. I described three ways of doing it. One way was 
direct method — second method was one described by O'Dwyer, and I de- 
scribed one of my own. I claim in that last method that any man does 
not have to have experience to use it, it is not hard on the child, it is easy 
on the doctor — it is one that any general practitioner can do — any spe- 
cialist or anyone else. I will describe this method to you : I wrap my 



208 NORTH CAROLINA MEDICAL SOCIETY 

patient from neck down, lay him on a table about the height of that one, 
perfectly straight head level, you have to have two good assistants, one 
to hold the head, and one to hold the body. I don't use the mouth gag, 
like that — I use the one that pulls from the front and lower teeth; I use 
a headlight, lighted by pocket battery. You can carry that with you at any 
time. I use a thin corrugated tongue depresser, one that will not slip on 
the tongue. It is made out of pressed steel, very simple and absolutely per- 
fect. You open the child's mouth, put this tongue depresser on its tongue, 
as far back as you can push its tongue down, pull it at the same time to- 
wards the child's teeth, at that time you will notice that the epyglotis comes 
in view. The minute this is on a horizontal plane or dropping backwards, 
stick the tube directly in it, then you release your tube with the introducer. 
I personally drop my tongue depresser and run my finger in the mouth 
to be sure that I don't pull it out with my introducer. The first time I 
failed on that. I tried it time and time again. You don't turn the child 
blue in the face by choking him. You should have a mop to get the mucuous 
out. I don't mind doing that now, but I did. If I could have gotten them 
off on my competitors three years ago they would have gotten them. The 
child is not exhausted when you get through. 

My instrument takes too much force for me to engage my tube, conse- 
quently I don't know how I have it engaged. I put a stout string on that 
tube — some say the child will chew the string in two, but they very seldom 
do that. I use a stout silk string. 

Dr. Hart, Lumberton: I didn't get to hear all of this interesting paper, 
but am convinced from what I heard that the method is very complicated. 
I don't know anything about this direct method, but I think the method 
that is commonly used is the most practical method. I don't believe it 
is necessary for me to try on a dead person 100 times to learn to use this 
method. Some of them tried it on probably less than 25 dead bodies. I 
had opportunity before the year was out to see five or six of these cases, 
which leads me to the belief that this is pretty common in rural sections. 
During that year we intubated six children ; three of them were colored. 
It is said that two of them coughed up these tubes and died after that. It 
is certainly harder to extubate than it is to intubate. You have to use 
a small size, because I have seen a child eight years old that you could not 
possibly put a tube in over three or four years' size ; but I do believe if the 
average practicing physician knew more about it that he could save at least 
50 to 75 per cent of these children, whereas death is claiming 100 per cent 
without the tube. 

Dr. Elias: I enjoyed Dr. Royster's paper very much. I belong to the 
class of doctors that would not make a good intubator. I would like to 
ask Dr. Royster if one was not able to intubate in the presence of the child 
who needed relief at once, what would he do? I also want to commend 
what he said about giving antitoxine without waiting for the diagnosis. 

Now that the State is furnishing antitoxine for 25 cents for all that you 
need, there is no excuse for not having it. The other point is that so many 
wait too long. 

Dr. Fassett, Durham, N. C. : I have been using a method of intubation 
which I found very simple. When I get ready to operate, I put the child 



PEDIATRICS 209 

in an angle of 30 degrees, with head raised a little. I use a little brush 
below the larnyx, pressed up and back. The tube is pressed in the larnyx 
and it is picked out. I don't know what the objection could be to using 
that method ; it is very simple and can be easily done. 

Chairman: I agree with the doctors that it is better to be safe than 
sorry. It is perfectly possible for us to know beforehand whether the child 
needs that treatment or not. You should know whether that case is going 

to have croup next week or month ; whether he has 

if he is going to have that, it will be criminal to give him antitoxine. 

I wish to thank Dr. Royster for coming before this society. 

Dr. Royster: I have had one case that did not have to be in- 
tubated. Dr. Elias asked me if a child needed relief, what must we do. 
Intubate it immediately, even if no one is at home. I don't think eight, 
ten or twelve attempts should ever be allowed. I flatter myself that I 
can do intubation with as little trouble on the child as anyone. I don't 
know anything about the direct method the doctor speaks of, but I can't 
see any advantage in it whatever. I dont know how long it takes him 
to do it. No expert intubator ever makes a child blue from using his 
finger, and when he does it is time for him not to do intubation. We all 
see a child break out with cold sweat — that is more often reaction from 
the relief that the child is getting from struggling so long. There should 
be in every community an expert intubator, and if there is not one in the 
community the rest of you doctors ought to get together and send a man 
off to take a course and learn it. I have seen wonderful work in direct 
intubation. Winter before last I had one child that came in with laryn- 
geal Diphtheria and Pneumonia — she coughed up that tube 21 times. I 
know two nights in the snow and sleet I went back and got that tube. That 
child can't live outside of the hospital because she can't retain her tube. I 
do say this, that there should be at least one expert intubator in every com- 
munity, then the rest of you can put yourselves to sleep about the loss of a 
child bj' this membraneous croup. He is practically the only man who is 
called on for this class of work. For twenty years up to the past winter 
I think I got $600 out of all my intubation. 

Paper By Dr. D. L. Smith, Saluda. 

As I have under my care each summer, at my private Sanitarium and 
at the Better Babies Camp at Saluda, N. C, about 200 cases of diseases 
of infants, the majority of which have been treated by other physicians, 
previous to admittance, for various troubles, it is interesting to note the 
difference as to the variety and uses of the various laxatives and purgatives 
given to them. 

In reviewing the literature on this subject, I also find the same difference 
as to the therapeutic value and use of these drugs. 

The conviction has grown upon me that the clinical course of a great 
many disorders of infants is protracted by the excessive use of drugs and 
especially the injudicious giving of calomel and castor oil. 

It is a very common history to find a child begin with some innocent 
upset and has been given a course of calomel in repeated doses followed 
by castor oil, then by other various drugs, which produces a severe intesti- 



210 NORTH CAROLINA MEDICAL SOCIETY 

nal irritation with mucous stools containing blood ; with a loss of appetite 
and a marked loss in weight. These children improve rapidly upon the 
withdrawal of the drugs and institution of a rational diet. 

Indeed, I think the greatest calamity to many infants, I have seen in 
the past two years, suffering with influenza, and in addition, the so-called 
eliminative treatment, which consists in giving repeated small doses of 
calomel and increasingly large doses of castor oil. Influenza, particularly 
in the last epidemic was purely a naso-phyarangeal infection, and nothing 
can be gained by the use of these drugs, which I think eliminates many of 
these infants. 

Calomel and castor oil tend to lessen the appetite and upset the digestion, 
and as an undisturbed appetite and good digestion are the most essential 
things in combating any disease in infants the use of these drugs is abso- 
lutely irrational. 

In diarrhoeal cases there is a positive contra-indication for either calomel 
or castor oil. For both, as I will show later, have the physiological effect 
of an irritant, and as diarrhoea is characterized by an irritation of the 
mucous of the intestinal tract, it is self-evident there is no indication fof a 
laxative, but first and foremost, for the rest of the bowels and second a 
bland and unirritating diet, which is easily digested and lessens the chances 
of fermentation and putrifaction. 

I have visited the various clinics of every authority on pediatrics in 
America in the past few years, many of them being authors of our best 
sellers, which are used as text books in our colleges, and in the hands of 
our practitioners. It is a singular fact, that these authors recommend and 
thereby encourage the use of these two drugs, but never use them them- 
selves. Their students who are fortunate enough to come in personal con- 
tact with their work are taught differently, but those less fortunate that 
use their works as a guide receive a faulty conception of their 
meaning, and inadvertently use them and feel that it is right, because these 
authors recommend them. I will later quote some of these authorities 
with comments. 

Another fact that I have observed in my rounds of the various hospitals, 
is this striking difference. If the hospital has a separate department of 
children with pedriatrician in charge, these drugs are absent. If it hap- 
pens that the children are under the same head as the adult patients, calo- 
mel and castor oil form the shock troop division in the drug armamentarium. 

Castor oil, chemically, consists of a combination of glycerine, fatty 
acids and ricinoleic acid. This combination goes through the stomach 
unchanged, but in the presence of bile and pancreatic juices it is broken 
up into glycerine and cineloic acid. The cineloic acid combines with so- 
dium and forms sodium-rincinoleate, which has marked irritating proper- 
ties.— ;-Morse and Talbot. All stools contain mucus after a dose of castor 
oil. Clinically, castor oil has been used for every known disease an infant 
is due to have. It is rather exceptional to see a baby sick that has not al- 
ready had the initial dose before the doctor arrives, as it has been so freely 
prescribed by physicians in the past. 

I have seen many cases of colic in babies a few days old, the cause of 
which I could ascribe to no other reason than the dose of oil someone had 



PEDIATRICS 211 

given. Castor oil is constipating in its effect. Still, in his recent book 
on diseases of children, says that he knows of no drug which is responsible 
for more chronic constipation in infancy than castor oil. Hare says the 
disadvantage of castor oil lies in its taste, the fact that it is oily, that it 
tends to produce hemorrhoids if used constantly, and finally that its fre- 
quent use, or even a single dose is generally followed by more obstinate 
constipation, than existed before, so that the dose must be rapidly increased 
in size to be effective. My personal observation of pre-school age, as well 
as school children, suffering with constipation, and the various accompany- 
ing symptoms, were directly attributable to the innocent doses of castor oil. 
In the Journal A. M. M., in The Use and Abuse of Purgatives: "It is 
one of the few purgatives that can be given in spite of nausea and vomiting. 
At times it stays in the stomach when nothing else will. On the other hand, 
the ease with which this subtle poison can be given invites its abuse, espe- 
cially in children. As soon as the calomel enters the intestines it is attacked 
by the alkaline pancreatic and intestinal juices, which decompose it into 
mercury and yellow mercuric oxide. The latter dissolves slowly and in- 
completely in the alkaline intestinal Huid. The small quantity of mercuric 
ions thus liberated excites peristalsis and at the same time inhibits the ab- 
sorption of fluids. These effects are so much greater in the small intestines 
than in the colon that calomel is unreliable as a cathartic. The abnormal 
amount of fluid in the large intestine may be completely reabsorbed, giving 
rise to diuresis instead of catharsis unless its reabsorption is inhibited by a 
saline purgative." 

Chondunsny, of Vienna, in his study of calomel, found fourteen fatalities 
from its therapeutic use. In a series of experiments he found that the pro- 
longed use of smqjl doses seemed to be more dangerous than the large one, 
but the larger seem to have a more intense action. His research also 
showed that the production of bile was diminished after calomel, and also 
that the drug had an irritating effect on the kidneys. 

Contrary to the common belief, that calomel is an intestinal antiseptic. 
Dr. Abt, in his series of experiments, shows that on the day after three 
grains of calomel was administered, the bacterial count of the stools rose 
from 210 million bacteria per gram to 762 million per gram of the faeces. 
Morse & Talbot, in their book on Diseases of Nutrition and Infant Feed- 
ing, writing on the subjects of 

"Medical Treatment of Disturbances of Digestion," 

"Indigestion With Fermentation," 

"Intestinal Toxemia of the New Born," 

"Treatment of Infestious Diarrhoea," 
recommend a thorough cleansing out of the intestinal tract; the best drug 
for this purpose is castor oil — it works quickly, thoroughly and causes less 
irritation of the intestine than other cathartics. The dose should be not 
less than two teaspoonfuls — it should be given plain. 

Castor oil should be tried first, even if the baby is vomiting, because it 
is often retained when food and water are vomited. If it is vomited — 
calomel may be given in its place. The usual dose is 1-lOth of a grain, 
combined with 1 grain of bicarbonate of soda every half hour — until 1 or 



212 NORTH CAROLINA MEDICAL SOCIETY 

1/^ grains have been given. It is wise to follow it with two or three tea- 
spoonfuls of milk of magnesia. And yet, neither of these men use calomel 
or castor oil in their hospital practice. 

Dunn, on page 173 in his book on Pediatrics, says of Castor Oil: This 
is the most useful general purgative for use in infancy and childhood. 
Nothing surpasses it in producing rapid and complete emptying of the 
bowels. Its chief indication is in various forms of indigestion, especially 
those characterized by diarrhoea. Infants and very young children do not 
object to the taste, and even older children will often not mind its taste if 
it has not been suggested to them that the taste is bad. When the taste is 
objected to castor oil may be given with orange juice, lemon juice or brandy. 

Calomel: This is a purgative and diuretic, but in children it is used 
almost wholly on acocunt of its purgative action. The toxic effects are 
renal irritation and stomatitis, but the purgative doses used with children 
never produce these effects. Calomel is used as a substitute for castor 
oil when vomiting is present and is often useful in the treatment of vomit- 
ing, as when given in repeated doses it tends to correct reversed peristalsis. 

On a recent visit to Dr. Dunn's clinic at the Infants Hospital in Boston, 
I asked Dr. Dunn how many times he had used castor oil and calomel in 
the work there, and his reply as well as his associates' was that they had 
never used either as far as they could remember. It is impossible to think 
that they never admitted an infant in this institution with the above men- 
tioned symptoms. I told Dr. Dunn that he recommended their use in his 
book, and his reply was that he was going to rewrite it. 

Dr. Richardson : I want to thank him for the fine piece of work he has 
done. He has done a bit of research work — that is searching literature. 
I used to be like most of them trying to get most of the hospitals to back us. 
Dr. Smith visited me ; I took him around and took him to this Orphan 
Asylum, where the nurse does most of the treatment. When I am on I let 
the nurse do most of the treatment. While I was looking at a case Dr. 
Smith asked a nurse how often I used calomel and castor oil there. When- 
ever he goes to the hospital he does not get out before he knows everything 
from the top to the bottom — of course, you know that takes time. You 
know there are a dozen names of women and men who are writing one 
thing in their text books and doing another in their hospitals. All of us 
have gotten to doing that way. Giving a good dose of castor oil. 

There is no such thing as a GOOD dose of Castor Oil, and yet everyone 
of us say that. The only medicine I ever carried with me was a vial of 
1-lOth grain Calomel tablets and I give 1-1 0th grain until I give ten doses. 
I thought that would satisfy them. 

Chairman: Many thanks to Dr. Smith for this valuable paper, and I 
am sure we have all profited by it. 



Public Health and Education 

IMPORTANCE OF A CITY TUBERCULOSIS SANATORIUM. 
Dr. R. L. Carlton, City Health Officer, Winston-Salem. 

In mentioning the importance of the municipal sanatorium for tubercu- 
losis we wish to go on record as being on very solid ground when we affirm 
that the sanatorium is only one of the means of efficiently carrying out a 
program in the fight against tuberculosis by a city or community. 

After a campaign of a few years' duration we have in my town a tuber- 
culosis dispensary, physician in charge of dispensary, special tuberculosis 
nurse, district nurses supervising the home lives and treatment of those 
in need of their instructions, a system of relief for those unable to provide 
themselves with the necessary food and medicines — all of these activities 
supported for the greater part by the municipality, as should be the case. 
There has been carried on a campaign of education which has accomplished 
something toward bringing to many of the people something of the knowl- 
edge of the disease and how to combat it. 

The purpose of the activities of the tuberculosis division of a municipal 
health department are (quoting from a U. S. P. H. Service bulletin) 

1. To alleviate the sufferings of the sick and see that they have comfort- 
able surroundings and proper care. 

2. To prevent the spread of the disease and to protect the well from 
infection. 

To be of effective service to those who are sick it is necessary to know 
of their existence. Here, as you all know, comes the importance of vital 
statistics — the prompt reporting of all cases of tuberculous immediately 
after an early diag:nosis has been made by the physician, the correctness 
of Siritements on death certificates certifying as to cause of death, the im- 
mediate following up by a competent person, and by this term is meant a 
nurse of training and ability, all cases reported as tuberculosis, the families 
and other contacts of persons certified to have died with tuberculosis; the 
encouragement of exposed persons to avail themselves of clinic examination 
and treatment, if needed ; the constant supervision of all cases diagnosed 
"tuberculous" to see that all necessary care of themselves and precautions 
as to others are observed — these constitute some of the activities of the 
tuberculosis nurse and dispensary. 

There should, of course, be other nurses to carry on educational work 
in the homes and schools. 

Open air schools should be one of the means of every municipality, and 
every rural community also, to combat the inroads of tuberculosis. Chil- 
dren who are undernourished and anemic should by no means be cooped 
up in a crowded, ill-ventilated school room — and neither should the normal 
child. It has been most successfully proven that all school children fare 
better physically and mentally when their classes are "open air" classes. 

The undernourished child should be cared for in a preventorium, where 
such is possible. The advanced cases of tuberculosis especially should have 
the care of sanatorium treatment. In Winston-Salem we are trying to 
carry out these measures as roughly outlined for the care of our tuberculous. 



214 NORTH CAROLINA MEDICAL SOCIETY 

Dispensary, special physician, specially trained nurse, home supervision, 
sanatorium for advanced cases- At the tuberculosis sanatorium or hospital 
situated just on the outskirts of the city is provision for thirty-two (32) 
patients, with possible expansion to sixty (60). The advantage of the 
location being nearby is apparent — the patient does not have a long trip 
to make, he may be visited by his friends and relatives, he is much more 
content than if sent away a hundred miles or more. The care and treat- 
ment of patients in the institution is good. There is every reason from 
our point of view that there should be a long waiting list for admission 
— for their own sake and for the sake of their families and neighbors. This 
condition does not always exist- The speaker agrees very heartily with 
Dr. John Dill Robertson, Dr. Rosenau and others that the forcible deten- 
tion in sanatoria of incorrigible consumptives will be one of the means of 
remedying the tuberculosis situation. The health officer is charged with 
the control of contagious diseases, and this power may be exercised with 
regard to cases of tuberculosis as well as in cases of scarlet fever or diph- 
theria. Education, exhibits, lectures, motion pictures have been used in 
the campaign against tuberculosis and much good has been done ; but we 
do not depend upon an educational campaign for control of diphtheria or 
scarlet fever. It is necessary to establish quarantine and lay down more 
or less rigid rules. Every reported case of tuberculosis should be visited 
by a nurse or physician and he should be told of the danger to his family 
and friends if he continues to expectorate on the floor ; of the danger to 
himself if he refuses to sleep outdoors; of the danger of over-indulgence 
in alcoholic drinks, and any other instructions necessary. He should be 
provided with sputum cups. If at subsequent visits the nurse finds her 
instructions obeyed, the patient using his paper cups and not expectorating 
elsewhere, and at least the head part of his bed outdoors and that he is fol- 
lowing other instructions, then he is permitted to remain at home and all 
assistance possible given him there. If, on the other hand, it is found that 
instructions are not being carried out, the nurse warns him that upon the 
next visit if conditions do not comply with regulations he will be sent to 
the sanatorium. Dr. Robertson believes, and so do we, that if every per- 
son suffering with open consumption was apprehended and by force com- 
pelled to conduct himself in the sanitary manner which patients at the 
sanatorium are compelled to adopt, the spread of tuberculosis would be 
greatly reduced. Every consumptive who is trained to follow the rules 
of hygiene in caring for himself and in protecting his family and associates 
against his disease is one of the strongest educational elements we can place 
in a community. Some such plan of forcible detention and education would 
mean more careful patient and more careful families, it would mean other 
cases developing in the family would be given earlier medical attention, it 
would mean gradual lessening of infection and very likely gradual elimina- 
tion of the spread of tuberculosis. 

CITY ABATTOIR AND MEAT INSPECTION- 

By Dr. R. L. Carlton, City Health Officer, Winston-Salem. 

Various means are used as a protection of the food supply of a city — 

among them being inspection and supervision by skilled persons 

of all places where foods are handled, stored or sold to determine that such 



PUBLIC HEALTH AND EDUCATION 215 

places are kept in a clean, sanitary manner; the physical examination by a 
physician of all food handlers to determine their freedom from communi- 
cable disease ; the requirement that utensils used in serving foods be properly 
washed and cleansed ; the requirement that all foods, especially meats, be 
sound and wholesome if to be used for human consumption. Regarding 
the handling of meats especially, it is our opinion that the supervision of 
this part of our food shall be done by a man of experience and training, 
preferably a veterinarian from a school of good standing. In Winston- 
Salem the slaughtering of animals for food is done at an abattoir owned 
and controlled by the municipality, and the arrangement seems to be prefer- 
able to that of having one or more slaughter houses owned by individuals. 
The city supplies the manager, laborers, meat inspectors and entire personnel 
for the abattoir. Every worker coming in contact with the meats under- 
goes a physical examination at least once a year — more often if in the opin- 
ion of the health officer it is thought necessary — to determine freedom from 
disease. All animals are seen by the inspector before and immediately after 
being slaughtered and any diseased conditions warranting condemnation 
cause such carcass to be promptly tanked for fertilizer. Meats are required 
to be left in cold storage at the abattoir a certain number of hours before 
being offered for sale. 

Fees are charged for slaughtering and after a certain number of days' 
storage fees are charged if meats are left in cold storage. Our arrangement 
seems to be working smoothly — the meats are thereby kept under close super- 
vision — all animals excepting calves and hogs may be slaughtered in the 
country, not in the city, by the producer, and he is required to bring such 
carcasses for inspection by city meat inspector before offering for sale. 

Certain rules are observed as to age and weight of calves and as to condi- 
tion of beeves, etc., and in the main our meat inspection as done by the city 
inspector at city markets and abattoir is very satisfactory. Of course, meats 
shipped into the city by outside packers bear the stamp of the B. A. L, and 
while looked after by our inspector to determine decay do not require rigid 
supervision to determine diseased conditions. 

Discussion. 
Dr. J. E. Brooks, Blowing Rock: There is one phase of this paper that 
impressed me as of grave importance. Before the fight against Tubercu- 
losis can ever progress very far, there must be compulsory detention of the 
tuberculous patient in the sanatorium or some institution where he or his 
movements can be directed, guided and controlled by those in authority. 
In going into a home and making a diagnosis of tuberculosis and giving 
instructions as to the management of that case I challenge the doctor, if he 
be here, who has had success in getting the carrj-ing out of their orders, to 
hold up his hand. 

Our work must fail until we get the hearty co-operation of the public 
in enforcing our work. The mere diagnosis of a tuberculous patient and 
outlining his management may amount to nothing at all, the doctor becomes 
discouraged and feels hopeless, and he is hopeless unless the public gives him 
that support that forces his patient against his will to take the proper treat- 
ment. 



216 NORTH CAROLINA MEDICAL SOCIETY 

Dr. C. E. Lowe, Wilmington: There is one thing hinted at by Dr. 
Carlton, which I have found to be very detrimental in Wilmington. We 
have had, for some years, a County Tuberculosis Sanitorium. It has never 
been the success it should have been. It was never the success it should 
have been before I began to work, nor has it been since. That arises 
through the difficulty of getting people to accept treatment in it and that 
bears out the statement just made that coercion must be the factor in the 
control of a large percentage of cases. I think it has been my observation 
that the case that needed control most, the open, free expectorating case, 
was the one hardest to get control of. The cases among the poor and illit- 
erate are particularly hard to get under control. There are great obstacles 
in our present state of public knowledge in regard to getting enforcement 
of the law, a compulsory law for detention in open cases. I think we are 
coming to that. They are the people, in my mind, who need it — the ad- 
vanced cases from the standpoint of protecting the rest of the public- 1 
am not speaking of advantages to be obtained from the incipient cases. Dr. 
McBrayer is the one to speak of that. Another important thing brought 
out in Dr. Carlton's paper is the Educational Value. 

Those people you get in the Sanitorium get instructions and they spread 
that instruction throughout the county, which is a most valuable means 
of spreading that information. It is given them through the Sanitorium. 
It becomes a matter of habit, and they carry it out, better oftentimes than 
they will under the direction of the physician. 

Dr. Lewis, Raleigh: 

I wish to ask Dr. Carlton — I was told yesterday that of the total number 
of patients that had been admitted to the Winston-Salem Sanitorium that 
only four ever left alive. Of course, if that is true, it seems that the educa- 
tional value from the Winston-Salem Sanitorium is very small. As a 
matter of common sense it does not seem to me that the expenditure of 
money for a Municipal Tuberculosis Sanitorium is the wisest method. 
I am not accurate as to the number of cases. A movement was started in 
Wake for the purpose of establishing a Municipal Tuberculosis Sanitorium, 
but it failed. We assumed that 75 beds in that Hospital would accommo- 
date one-tenth of the patients, and I am told it would cost $2 or $3 per 
day to support a patient. On a basis of 100 patients it would cost about 
$100,000 per year to support that institution. It does seem to me that the 
money that would be expended on a Municipal Sanitorium, that it would 
be practically only a house of detention, from the late cases which we must 
bear in mind are not taken into the institution until they are late cases, or 
until they have infected the other members of the family before they are 
taken away. 

In 1906, when I was President of the National Conference of the State 
and Provincial Boards of Health, my address was on Tuberculosis. I took 
the position that money spent on a Sanatorium at that stage of the con- 
test was not spent to the best advantage ; that so far as the cure of the 
patient was concerned that would cost about $42,000 a year to run it. I 
took the position that if that $42,000 was invested in Health Officers, that 
the result would be to educate the people on the subject, and the total num- 
ber of cases that would be cured through that method, by home treatment, 



PUBLIC HEALTH AND EDUCATION 217 

would amount to 50 or 100 more than would be in the hospital. It does 
seem to me that the money that would be necessary to spend on a Municipal 
Sanatorium to segregate these patients in the last stages, that if that money 
was spent for the instruction of the people, employment of skilled nurses, 
etc., I believe we would get greater results than we do from the Sanatorium.' 
I am more and more confirmed in the idea when we have such a tremendous 
proposition to handle and not money enough to take care of more than one- 
tenth of them that we could spend it to a much better advantage. 

Dr. McBrayer, R. A. : I am strongly in favor of the educational program. 
We ought to have a better one than we have. In our aim and struggle I 
think at times we have overlooked something that we can right now, in 
the three million discharged soldiers we have. They were trained to accept 
the hospital treatment for a slight ill. When we find a family that has a 
case of Tuberculosis in it, if it is father, son or brother that has much 
training in the army, ycu can tell him that this sister, wife, husband or 
brother ought to accept Sanatorium treatment, and I bet you 99 times out 
of 100 this ex-soldier will agree with you, and he will do his best to get 
that person to go to the Sanatorium. They know that Sanatoriums are 
the places for tuberculosis patients, and you are doing wrong if you don't 
go. I think lots of times when we are doing this educational work if we 
made our appeal to or through the soldiers, who are so well trained in the 
use of Sanatoriums and the like, we would get better results. 

Dr. Lewis: I want to express my great appreciation in the great work 
along the educational line, that is being done at our State Sanatorium. 

Dr. Carlton : I would like to say, for the benefit of Dr. Lewis that 
more than four patients have left alive, because more than that many have 
left there without permission. We have no means of forcing them to stay 
there. We cannot near take all the patients in Forsyth County. I wish 
we could. I would think that we ought to have a number of beds in this 
Hospital to be used for educational purposes and educate them how to take 
care of themselves and look after the family at home. 

REMEDIAL CONDITIONS IN SCHOOL CHILDREN. 
Margery J. Lord, M. D., Asheville. 

Gentlemen, you are all interested in health problems and in preventive 
medicine or you would not claim to be practicing medicine, in 1920. And 
yet I am sure to many of you Medical Inspection of school children is a new 
phase of nealth work. France began this work when, in. ]P,^\^, she estab- 
lished a royal ordinance decreeing that school authorities should look after 
the sanitary conditions of the school children. In the United States, Boston 
M'as the first city to establish a regular system -.'.: medical inspecti^.n, begin- 
nmg m 1894 with a staff of fifty physicians. This work has steadily grown 
until now Medical Inspection is provided for by the law in nearly one- 
half of our states; regular organized systems of Medical Inspection are 
found in about one-half of our cities, while some sort of a beginning has 
been made in nearly three-fourths of them. 

With this bit of history to refresh your minds, let me now get at the real 
purpose of this paper. I have divided my paper into three sub-heads, the 
first of which is: 



218 NORTH CAROLINA MEDICAL SOCIETY 

1. Educational Handicaps: These handicaps concern not only the 
physical welfare of the child, but are an economic problem of every city 
and state. Here are some facts concerning New York City children : A 
child with seriously defective teeth requires one-half year more than a non- 
defective child to complete the eight grades. About one-half of all school 
children have defective teeth. In the same manner, the child with hyper- 
trophied tonsils takes seven-tenths of a year more than he should. One 
child in four has hypertrophied tonsils. The extra time required by a 
child with adenoids is one and one-tenth years. One child in eight has 
adenoids. The pupil with enlarged glands requires one and two-tenths 
years longer- Nearly one-half of the children have enlarged glands. These 
handicaps to a child's education, therefore, become an economical problem, 
and it is a simple matter to compute how many dollars are wasted each year 
in the futile attempt to impart instructions to pupils whose mental faculties 
are dulled through remediable physical defects. Conservatively speaking, 
then, we may say that 60% of all school children suffer from such defects 
and that the instruction given these children suffers a loss in effectiveness 
of nearly 10% because of physical defects which could be removed. It is 
indeed very evident that our problem is of real financial importance. 

In Bridgeport, Conn., A. C. Fones, D. D. S., has made some interesting 
and instructive observations. He found in 1912 the cost for re-education 
in Bridgeport equalled 42% of the entire budget With this fact staring 
him in the face and realizing that something could and should be done 
to better the health of the school children, Dr. Fones decided that the most 
conspicuous defect of the child is the unsanitary condition of his mouth. 
On examination he found teeth covered with green stain, temporary and 
permanent teeth badly decayed, fistulas on the gum surface showing ; 
outlet for pus from an abscessed tooth and decomposing food around and 
between the teeth. Why go any further in your examination of the child ? 
Right here at the gateway of the entire human system is a source of infec- 
tion and poison sufficient to contaminate every mouthful of food taken. If 
Dr. Fones were right in his deductions that the most unhygienic feature 
of a child's life is its mouth, then clean mouths, sound teeth, and toothbrush 
habit should, to a large extent, rid us of educational handicaps. He has 
taken up this problem in a very efficient manner, and with a corps of three 
dentists and twenty-six dental hygienists, he has accomplished an untold 
amount- There are four distinct parts to this system. First — Prophylac- 
tic treatment, or actual cleaning and polishing of the children's teeth and 
chart examinations of their mouths. Second — Toothbrush drills and class- 
room talks. Third — Stereopticon lectures for the children in the higher 
grades. Fourth — Educational work in the homes by means of special lit- 
erature for the parents. The result of this mouth hygiene has been roughly 
as follows: In 1918 the cost for re-education in Bridgeport was 17% of 
the entire budget instead of 42% as it was in 1912. This work is of eco- 
nomic value certainly. But it does not stop there. This change has been 
a vital one to the self-respect of the pupils and in advance of the normal 
conditions of the normal children. In 1912, 1,356 children in grades II 
to VI, all of whom were in the retarded class and over 14 years old, left 
school to go to work. In 1918, less than 300, all in grades V and VI, re- 
ceived working certificates. In other words, the children had been edv 



PUBLIC HEALTH AND EDUCATION 219 

cated to see the value of higher education. They had not been retarded 
through physical handicaps and become discouraged, but their clean mouths 
and cleanly habits had given them self-respect which in turn made them 
wish to really amount to something. 

So far I have emphasized the economical side of educational handicaps, 
chiefly because a mathematical problem may be proved without any ques- 
tioning and when reduced to dollars and cents health problems become more 
convincing to a community. You, as physicians, have but to give this 
matter your serious attention to bring before you the possible wrecks of 
adult life because of defects which should have been removed in childhood. 
The mentally deficient, the blind, the deaf, the deformed, undernourished, 
anemic specimens, advanced tuberculosis, organic heart trouble and the like. 

I\Iy second sub-head : 

2. Medical Inspection: There is no one present, I hope, Avho will 
not agree that school children have defects which are hindering them from 
pursuing their studies either because of frequent absences due to illness or 
actually making them incapable for their work. The first step, therefore, 
is to find these defects — to seek out the reason that some children "just 
can't keep up" with their studies or are absent one week each month. We 
as a state say these children shall go to school, whether they be rich or poor, 
bright or dull, healthy or sick. Should we not, therefore, be responsible 
that the child be in the best possible condition to receive this required educa- 
tion and derive every benefit therefrom? Is it not up to us to remove every 
possible stumbling block from his path so that physically as well as mentally 
he will beccme a well rounded and as nearly as possible perfect citizen of 
our United States? This is what medical inspection and medical inspectors 
are trying to do, to back up education with health. 

Some may argue that it is the parent's duty to take his child for frequent 
examinations to the family physician. That would be excellent, but there 
are three drawbacks: First — The majority of parents would never take 
the trouble to do this. Second — The family physician, when asked to look 
the child over, "chucks" him under the chin and asks a few vague questions, 
prescribes a tonic, and the interview is at an end, without the doctor even 
looking at the boy's mouth and throat — let alone stripping him to the waist 
and examining his heart and lungs. Third — The expense, if the physician 
does examine the child and makes a proper charge, the parents will consider 
it useless to throw away that amount of money on Johnny "when he really 
i?n t SICK- 

The medical inspector makes a uniform examination of each pupil and 
after each examination keeps a record of it, and this record is kept in the 
school building with the child's report cards. There it is in a nutsliell, 
the child's physical standing as well as mental. The physical examination 
card has room enough to record four examinations on it, thus showing any 
changes in health throughout the grammar school, at least. 

There are many other duties of the medical inspector besides purely the 
physical examination of the children. His duty, in my opinion, covers 
anything whereby the health of the school children will be improved. But 
as my paper is dealing with the children themselves I will not warider too 
far from my subject. 

My third and last sub-head is my real reason for writing this paper. 



220 NORTH CAROLINA MEDICAL SOCIETY 

3. What Shall We Do With These Defects? I want each one 
of you to ask yourself this question. What shall we do with these defects 
these educational handicaps revealed to us by medical inspection of our 
school children? Can we, who are medical inspectors, spend our evenings 
congratulating ourselves on a big day's work because we have examined 
thirty children and sent cards home notifying the parents that twenty of 
these children had some defects which we wished corrected at once? This 
is but a waste of time and paper if we stop here. Our influence must be 
brought to bear on the parents themselves and they must be made to see 
the necessity of the treatment advised for their children. Here is where the 
school nurse is indispensable. She goes to the home, talks to the mother, 
leaves a health pamphlet and possibly comes away feeling there is no use 
to waste time in that home, but eventually, when she has made four or five 
visits, the parents are convinced that the child should have his tonsils 
removed or hir teeth tilled or whatever the defect is remedied. Now comes 
the hard part. The parents can afford to pay something and their pride 
makes them want to, but they know they can't afford a specialist's fee. What 
is to be done? The Medical Inspector has found the defect. The nurse 
has educated the family into being willing for the operation. The specialist 
will do the operation gladly for nothing, but the people won't submit to 
that. One way has been provided by the State Board of Health in their 
tonsil and adenoid clinics. They look upon school children as all being 
equal and make a charge of $12-50 for each tonsillectomy, planning to do 
enough operations in one day to permit about four children who are too 
poor to pay to be included and paid for by the $12.50 from the others. In 
this way the surgeon may receive the sum of $100 per day for his services 
and all expenses of the clinic defrayed by the children themselves. This 
plan certainly has many advantages and has provided a means whereby 
many of the rural children have received surgical aid this past year. Rut, 
like every good thing, this has been criticised. It was thought by some that 
the sheep and goats should be further separated and the rich made to nay 
the specialists fee, and hence refused the clinic. 

The Buncombe County Medical Society has adopted the following plan: 

"The committee appointed by the Buncombs County Medical Society 
to devise a plan for organizing a tonsil and adenoid clinic in Asheville, begs 
to submit the following recommendations: 

1. That the public at large, regardless of age, includmg not only those 
of tichool age, but th.se above and below that period, ha>e the piivileges 
of the clinic. 

2. That the privileges of the clinic be extended not only to the City of 
Asheville, but to Buncombe County. 

3. For the purpose of defining the object and the scope of the clinic that 
the public be divided into the following classes: 

A. Those who are unable to pay a hospital fee. 

B. Those who are able to pay a hospital fee and no more. 

C. Those who are able to pay a clinic fee of ^U2.50 and no more. 

D. Those who are able to pay more than the clinic fee. 

4. In order to provide for those whose means place them between Classes 



PUBLIC HEALTH AND EDUCATION 221 

A and B, and between Classes B and C, and that no one may be denied 
the privilege of contributing to the support of the clinic according to his 
means, that flexible limits be placed on Class B. 

5. That the privileges of the clinic be extended to Classes A, B and C. 

6. That Class D be referred to their family phj'sician for advice. 

7. That each applicant for the clinic must bring from his family physi- 
cian a written statement as to which class he belongs, or what fee he is able 
to pay. 

8. That the clinic be held in the three general hospitajs of Asheville and 
Biltmore, North Carolina, all three of these hospitals having generously 
offered their hospital facilities for the purposes of the clinic, conducted as 
herein set forth. 

9. That all clinic fees be collected by and apply to the support of the 
hospitals. 

10. That the clinics be conducted in the various hospitals from day to 
day as applicants present themselves and as facilities permit, rather than in 
large groups. 

11. That the managements of the various hospitals be requ -sted to co- 
operate in developing further details of the clinic. 

12. That the co-operation of City and County health ifficer> he solicited. 

13. That no physician make any charge for services rendered in the 
clinic." 

But we find more defective teeth than we do tonsils and adenoids. We 
could keep every dentist in Asheville busy filling children's teeth. A dental 
clinic is just as important as a tonsil and adenoid clinic- Last summer we 
had a chance to see what the State Board of Health was doing along this 
line when they sent Dr. Schultz to us, who in six weeks' time based on our 
local charges did work amounting to $2,500 on our school children. The 
authorities of the city of Asheville have already signified their willingness 
to furnish funds for the equipment of a dental clinic, and it is my hope that 
next September will see us ready to start the school year with a permanent 
dental clinic — operated by, if necessary, only a part time dentist, whose 
salary shall be paid for by both county and city, thus giving the children 
of the county the same privilege as those of the city. 

The school nurses are doing all in their power to prevent dental decay, 
by toothbrush drills and by making it possible for every child to own a tooth 
brush. From the Prophylactic Company children's tooth brushes, factory 
seconds, can be secured for the children at 6c each. Many gross of these 
tooth brushes have been sold to the children this year. The Modern Health 
Crusaders Movement, literature published by Dental Manufacturing Com- 
panies and the Metropolitan Life Insurance Company, has done much to 
interest the children and parents in the proper care of their bodies, the 
necessity of plenty of sleep for growing children and the value of regular 
meals composed of nutritious food. All this is doing its part to improve 
the physical standard of our school children. 

To summarize them: Medical Inspection began in this country in 1894 
and has increased until now three-fourths of our cities have some form of 



222 NORTH CAROLINA MEDICAL SOCIETY 

Medical Inspection. Physical defects which mainly are — decayed teeth, 
adenoids, hypertrophied tonsils and enlarged glands, are educational handi- 
caps, which, if properly attended to in early child life, would relieve the 
state of a large financial burden due to the cost of re-education of retarded 
children. Medical Inspection has become a necessary part of preventive 
medicine practiced by every board of health, but Medical Inspection is 
pow^erless to reach its full value unless a means be provided which will 
amply and adequately give the public a way to have these defects treated 
which will bear in mind the fact that all people have a great deal of pride, 
that very few want to be on a charity list. Yet many have a nearly empty 
pocketbook. 

In concluding, gentlemen, let me urge you to a candid discussion of this 
paper. I am expecting to learn more from your discussions than you have 
from my paper. 

Discussion. 

Dr. George M. Cooper, Raleigh : I wish to emphasize the fact that 
Dr. Lord in her grand paper has sounded the key note of this profession. 
She stated the financial problem was the key note of the whole thing. She 
brought out another important problem. That is "To back up the educa- 
tion of the children with health." I think that is the whole thing in a nut- 
shell. As to the Asheville, Buncombe County, plan for getting this work 
done, I think it will succeed. I don't know of another place in North 
Carolina where it would succeed. That is that the Medical Inspector and 
those three skilled employees will camp on the trail of every physician in 
that county. I would hate to be the doctor that would prescribe a medicine 
for diseases of the throat and let one of these people find it out. I will 
close by saying that four officials are four sulid bricks in Asheville. 

F. H. Richardson, Brooklyn, N. Y. : I wish to thank Dr. Lord for one 
idea she gave me, that is practical application of a way to put across the 
corrections after you have found them. We have been working this along 
with ideas that originated in Boston for Tuberculosis. We get children 
from the general clinic, who we find undernourished and take in our case 
the weight, where she takes the retardation. We find the teeth common 
and tonsilis and defective heart quite common. Eye defects common. We 
find we can never increase the weight until we get the tonsils out and teeth 
cleaned up, until we can get the youngsters to get those things done, no 
matter what he does he will not gain weight. Another thing is getting 
20 to 60 children together with their parents, if they can come, and put a 
little boy scout in it. Say a little boy has a chart and he sees a two or three- 
ounce gain, and we give a certain prize if he gains one-half pound or one 
pound, and it is surprising how keen those children are to get that prize. 
They make their parents do things that they don't want to. The children 
are the ones who initiate the improvement. The New York City Board 
of Health tried getting the family physician. They brought out the defects 
found by the family physician, and the Medical Inspector had it on the 
family physician. They could not get enough family physicians to make 
this inspection. It is very interesting for me to find how large a proportion 
of the special practice can be composed of mere children. They are urging 
me for treatment. 



PUBLIC HEALTH AND EDUCATION 223 

The Tj'phoid inoculation and all those things are being urged by the 
people, and the doctor who is not prepared to do that has, in my mind, a 
very serious responsibility. The hospitals seem to set a good example to be 
followed by the city when they urge the establishment of school examina- 
tion. I think the hospitals can well set the example. 

Dr. Lewis, Raleigh: As the oldest specialist in North Carolina and a 
man who has been associated with Public Health work in the State thirty- 
odd years, I feel it my duty to say a word or two. I think this work that 
is being done by the clinics is extremely important, and I think the present 
plan that has been devised is the best plan- As I understand, at Asheville 
the children are brought to the clinic. And for the reason that the rich 
man can't bring his child to the clinic and have him operated on for any 
less than the specialist will charge. You will see, I think, in a moment 
how it is that the clinic conducted upon the present plan is one of the best 
methods ever devised for the purpose of advertising the business of the 
specialist. 

These clinics are held in a certain county and a number of defective 
children have been operated on in these clinics, and they go back home and 
the neighborhood w^ill see the effect the operation has had. The clinic is 
not held in that county for a long time after that. What is the consequence ? 
The consequence is that the people knowing they could not get advantage 
of the clinic for twelve months send their children to the specialist. The 
specialists who do these operations have nothing to lose from the financial 
point, but everything to gain. There are thousands of children in this state 
who need to be operated on, and a'majority of those would never be reached 
if not by this method. This will not only be the means of extending benefit 
to a larger number of children in the community, but of putting more dol- 
lars in our pockets. 

If there is not something else in the Medical Profession besides money, 
I think it is time for us to get out. In contrast to the attitude that the 
physician is after the money, ignoring the welfare of the community, I 
want to tell you a beautiful story of Erwin Cobb. He said : "The story 
I propose to tell j^ou now, the beauty of it, is that it is true." He said that 
in one of our Southwestern towns there lived a Dr. Thomas Lyerly, a coun- 
try doctor. The rich people had never heard of him. His practice con- 
sisted of down and outs and drunkards. He had an oflUce in a respectable 
building for a while and something came along and he had to move, and 
the only place he could find for an office was over a Livery Stable. He 
took a plank and painted a sign on it — "Dr. Thomas Lyerly, his office is 
upstairs," and nailed that to the stable. He had a call several miles off, 
and as a result of exposure he contracted pneumonia- He came home, went 
to his room and locked the door. In a day or two they missed him and 
found the door locked and broke it open. There lying on the bed was Dr. 
Thomas Lyerly, with his old account book and pencil in his dead hand, and 
he had written across each account, "Paid in full." He was taken to the 
cemetery, and these people followed him on foot, no carriages. They came 
back to town and were discussing that they ought to put a monument over 
his grave. They took up the post on which he had painted this sign on it, 
and planted it at the head of his grave — 



224 NORTH CAROLINA MEDICAL SOCIETY 

"DR. THOMAS LYERLY, HIS OFFICE IS UP STAIRS." 

I think when we compare that, we can say there are thousands of them 
in this country. When we compare that attitude towards humanity, I 
don't believe any of you have it in your heart to say that this society is out 
for the love of monej^ 

Discussion closed. Dr. Lord: I want to say, gentlemen, that the clinic 
I outlined is at work in Asheville. We have been decidedly handicapped, 
but we are running it, and next year I hope we will be able to report what 
has been done. 

I will say that the only thing we have done of much importance is to 
get weight charts from the Colnos Dental people. They send us large 
charts that will hold the names of between 40 and 50 children. We try 
to have one in each room in each school building and record the weights of 
the children on this chart. On a table in one corner is correct weight, age 
and height. We hope to get up to the standard. 

These clinics that have been held by the State Board of Health or by 
any city, for tonsils, adenoids or dental, I think the highest value is un- 
doubtedly the educational. The weight and health of the child cannot be 
improved unless these defects are removed. In order to do so we have cer- 
tainly got to educate the parents- 

Dr. George M. Cooper, Raleigh: Before reading my paper I wish to 
express my cordial appreciation to Dr. Lewis for the power of strength he 
has been to us in the past. For the benefit of some of the younger men 
and women. Dr. Lord may not know that Dr. Lewis was the first recog- 
nized specialist of ability in the State of North Carolina. For forty years 
or more he has maintained his position all the time in his profession. This 
generation will never know how much good he has done in the world, and 
I wish to commend his admirable spirit, in placing his service before money, 
to some men in our profession. 

THE STATE PLAN FOR SECURING MEDICAL AND DENTAL 

CARE OF SCHOOL CHILDREN. 

By G. M. Cooper, M. D., 

Director Medical Inspection of Schools, State Board of Health, Raleigh. 

On assuming the duties of Medical Inspector of Schools for the State 
of North Carolina some five years ago, and after having had a previous 
experience of two years in county work of this nature, it did not take but 
a short while to reach the conclusion which every experienced person engaged 
in this work soon reaches, that medical inspection that does not provide a 
systematic plan of follow-up work is practically worthless. 

Anything short of a State plan for meeting the many problems that one 
confronts at every turn will not be satisfactory. There are certain things 
to do which must combine the preventive with the remedial problems. In 
the first place, every inspector soon finds that the epidemiology division 
must function properly or the schools are demoralized for a certain period 
during each session. Parents of perfectly well, healthy children will be 
found keeping their children at home because of the fear of whooping cough 
or measles, and the children of careless parents will be found spreading 



PUBLIC HEALTH AND EDUCATION 225 

such infections in the schools. So the first thing that has to be done, is to 
see that the well children are not penalized by the few careless patrons of 
the school. The intelligent and watchful interest of the teacher is abso- 
lutely essential. Again, in practically half the State every year as soon as 
the schools settle down to work after the Christmas holidays, outbreaks of 
smallpox "begin to demoralize the attendance again, especially in the country 
districts where compulsory vaccination against smallpox before entrance 
in school is not enforced. So we find that often 90 per cent of healthy chil- 
dren are kept at home certain days because 10 per cent of the children may 
have been thought exposed to smallpox. The only sensible thing to do in 
this matter is to require county-wide vaccination against smallpox before 
children are admitted to the parochial or public schools. But the real big 
problem with which medical inspectors should be concerned is in the cor- 
rection of physical defects after found. 

The State Board of Health of North Carolina has developed a systc; 
of caring for defective children, both surgical and dental, which has been 
carefully worked out over a period of several years, and is primarily based 
on necessity. The first effort was directed toward the care of the school 
children's teeth because of the fact that about 80 per cent of the chiuren 
enrolled in the schools of the State were known to have need or dental treat- 
ment. On July 10, 1918, we started the first systematic work in this field. 
The plan, as everyone here knows, is to take the dentist to the children out 
in the school houses or in convenient country centers, whether the schools 
are in session or not, and have the children from six to twelve years of age 
who are known to be in need of dental treatment brought to the dentist 
for the simple forms of treatment. Each dentist is equipped with a portable 
outfit and the emphasis is placed on prophjdaxis. The idea here is to cause 
a state-wide awakening of all the people from the homes of the wealthiest 
to the remote cabins of the poorest of the State's children to the necessity 
of dental care at the right time for the teeth of every child. We need not 
go into figures, but simply state that the importance of this move is becom- 
ing more and more appreciated by responsible people throughout the length 
and breadth of the State. 

The problem of carrying surgical aid to children suffering from the more 
common defects of childhood, such as diseased tonsils and adenoids, has 
been much harder to solve than the dental care, but the necessity of some 
solution has been no less imperative. After an experience, as stated 
in the beginning of this paper, of several years, based on careful medical 
examinations and observations in many counties, it has been found that 
there are no less than fifteen out of every hundred school children enrolled 
in the schools of the state suffering from diseased throats demanding opera- 
tion by competent throat surgeons. These defects have been so patent 
that the teacher, the parent and even the neighbors readily assert that some- 
thing is wrong and ought to be remedied. Some of these children have 
tubercular or rheumatic ancestry either direct or closely collateral. None 
of them without the operation can be reasonably expected to develop into 
healthy men and women without such operations at the proper time. It 
has been learned beyond question that less than 1 per cent of such childreit 
ever even consult a specialist and less than 10 per cent ever taken to the 



226 NORTH CAROLINA MEDICAL SOCIETY 

family physician. We have found in the majority of such cases that the 
average fees of specialists are beyond their reach ; but what is a much nn^re 
difficult problem, there is widespread fear of the operation, ingrained belief 
that it is devised for the enrichment of doctors and specialists. So, primarily 
to dispel such foolish beliefs and at the same time to convince the most 
doubting that the sole purpose of this operation must be for the benefit 
of the children and the children alone, and finding that in order to do this 
the only possible way to do it was to adopt mass strategy, the organization 
of what we have been pleased to term tonsil and adenoid clubs has naturally 
been the logical step- It is not necessary here either to go into details, but 
to simply state that these clubs have been devised and put into operation 
successfully in enough counties and different sections of North Carolina to 
create a wide-spread interest in the operation and what it means for the 
children. The specialists engaged in the work have been amply paid for 
their service, the people have not been pauperized and the whole thing has 
been taken out of the haze and fog of commercialism to the everlastmg 
benefit of the children, for whom every medical inspector and every school 
authority in North Carolina should be most concerned- The future of this 
work for the children of the State depends to a great extent upon the sup- 
port, financial and moral, of the medical profession and the teachers and 
school officials, high and low, in the State of North Carolina. 

Discussion. 

Dr. S. A. Stevens, Monroe, N. C. : It has just happened that an Adenoid 
and Tonsil Clinic was conducted in my county week before last. I think 
they operated on about 82. They turned down over 100 in the county, 
and did not get to operate on any of the town children. So far as I have 
been able to learn from comments of the people at large, it certainly has 
met with the approval of the public. I think if you will put it on a selfish 
basis, let them have no other thought, but that I am fully persuaded that 
it will be of benefit to the specialists themselves financially. In the first 
place it makes the people acquainted with the specialist who does the work, 
and for every case that he operates on at that clinic I have no doubt that 
he will get at least five cases that will come and pay him his full fee. If 
they want to put it on a selfish basis, I think it is a good thing for the 
specialist himself and a great benefit for the ones that are operated on. My 
people are begging for another Clinic. I hope the State Board will be able 
to put these Clinics on as often as necessary until we get all these things 
cleaned up. I think it will do as much good as our Typhoid campaign did. 
We gave the Anti-Typhoid Treatment to ten patients. 

Dr. Lewis, Raleigh : As you gentlemen all know, I am extremely lame 
from a joint disease Tuberculosis at the age of 2^ years. 

My oldest grandson was visiting me last summer ; he complained of his 
knees and limbs precisely like my old attack began. When I heard him 
crying you can imagine what dagger that was in my heart. My son carried 
him to the University of Virginia, and they decided that he had Tuber- 
culosis of the joint. Dr. Holt examined him and ordered that he be put 
to bed and have his tonsils removed. He was kept in bed with this bandage 
on one month, and then it was taken off. He was kept in bed another month 



PUBLIC HEALTH AND EDUCATION 227 

without the bandage, and in two or three weeks after that he was turned 
loose, a perfectly well and strong boy. This is a striking instance of the 
value of the removal of affected tonsils. 

Dr. Laughinghouse : There is one' point in this discussion that has not 
as yet been touched upon, and to my mind it is one of the most important 
points that we have to consider in perfecting a program for tonsils and 
adenoids. The point is that 82 per cent of the people in North Carolina 
are rural people. If we do not have some glaringly, impressively, almost 
forcible plan, to bring to the attention of the rural father and mother the 
necessity of removal of tonsils, we will for a long, long time be greatly 
behind in this undertaking. 

Asheville, Charlotte, Winston-Salem and cities of such size can very 
easily handle the proposition within their own corporate limits, but I 'loubt 
if they are able to handle it right aw^ay outside. We had in Pitt County 
a Tonsil Clinic; it has 50 to 60 thousand inhabitants. The man who did 
the work was a nose and throat man in the county. He operated on some- 
where between 20, 30 or 40 patients for two daj^s for the Board of Health. 
His work has more than doubled since that clinic. That is what it means 
to the Specialist, and if the Specialist sees fit to look upon this proposition 
from a selfish motive or from a financial viewpoint only, if he does not care 
whether his office is up stairs or down, he is bound to see that this is a good 
form of advertising- Say if we give him an opportunity to hire an advertis- 
ing manager, he can't to save his life get before the public the actual value 
of the job quite so well as the North Carolina Board of Health is putting 
it before the public. I verily believe that the Eye, Ear, Nose and Throat 
man who is opposing this proposition because of encroachment upon his 
privilege, I believe he has well developed myopia. 

I sincerely hope that Dr. Lewis, with his long experience, can take them 
in his office and see if he can't clear away this shortsightedness that is in 
their financial eye. In addition to that, the people of North Carolina are 
iiot an easy people to satisfy. Charlotte can do it, Asheville and Winston- 
Salem can do it, and a number of the other great big towns. But we can't 
classify 82 per cent of these people ; it is impossible for us to do it. I know 
men w^ho took their children to the Board of Health clinic and paid the 
$10 or $15 and went to some of their neighbors, some who were poverty- 
stricken, and brought their children to the Nose and Throat men and paid 
the fees out of their own pocket that the doctor charged. There is nothing 
that we can do that will help the Tonsil and Adenoid work as this Clinic 
work has done. 

The dentists will tell you that Dr. Shultz sent into their offices five or ten 
times as much work as he himself did, or they would have gotten had he not 
been there. 

OUR TUBERCULOSIS PROBLEMS. 
By Dr. B. O. Edwards, Asheville, N. C. 

There has been so much said and written on this subject and so little 
seemingly has been accomplished that I hardly know where to start to 
discuss it. 

There were 42,274 deaths in North Carolina from all causes in 1918. 



228 NORTH CAROLINA MEDICAL SOCIETY 

Of this number 7,948 died of influenza. and 3,412 from tuberculosis; 1,793 
of these were colored and 1,615 white. This is the official report by the 
Bureau of Census at Washington. I was unable to get the figures for 1919. 
Dr. L. B. McBrayer states that we have at present 9,500 reported cases 
of tuberculosis in North Carolina, and he estimates that 3,000 of these are 
colored. I would estimate that we have at least as many more cases in the 
State that have not yet been diagnosed and reported. We have one State 
sanatorium and two county (at Winston-Salem) tuberculosis hospitals to 
take care of all this number and while there has been a great deal of good 
work done in the State institution both directly for the patient and also in 
an educational way, 

After having visited a number of our best tubercular institutions in the 
United States and studying the different methods of management of tuber- 
culosis patients here and having had the privilege of visiting more than 
thirty of the best tuberculosis sanatoria in Central Europe, scattered through 
England, Scotland, Ireland, Switzerland, France and Italy, as well as a 
great many of their tuberculosis dispensaries and several open-air schools. 
And having studied and observed their methods carefully I am thoroughly 
convinced that the modified Edinburgh scheme, originated by Sir Robert 
Phillip of Ediburgh, is far superior to any I have studied. 

Pennsylvania has adopted a modification of the Edinburgh scheme and 
is getting good results. 

The Edinburgh Scheme consists: 

1st, of the tuberculosis dispensary; 2nd, of a Sanatorium for early cases; 
3rd, of a Hospital for advanced cases; 4th, of a Tuberculosis Colony for 
those that improve, but need a more prolonged treatment ; 5th, of an Open- 
Air School. 

Taking up in detail the Edinburgh Scheme of the tuberculosis organiza- 
tion, the London Dispensary. will be described. London is divided into 29 
metropolitan boroughs, including the city of London, and the population is 
approximately 5,000,000, carrying in different boroughs from 50,000 to 
250,000. There is one dispensary for each borough, and the total number 
of dispensaries has been determined by the number of governmental units 
rather than by the medical requirements of the situation from the standpoint 
of tuberculosis. The -dispensaries are under the Public Health Department 
of the London City Council. Several of the dispensaries have only been 
in operation for a short time, while a few of the others were established 
about ten years ago. 

The Paddington Dispensary at 20 Talbot Road, which I had the pleasure 
of visiting several times, is one of the oldest and best -equipped, and was 
opened in 1909. The medical work is of a high order, and is done by Dr. 
R. S. Walker, a trained tuberculosis doctor, who devotes his entire time 
to this dispensary -and its patients. Special hours are arranged for new 
cases. Old cases and working adults- These latter attending evening sessions 
of the dispensary. 

There remains much yet to be done that could be done if we had adequate 
facilities for caring for several hundred more patients each year. There is 
usually a long waiting list and it often takes several months for them to gain 



PUBLIC HEALTH AND EDUCATION 229 

admission. I find that many of the patients treated there do well and show 
marked improvement, but have to be discharged in about four months to 
give room for others and often go back to their homes and former conditions 
and relapse and die ; where if they could have had twelve or sixteen months' 
treatment in the .institution they might have been permanently benefited 
or cured. 

All caes of tuberculosis who desire treatment are examined and a suitable 
form of treatment is decided upon and advised. At the same time useful 
advice and instructions are given on the subject of diet, ventilation, sputum 
disposal, occupation, etc. 

Some throat work, but routine laryngological examinations for all new 
patients are not carried out. There is no service of radiology at the dis- 
pensary, and adequate records of all cases are kept in convenient files. The 
patients receive medicine there, and are expected to pay two cents for con- 
sultation. 

An open air school (The Kensel House) is closely affiliated with the 
dispensary. This is an admirable institution and is efficiently managed. 
Hot coca is served at 10:30 and an excellent lunch at noon, for which the 
children pay seven cents. 

During 1918, 700 patients were treated at the Paddington Dispensary, 
of whom 22 per cent were definitely tuberculous and 25 per cent were 
classed as suspects. A reasonable amount of follow-up work in the home 
was done, and the quality of the social service is excellent and is done by 
trained social workers. The whole time and one part time worker is em- 
ployed. Local tuberculosis care committees which are a compartively recent 
development form a part of the organization of each tuberculosis dispensary 
in London. This is an example of the dispensary systems of the scheme. 
I found this carried on about the same, with some slight modifications, in 
Edinburgh, Aberdeen and Glasgow, Scotland, also in Dublin and Liverpool. 

Farm Colony System. 

I had the privilege of visiting the Cambridgeshire or Papworth colony 
in England and Edinburgh or Polton colony and Hairmyres colony in 
Scotland last year. 

I will describe briefly the Hairmyres Colony Scheme. The scheme em- 
braces a large sanatorium and work colony at Hairmyres, located nine miles 
from Glasgow, Scotland, in an agricultural parish lying a little more than 
500 feet elevation above the sea level and situated within easy reach of 
Lanarkshire. The Hairmyre Scheme is of a special character and is fairly 
representative in its object and purposes. It proposes to deal with those 
cases of tuberculosis which have so far advanced and improved by institu- 
tional treatment that it is expedient the treatment should be continued and 
extended in such a form as will restore the persons affected to a condition 
that they are again fitted to take up active work. At Hairmyres the 
Local Authority have lands extending to about 300 acres, and it is proposed 
that the persons transferred there should be under medical supervision, un- 
dertake graded labor of a character suitable to their condition, and at the 
same time be trained in different occupations connected with work on the 
land, so that they will be fitted to follow and obtain their living from an 



230 NORTH CAROLINA MEDICAL SOCIETY 

outdoor life in the future. Children will also be treated at the Colony. 
The capital cost of establishing the scheme is estimated at about 150,000 
pounds or $700,000. The necessity for the inception of a Farm Colony 
as an indispensable part of the scheme for dealing with tuberculosis has 
been unreservedly recognized. It is found from past experience that simply 
to afford Hospital or Sanitorium treatment to persons affected with the 
disease and then to discharge them with no alternative but the resumption 
of their former occupation, which in most cases is wholly unsuited to their 
conditions was entirely futile. At Hairmyres, as already mentioned, graded 
labor is provided and instruction is given in farm work, market gardening, 
poultry and pig raising and elementary forestry work, and in connection 
with the forestry a tree nursery has been established at Hairmyres. 

At Hairmyres, up till December 1, 1919, only children had been treated. 
The Scheme not having been at the stage that adults could be admitted. 
The buildings and the Scheme generally, however, were practically com- 
pleted and would be available for the reception of patients within a month's 
time. Accommodations have been provided for 250 to 300 patients. The 
Pavilion stands at an elevation of 580 feet above sea level. They are of the 
Butterfly type, and are erected on the ridge of a general slope facing the 
south, thus ensuring the maximum of sunshine ; they command a magnificent 
view of the surrounding country. The pavilion administrative block and 
associated buildings are spread over an area embracing thirty acres. An 
established belt of trees gives adequate protection from the North, and 
Shelter Belts have been planted to acord cover from the prevailing winds. 
The buildings are fitted with all the most modern appliances. There are in 
residence at Hairmyres an experienced Physician-Superintendent, Mr. A. M. 
McPherson; a Matron and stac, a Farm Manager and assistants, a fully 
qualified Dairymaid and assistant; a Head Forester and assistants, and a 
Head Gardener and garden laborers. 

Those members of the staff have been selected having in view not only 
their qualifications for the work under their charge, but also their suitability 
by temperament and otherwise for working and training the patients at 
the Institution. 

In conclusion, I advocate a modification of this scheme to suit our scat- 
tered population, which should consist of a dispensary in each county, and 
a doctor the whole time, health officer where there is one employed, or the 
county physician and one or two nurses specially trained for this work. Also 
a tuberculosis doctor as consultant who could serve in about four counties 
and should visit each dispensary at least once each week and consult with 
the doctor in charge. 

Also the building of a new hospital with ample room for the early cases. 
The doubling of the capacity of the present institution for advanced and 
moderately advanced cases, the establishment of a tuberculosis colony for 
those showing improvement and requiring a more prolonged treatment. A 
new and separate institution of like nature for the colored people. 

To do what I have outlined will cost money, but what better investment 
could the great commonwealth of North Carolina make than saving the 
lives of thousands each year from the great White Plague? The best in- 
vestment any state or nation can make is to care for the health of its people. 



PUBLIC HEALTH AND EDUCATION 231 

The state has provided amply for the deaf, dumb and blind, for the insane, 
ample room and attendants are provided ; yet for the thousands afflicted with 
tuberculosis, who have not the means by which they can get the proper care 
and attention professionally at home, we have only one sanatorium for 
the entire State- It is up to us medical men to stand together as a unit 
and make an earnest appeal to the State to lend a hand to help our cause 
in this, the most terrible and surest life destroyer within the confines of its 
borders today. 

May I close by quoting the words of a consumptive — Washington Irving: 
"What, after all, is the mite of wisdom that I could throw into the mass 
of knowledge, or how am I sure that my sagest deductions may be safe 
guides for the opinion of others but in writing ... if I fail, the only evil is 
my disappointment; if, however, I can by any lucky chance, in these days 
of evil, rub out one wrinkle from the brow of care or beguile the heavy 
heart of one moment of sorrow, if I can now and then penetrate through 
the gathering film of misanthropy, prompt a benevolent view of human 
nature and make my reader more in good humor with his fellow-beings and 
himself, surely, surely, then, I shall have not written in vain." 

SOME OF THE THINGS NECESSARY TO THE ERADICA- 
TION OF TUBERCULOSIS. 
Dr. J. E. Brooks^ Blowing Rock. 

The days of secrecy and mysticism in medicine are gone. The doors are 
now thrown wide open, and all men are invited to come in, see for them- 
selves, examine our work, put it to the test, and decide for themselves its 
worth. We have approached a new stage, live on a higher plane and invite 
constructive criticism. We are applying our knowledge to the common 
good, and giving without the asking the fruits of our investigation to the 
general welfare. We know we are at the dawn of a new era. A world- 
wide age is upon us. Universal democracy is thrust in. The destiny of 
man is the chiefest concern of the doctor, and those who assay to lead must 
be capable, without spot or blemish, and worthy of the golden day that 
awaits us. The great doctor will heed the call, and the small one must 
We have no time to lower our ideals or to gather gear, because our work 
deals without limit or class with every creature under the sun. The doctor 
may not be a benefactor to begin with, but his work leads to that destiny 
if he pursues it free from fraud and guile. The new age in medicine has 
not yet seen wide experience or effected a good working organization, but 
the results obtained by it are so vast and promising that no man whose eyes 
are open can dispute its worth or work. I confess no liking for the apothe- 
cary shop — but there is a divine thrill in getting there ahead of the proces- 
sion. In preventing disease you plant a rose instead of inurning ashes. . . . 
The new open door of co-operation of the profession and the public does 
not aim to make practitioners of the laity. It means to educate the laity to 
co-operate with the doctor and bear him up in every f:;ood word and i^-ork 
Nor does it mean the loosening of its hard rules to the quack and vendor, 
but it does mean to cut off the quack's head through education. It means 
to give to the public sufficient scientific knowledge concerning contagion to 
secure his help in eradicating disease. Blackstone wrote his Common Law 



232 NORTH CAROLINA MEDICAL SOCIETY 

for the gentry of England that better citizens might result therefrom. After 
the beginning of the world war Sir William Osier chided England be- 
cause its ruling classes, though graduates of Eton and Oxford, knew too 
little science to be capable of their work. He ■:ited as witness the fact that 
the Minister of Foreign Affairs, when called down for allowing hog lard 
to be shipped to Germany, confessed he did not know that glycerine, one 
of the chief sources of explosives, could be derived from hog lard. Dr. 
Osier demanded that England teach all of her men the rudiments of science 
as a necessity. 

For years I have read with interest the current literature on public health 
and preventive medicine ; and the accomplishmnets along these lines are 
so fine that men thought them impossible. The sanitary work of General 
Gorgas at Panama enabled the United States to build the Panama canal 
— a thing which the world-renowned engineer. Count Ferdenan De-Lessips, 
could not do because the enemy, disease, was stronger than his skill as an 
engineer. The fight against yellow fever, typhoid and cholera are almost 
won, and the fangs have been extracted from diphtheria and smallpox, while 
a great war is being waged against tuberculosis- And brilliant addresses, 
illustrated until the eye can see, are being delivered daily. These shows and 
addresses have amazed and thrilled the public mind. Edwin Booth could 
entertain no more brilliantly in impersonating Hamlet than a brilliant lec- 
turer, well equipped with illustrations, can do with an up-to-date address 
on public health. A thousand times have I been asked to explain phases 
of these writings and addresses by those who saw and heard them. And 
it is indeed an impossible task for me to make intelligible a subject when 
the questioner has no scientific knowledge upon which my explanation must 
rest. I answer his questions, but I leave him without understanding. These 
lectures, though as good as they can be made, cannot enlighten me on a 
subject that requires some science as a basis for such enlightenment. The 
public must understand before it volunteers its whole-hearted co-operation. 
None of us believe anything we have no way of understanding. 

The public is inviting us to go deeper into the subject than we have ever 
gone- It is placing its children at our disposal ; and it is through the coming 
generations that Providence is showing us the way. Through the public 
schools the future problems of public health and preventive medicine must 
be solved. I do not believe j^ou can make a man all-around fit by making 
laws to make him whole. You must lead him and show him the way. Let 
us be reminded that in a few short years the world in miniature will be in 
school. If the parents or guardians are indifferent, the State is not going 
to be a slacker with its own life — and the State must educate to save its life. 
In the schools will be laid the foundation to fight all contagion and make 
the term prevention a reality. Out of all the expense, the suffering and 
tragedy and death and victory of the world war comes one word clear above 
all else, a word that will be the watchword of civilization in the unnumbered 
generations to come, and that word is 'TITNESS." Physical fitness is the 
basis of mental and moral fitness, and there can be no absolute fitness that 
does not qualify the man and woman to think normally, possess normal 
health and a sound moral character. I believe that a majority of the weak- 
nesses human flesh is heir to are traceable to physical unfitness. 



PUBLIC HEALTH AND EDUCATION 233 

The doctor of medicine gives his life to the study of life, and by virtue 
of his work becomes a biologist. We all know that mediocraty as rule 
biology applies to man, with the great and powerful the exception ; and of 
these exceptions no known law governs their advent and no one knows from 
whence they come. Shall the doctor use his biology to no higher purpose 
than the pasting together of broken pottery? Would it not be better that 
he use his science to remove the cause of this order so that the great and 
powerful wnll be the rule, and the weaklings the exception. Indeed, we do 
produce numberless intellectuals and geniuses of varied kinds, but it is only 
the few who are touched by greatness, and though widely separated, they 
are generally contemporaries in periods far apart. 

EDUCATION. 

The hour is at hand when the doctor must begin the work in the school- 
room. This will reach the world in a score of years. The rudiments of 
physiology taught in the public schools taught phj'siology to no one, but 
the simply and beautifully illustrated chapter on the baneful effects of 
alcohol on the human system had far greater results in driving alcohol out 
of America than did all the bread-counter oratory of the world. Let the 
Medical Society of North Carolina, with the State Board of Health, ap- 
point a committee to collaborate and formulate a manual of preventive 
medicine and public health and embrace concrete primary information of 
contagious, infectious and communicable diseases, their causes, modes of 
conveyance and transmission. It should contain the information the laity 
must have before the public can give the doctor a whole-hearted helping 
hand in prevention. This treatise should be one that can be used from 
the fifth to the seventh grades, and made a part of these grades. Of course, 
the committee would decide the nature and thoroughness of the text. It 
must be made clear and understandable to every student capable of passing 
the seventh grade. The public teachers must prepare themscives to teacn 
this text. The colleges and normal schools must give them these courses, 
and the course must be more complete for the high school and college. This, 
when properly put in operation, cannot fail to produce world-wide results. 

Gentlemen, when we begin with this method of fighting communicable 
disease we begin a revolution in public health work that can never look 
back, and by this method tuberculosis will be made a rare disease indeed. 
I approve of the great work of the Sanatorium, but the Sanatorium gets 
many a patient when he is too sick to be taught or when the work on him 
is but patchwork. I am fully aware that the Sanatorium has done vast 
good. Now let us go to the root of the evil and cut it out. 

THE NEGRO. 

Has anybody in our state done anything to prevent the dissemination 
of tuberculosis in the negroes among themselves, and from them to the 
whites? Does anybody have any idea what percentage of the negro race 
What provision has been made to treat the negro patient when his case is 
pronounced tuberculosis? Can we accomplish any serious results among 
the whites until like results have been accomplished among the negroes? 
Can you prevent flies swarming ar.ound the mansion of the rich man while 
his neighbor's filthy hut is a breeding place for them? Does not sanitation 



234 NORTH CAROLINA MEDICAL SOCIETY 

itself mean complete sanitation, Why not use the incipient tubercular 
patients, and there are many of them, among the negro convicts of the state, 
to build a sanatorium and develop a farm for the tubercular patients of 
that race ? And may I not add that it might be a good thing if the incipient 
tubercular patients among the white convicts be employed to develop and 
cultivate the farm at Montrose for that institution ? While their recovery 
is directed by that institution. 

Discussion. 

Dr. Frazer, Asheville : I think there could be no question as to shortage 
of Sanatorium in this state. We have begun to wake the doctors up to the 
necessity of taking care of these cases. 

We realize it is a chronic infection. In my opinion, it is a large economic 
disease. I am suprised that this was not brought out more in the papers. 
We know that infection takes place and that all the education we may give 
the child is very valuable, but it will not prevent the infection that has taken 
place. We cannot always cope with the condition that the patient arrives 
at when he becomes of age or takes his place in the work of the world. We 
will say with long hours, or hard work and not enough food that the patient 
loses his resistance and becomes incipient tuberculosis. 

Dr. Brooks spoke of the negro, and I think that is going to deserve con- 
siderable attention- We have been regarding them as doomed. We felt 
that no matter what we did for them, in the end the result was the same. 

I saw recently the report of the Maryland Tuberculosis Association, that 
the negro had made about four-fifths of the progress in the Tuberculosis 
Sanatorium at Maryland compared to the white man. It is not quite fair . 
to compare the death rate of negroes to the whites. When we say that eight 
negroes died to four whites of Tuberculosis we might think that is the racial 
trait. The negro is by no means given a fair chance. The recent teachings 
have shown that if we give the negro a chance he will get well. 

The establishment of a sanatorium for the treatment of patients privately, 
while we may get great results in the near future, it does not mean that 
that patient is cured, that was followed by the word "arrest." We may 
say "arrest-ed." It is going to take not only Sanatorium Treatment, but 
after-care for months and years until we can decide that the patient is cured. 

Dr. R. McBrayer, Sanatorium: In answer to Dr. Brooks' question as to 
what is now being done for the negro, I would like to say the State Tuber- 
culosis Association is running a truck, with motion pictures that is carrying 
its films on Tuberculosis, the Modern Health Crusader, the Public Health 
Nurse, Oral Hygiene, etc. This car goes to the county and is under super- 
vision of the Public Health Instructor — he is in Mecklenburg this week. 
The negroes are taking much interest in this, and it is going to give excellent 
results. I think his point was well taken when he said we can't stop infec- 
tion in the white people when we have that infection living at the back door. 
We don't notice the negro much when he gives a little cough, but we should- 
However, I think that is a very important problem from now on, and we 
probably have been a little negligent about it up until now. 

Dr. Carlton, Winston-Salem: I would like to say in addition to what 
Dr. McBrayer has said in defense of my own health department. We have 



PUBLIC HEALTH AND EDUCATION 235 

a dispensary in our citJ^for white and colored, and in our hospital for tuber- 
culosis we have as many beds for colored as white and as many treatments 
among colored children as white. 

Dr. Stevens: I would like to say a few words as regards the negro. It 
is a well known fact to all of us that the virulence of bacteria vary. One 
condition is passing bacteria through an animal that offers low resisting 
power. As has been said here, the negro as a race offers lower resisting 
power to the growth of tubercle bacillus. The negro being infected with 
tuberculosis develops a more virulent type of the disease. Any negro in- 
fected with it is a greater possibility of danger to others than from any 
one else infected with it. An infection from him is apt to be a very acute 
type of infection. Protecting the negro is a very important question of 
protecting the white race also. 

Dr. Anderson, Raleigh : I want to endorse this paper of Dr. Brooks on 
one point, and I am glad to hear a man of his information and work stress 
the point of education, of management and prevention of tuberculosis. I 
feel in my own work rather pessimistic at times, because of the lack of in- 
formation and education in the prevention of the mental diseases- I have 
gotten so much information that I feel inspired to be more hopeful in my 
special line of work from the work you folks are doing in the public health 
work. 

I am reminded more and more of what we lack in the prevention and 
real education along the lines of mental diseases. If you look at it right, 
the mind is really more important to keep well than the body, and as our 
Governor expressed it some time ago, that we have the cart before the horse, 
and therefore the importance of education as Dr. Brooks emphasized. We 
have to go on in the school room and educate our children on this subject 
of disease prevention, whether physical or mental- When we come to think 
of the educational forces that we have in North Carolina, if I understand 
it right, it makes a man feel pessimistic. They tell me those school houses 
are occupied or frequently occupied by incompetent workers. That 
talk that the lady made from Randolph county yesterday was the best thing 
I have heard in a long time. If we could get a few workers in North Caro- 
lina to handle diseases of the body and mind, it wouldn't take us long to 
educate the people in the right direction. Education is the key-note, and 
when we can get it into our schools and get these things handled by compe- 
tent school teachers, then a brighter day is coming. 

Dr. Edwards: I want to say that I hope to see the time in the nea/r 
future when we will have ample facilities for taking care of tuberculosis. 
That we will have room at the State Institutions for both colored and white 
patients, and that in the South we will have separate institutions. I think 
in the very near future we will have such. 

Closing Discussion, Dr. Brooks: I think if you will ask any man who 
has ever done any tuberculosis work he will tell you his greatest difficulty 
is establishing an intelligent understanding between himself and the patient. 
It does not matter if this patient is a lawyer capable of becoming a Supreme 
Court Judge, even down to the illiterate. You talk to him in a foreign 
language and he goes away from you without understanding the basis upon 
which fear and knowledge rests. This has been my experience, and a very 



236 NORTH CAROLINA MEDICAL SOCIETY 

painful experience. At 4:imes it would seem that we get brilliant results. 
We flatter ourselves that we have a patient we are going to restore, and 
in that time he gets away from us. He does not like these fundamental 
principles of science. It must be taught to the children in the school- 
room. I insist that this scientific information about communicable dis- 
eases must be a part of your child's course. He must study this as he 
studies grammar and English. He is supposed to get something of the 
nature of a disease, and something of its prevention and what his part of 
prevention must be, and you can't ever get him to understand that or 
follow it until you teach it to him. I have failed in my patients, and 
many times I have felt I was a failure all over, because I couldn't achieve 
anything except that my fellow-servant was doing it all, and if I dropped 
out he could do it far better than I ; but he was doing nothing but patch- 
work. His work is constructive, and he must teach the race how to be 
strong, and he cannot do that until there is a line of communication between 
him and that race, because that race cannot know what he is talking 
about, and does not know. 

I have gone away many times from a patient feeling that I was utterly 
helpless. I could not control that patient, and no one else could, because 
he could not talk with him. Let the school rooms teach the rudiments 
of science. 

VENEREAL DISEASES— A PUBLIC PROBLEM. 

The Physician's Responsibility for Their Control. 

By Millard Knowlton, M. D., C. P. H., 

Director Bureau of Venereal Diseases, N. C. State Board of Helath. 

THE PROBLEM. 

A sense of public responsibility for the venereal disease problem is one 
of the by-products of the war. When faced with the necessity of utiliz- 
ing the manpower of the nation to the limit in combat with a first-class 
military power, America soon recognized venereal disease as the most 
serious communicable disease menace to its military strength. Medical 
men have not forgotten that 5.4 per cent of the second million men called 
to arms had venereal disease when they reached camp. Thus the war 
brought the venereal disease problem to the front as a public problem. 

Even in war time the venereal disease problem is essentially and funda- 
mentally a civilian health problem. Five out of six of the soldiers suffer- 
ing from venereal diseases were infected before enlistment- The others 
became infected by contact with the civilian population. Adequate 
preparation for the defense of the nation against future aggression requires 
careful attention to the venereal disease problem by the civilian com- 
munities. Any problem so closely related to the defense of the nation 
is a public problem. 

Inasmuch as gonorrhea is looked upon as the greatest sterilizer, and 
syphilis as the greatest abortifacient, it behooves the people to take 
measures against the ravages of these diseases in order to maintain the birth 
rate that will give the best assurance for the future of the nation. An ex- 
cess of births over deaths is necessary if a nation is to grow strong. France 



PUBLIC HEALTH AND EDUCATION 237 

is now suffering because of a low birth rate. Any factor that affects the 
birth rate as does venereal disease is a vital public problem. 

During the war it was found that in a large munition plant employing 
10,000 workmen, 68 per cent of the workers on the non-effective list each 
day were listed because of venereal diseases. Production among those so 
infected was found to be 33 per cent below normal. Facilities for treat- 
ment were provided, and 2,000 employees were treated during the year. 
Every man's output returned to normal after treatment was concluded 
and the man returned to health. The company estimated that the work 
was worth at least $150,000 per year in increased production. At this 
time of high prices whatever tends to retard production is a public problem. 

Another factor of immediate public concern because it involves the ex- 
penditure of public funds is the relation of venereal diseases to dependency 
and defectiveness. How much of the State and local expenditures for the 
care and maintenance of dependents and defectives have been made neces- 
sary by venereal disease cannot be said. That such expenditure is far 
beyond the cost of prevention must be apparent to anyone w^ho will give 
the matter a second thought. Indeed, when we consider the public charges 
in the alms houses and other institutions whose lameness, epilepsy, blind- 
ness, feeble-mindedness, insanity or other cause of dependency is due to 
venereal disease, we may well believe that the State would profit by taking 
measures to prevent these diseases, as did the munition plant, by providing 
treatment for infected persons. Thus it appears that when viewed from 
any angle the venereal disease problem is a public problem. Even from a 
clinical point of view, pay for the treatment of such diseases among the 
indigents must come from the public purse. 

THE REMEDY. 

Owing to the complicated and intricate character of the venereal disease 
problem, the remedy has not been one of easy attainment. Experience has 
led to the direction of the campaign against venereal diseases along three 
general lines: 

1. Educational measures for the dissemination of information are re- 
garded as fundamental for any kind of advancement under a popular form 
of government. 

2. It is now almost universally recognized that effective measures against 
venereal diseases will include the repression of prostitution, which is the 
great source of infection. Prostitution is no longer to be regarded as a 
fixed part of the social structure or even as a "necessary" evil. As a com- 
mercialized institution its doom is sealed. The public will not permit a 
return to the old conditions. 

3. That part of the attack against venereal diseases which is of most 
interest to physicians is treatment. It is by proper treatment that infected 
persons are rendered non-infectious. Thus, treatment is a matter of public 
concern and the physician who properly treats a case of venereal disease 
performs an important public service. 

So much by way of introduction. I wish to use the rest of the time 
allotted to this paper in a discussion of the problem of treatment. I have 
no information or suggestions to offer concerning the methods of treatment. 



238 NORTH CAROLINA MEDICAL SOCIETY 

I wish merely to make a plea for better treatment, and to suggest a plan 
whereby I believe that better treatment may be provided for patients in 
remote communities. 

THE physician's RESPONSIBILITY. 

No one but a physician is qualified to properly treat venereal diseases. 
This is one branch of the healing art in which physicians have the monop- 
oly. The osteopath, the chiropractor and the Christian scientist are con- 
strained to withdraw from the field and leave the medical man in full con- 
trol. This monopoly pre-supposes a responsibility and a better preparation 
for the discharge of their full duties that I now wish to plead with the 
physicians of North Carolina. 

Medical men are disposed to take venereal diseases somewhat more seri- 
ously than formerly, but many physicians still do not care to treat such 
cases. To be sure, there are unpleasant features about this work; but the 
physician's responsibility cannot be fully discharged by giving indififerent 
or careless treatment. The physician owes it to both his patient and the 
public to see that the best possible treatment is given. 

All physicians will agree that patients should not attempt to treat them- 
selves and should not rely upon drug-store treatment or treatment by quacks. 
In our propaganda designed to turn patients away from self-treatment, the 
counter-prescriber, and the quack, it is constantly urged that proper treat- 
ment can be given only by a qualified physician who can examine the patient 
carefully in order to determine what treatment is needed. Sometimes the 
busy doctor makes an unfavorable impression upon the patient by failure 
to live up to our promises concerning a careful examination. A case in 
point is that of a North Carolina woman who was infected with gonorrhea 
by her husband upon his return from the army. Before treatment was com- 
pleted it became necessary for her to move to another city, where she sought 
to continue treatment under a physician's care. Her experiences in that 
connection are given in the following extracts from a letter recently received 
in our office: 

"I have tried three doctors, and the one who was most recommended, 

Dr. , merely asked me what treatment the doctor in had 

given me, and told me to continue that treatment. He did not sjiy for how 
long, nor did he offer to make an examination. According to your pamphlet 
and letter such indifferent advice is unsatisfactory- This doctor did not even 
ask me to come to see him again. He acted as if he were wholly incompe- 
tent to give advice in this case." 

"I am very much concerned about my condition, and I want to be helped. 
I have already spent a large sum of money for medicines, doctors' advice, 
etc., and a great deal of time in treating myself, and I think I am entitled 
to some results for my outlay of time and money. Why cannot the law 
require doctors to be more competent? I think any doctor as negligent 
as the one I have mentioned should be reportable by the patient. A case 
like this is too serious for a doctor to be careless about." 

The foregoing statement by a woman of education and refinement merits 
serious consideration by physicians. If the medical profession is to maintain 
its prestige with the people and continue to enjoy the fullest public confi- 



PUBLIC HEALTH AND EDUCATION 239 

dence, it is highly important that physicians meet the increasing demands 
of a more fully educated public. 

In meeting these requirements only two courses are open to a physisian 
when a venereal disease patient applies for treatment. These are either to 
give the best possible treatment himself or refer the patient to a physician 
who will give the best possible treatment according to modern methods. 
Remembering that each uncured case of venereal disease is a source of dan- 
ger to others, the physician can perform his full duty to himself, his patient, 
and the public only by pursuing one or the other of these courses. 

The public interest requires that all patients suffering from venereal 
disease be properly treated, no matetr what their, race, color, or social posi- 
tiori may be. Venereal diseases, like other communicable diseases, know no 
racial boundaries. Where different races of mankind are intermingled 
It is to the interest of each race as a matter of racial self-preservation if 
from no higher motive to have venereal diseases properly treated in mem- 
bers of the other race. The physicians of North Carolina have it within 
their power to see that proper treatment is given to all citizens of the State 
suffering from venereal disease. 

I am not asking physicians to work without remuneration. Most venereal 
patients can afford to pay at least a reasonable fee for treatment. In the 
few instances where a person suffering from venereal disease in communi- 
cable form is really indigent, it is simply a matter of self-protection for a 
community to provide treatment at public expense. The State Board of 
Health will provide arsphenamine free for the treatment of indigent syphil- 
itics who are infectious, provided the community or a big-hearted doctor 
will see that the drug is properly administered- In the larger communities 
the most convenient way of providing treatment at public expense is by 
means of clinics. In the smaller communities some modification of the 
clinic arrangement may be necessary. 

I have urged that each physician either give the best possible treatment 
or refer his cases. Perhaps you are asking to whom the cases maybe re- 
ferred. It is realized, of course, that only the larger cities can support 
specialists. As North Carolina is a rural state, only a small percentage of 
its population live in or near the larger cities. 

To the end that rural medical service may be improved, it is proposed 
that the medical men of each community provide at least partial specializa- 
tion in medical service to that community. This will be possible through 
concerted action. As a first step, let the physicians in each county get* 
together, talk over the proposition and select from their number one who 
is willing to make special preparation by study and equipment for the proper 
treatment of venereal diseases. Of course, he cannot hope to limit his prac- 
tice to this line in a small community, but by partial specialization he can 
become an authority on the matter for his own community to whom patients 
may be referred or who may be called in consultation in difficult cases. The 
man who thus qualifies himself for the better treatment of venereal diseases 
should be selected by the board of county commissioners to treat indigent 
patients. He should be recognized by the medical profession of the com. 
munity in such measure as to make worth while his expenditures in time 
and money for special training and equipment. 



240 NORTH CAROLINA MEDICAL SOCIETY 

The plan here proposed would result in advantage to both the medical 
profession and the public. Thus it would accord with a principle that is 
now happily appearing more clearly in the vision of far-seeing medical men. 
This principle is that the ultimate interests of the medical profession are 
parallel to the best interests of the public in medical matters. While recog- 
nizing the fact that public interests are paramount to those of any class or 
group, medical men will do well to remember that the doctor serves himself 
best by serving others. 

The gist of the whole matter is that the level of medical practice with 
respect to the treatment of venereal diseases should be raised to as high a 
point as possible in all communities of the State. This requires a specializa- 
tion which comes as a natural process in larger communities. In smaller 
communities the same end can be reached in lesser degree perhaps by a pro- 
cess of partial specialization encouraged and stimulated by the medical pro- 
fession. It falls to the lot of medical men to prevent the spread ^f venereal 
diseases by the proper treatment of existing cases. For the best results 
united co-operative efforts for encouraging specialization are required 

Here I beg to leave the matter in the hands of the medical men of North 
Carolina, in full confidence that they will rise to the opportunity for public 
service and take active measures to provide better treatment for venereal 
iisease cases in all parts of this State- Let me urge again that united effort 
ind co-operation are necessary. If we doctors do not hang together, the 
public may give us a chance to hang separately. 

THE STATE PROGRAM FOR VENEREAL DISEASE CONTROL 
By Millard Knowlton, M. D., C. P. H. 

Director Bureau of Venereal Diseases, N. C. State Board of Health. 

The venereal disease campaign that has been pushed so vigorously for 
the past two years has been an experimental excursion into an unexplored 
realm. Prodded by war recessity, the country and the various states have 
undertaken to follow the vision of a few forward-looking men. The course 
has led through bramble and thicket, and we are not yet out of the woods, 
but slowly some of the fundamental things nre emcrgmg from the chaotic 
thought surrounding the subject. 

Before the war, efforts for venereal disease control were spasmodic and 
intermittent. Here .^nd there health authorities feebly called upon doctors 
to report their cases by number, and a few state legislatures were beginning- 
to -consider measures dealing with the problem. The chief energies 
focused on the subject had been expended in propaganda by a few voluntary 
organizations. Thus, while the preliminary work of gathering and dis- 
seminating information and formulating speculative and theoretical plans 
had been under way for some time, there had been little practical experience 
in applying such plans to the actual problem of venereal disease control. 

Accordingly, those of us who plunged into venereal disease work on a 
wave of war enthusiasm found a field unknown, to be cultivated by methods 
untried. In proceeding from the known to the unknown, it was but natural 
that the course adopted should be analogous to that pursued in the preven- 
tion of other communicable diseases- Experience soon demonstrated, how- 
ever, that there were certain fundamental differences between venereal 
diseases and other communicable diseases that must be taken into account. 



PUBLIC HEALTH AND EDUCATION 241 

In the first place, all cases of venereal disease are not in communicable 
form, and, therefore, all cases are not subject to control by administrative 
procedure of a health officer. Thus, a case of syphilis of the central 
nervous system may give a positive Wassermann of both blood and spinal 
fluid yet not be a case to come under the jurisdiction of a health officer, 
for the reason that evidence cannot be produced to show that it is possible 
for such a patient to convey the disease to others. From a public health 
point of view it is necessary to make a clear distinction between a case that 
is infectious and a case that is not infectious. The health officer is interested 
in a case only so long as it is infectious and capable of transmitting infec- 
tion to others It is the health officer's business to prevent such transmis-. 
sion of infection. However much need there may be for a continuation of 
treatment until a clinical cure is effected, the health officer is officially 
concerned with treatment only until the patient becomes non-infectious. 
In making an examination of a patient to determine whether or not such 
patient is a menace to the public health, the health officer must determine 
two things: First, the presence of venereal disease! and, second, whether 
or not the disease is present in communicable form. Action to protect the 
public health is based on the presence of disease in communicable form 
and not en the presence of disease per se. 

Another and still more important difference between venereal diseases 
and other communicable diseases is that in the case of venereal diseases not 
all patients suffering from such diseases in communicable form are menaces 
to the public health. In fact, very few patients will endanger the public 
health if properly instructed in methods of prevention unless, as in some 
instances, their occupations are such as will endanger others by the ordinary 
contact of daily life. Whether or not such a patient is a menace to the 
public health depends ordinarily upon his sex conduct. This introduces a 
factor which makes the venereal disease problem at once the most compli- 
cated, the most difficult, the most intricate and in some respects the most 
important of all the public health problems. 

The bearing of these differences between venereal diseases and other 
communicable disease upon administrative measures to be taken for the pro- 
tection of the public health is apparent upon a moment's reflection. Obvi- 
ously, those cases that most concern the health officer are those that are 
most dangerous to the public health. Thus reporting regulations that will 
result in having brought to the health officer's attention only those cases 
of venereal disease that are dangerous to the public health will save his 
time in the investigation of non-infectious cases. If such regulations can 
be made to serve as a filter to catch only infectious cases, the public health 
will be protected as well as if the health officer had to examine all patients 
suffering from these diseases. This end is attained by permitting the phy- 
sician to report patients not dangerous to the public health by number Avith- 
out disclosure of names, and requiring the name and address to be reported 
only in case the physician thinks the patient should come under a health 
officer's supervision for the protection of the public against his infection. 
Reports by number are as useful for statistical purposes as reports by name. 

Likewise, the invoking of quarantine as a measure to protect the public 



242 NORTH CAROLINA MEDICAL SOCIETY 

health will depend upon conditions outside the existence of venereal disease. 
In the majority of cases quarantine will not be required- Only in those 
cases that cannot be trusted to so conduct themselves as to avoid exposing 
others to infection will restrictive measures be necessary. 

On account of the very complex factors involved, the method of carry- 
ing out quarantine procedure in venereal diseases must of necessity be 
■different from the method of carrying out such procedure in other com- 
municable diseases. In scarlet fever, for example, every case is a menace 
to the public health, and, therefore, all cases are equally subject to quar- 
antine. In such cases, quarantine can be carried out by isolation in the 
home. Most people wish to do the square thing, and the opinion of the 
neighbors is a powerful factor in preventing attempts to evade quarantine 
regulations when the house is placarded. In the case of venereal diseases, 
however, law-abiding, responsible citizens who have had the misfortune 
to become infected may be trusted to avoid spreading the disease to others 
if they are properly instructed. Accordingly restrictive measures to pro- 
tect the public health may with safety be limited to those who would not 
carry out instructions, and who could not be trusted to avoid exposing 
others to infection while under treatment. Chief among this group of 
irresponsible people are the pimps and prostitutes. In applying quarantine 
to such characters isolation in the home has not been found to be effective 
Forcible detention is necessary for the adequate protection of the public 
health. It is for this reason that the law authorizes quarantine in jail if 
no other suitable place for quarantine is available. 

So much for the rather technical public health side of the problem. 
There are other aspects of the problem in its larger relations that extend 
beyond the field of public health, and interlock with the duties of other 
officials and functions of other departments of government. While the 
treatment of existing cases is now recognized as a primary necessity in 
order to render them non-infectious, and thus not dangerous to the public 
health, it is clearly seen that treatment alone without taking steps to stop 
the source of supply is a good deal like the building of a hospital at the 
base of a clil5 to care for those who fall over instead of building a fence 
at the top to prevent them from falling. In the one case the hospital is a 
humane measure of cure, but it is more expensive and less effective than 
the fence as a measure of prevention. In the other, the necessity for treat- 
ment to render patients non-infectious would be greatly lessened by effective 
measures for the repression of prostitution, which is the source from which 
venereal disease is obtained and passed on to innocent victims. The re- 
pression of prostitution is primarily the duty of peace officer and court 
officials, but the law recognizes the relation of prostitution to the spread 
of venereal disease by requiring health officers to co-operate with other 
officials in performing this function. Such a broadening of duties greatly 
extends the horizon of the health officer and requires him to recognize and 
grapple with social problems as never before. 

Of special importance in the promotion of any movement requiring 
public support in a popular government are those activities concerned with 
the dissemination of information usually designated as educational work. 
In the venereal disease campaign educational work is particularly difficult 



PUBLIC HEALTH AND EDUCATION 243 

owing to the relation of venereal diseases to sex conduct and the delicacy 
of the questions involved. Here again the things that must be done extend 
beyond the field of public health, this time into that of the school. In- 
struction concerning the contribution that sex makes to life and the physi- 
ology and hygiene of reproduction is distinctly an educational activity 
rather than a health activity. The health authorities are taking the initia- 
tive in this work because the educational authorities are not yet equipped 
to do so. The kind of educational work concerning this subject that belongs 
definitely to the health authorities is instruction concerning the ravages of 
venereal disease, and the methods of cure, prevention and control. When 
the period of experimentation is over and the functions of the different 
branches of government with reference to this problem are more perfectly 
adjusted, the educational work will be divided between the health authori- 
ties along these general lines. 

The provision of recreational facilities as a preventive measure against 
venereal disease is mentioned here merely for the sake of completeness. 
While this line of work is important, it is not a health department function. 

Thus, the huge, country-wide experiment that has been carried on for 
the last two or three years, has resulted in fixing certain definite lines of 
activity as fundamental to any complete program of venereal disease con- 
trol. These may be enumerated as follows : 

1. Treatment of existing cases to render them non-infectious. 

2. Administrative measures of control by the health officer. 

3. The repression of prostitution, for the purpose of cutting off the 
supply of infection. 

4. Educational measures directed toward giving higher standards of 
sex conduct and disseminating information concerning the ravages and 
prevention of venereal disease. 

These, then, are the principles underlying venereal disease control. In 
carrying out this program in North Carolina, clinics for treatment have 
been established in nearly all the larger cities and an active campaign is 
now being conducted among physicians to stimulate interest in the better 
treatment of venereal diseases. 

The educational work is being developed along approved lines by means 
of lectures, exhibits, motion pictures and an extensive distribution of 
pamphlets. Lectures are arranged for men and women separately, and the 
work includes a special educational campaign among negroes by a colored 
physician. More than a quarter of a million pamphlets have already been 
distributed. 

The repression of prostitution by officials of local communities has been 
encouraged through the collection and presentation of information con- 
cerning vice conditions. Responsibility for this line of work has recently 
been taken over by the Inter-Departmental Social Hygiene Board, who 
are furnishing personnel for a division of protective social measures that 
will soon be functioning. 

The final working out of the program of venereal disease control will 
include administrative procedures for handling individual cases dangerous 
to the public health. Among these procedures will be that of quarantine. 



244 NORTH CAROLINA MEDICAL SOCIETY 

for which ample powers have been granted health officers by the Legisla- 
ture. The Supreme Courts of the States of California, Iowa, Kansas, 
Nebraska, Texas and Washington have sustained laws or regulations 
conferring powers of quarantine for venereal disease upon health officers. 
There have been no adverse decisions. Quarantine for venereal disease is 
thus placed on a sound legal basis. A health officer's order of quarantine 
is not subject to judicial review, unless fraud or bad faith is alleged. A 
person held under quarantine cannot be released on bail. Thus a health 
officer has more power than a judge of the court. 

The greater the power the greater the dignity of the office. When the 
public comes to realize that such great powers are vested in health officers, 
the health officer will be given greater public recognition and appreciation. 
If the power vested in an officer be considered as indicating the importance 
of the office, then the whole cause of public health will be advanced 
by gaining such public recognition through exercise of the quarantine 
power. 

AN IDEAL VENEREAL DISEASE CLINIC ORGANIZATION. 

By Raymond Thompson, M. D-, 

Of the Crowell Urological Clinic, Charlotte, N. C. 

It is the aim and purpose of the venereal disease clinic organization to 
reduce the prevalence of the venereal diseases as much and as rapidly as 
possible by the detection and treatment of all carriers not otherwise under 
treatment. There must therefore be a thorough campaign of medical treat- 
ment, combined with the application of all measures that experience has 
shown to be helpful, such as education, law enforcement, follow up work, 
etc. 

1. Organization of Clinic: It is the purpose of the United States Gov- 
ernment, State and County authorities, to establish venereal disease clinics, 
not only to treat patients who are infected, but to inform the people of the 
seriousness of these diseases and prevent as far as possible the infection 
being transmitted to other persons. The clinic should have the undivided 
support of the local board of health, local medical profession, city officials, 
Chamber of Commerce, the press, religious bodies, druggists, and all other 
organizations interested in public health and social hygiene, /Jterature 
prepared by the United States Public Health Service regarding sex diseases, 
and how to obtain proper treatment, should be freely distributed. Stricf 
di.^cipline s)iouM be niaintained among the Per-Jonnel and Clinic. The 
officers should not forget the advantage in promoting a hopeful and inspip 
ing atmosphere in connection with the scientific treatment of venereal 
diseases. 

2. Staff or Personnel: Two physicians, one female nurse, one male 
nurse, one female social worker, one clerk. 

The physician should be well trained in this special work. One physi- 
cian should be the director of the Clinic, and the other the assistant director. 
The physicians should direct the diagnosis and treatment of all cases, as 
well as the general management of the Clinic. 

The female nurse should assist at the examination and treatment of 



PUBLIC HEALTH AND EDUCATION 245 

female patients. After thorough instruction she may give the simpler 
treatments. 

The male nurse or attendant should assist with the examination and 
treatment of male patients. 

The social worker should see the patients on their first or second visit 
and investigate their social relations and home conditions. It will be her 
duty to bring in members of the patient's family who might be infected. 

The clerk should keep a complete and accurate record of all the cases 
and work connected with the clinic. 

Follow up Staff: One of the greatest aids to the Venereal Disease 
Clinic is a well organized follow up system. The social worker should 
have charge of this department. The female nurse and male attendant 
should assist in locating patients who fail to return for treatment. The 
nurse will have the advantage of having seen the patients in the Clinic and 
will be capable of impressing on them the importance of taking treatment. 

Location: The Clinic should be convenient and easily accessible in loca- 
tion. There should be not less than four rooms. It is necessary to have 
separate waiting rooms for male and female patients. The races should 
be separated or not — according to local customs. It is best to have separate 
treatment rooms for gonorrhea and syphilis. 

Equipment: The equipment recommended by the United States Public 
Health Service is as follows: 

1 operating table. 

1 to 4 cheap wooden treatment tables. 

1 instrument cabinet. 

2 two-piede sterilizing outfit. 
2 waste receptacle buckets. 

1 office treatment stand- 

1 Salvarsan outfit, with two 250cc glass containers, rubber tubing. 

2 two-way stop cocks. 

2 300 cc glass-stoppered mixing cylinders, graduated. 
1 dozen Schreiber thumb needles. 

1 Record syringe, 5cc. 
6 Record syringes. Ice. 

3 Record syringes, 2cc. 

2 dozen 154-inch No. 21 steel needles. 

1 bandage scissors. 

3 knives. 

6 haemostats. 

2 pair scissors. 

2 pair tissue forceps. 
1 needle holder. 

1 dozen assorted needles, catgut, silk, etc, 

3 dozen finger cots. 

1 dozen pair rubber gloves. 

1 Janet syringe, lOOcc. 

1 dozen olivary bougies. 

1 dozen French olivary bougies. 



246 NORTH CAROLINA MEDICAL SOCIETY 

1 dozen Porgas olivary bougies. 
6 filiform bougies. 
6 filiform bougies, whalebone. 
1 dozen Gonley's bougies. 
1 Valentine irrigator. 
1 Keyes-Ultzmann urethral syringe. 
6 Fowler sounds. 
12 Van Buren sounds. 
6 female catheters. 
1 dozen assorted rubber catheters. 
1 Dickinson female double flow catheter. 
1 cysto-urethroscope. 
1 urethroscope. 
1 Jollman dilator. 
1 vaginal speculum. 
1 uterine forceps. 
6 sediment glasses. 
1 Bausch & Lomb microscope, with Nos. 1-3, 1-6 and 1-12 lenses. 

1 Bausch & Lomb dark field illuminator (full equipment, with two extra 
boxes of carbon). 

10 dozen lOOcc bottles- 
10 dozen 180cc bottles. 

2 pounds corks. 

3 glass rods. 

2 basins with covers for sterilizing purposes. 
1 Bunsen burner. 

5 feet rubber hose. 
500 test tubes, regular size. 
3000 wooden tongue depressors. 
2000 wooden applicators. 

3 card-index system : 

A — Patients by name and number, 

B — Patients by dates and names, 

C — Patients by diagnosis and number. 

History cards. 
1 platinum loop. 
1 dozen 2-liter flasks. 

1 dozen 1 -liter flasks. 

10 pounds hydrogen peroxide. 
5 pounds phenol. 
5 gallons alcohol. 

2 pounds potassium permanganate. 
5000 formin tablets, 5 gr. 

1 pound iodine crystals. 
5 pounds thymol iodid. 
1 ounce silver nitrate. 
1 pound calomel powder. 
10 pounds 1 and 2-inch gauze bandages. 
500 yards surgical gauze for dressings. 
20 pounds sterile absorbent cotton. 



PUBLIC HEALTH AND EDUCATION 247 

10 gallons Mistura copaibae compositus, N. F. 
2 pounds corrosive sublimate tablets. 
2 pounds arg>Tol. 
2 pounds protargol. 
1000 glass slides. 
1000 cover slips. 
Cedar oil. 
5 pounds mercury salicylate, 1-2 to 1 per cent in sterile liquid petroleum, 
made up in lOOcc, wide mouth, shallow bottles. 
50 pounds Unguentum hydrargarum, U. S. P., 50%. 
1000 ointment boxes, 1 ounce. 
Desirable additions: 

High-pressure steam sterilizer, 
Hot-air sterilizer, 
Small incubator. 

Clinical Hours: The clinic should be opened daily, except Sunday, for 
as long a period as necessary to properly treat all cases. The female 
patients can usually attend early afternoon hours best — three to five 
o'clock ; male patients later hours — five to seven. Unless you have separate 
waiting and treatment rooms it is better to have female patients come early 
and male at a later hour. The Clinic should always open promptly at a 
regular hour and close at a specified time. 

Examination of Patients: The first examination should be made by a 
physician, a complete history, clinical findings and routine laboratory tests 
made and recorded- The patient should be treated "humanely" and given 
intelligent information regarding the importance of proper treatment. 

Records: Accurate records on forms provided for this purpose should 
be kept of all cases. These records include history, symptoms, physical 
signs, clinical findings, laboratory reports, special examinations, treatment 
at each visit, and final results. Report of social worker, visiting nurse and 
other reports dealing with the case should be recorded. 

Laboratory: There should be a laboratory conveniently located, in com- 
petent hands and fully equipped to make all desired examinations. The 
bulk of laboratory work will consist of dark-field examinations, Wasser- 
mann tests, smear examinations and urinalysis. 

Regulations Regarding Standard Treatment: The clinic should follow 
as nearly as possible the standard adopted by the U. S. P. H. S. and State 
authorities. 

Hospital Cases: It is necessary to make arrangements with a local hos- 
pital for taking care of patients needing hospital treatment. There will 
be a great many minor operations in addition to medical cases which re- 
quire institutional care. 

Management of Patient: If the phj'sicians will assume the attitude that 
they are treating patients, with an infectious disease, and not outcasts, who 
should be damned on account of having venereal disease, the patients will 
feel that you are doing what is best for them and at least a great majority 
will gladly return for treatment. 



248 NORTH CAROLINA MEDICAL SOCIETY 

THE IMPORTANCE OF LABORATORY FACILITIES FOR A 

VENEREAL DISEASE CLINIC. 

By Dr. L. C. Todd, Charlotte. 

In the organization of the State Venereal Clinics under the direct super- 
vision of the United States Public Health Service, the latter has emphasized 
the need of the laboratory as an integral part of the local clinic. In the 
case of the smaller clinics, whatever laboratory work that is done locally is 
usually taken care of by the director or his assistant together with the 
State Board of Health laboratory assisting by doing the serological work. 
This will be accomplished by establishing necessary laboratory facilities 
for doing a complete urinalysis, for examining smears and for making dark- 
field examinations. 

Where the number of cases cared for increases to such a point that the 
medical workers are obliged to neglect even the simpler' laboratory pro- 
cedures, a much larger volume of work of a more prompt and more accurate 
nature will be accomplished by establishing the necessary laboratory facilities 
in the hands of a qualified laboratory technician as a part of the organization. 
The number of laboratory examinations can then be increased without 
taking time from the examinations of new patients or from the case of 
those already under treatment- Thus the clinical members of the staff 
may be entirely released to devote their ^ time to their outlined work, and 
they will not be tempted to forego the advantages of what the laboratory 
has to offer in the way of a corroboration of their diagnosis or as a guide 
to their treatment because they may be over-burdened with other work. 

To be of most service to the clinician, the laboratory should be as con- 
veniently located as possible, so that its function as a diagnostic aid may be 
called into use without delay and its place as a guide to treatment may be 
always filled. 

Upon admission, the new patient's examination should include routinely 
the collection of a blood specimen for the Wassermann test. Whether the 
entrance examination reveals a clinical case of lues or not, this procedure 
may add evidence to the clinical diagnosis and may frequently, in a clinic 
of this nature especially, draw attention to the fact that the patient has a 
latent luetic infection. Of the entrance blood Wassermarins of the last 1090 
cases admitted to the local clinic, 482, or 44 per cent, were found to be 
positive. Among the cases reported negative were many early primaries, 
but among the positive cases were many coming to the clinic because of an 
acute gonorrhoeal urethritis. Thus attention was drawn to a latent syphilitic 
infection in the latter group. 

All penile sores are to be examined particularly with the view of proving 
whether or not the lesion is the initial site of a syphilitic infection. When 
we recall that only about 36 per cent of blood Wassermanns are positive 
by the end of the first week following the appearance of the chancre and 
about 60 per cent are positive by the end of the second week, we are im- 
pressed with the importance of using every effort to establish a diagnosis 
by the earliest means at our command — i. e., the dark-field examiantion. 
Repeated thorough dark-field examinations are made in search for the 
spirochaeta pallida. No local applications except non-spirochaeticial moist 



PUBLIC HEALTH AXD EDUCATION 249 

dressings should be used until an earnest search has been made and the 
absolute diagnosis arrived at or the quest abandoned. Only then should 
active treatment be instituted. Every physician coming in contact with' 
patients exhibiting penile sores or suspicious extragenital lesions should 
consider it his bounden duty to arrive at a diagnosis as early as possible, 
and especially before the positive blood Wassermann gives evidence of a 
generalized infection. Before such generalization takes place treatment 
more frequently results in a prompt cure. Failure to find the organism 
has little value in proving the lesion non-syphilitic. Chancroid is so fre- 
quently complicated with syphilis that a diagnosis of pure chancroid should 
not be made until a fair attempt has been made to determine the presence 
of syphilis. When the dark-field search is fruitless, weekly Wassermann 
tests should be made for six weeks and treatment instituted immediately 
if indicated — at the same time repeating the blood test to further corroborate 
the positive finding. 

Routine smears — urethral, cervical, vaginal, etc., are indicated on all 
new admissions, chiefly for the establishment of the diagnosis, but also for 
the observation of the stage of the disease and for the selection of the ap- 
propriate treatment- Many syphilitic patients should also have an exam- 
ination made of the prostatic secretion to discover the latent cases of gonor- 
rhoea. 

All patients to receiv'e arsphenamine should have a complete urinalysis 
done at the commencement of their treatment, and their urine should be 
examined for albumin and casts preceding each subsequent intravenous 
injection — occasionally during their mercurial treatment and at such other 
occasions as their signs and symptoms indicate. By this means there will 
be avoided the possibilit}^ of super-imposing a severe arsphenamine intoxi- 
cation upon a patient already suffering from acute nephritis. 

The influence of specific treatment upon the Wassermann reaction of 
the blood should be watched during the course of treatment — a test being 
made a month after completion of the first course of mercury and subse- 
quent tests being made at the interim intervals during the various courses 
of the treatment. The blood test may prove a valuable guide to further 
treatment, but it should be kept in mind that in a certain number of cases 
serological cure is impossible. 

In the gonorrhoea cases, examination of smears aids the clinician to follow 
the progress of treatmenj: — negative urethral and prostatic smears being 
some of the usual criteria for determining the patient's fitness for release. 

In the follow-up management, syphilitic patients who have been treated 
in the clinics are told to report back at stated periods for physical exam- 
ination and a blood test. At first these examinations are made at frequent 
intervals, keeping in mind that a single negative reaction means little but 
that the blood should remain negative over a period of months. Later the 
intervals may well be lengthened and the patient be regarded as free from 
the necessity of further observation or treatment when examination and 
Wassermann tests have been negative at intervals of two months from a 
period of at least a j'ear. Most clinicians would state that a routine lumbar 
puncture for the purpose of examining the spinal fluid for evidences ot cen 
tral nervous svstem involvement should be done at a suitable time during 



250 NORTH CAROLINA MEDICAL SOCIETY 

the treatment and before dismissing the patient. This should be the pro- 
cedure where the clinic has hospital facilities. The follow-up care of the 
gonorrhoea patients also necessitates their reporting for examination, includ- 
ing examinations of smears, at intervals outlined by the physician. 

The chief value of having laboratory facilities close at hand, as a part 
of the clinic, will lie in the ease and readiness with which the desired ex- 
amination can be made, leaving the clinical members of the stalif free to 
handle their own numerous duties. The laboratory's aid will make for 
more exact and complete diagnosis and will place the treatment upon a 
more direct course and the subsequent management upon a more logical 
basis. 

GONORRHOEAL COMPLICATIONS IN THEIR RELATION 

TO INFECTIVITY. 

By Dr. A. F. Toole, Asheville. 

From the preceding papers of this symposium you have doubtless caught 
the angle of today's viewpoint on venereal diseases. It is an angle which 
gives us a focus not on the individual patient's symptoms, not on the pathol- 
ogy and treatment of the case itself, but a focus on the infected patient as 
a carrier of disease and as a menace to the uninfected- Gonococci and 
spirochaetes hit the individual, but tend to rebound toward the general 
public, thereby creating a health problem ; so, of course, with every infec- 
tious disease. 

Prior to the time when preventive medicine began to take on some of 
its present and promising activity, gonorrhcea and some of its complications 
were handled in almost numberless papers, from predisposing causes to 
prognosis, with a maximum of attention to pathology and treatment, but 
a minimum — too often — toward infectivity. My brief remarks on gonor- 
rhoeal complications will therefore be confined to such as conform to the 
above angle. 

As a matter of fact, the complications of the disease outrank in impor- 
tance the disease itself, in that the problem of prevention revolves around 
them instead of around the simple infection. Indeed, that all-too-rare oc- 
currence — an acute uncomplicated gonorrhoea — is relatively a small prob- 
lem, since we have here to deal merely with a surface infetcion of the 
mucosa of the anterior urethra, easily controlled, easily cured, and of brief 
duration. Its victim is relatively innocuous as a spreader of disease, since 
he is inhibited partly through his own discomfort, partly through a variable 
and limited restraint imposed by his conscience and sense of decency, from 
inflicting his visible and recognized infection upon others. Exceptions to 
such exercise of moral inhibition are of course numerous; perhaps, if or 
when alcohol is introduced as a factor, almost as numerous as the c?ses 
cited for the rule ; but beyond doubt the real male infector is he who carries 
a chronic gonorrhoea; and a chronic gonorrhoeic is merely one whose acute 
gonorrhoea has been attended by one or more complications- Or we may 
state our equation as follows: — Complications produce chronicity, and 
chronicity multiplies new infections. 

The crux of our problem, therefore, is the prevention or detection of 
complications. These may develop insidiously; once developed, they are 



PUBLIC HEALTH AND EDUCATION 251 

often unrecognized by the patient and far too often undiscovered by his 
medical adviser. Yet recognition, or discovery, or diagnosis, of them is 
always possible; which is fortunate, since such recognition is essential to 
that particular treatment which alone can render the quondam carrier non- 
infectious. 

In what ways are we to handle this problem of complications? I shall 
suggest a few, with brief remarks on each as I proceed : 

First. — Continue our attack on the patent or proprietary nostrums, and 
on the counter-prescribing druggist. There was a time when some weakly 
plausible arguments were advanced in extenuation ; but if ever there did 
exist any justification for this abuse, these arguments are scarcely valid 
now. I do not believe there is any other agency so potent in the production 
of gonnorrhoeal complications and in their perpetuation. Nor is there any- 
thing which so spreads and fosters the untruth as to one mode of treatment 
being applicable to all stages and kinds of gonorrhoeal infection. 

Second. — ^Anything which will discourage or minimize the above prac- 
tice will encourage the habit of coming early to the doctor or clinic for 
treatment, before complications have set in. As it is, the average gonor- 
rhoeic is inclined to hold the doctor in reserve as a last resort ; (a compliment 
— if such — too often undeserved-) 

Third. — Watch closely and examine systematically for complications 
during the acute stage. Subjective symptoms may be slight or absent, and 
the onset of complications — even of prostatitis — may be (as said above) 
insidious. Gently examine the prostate at intervals throughout treatment ; 
employ the sound or the dilator at least once on the conclusion of all acute 
or so-called sub-acute symptoms, and where possible inspect the supposedly 
healed urethra through the urethroscope. 

Fourth. — In every chronic case diagnose the cause of the chronicity; 
that is, localize the focus or foci of infection. This should always be the 
first step ; in fact, it is the only logical step. Merely to change the patient's 
injection is either laziness, or, if possible, worse. You may be sure that 
his morning drop is not the outward expression of a single gonococcal 
growth on the surface of his mucosa. The main colony of germs has gone 
into some retreat ; and one might as well use a gargle for pulmonary tuber- 
culosis, as to temporize by shooting in their general direction. The job is 
to find them, and it is not so hard a job when undertaken systematically. 

Such search would most frequently reveal chronic prostatis as the under- 
lying obstacle to recovery ; next in frequency would one find infected folli- 
cles along the anterior urethra, and next a localized thickening of some 
portion of the urethral wall, — in effect a stricture, even though of minor 
degree. I believe one or more of the above three conditions would account 
for fully 90 per cent of our cases of gonorrhoeal chronicity. 

Space forbids any discussion here of diagnostic procedure ; that I can 
leave to the text-books; the point of emphasis just now is the matter of 
careful search for the offending focus. 

Fifth. — The fifth and the naturally succeeding sub-topic is the applica- 
tion of such particular treatment as will rid the focus when found of gono- 
cocci. Emphasis on this consists of course in repetition of the truth that 



252 NORTH CAROLINA MEDICAL SOCIETY 

one must go after each individual condition with special aim and method. 
The way to cure a prostatis is not the way to sterilize the anterior urethra. 
True, this is indeed obvious; but it is too often obvious theory instead of 
practice. 

It does, I will admit, call for some degree of equipment and skill hereto- 
fore delegated to the all-time urologist; but with equipment and skill 
sufficient to handle the average case can be fairly easily acquired. One must 
learn the feel of a normal and an abnormal prostate, must learn the ap- 
pearance of diseased prostatic secretion as seen under the microsope, and 
become familiar with the appearance of the healthy and the diseased urethra; 
the possession of sounds is far more common than is skill and gentleness in 
their use; and a Kohlman dilator, if em.ployed with a due regard for its 
power to do damage when handled recklessly, is a valuable adjunct to the 
armamentarium. 

And just here let me assure you that careful diagnosis and proper treat- 
ment pay, in every sense of the word. For even those patients seemingly 
most ignorant are rapidly learning to distinguish between the old shot-gun, 
hit-or-miss modes of treatment, and treatment which they can see is aimed 
at their own individual troubles. This is daily evident in the clinics; in 
fact, I must say that taking it all in all', the laity has responded more keenly 
to the nation-wide propaganda against these diseases than has the profession. 
You may be certain that for every chronic gonorrhoeic coming to your office 
there is a little crowd of boon companions on the invisible sidelines watch- 
ing the game, and keeping their eyes on that morning drop ; if you win, 
the procession will file in ; if you lose, the next gonorrhoeic will be a 
straggler. 

But careful diagnosis and proper treatment will pay of course in the 
best sense through the satisfaction gained in helping to refute the old fallacy 
which claims that gonorrhoea is incurable, and through lessening the spread 
of the disease by changing a patient from a carrier to a sexually sound 
citizen. 

Summary: By way of repetition, let us say: 

(1) That gonorrhoea is spread by the victim of the chronic form thereof; 

(2) That this chronic stage depends upon the development of some com- 
plication during the acute stage ; 

(3) That to lessen the occurrence of complications, we should 

(a) preach early medical attention, 

(b) fight nostrums and prescribing drug-stores, 

(c) closely watch acute cases for complications; 

(4) That to properly attack complications when chronic, we should 

(a) locate the infected areas of the urinary tract, and 

(b) direct specific treatment against these foci. 



THE DIAGNOSIS AND TREATMENT OF SYPHILIS. 

By C. O. Abernethy, B. S., M. D., Raleigh, N. C. 

I have been asked to say a few words upon the diagnosis and treatment 
of syphilis. My excuse for doing so is the following case reports: 



public health axd education 253 

Case (1) 
Mr. J. H., (white) 40 years old, married, came in my office February 
15, 1920. Gave history of having had little blisters around margin of 
foreskin eight weeks prior to above date. A doctor gave him some bichloride 
of mercury^ for a wash and told him "it would not amount to anything." 
Examination showed a condition of phimosis, with inflammation and ulcera- 
tion of foreskin and glans, due to using too strong solution. Hot applica- 
tions reduced the swelling until I could get a dark-field, which was nega- 
tive on two successive occasions. Wassermann four plus. 

Case (2) 
Mr, R. M., (white) 22 years old, single, was seen by us February 14, 
1920. He gave history of having been cut by barbed wire fence four months 
ago, which caused a sore on penis. Doctor gave him some dusting powder 
and pills, and sore disappeared. Examination showed hard knot on fore- 
skin just at coronal junction. No abrasion. Wassermann negative. Saw 
him again February 20. Knot had increased in size, and finding slight 
abrasion demonstrated spirochetes with dark field. 

Case (3) 
Mrs. W. W., (white) 30 years old, married ten months. No history 
of venereal infection. She had a generalized maculo-papular eruption over 
body, which had been present for over two months and had been variously 
treated. Examination showed general glandular enlargement and slight 
abrasion in lips of vagina. Spirochetes were demonstrated from abrasion. 
No Wassermann taken. 

Case (4) 

Mr. W. D., (white) 26 and married, with one child four years old. 
He had "flu" in January, 1920, followed by an eruption which was treated 
for psoriasis. We saw him April 7, 1920, with generalized eruption which 
resembled psoriasis. He had mucous patches in mouth, from which the 
spirochetes were demonstrated. Wassermann 4 plus. 
Case (5) 

Mr. B. S., (white) 22, single. Sore on shaft of penis two months ago. 
Had worn a "rubber" during exposure. Now has generalized eruption, 
but no abrasion except in folds of mucous membrane of anus, from which 
the spirochetes were demonstrated. Wassermann 4 plus. 
Case (6) 

Showing the possibility of an early diagnosis. Mr. H. B., 21, single. 
Saw him April 12, 1920. Two small sores resembling herpes appeared on 
penis April 9th. Spirochetes demonstrated from these. Wassermann nega' 
tive. 

Case (7) 

Illustrates that sometimes a positive diagnosis cannot be made. 

Mr. W. D., (white) 22 single, had a small sore on penis four months 
ago, and was given one antiseptic wash and ulcer cauterized with nitric 
acid. Saw him February 23. 1920, with ulcer about the size of half dollar 
on under surface of penis at junction of glans and prepuce- Spirochetes 
negative and Wassermann negative on several different occasions. We had 



254 NORTH CAROLINA MEDICAL SOCIETY 

him to soak the penis in normal salt solution, and ulcer is slowly healing- 
These cases were selected from my office practice, and not from the 
clinic, to show the awful tragedies that are being enacted every day in our 
midst among some of our very best people, and to show the importance of 
a thorough examination upon every patient, whether suspected or not. Case 
( 1 ) was a "well-to-do!" professional man and could not possibly have had 
syphilis. Case (2) had an injury to account for his having had a "sore." 
Case (3) was a married woman of the very best family, and therefore could 
not possibly have had a Venereal disease. Case (4) of course had an erup- 
tion following "flu," which could be easily explained. Case (5) wore a 
"rubber" and could not possibly have become infected. While case (6) 
came for an early examination and "took his medicine." And case (7) 
shows the futility of nitric acid cauterization and strong antiseptics. 

THE DIAGNOSIS OF SYPHILIS. 

The most important point in the diagnosis of syphilis, like everything 
else in medicine, is the examination of the patient. Let us not forget that 
most of the mistakes in diagnosis are due to lack of examination and not 
to ignorance. And remember that the station in life of the patient makes 
no difference in the examination. The spirochete thrives in the palaces 
of the rich as well as in the hovels of the poor. 

The only absolute diagnosis of syphilis is the demonstration of the spiro- 
chete pallida. This is usually a comparatively easy matter, provided the 
examination is thorough enough. Don't forget that you can often demon- 
strate the presence of the spirochete more easily in other abrasions of the 
skin and mucous membrane than in the chancre itself. Especially is this 
so in abrasions in the anus — mouth and throat. Get the habit of believing 
that every "sore" on a penis is spyhilis until you have proven it otherwise. 
And while you are proving it be sure not to use any anti-syphilitic treat- 
ment. 

The Wassermann test is a very valuable adjunct in the diagnosis of 
syphilis and should be used in all cases. But remember that the test is late 
in appearing, usually being about one month, and that only 85 °(, of them 
are correct. 

The physical findings are exceedingly important. Let us all remember 
that we are still practitioners of medicine and that our judgment in all 
cases is important. Don't try to diagnose a chancre from a chancroid by 
the appearance, because the man does not live who can do this. Of course, 
there are certain differences between the two which makes one suspect very 
strongly one way or the other, but there are so many mixed infections that 
one can never be certain. But when a patient gives a history of having a 
sore, with general glandular enlargement, followed by an eruption at the 
regular time, be very slow to give up your diagnosis because the laboratory 
findings are negative. 

THE TREATMENT OF SYPHILIS. 

The only treatment of syphilis is the combined treatment ; that is, using 
all drugs at your command that are indicated. Let us get away from the 
terms salvarsan treatment and mercurial treatment. One drug is just as 



PUBLIC HEALTH AND EDUCATION 255 

important as the other, and in the tertiary stage potassium iodide is as im- 
portant as both. 

I do not care what form of arsenic you use nor what form of mercury, 
but I do believe that saturation with both as early as possible is very im- 
portant. 

If you study the literature you will find almost as many different meth- 
ods of using salvarsan and mercury as you have specialists. The method 
which we recommend is arsphenamine (which means any of the salvarsan 
or neo-salvarsan groups) once weekly and mercury during the same period. 

In my office and clinic I use arsenobenzol on Saturday and salicylate of 
mercury on Wednesday for six weeks, then only the mercury once a week 
for six more weeks. Then I rest from all medication for six weeks. Have 
a Wassermann made and regardless of what it shows repeat the above 
twelve weeks' treatment. Then, to be certain that I am over-treating 
instead of under-treating, I recommend after a rest of two or three months 
another twelve weeks course. After this I recommend a Wassermann 
every three months for a year, and if they all are negative I discharge the 
patient as probably cured. 

I think that it is generally conceded that the rest periods between the 
courses of treatment are very important due to the fact that the spirochetes 
either encapsulate themselves or acquire an immunity against a drug after 
given over a long period of time. 

CENTRAL NERVOUS SYSTEM SYPHILIS; ITS INCIDENCE 

AND TREATMENT. 

By Joseph A. Elliott^ M. D., Charlotte, N, C. 

Invasion of the central nervous system by syphilis has been recognized 
as a clinical entity for many years; however, there has been a great deal 
of discussion during the past half century as to the part played by syphilis 
in the more remote conditions, viz. : general paresis and tabes dorsalis. To 
Esmarch and Jessen belong the honor of first having discussed the relation- 
ship between general paresis and syphilis. These observers reported in 
1857 three cases of paresis and syphilis in which they attributed the paresis 
as due to syphilis. In 1875, Fournier advanced the theory that tabes 
dorsalis was due to syphilis. Since that time these theories, so long as they 
remained theories, were discussed very exhaustively both pro and con. 

With the advent of the Wassermann reaction, and its application to 
the spinal fluid, syphilis as the etiological agent was practically established. 
Many who admitted that these nervous disorders were syphilitic in origin 
were of the opinion that the pathology was due to toxins from remote 
foci and not to the invasion of the brain and cord tissues by the organism 
of syphilis. They therefore classified these conditions as parasyphilis. Not 
until 1912 did the light begin to dawn on this important question, when 
Noguchi demonstrated spirochastse pallidre in pathological sections taken 
from the brains of paretics. His excellent research stimulated others in 
their efforts to confirm his work, Avhich has been done in many instances. 
Wile went a step further, obtaining small bits of tissue from living paretics, 
and demonstrated spirochaetes both by dark field examinations and animal 



256 NORTH CAROLINA MEDICAL SQCIETY 

inoculations. He then obtained spinal fluid from paretics, tabetics, and 
acute syphilitic meningitis caseis. While he was not able to demonstrate 
the organism in the dark field examinations, he obtained positive animal 
inoculations in a number of instances from all classes of patients. Thus, 
it has been definitely proven that tabes dorsalis and paresis as well as syphil- 
itic meningitis are due to active spirochastes localized in the central nervous 
system and not, as was once thought, to circulating toxins from a distant 
focal infection. 

INCIDENCE OF CENTRAL NERVOUS SYSTEM SYPHILIS. 

It is now generally conceded that tabes dorsalis and general paresis are 
not due to a sudden invasion of the central nervous system producing 
symptoms within a short time, but that the processes are slowly progressive 
ones and that infection takes place at the time of the general dissemination 
of the organisms from the primary lesion. It is no more likely for these 
marked changes to take place in a short time than it is for an aneurism to 
occur shortly after infection. The pathology of these lesions is one of 
slow progressive changes which are manifested first by lymphocytic and 
plasama cell infiltration, followed by a replacement fibrosis, which in turn 
causes the clinical symptoms. 

During the early dissemination of the spirochaetes there may be symptoms 
referable to the central nervous system which are due to acute inflam- 
matory reactions and which in some instances are undoubtedly the precursors 
of the later manifestations of lues. A few years ago the number of cases 
of lues showing central nervous involvement was thought to be very small, 
due to the fact that patients were not carefully examined for such lesions, 
and only those with very obvious clinical manifestations, such as nerve 
palsies, hemiplegias, etc., were diagnosed. Today, however, the entire 
nervous system is very carefully examined in all cases of syphilis, besides 
lumbar punctures are done as routine by many syphilologists- These re- 
sults of these more careful examinations have revealed amazing facts. 
Fordyce states that from 25% to 35% per cent of patients in the first year 
of infection show pathological changes in the spinal fluid, wihile Pollitzer 
believes more than half the cases during this period show changes. In 1915 
Wile and Stokes made very careful studies on a series of early syphilitics, 
in which they had the fundus ocuH, the eighth nerve, and a very careful 
neurological examination made by experts in each line of work. They 
found that from 60% to 70% of their cases showed some evidence of cen- 
tral nervous system involvement. A small percentage of cases showing 
no clinical evidence whatever show positive spinal fluid findings, which is 
a strong argument for the adoption of the lumbar puncture as a routine 
procedure. 

TREATMENT. 

While there are a few prominent syphilographers who still hold to the 
view that central nervous system syphilis can be treated successfullv by 
intravenous and intramuscular medication, by far the largest majority have 
demonstrated to their satisfaction that intraspinous therapy is an essential 
part of practically ever>^ syphilitic's treatment showing such involvement. 
This has been demonstrated over and over again by first having failed with 



PUBLIC HEALTH AND EDUCATION 257 

the former and obtaining results with the latter. I shall not go further 
into the merits by which intraspinal treatment has won its place in our 
therapeutic armamentarium, but will take up the methods which are com- 
monlj' in vogue today. There are three principal ones: 1. Swift-Ellis; 
2. Ogilvie's; 3. Wile's. The procedure of Swift-Ellis is well known, and 
is, briefly, as follows: One hour after the intravenous administration of 
arsphenamine or neo-arsphenamine 40 c. c. of blood is drawn directly into 
a sterile centrifuge tube and centrifuged after the clot has formed. The 
clear serum is pipetted off and placed in the ice box over night. It is then 
heated in a water bath at 56°C for thirty minutes; 12 c. c. of the serum is 
diluted with 18 c. c of normal salt solution and introduced into the lumbar 
portion of the spinal canal. The amount of serum may be increased at sub- 
sequent injections. The criticism that has been made of this method is- 
based on the small amount of arsphenamine contained in the serum. To 
obviate this defect Ogilvie has modified the method by adding to the serum 
a specific amount of arsphenamine. A refinement of the Ogilvie modifica- 
tion has recently been published by Kolmer. He gives the patient 0.6 
gms. of arsphenamine intravenously and immediately withdraws 25 c. c. 
of blood from the opposite arm and expels it into a 50 c. c. sterile centri- 
fuge tube to which has been added 4 c. c. of a 10% solution of sodium 
citrate. This is agitated to mix the two fluids and centrifuged. To 
10-12 c. c. of the clear serum is added from 1-3 to 1 mg. arsphenamine. 
The arsphenaminzed serum is then placed in a water bath at 56° C- for 
thirty minutes, following which it is ready for injection into the spinal canal. 
Wile's method consists in preparing the arsphenamine so that 0.1 gm. is 
dissolved in 30 c. c. of freshly distilled water. A lumbar puncture is per- 
formed in the usual manner, a 20 c. c. luer syringe is attached to the lumbar 
puncture needle by means of a rubber tube containing a glass window and 
a metal adapter. The syringe is then low^ered below the level of the lum- 
bar puncture needle until 10-15 c. c. of the spinal fluid is collected. To 
this is added, two to three minims of the arsphenamine preparation and 
the mixture is stirred thoroughly with a glass rod. The syringe is then 
raised above the level of the needle and the arsphenaminized fluid is allowed 
to flow back by gravity. If the pressure is very high the piston of the syringe 
may be inserted and the fluid very gently forced into the canal. 

COMPARISON OF METHODS. 

The small amount of arsphenamine contained in the serum given by the 
Swift-Ellis method is not sufficient to produce an efficient therapeutic 
result. On that account Ogilvie devised his modification of this method, 
which has proven much more efficient and in many instances has given 
excellent results. Both methods, however, have the decided disadvantages 
of introducing foreign substances other than arsphenamine into the spinal 
canal, which to my mind is an important factor unless it can be proven that 
the serum per se has a definite therapeutic effect. Wile's method has the 
following points in its favor: First, the arsphenamine is diluted with spinal 
fluid, the most logical media to use. Second, the technique is simple. 
Third, intravenous and intraspinous treatments may be given within a 
few minutes of each other, thereby avoiding an hour's suspense on the 
patient's part and completing both treatments before there is time for a 



258 NORTH CAROLINA MEDICAL SOCIETY 

possible reaction from the intravenous. Fourth, exact knowledge of dosage 
of arsphenamine. From the standpoint of technique, etc., this treatment 
seems to have decided advantages over the preceeding ones. If its thera- 
peutic value compares favorably with the other methods, and it has in oui 
experience, its simplicity makes it the method of choice. 

While on Dr. Wile's service at the University of Michigan hospital I 
had the opportunity of treating, by his method, most of the central nervous 
sj^stem syphilis cases for a period of over two years, during which time several 
hundred cases were treated. The results were gratifying in over 90% of the 
meningitis cases and in a very large percentage of tabetics. Our results in 
paresis have been uniformly unsatisfactory. The acute cases, as would be 
expected, respond more rapidly than any other class of patients. The cell 
count usually comes down very rapidly with a corresponding clearing up of 
symptoms. Virtually all cases of early tabes show improvement under this 
form of therapy, whereas those with advanced nerve degeneration do not re- 
spond readily. This may be explained on the grounds that in early tabes many 
of the symptoms are the results of the inflammation present rather than 
degenerative changes, and under intraspinous treatment many of the organ- 
isms are killed off with a resulting disappearance of the inflammation and 
clearing up of symptoms. Once there is degeneration, no amount of treat- 
ment will repair the destruction that has taken place in the nerve structures; 
however, the process may be halted by treatment, and in many instances one 
is impressed with the marked improvement in symptoms. I recall a case that 
I treated 3 years ago that was suffering most severely with lightning pains 
and whose gait was markedly ataxic- After receiving a course of four intra- 
spinous treatments, the pains entirely disappeared and his gait showedsome 
improvement. One year later I again saw the same patient, and while he 
was still very ataxic he had been entirely free from pains during the interval. 
Just recently I had a patient with gastric crises who had received four intra- 
venous arsphenamine during the two months preceding the onset of the crises- 
She was given an intraspinous treatment and within one hour the vomiting 
and pains stopped, although they had persisted for four days in spite of all 
other measures. 

I shall now present a few lantern slides furnished me through the courtesy 
of Prof. Udo J. Wile of Michigan. These slides were made during the 
early days of his method of treatment, and I can vouch for the fact that 
even better results are being obtained at the present tim.e with the same 
technique as employed then, but with a larger number of treatments. 

DISCUSSION. 

Prof. Udo.J. Wile, of the University of Michigan. 
Mr. President and Members of the North Carolina Medical Society: 

I wish to express my appreciation for the privilege of listening to these 
papers. The hour is so late that I hesitate to take up the very excellent paper 
of Dr. Knowlton, which was presented in a very clear cut manner. Those 
interested might be helped by studying the law we have in Michigan today. 
Michigan was a pioneer state in attempting to frame and enforce a law which 
in substance was a good law, and which should have the backing of the medi- 
cal profession, but it has not It fails because of a few unfortunate features 



PUBLIC HEALTH AND EDUCATION 259 

which I think will be eliminated in the next session of the legislature. I 
am not qualified to discuss the papers on Gonorrhoea, but I would like to 
say a few words to you about the treatment of Syphilis of the nervous sys- 
tem. There is no treatment for syphilis which is not intensive. I am 
going to make the statement that the unfortunate effects that we see are 
a direct indictment against medical practice and medical treatment. There 
is no excuse for these venereal diseases or the conditions which result from 
• syphilis, except that they are not treated correctly. The proper time to 
treat S3^philis is the first week and first month of infection. That is the 
time the patient seeks your advice when the patient is from the standpoint 
of infection most dangerous. That is the time you have the best chance 
to treat him. It is unquestionably a fact that a few weeks of treatment 
in the first months of infection is the important thing. At the outset you 
deal with a local disease, which very soon becomes a general disease, and it 
is believed at this time that you have a chance of eradicating the disease. 
After the patient's treatment has been neglected or no treatment whatever 
given he is syphilizd, and then his chances for recovery are very slim. It 
is only as Dr. Elliott has pointed out, in the late years that we realize 
that the disease is braced with nervous infection. I think there is no simpler 
thing in the hands of the general practitioner than the examination of 
all patients for Syphilis. How else could it be? You have during the first 
three or four weeks an infection in the blood stream. The same blood 
that goes to the liver goes to the nervous system. It is at that time the 
patient is potentially a nervous- wreck. I have been so impressed with this, 
that a number of years ago I formulated a little rule which I have written 
about and told my students about, that the fate of every syphilitic is de- 
termined in the first stage of the infection." 

If you are attempting to inject into the spinal canal any foreign sub- 
stance, take the substance that is the least irritating and the smallest 
quantity. I have felt that the direct application of the minutest dose of 
Salvarsan is a method of choice, in cases of paresis or those in which you 
have a softening of the brain. I mean he is not the ideal case for intensive 
treatment, and you have only the right to expect that by certain treatment 
you may get rid of the worst- I have been using this method for six years, 
and I can truthfully say that I have never seen an early case of syphilis 
develop into syphilis of the nervous system. I have seen a number come 
back, but they have been made entirely well. For a case of paresis you 
need not wait 10 or 15 years. I have seen it develop 11 months after the 
infection. I am sure that we see more syphilis today, first because there 
is more syphilis, and, second, there are more diagnoses. In years gone by 
we waited for the patient to become blind before we made the diagnosis. 
Today we diagnose the case immediately in order to enable us to cure it. 
I appreciate the opportunity of discussing these splendid papers and to 
impress upon you that Syphilis is a disease which has so many aspects that 
it requires intelligence and not routine treatment. Each case is a case of 
itself. We must regard the patient, rather than the disease, as n problem. 

Dr. Anderson : 

I want to express my thanks and I believe the thanks of this entire body 
for the exposition of truth we have just listened to- I happen to be in charge 
of the State Hospital and I know what these terrible results mean, caused 



260 NORTH CAROLINA MEDICAL SOCIETY 

by the lack of proper treatment. I wish everyone connected with this work 
could know something of the value of this address we have listened to. 
I thank Dr. Wile personally, and know all of us feel under obligation to 
him for coming here. 

Dr. Abernathy: 

I also want to thank Dr. Wile for coming here and giving us some real 
information about Syphilis. I want to ask him: "Don't you use mercury 
at all?" 

Dr. Wile: 

I think if I had to choose a remedy and use it unintelligently, I would 
use mercury itself. Salvarsan cannot be unintelligently used, but there is 
no drug that is as unintelligently used as mercury. A number of years 
ago I had occasion to analyze some hundred cases of Syphilis, in which 
all of the treatment was perfectly plain. We discarded all of those who 
had not been treated at all, and took one hundred severe cases in which 
treatment had been given. In that number 90% had been given proto 
iodide pills. It is the most convenient way for administering mercury 
so far as the patient is concerned. In order to saturate the patient you 
have to give him such severe doses that the proper treatment is never 
reached. It must be an accepted fact that the interrupted form of treat- 
ment in the form of injection stands first. I do not mean to say that there 
are cases in which we should not use the injection treatment, because young 
infants and elderly people present a different aspect. Salvarsan acts very 
differently from mercury. There is a time when we do not know what 
Salvarsan is doing. I cannot tell anyone how much of that to give a patient 
and how much not to. I think a patient should receive it and mercury also. 

Dr. C. B. McNairy: 

In regard to the children of these people suffering from Nervous Syphilis, 
as to the longevity of children and their mental condition? 

Dr. Wiles: 

If you refer particularly to the children of the patients, I am not pre- 
pared to answer, so few have had children, time has been so short. I have 
seen numbers of cases where patients have married and had children and 
they were alright; but as to children, we have a very interesting problem. 
It brings up the whole question of transmission of Syphilis from father 
and mother to the child. But it must be admitted, beyond any question, 
that they do have perfectly healthy children. I have in mind a dozen, 
off hand, and then members of the community whose parents have been 
syphilized. Only very recently one of my pupils brought me his fathet 
in an advanced stage. I have had a number of cases. I know of a man 
who is an excellent man, whose father I treated and whose mother died 
of syphilis of the bowels. On the other hand, we find cases where children 
are not strong and healthy. But I am prepared to state if a person marries 
a syphilitic, then the chances of the children are far less than the one who 
marries a woman without syphilis. 

Dr. McNairy: 

My record shows that most of the children that show affection are th*' 
first child. 



PUBLIC HEALTH AND EDUCATION 261 

^: i 

Dr. Wile: 

I am perfectly convinced that Syphilis is contagious, but that most feeble- 
minded children are not syphilitic; that Syphilis does not play a very big 
role in the incidence of feeble-mindedness. 

Not very long ago in the State Hospital in Michigan a very careful 
study was made, and I think only 3 or 4 per cent was found to be syphilitic. 
Their parents had other diseases besides Syphilis, without doubt- Occa- 
sionally we found a very direct nervous syphilis in a mother and child. I 
know of three young children whose parents had nervous syphilis and all 
three of the children developed the disease, but that is a very striking case. 

Dr. Crowell, Charlotte: 

The field has certainly been well covered this evening. I simply want 
to call the attention of the members of the staff to the appalling fact that 
it is a very serious disease, and that the early diagnosis, the facts and figures 
that have been brought out this afternoon from Dr. Abernathy's paper on 
the early diagnosis, the recognition of the disease in its early development 
is enough to arouse the profession to its great importance, and to go away 
with the determination that they will do more than ever before to prevent 
the spread of the disease. I am so glad to see our State authorities taking 
hold of this problem with such vigor and may we not hope that the day is 
not far distant when these late results will practically be no more, because 
if we will carry out the plan of treatment outlined in these papers it seems 
to me that we can prevent these late manifestations, treating the patient, 
rather than the disease, as Dr. Wile stated. 

Dr. McBrayer, R. A.: 

With two excellent teachers, Dr. Wile and Dr. Crowell, we have had 
a corking good lesson, with help from the others. I thank them on behalf 
of the medical profession and the people of North Carolina. 

Dr. Abernathy: 

We are attacking the problem as a public health problem- 
There is no question about the fact that the treatment of Syphilis is alright; 
there is no argument about that. But all of us can't use a spinal treatment 
for syphilis. We have got to use what we can get our hands on. We are 
compelled to use the best way we know how. All the syphilitics in North 
Carolina can't come to Charlotte or go to Raleigh and be treated. We 
are trying to get the men in the country who know how to do it, or get 
so interested in it that they will learn how to do it. I don't know whether 
or not I am fully converted that all Syphilitics should be treated by the 
spinal canal. I have two cases in my records, paralysis below the waist 
which was relieved of paralj^sis and made a good citizen by the intravenous 
injection of salvarsan and mercury and large doses of iodine. I don't 
know how it got in there, but they were taken out of the bed where they 
lay helplessly paralyzed and are now walking around doing their work, 
and didn't get any spinal treatment. We are trying to reach the man out 
in the woods, the man who has not got the money to go and be treated, 
and get some man in that county that can give Salvarsan and Mercury 
correctly. 



262 NORTH CAROLINA MEDICAL SOCIETY 

Men are ready to say we can't go into the diagnosis and management 
of these early nervous syphilis conditions. But the time is not far distant 
when the men throughout the country will equip themselves to do this 
line of work, and we will be cutting out a whole lot of work Dr. Anderson 
is doing as the result of Syphilis. He is caring for this a great deal in the 
Insane Asylum, and I believe with care of these patients we will prevent 
the spread, as well as the nervous cases in the State Hospital. 

Dr. Knowlton, closing discussion on his paper: 

I would like to say a word or two in regard to the point Dr. Wile men- 
tioned concerning reporting. We must not lose sight of the fact that the 
primary object of having communicable diseases reported is to permit the 
health authority to exercise supervision over the cases that need supervision 
in order to protect the public health, as pointed out in one of the papers 
I read. "A case of venereal disease, even though they be in the infectious 
stages, should be so handled as not to be a menace to the public health." 
So it is not necessary to have the names and addresses of all cases reported- 
It seems to me that the best practicable solution of that problem — that 
has been worked out in several places and applied satisfactorily — is to put 
the proposition up to the physician himself as to whether or not he will 
report the cases by number. So it seems to me that the common sense, 
practical way of requiring reporting gives the physician the option of re- 
porting by name and address or by number, which will give the Health 
Officer information concerning cases that ought to come under his super- 
vision. 

Adjourned. 

WEDNESDAY, APRIL 21, 2:30 P. M. 

The President announced that according to adjournment we would pro- 
ceed to ballot for seven members of the Board of Medical Examiners of 
the State of North Carolina. Before doing so, Dr. H. A. Royster, Sec- 
retary of the retiring Board of Medical Examiners, made the following 
report: 

REPORT OF BOARD OF EXAMINERS. 
By H. A. Royster, Secretary. 
To the Medical Society of the State of North Carolina: 

The Board of Medical Examiners, elected by you in 1914 and come now 
to the close of its six years of service, desires to return to you the trust im- 
posed and to render an account of its labors. Each year a report of our 
examinations has been published in the Transactions of the Society; but 
the members of this Board resolved to present to you a summary of their 
complete record, and of their own accord requested the privilege of address- 
ing you today. 

It will be manifestly unnecessary, and in some respects impossible, to 
offer you all the details of the work. What seems essential is to state the 
principles which guided our conduct from the beginning, to outline definite 
alterations that were made in the laws, to express some of the results 
achieved and to propose certain recommendations for your judgment. 



PUBLIC HEALTH AND EDUCATION 263 

Our Initial controlling desire was to elevate the requirements for admis- 
sion to examinations. From the results of our first examination in 1915 
it was seen that a large number of applicants were poorly prepared both 
academically and professionally and had been unsuccessful before the Board 
year after year, running the number of failures up high. Practically all 
of these were found to be graduates of schools rated lowest by the Council 
on Education of the American Medical Association (Class C). Our plain 
duty was to eliminate these applicants. It was further evident that eleva- 
tion of the requirements should be gradual, but decisive. Accordingly, 
under the statute giving the Board authority to define a "reputable" med- 
ical college, the rule was adopted rejecting Class C applicants after 1915 
Class B applicants after 1916 and after 1917 accepting only Class A 
applicants. This rule has continued in force. Its adoption has reduced 
the percentage of failures by one-half, or more, because those who come 
from the high grade schools are already qualified by preliminary and pro- 
fessional education, and the only question for- a Board of Examiners to 
determine is whether by character and attainments these applicants are 
competent to practice medicine in North Carolina. 

There is still a flaw that prevents the perfect working of our Class A 
rule, namely, a proviso in the statute which states that a license in another 
State stands in lieu of a diploma and entitles to examination. This amend- 
ment was passed before our reciprocity act became a law, and, as it exists 
today, nullifies our rule to accept only Class A applicants. It should be 
repealed. Two attempts have been made to do so, but each time the re- 
sult was a failure, in the one case owing to a misunderstanding fostered 
by a medical member of the legislature, and in the other due to physical 
loss of the bill in committee. There could be no possible objection to re- 
peal of the amendment, since it cannot operate to the disadvantage of any 
North Carolina citizen. In the meantime, it must be confessed that this 
little proviso has enabled the Board to sidestep the issue of the so-called 
"limited license" in particular cases. It may be observed in passing that 
doing away with the limited license law may soon come to pass, since it has 
fulfiOed its mission and because of a demand even from its legislative 
author and some of his constituents to remove the stigma which the act 
implies. But this is an affair which coming boards must decide. 

One of the innovations adopted by the present Board was the passing 
of a law allowing students the privilege of coming up for examination 
on the fundamental medical branches — anatomy, physiology and chenn^try, 
with their accessory subjects — at the end of their first two years of study. 
The Board members were unanimously in favor of this provision and had 
discussed the propriety of adopting it on their own motion as a rule* out 
it was undoubtedly a stronger feature to enact a law covering the situation, 
and the Board acknowledges the help of a member of a former Board who 
at the time was a representative in the lower legislative house and who 
proposed and introduced the bill. In the opinion of our Board, this change, 
on the whole, has worked well. It affords, of course, an imnicnse ad- 
vantage to the applicants, while entailing only a slightly increased amount 



264 NORTH CAROLINA MEDICAL SOCIETY 

of clerical work upon the examiners. With apology for the personal .illu- 
sion, it is on record as far back as 1893 that the Secretary of the present 
Board was the first to apply for the privilege of passing the first two years' 
work separately and that the request was respectfully denied. Thus is fate 
reversed. 

Very early in its deliberations the Board keenly realized three impor- 
tant facts : First, that it would be desirable to divorce its own sessions from 
the meetings of the State Medical Society; second, that a permanent place 
centrally located would be advantageous both for the examiners and the 
applicants; third, that in justice to themselves and to the students, the 
Board should take the papers home for inspection and report later and not 
grade them during the rush of examinations. Means were devised to bring 
about these reforms. 

Before the county unit organization plan was agreed to in 1904, it was 
vitally necessary for the examining Board to meet just prior to and along 
with the Society, for by this arrangement the newly licensed physicians could 
immediately be admitted to the State organization. But after 1904 all 
new members came in through the county societies, and the need for an 
overlapping session no longer existed. Besides, it seemed very desirable to 
place the time of examinations later in the summer, long after the closing 
of all the medical schools. Further, there was to us a yearning for a de- 
tached, quiet session, without let or hindrance, visitors or assistants. Finally, 
there appeared to be no valid reason against the change. The law was 
amended by act of the legislature without shadow of opposition and with 
every commendation for the improvement- Having had one trial under 
the old system, we assert unhesitatingly that nothing could induce us to go 
back to it. 

The question of a permanent place for meeting is somewhat bound up 
in the foregoing arrangement. As long as the Board was compelled to meet 
with the Society, the transfer of books, records, apparatus and other para- 
phernalia entailed expense, trouble and losses. Previous Boards had no 
chance to accumulate fixtures, to develop enduring plans for conducting 
their examinations or to carry on efficiently the routine work of the Secre- 
tary's office. The advantages of a central location for the permanent meet- 
ing place are obvious. It means a saving of time, money and labor for ex- 
aminers and applicants. Our law now provides that the principal meeting 
shall be held each year in the city of Raleigh, but that other meetings may 
be called there or elsewhere, in the discretion of the Board. It is but fair 
to say that the resolution calling for this change in the law was introduced, 
not by a member of the Board living in Raleigh or vicinity, but by a mem- 
ber from the western section of the State. The Board is now of one mind 
in declaring the step wisely taken and more than justified by the results. 
What the incoming Board may decide to do with this matter will depend 
upon availability, geography and personality. 

Under the old regime, when the Board assembled one week in advance 
of the Society session, they were forced to do their work under high pressure, 
using every moment night and day in which to get their report ready for 
the first day's meeting of the Society. The members of the present Board 
frankly felt unwilling to continue this method, if possible to avoid it, after 



PUBLIC HEALTH AND EDUCATION 265 

their one trial in 1915, when 134 applicants presented themselves for ex- 
amination. As soon as the conditions were changed there was no occasion 
for an oral report and no hurry for the inspection of examination papers. 
The safe and sound policy at once suggested itself, namely, to grade the 
papers carefully and leisurely, giving such time as might be necessary for 
deliberation and discussion. The custom of this Board, therefore, has been 
for the examiners to take their papers home, read Vnd mark them at their 
own convenience, forward the grades to the Secretary as soon as completed, 
and then about two weeks after the examinations to meet for conference. 
Immediately following this, the names of the successful candidates are 
published as required by law. The relief and the satisfaction gained by 
this improved procedure can be felt only by those who have had experience 
of both the old and the new method. 

In the foregoing discussion of the three important objectives which the 
Board set out to reach and finally attained, it will be observed that the first 
move was the most essential. Indeed, upon the separation of the Society 
and Board .sessions everything hinged; for the selection of a permanent 
meeting place and the orderly examination of papers could not have been 
accomplished without a change in the law which formerly required the two 
bodies to meet near each other in time and place. So far from pulling them 
apart, however, the new plan really brings the Board and the Society closer 
together; for it allows the examiners greater liberty to attend the Society 
meetings and accentuates their responsibility and their co-operation. It 
should constantly be emphasized that the Board is the creature of the So- 
ciety, and the present Board has sought to strengthen this relation, believ- 
ing that the selection of its members by the Society in open session is the 
soundest method whereby expression of its will may be made by the larger 
organization and through which the smaller body may accept its obliga- 
tions. 

An inspection of the former laws relating to the prosecution of illegal 
practitioners caused us to realize very promptly that they were inadequate. 
These prosecutions had been left to the local societies or to individuals, and 
there was no definite machinery for the conduct of such cases. There was 
no provision for the Board itself to handle them. We were convinced that 
a Board that had power to give license should have the power to prosecute 
those who violate the law under which it was created. We felt that these 
prosecutions should be taken out of local hands and placed in those of a cen- 
tral authority, and that at the same time rules should be made for beginning 
the actions and carrying them on to successful conclusions. The outcome 
of our efforts was the present law, passed without opposition, founded on 
a like measure which had proved adequate in other States. It provides, 
in effect, that upon complaint of the Board of Examiners the Attorney- 
General of the State shall investigate the case, and, if in his opinion, the 
law has been violated, he shall direct the Solicitor to prosecute, and the 
original jurisdiction shall lie in the Superior Court. The strong elements 
appear in this law, viz. : the psychological power of the State's chief prose- 
cutor, his direct control over the district solicitors (as set out in the con- 
stitution, but not generally recognized), and the primary handling of the 
cause in the Superior Court instead of by a magistrate. Thus each case 
is divested of its local color and so-called personal prejudice. It immedi- 



266 NORTH CAROLINA MEDICAL SOCIETY 

ately becomes a State-wide matter — an offense against a North Carolina 
statute, and not merely a community affair. The effect of the operation of 
this law has been most satisfactory. By its aid we have been enabled to 
convict or drive out of the State a dozen of the most notorious quacks and 
in addition to eliminate at least a score of lesser offenders. At times the 
routine letter from the Attorney General's office is all that is required to 
deter would-be violators of the law. No such results could have been ob- 
tained without the employment by the Board of its own attorney, as sug- 
gested in the act, and this Board goes on record as having been the first to 
make such an arrangement. We give it our unqualified endorsement. The 
services of a legal advisor are vital and especially if he is available to rep- 
resent the Board and assist the Solicitor in any court in the State. During 
our incumbency the license of one physician has been revoked because of 
conviction in court of criminal abortion. Only fcne cause is now in our 
statute for revoking a medical license — grossly immoral conduct. At best, 
this is vague and indefinte. The number of causes should be increased and 
proper methods prescribed for procuring the result. 

No attempt has been made to cover all the points which might be sub- 
jects for discussion. The Board is conscious of its limitations in making 
its report at this session of the Society. There is one more examination for 
us to hold, and we are not able, therefore, to include all of our work in the 
summary given. But at this meeting you will elect our successors, who, 
thanks to the separate meeting of Society and Board, will have the advan- 
tage of attending examinations before their term of office begins. We 
tender them (whoever they may be) a cordial invitation to join us at 
Raleigh on June 21, 1920, and engage with us in the conduct of our last 
series of examinations. It is to them that this report is largely addressed, 
for we know the burdens and the labors which lie ahead of them, and if 
it is in our power to lighten the load we are only too glad to do it. The 
fact that the incoming Board will have the benefit of consultation and dem- 
onstration beforehand (which we did not have), precludes the necessity 
of recommending a return to the old plan of electing two examiners every 
other year. But for this attendance on the retiring Board's examinations, 
we would be sorely tempted to advise the fractional system ; for the assump- 
tion of office by seven*perfectly new men, with no hold-over to furnish in- 
struction or encouragement, is not an alluring prospect, to say the least. 

There has been so much pleasant association, so great reward in duty 
honestly performed and so many opportunities for service that we have been 
forced to forget the toil and the tribulations. Among the members of this 
Board have existed the most affectionate feelings, the closest comity, the 
greatest good-will and the sincerest devotion to the same high purposes. 
All of these outweigh any sacrifice or labor or time or trouble. 

We hope for our successors the same harmonious relations that have 
attended our deliberations. Differences there have been, but none created 
or held in a spirit of rancor, and always there was a sense of right and justice 
prevailing. We had always before us the consciousness that we were in 
fact officers of the State, commissioned to protect the people from imposters 
and incompetents, not dealers in favors or promoters of the unfit. An ab- 
solute standard and rigorous enforcement of rules represented our ideals. 



PUBLIC HEALTH AND EDUCATION- 267 

We are turning over to the next Board certain financial and physical assets 
— things which were not in our hands when we assumed office. That these 
will be made proper use of goes without saying. The new Board will 
possess benefits never before granted to any other. We wish for them an 
abundance of success. 



General Session 

Wednesday, April 21, 11 :15 A. M. 
NOMINATIONS FOR MEMBERS BOARD OF MEDICAL 

EXAMINERS. 

Meeting called to order by Dr. Reynolds. 

"We have met here for the purpose of receiving nominations for seven 
members of the Examining Board." 
Dr. Faison: 

Gentlemen of the North Carolina Medical Convention, I want to intro- 
duce this resolution: 

"North Carolina State Medical Association, in annual convention assem- 
bled, sends its greetings to the distinguished head of the nation — President 
Woodrow Wilson, and pfay for him a speedy and complete recovery and 
express our continued confidence in the righteousness of his guiding hand." 

Motion seconded. Carried. 
Dr. Moore, Elm City: 

North Carolina has four candidates for its Governor, and one open 
aspirant for the National President. May we indulge in the hope that in 
the month of June, on the shores of the golden west, he will pluck the fruit 
from the tree which bears his name. The North Carolina Medical Society 
is not ready for an election which I now conceive to be of the highest im- 
portance, both to the profession and the State. Modesty is more a heritage 
than a seeming virtue. If we make an error it is our error. If we blunder 
in our choice it is our fault, and the responsibility as well as the penalty will 
be ours. Suggesting one man as a member of the Board of Examiners to 
be elected, whom I would endorse as a capable and worthy as trusty and 
still worthier of a further trust, I take great pleasure in presenting to you 
the name of Dr. E. T. Dickinson, of Wilson, N. C- 

Dr. Brooks, of Blowing Rock, nominated Dr. Carl Reynolds of Ashe- 
ville. 

Dr. Fletcher, of Asheville, nominated Dr. D. E. Sevier of Buncombe. 

Dr. J. P. Monroe, of Charlotte, nominated Dr. L. A. Crowell of Lincoln- 
ton, N. C. 

Dr. J. W. Long, of Greensboro, N. C, nominated Dr. D. A. Stanton 
of High Point, N. C. (Seconded.) 

Dr. J. E. S. Davidson, of Charlotte, placed in nomination Dr. L. N. 
Glenn of Gastonia, N. C. (Seconded.) 

Dr. Cramner, of Winston-Salem, placed in nomination Dr. J. G. Murphy 
of Wilmington, N. C. 

Dr. MacNider, of Chapel Hill, placed in nomination Dr. C. A. Shore 
of Raleigh, N. C. 

Dr. J. T. J. Battle, of Greensboro, placed in nomination Dr. W. M. 
Jones of Greensboro, N. C. (Seconded.) 

Dr. J. F. Highsmith, of Fayetteville, placed in nomination Dr. W. P. 
Holt of Duke, N. C (Seconded by Dr. E. B. Glenn of Asheville.) 



GENERAL SESSION 



269 



Dr. J. M. Templeton, of Gary, placed in nomination Dr. J. Rainey 
Parker of Graham, N. C. 

Dr. C. B. McNairy, of Kinston, placed in nomination Dr. L. A. Crowell 
of Kinston, N. C. 

Dr. H. D. Stuart, of Monroe, placed in nomination Dr. Sam Stevens 
of Monroe, N. C. (Seconded.) 

Dr. Cyrus Thompson, of Jacksonville, placed in nomination Dr. K. 
P. B. Bonner of Morehead City. 

Dr. W. H. Scruggs, of Asheville, placed in nomination Dr. F. W. 
Griffith of Asheville. (Seconded.) 

Dr. J. R. Alexander, of Charlotte, placed in nomination Dr. B. J. 
Witherspoon of Charlotte, N. C. 

Dr. M. A. Adams placed in nomination Dr. J. W. McConnell of David- 
son, N. C. 

Dr. Bullitt, of Chapel Hill, placed in nomination Dr. Fletcher of Ashe- 
ville, N. C. (Dr. Fletcher stated he had served six years on that board 
and requested that his name be withdrawn, which was granted. ) 

Dr. J. L. Spruill placed in nomination Dr. H. D. Walker of Elizabeth 
City, N. C. 

Dr. E. B. Glenn, nominated Dr. Percival Bennett of Bryson City, N. C. 

Nomination closed. 

General Session adjourned to 2:30 P. M. 

The President declared balloting for seven members of the. Board of 
Medical Examiners of North Carolina in order and the balloting was 
proceeded with. Dr. Cyrus Thompson reported for the tellers that each 
of the following gentlemen had received a majority of all the votes cast: 
Dr. L. A. Crowell, Charlotte; Dr. K. P. B. Bonner, Morehead City; 
Dr. W. M. Jones, Greensboro; Dr. C. A. Shore, Raleigh; Dr. J. G. 
Murphy, Wilmington ; Dr. W. P. Holt, Duke ; Dr. L. N. Glenn, Gastonia. 

Dr. Thompson stated that this was the first time in the history of the 
Medical Society of the State of North Carolina that seven members of the 
Board of Medical Examiners of North Carolina had ever been elected on 
the first ballot. 

Thereupon the President declared the gentlemen named above duly 
elected for a term of six years, beginning at the expiration of the term of 
the retiring Board, June, 1920. 

WEDNESDAY, APRIL 21, 3 P. M. 
Dr. Tom A. Williams, Washington, D. C. : 

The oldest body in this country devoted to sociological medicine is the 
American Academy of Medicine. It is a body the requirements for mem- 
bership in which include a medical degree plus an academic degree. It 
has been decided that the latter qualification shall no longer be necessary. 
I have been asked to make an announcement to the several societies which 
I am going to visit that the American Academy of Medicine wishes to 
enlarge its membership. What it has done is well known only to the 



270 NORTH CAROLINA MEDICAL SOCIETY 

public health workers and the sociologists- It was the forerunner of most 
of the public health movements which are now interesting us and in which 
the laity are beginning to be interested: I have with me a list of the 
publications of the body, and it is most impressive. This sheet contains 
merely the titles of the publications of that organization. They were all 
published in the Journal of Sociological Medicine. Those who are inter- 
ested in this association have only to write to the secretary, Dr. Grayson, 
of Pittsburgh, or to me, stating their interest and that they wish to join. 
For the membership fee one obtains the Journal of Sociological Medicine, 
and the privilege of attending the meetings, which occur once a year, and 
of taking part in the discussions. A great body of literature is also sent. 
I shall be very glad if those who are interested will take from the table 
one of the catalogs of publications. If those who are further interested 
will then write to the secretary. Dr. Grayson, in Pittsburgh, or to myself, 
they will be put in touch with a body which has done and we hope will 
continue to do most fundamental work for the benefit of the cornmunity, 
as well as in raising the standard among medical men engaged in sociological 
work. 

ELECTION OF MEMBERS OF NURSES' EXAMINING BOARD. 

Wednesday, April 21, 6 P. M. 
Dr. Reynolds, President: 

The election of a member of the State Board of Examiners for Nurses is 
now in order. 

Dr. L." B. McBrayer nominated Dr. D. E. Sevier,* of Asheville for this 
place. The motion was seconded and unanimously carried. 
Board of Examiners for Trained Nurses: — 

Miss Lois A. Toomer, President, Wilmington. 
Miss Effie E. Cain, Secretary-Treasurer, Salisbury. 
Miss Mary Laxton, Biltmore. 
Dr. J. M. Parrott, Kinston. 
Dr. C. F. Strosnider, Goldsboro. 

Wednesday Night, April 21, 8:30 P. M. 
Dr. W. P. Whittington, Asheville: 

It gives me great pleasure tonight to have the privilege of introducing 
to you — without any flowery speech, for I think the flowery part of the 
speech-making was done this morning in nominating candidates — Dr. Wil- 
liam L. Clark, of Philadelphia, who is lecturer on applied electricity at 
Jefferson Medical College and co-worker with John Chalmers DaCosta, 
whom we all know and love. Dr. Clark will give a lecture on "New 
Conceptions Relative to the Treatment of Malignant Diseases and Some 
Other Refractory Pathological Conditions," illustrated by lantern slides. 

Dr. William L. Clark, Philadelphia: 

I desire to thank the Committee on Scientific Work and the Society for 



*Dr. D. E. Sevier resigned on June 4, 1920, and Dr. J. M. Parrott, 
of Kinston, was elected to serve until the Medical Society shall have elected 
a member to serve a three-year term. 



GENERAL SESSION 



271 



the invitation to speak to you tonight upon some matters of mutual interest, 
and I am glad to renew acquaintance with various members of the Society 
whom I have met from time to time. I am also glad of the opportunity 
to present some of my views upon the cancer problem, especially, and upon 
some other pathological conditions as well. 

During the last twelve years I have devoted my best thought and study 
to the management of cancer cases. I have had the opportunity of seeing 
a large number of all types of cases in almost every possible anatomical 
location. This subject is a very broad one, and we are very far from the 
solution yet- I may say, however, that much progress has been made in 
the last few years, and there are some phases of the cancer question which 
I believe I may say have been solved. There are some very malignant types 
of internal cases about which we do not yet know much, but so far as the 
skin cases are concerned I believe they have been solved. 

Until we find the exact cause of cancer we have very little upon which 
to work. It may be that like a bolt cut of a clear sky the discovery of the 
real cause will be announced. It may be then that we shall have a specific 
for cancer, as we have a specific for diphtheria and other conditions. But 
at present local attack seems to be the best w^e can do, and until we find 
the cause of cancer and find a specific we must devote our energies to the 
best way of attacking cancer locally. 

We have different degrees of malignancy in cancer. 

We have the type that progresses slowly and never metastasizes. If we 
get it in its entirety, we may expect a cure. It may recur sometimes, but 
that is due to bad technique or lack of thoroughness. With the squamous, 
slow type, involving mucous membranes, we have a different type of cancer, 
one that metastasizes early, and we can never tell where we are. For- 
tunately, however, we have ways and means for combating that, which I 
will discuss later. 

The methods worthy of consideration at the present time are operative 
surgery, which we cannot do without in many phases ; radium, dissection, 
and the Roentgen rays. Of course, results are obtained oftentimes by 
our escharotics, carbon dioxide snow, etc. Sometimes results are ob- 
tained, but more often bad results than good ones. My experience 
in my own work, and my observation of the work of others who have had 
considerable experience with these pastes, etc., have led to the conclusion 
that good results are due more to good luck than to 'anything else. How- 
ever, some results are obtained by their use, and sometimes it is impossible 
to have other facilities, and of course then we are justified in using these 
pastes, etc. But if other means are available we should use them. 

Of course, all the methods are valuable, and all have their distinct place. 
However, the surgeon who depends upon surgery alone, the electrical man 
who depends upon electricity alone, the radium man who depends upon 
that alone, will fail and will not do justice either to his patients or himself. 
A man who makes a pretense of specializing in malignant disease should 
be able to treat malignancy from every angle. He should know the indica- 
tions for every method of treatment. Therefore, my experience has been 
that to obtain the best results by local attack we should be able to use these 
tried methods in combination. I have a great many slides showing various 



272 NORTH CAROLINA MEDICAL SOCIETY 

angles of this work, and what has been done up to this time and what may 
be expected in the future. Some phases of it are a treatment hitherto 
unpublished, to which I shall allude as I go along. I shall be glad to have 
you ask any questions which may occur to you. 

Radium is a method which gives good palliative results in uterine cases. 
Radium needles have cleared up some uterine cases, though none have 
passed the five-year limit. Rectal cases are the worst of all. Uusually the 
liver is involved. They are bad cases. 

There is a big field in our dissection method in surgical tonsils. Our 
ordinary method of destroying tonsils with a snare or taking them out is 
perfectly satisfactory- But there are other cases in which we may use the 
dissection method as a very worthy substitute for our surgical procedure. 
It can be used also for destroying hemorrhoids. There are many other uses 
for these methods, but as my time is up I cannot mention them now. 

STATE MEDICINE. 

W. S. Rankin, 
Secretary North Carolina State Board of Health, Raleigh, N. C. 

My understanding is that the Secretary of the Society endeavored to 
get several men — men of national reputation, and men who have been 
giving a great deal of time to this question of State Medicine, what it is 
and what it covers — to discuss it before you. They were unable to get Dr. 
Lambert and Dr. Warren, of the United States Public Health Service. 
So finally Dr. McBrayer had to fall back upon me, and he consigned the 
entire subject to me. 

Definition : This term has been applied at different times and places 
to various activities undertaken by collective and sovereign people for the 
treatment and prevention of human diseases. It has been applied to steps 
faken by states in determining the qualifications of those who should attend 
their sick; it was applied in the 80's and 90's to the official acts of boards 
of health ; in England and in Europe the term when used today refers to 
social insurance. Obviously, before entering into a discussion of this sub- 
ject, which has come to mean different things to different persons, it will 
be necessary, in order to forestall useless discussion and to prevent mis- 
understandings, that we all have the same conception of the term. For 
this purpose I think the following definition will pass muster: State 
Medicine is any part which a state or any of its constituent parts may 
assume in combating disease. 

The Basis of State Medidine: State Medicine was foreordained and its 
secure foundations laid on Sinai. The ten great basic principles of civilized 
law there established follow a significant order: In the first four God defines 
man's relation to Himself; in the fifth, man's relation to his home; and 
in the last five, man's relation to his fellow-man. The first of the laws 
defining man's relation to his fellow-man is the law protecting human 
life, and protecting it from every agency and factor which may contribute 
to its destruction. After the words "Thou shalt not kill" there are no 
provided howevers, permitting life to be destroyed in some particular 
manner or manners. This law applies to the individual man, but it is 



GENERAL SESSION 273 

not restricted to the individual ; it applies to man collectively, to the group, 
to the citizen, to the state. This law forbids the destruction of life by 
willful acts of commission and by careless, passive omission ; it forbids the 
destruction of life in murder, by violent and sudden means; it forbids the 
destruction of life by the almost imperceptible and long-drawn-out imposition 
of conditions on men, women and children that slowly sap their energy, 
their blood and vitality through a course of years. This law commands that 
the individual and citizen not only refrain from acts that kill suddenly and 
that kill slowly, but it commands that we shall not neglect or refuse to do 
anything that, left undone, would result in the loss of life. As the oppor- 
tunity to save life exists until the last breath, the law "Thou shalt not 
kill" requires the individual and the state not only to prevent disease, but 
also to see that diseases are properly treated and cured, where possible, 
covering, therefore, both the field of disease prevention and that of medical 
relief. 

Sub-divisions of State Medicine: As suggested above, there are two 
main sub-divisions in State Medicine: Disease pr.evention and disease cure. 
The first, disease prevention, is the more important of the two. The 
population, the well, with which it is concerned is thirty-three times the 
size of the sick population. The dividends on money and energy invested 
in disease prevention and in the promotion of health — in keeping the fit 
fit and making them fitter — are much larger than the dividends on invest- 
ments in the repair of broken-down vital machinery- The fact that the field 
of disease prevention is the larger does not altar the related fact that the 
field of medical relief is large enough to justify the best efforts of both 
the individual and the citizen. The citizen of the State cannot draw an 
arbitrary line between health and sickness and say "to this line the respon- 
sibility rests upon me of saving life, but beyond this line, in the field of 
cure, of medical relief, neither I nor my State have any responsibility; the 
case is wholly with the medical profession." The obligation, with the 
individual and citizen, to save life exists until life is gone, to the very last 
breath. Moreover, the treatment of the sick, the cure of disease, is a very 
necessary means of preventing disease. This Is particularly true in prevent- 
ing tuberculosis and venereal diseases With this general statement as to 
methods of State Medicine, we shall proceed now to the consideration 
of the more important special activities undertaken by the State, first, in 
the field of disease prevention, and, second, in the field of medical relief. 

DISEASE PREVENTION. 

1. Vital Statistics: A division of vital statistics in state government is 
the exact parallel or counterpart of an intelligence division in an army. 
It is the business of an intelligence division in an army to ascertain the 
number of the enemy, the position of his various units — cavalry, artillery, 
infantry, aviation, etc., where an attack on him is likely to be most ef- 
fective, and if and where the enemy expects to attack. The vital statistics 
division of a state government has identically the same essential function. 
Its business is to determine the size of the enemy, his potential power to 
destroy life and health, his divisions into various diseases, the location within 
the state, the counties, towns and townships where these diseases are most 
prevalent, and to ascertain where an attack on preventable diseases is^ 



274 NORTH CAROLINA MEDICAL SOCIETY 

likely to get the biggest returns for the expenditure to be made, and where 
disease is next likely to attack. Without birth, death and morbidity statis- 
tics the ship of state sails an uncharted sea of human life ; it has neither 
log nor compass, and cannot know whether it is drifting backward or 
moving forward. I may say, on account of the professional character of 
this occasion, that the only incontrovertible proof of the large contributions 
of medicine to human progress is in the form of statistics, the declining 
death rates following and closely related to medical discoveries. Do away 
with the statistics, which some of the short-sighted, over-worked members 
of the profession hate so much to assist in collecting, and you do away with 
the material proof of medical achievement and with much of the glory 
of our profession. 

2. Health Education : In the recent war the Government found it 
necessary to mobilize the resources, military and civilian, of the entire 
nation. The co-operation of all the people was absolutely essential in 
undertaking to carry to a successful conclusion our preparedness program. 
To secure that co-operation it became necessary to inform the people by 
every known educational method — press, moving picture, pamphlet, the 
living voice — of the reasons for the war, of the purpose of the Government, 
and of the part each and every individual could play and should play in the 
winning of the war. The war with Germany has been won. In the 
winning of that war North Carolina lost approximately 1,000 men killed 
in battle, and had 4,000 others wounded. The war against preventable 
disease has not been won; it continues, and we have every year 10,000 to 
12,000 unnecessary deaths and from 100,000 to 150,000 wounded in this 
as yet unsettled contest. Our loss annually in the fight against preventable 
diseases is from twelve to fifteen times greater than our loss in the war 
against Germany which we helped to win. Educational methods for in- 
forming all the people of the reasons for the war against preventable dis- 
ease and death and the part that each and all can play and should play is 
just as necessary in fighting preventable diseases as it was in fighting pre- 
ventable autocracy. Health education is the primary and most fundamental 
activity of the state in maintaining and promoting its public health. 

3. Quarantine: A quarantine service has a reason and purpose for its 
existence, as a fire department. It is to put out a fire, but a fire that burns 
and destroys, not wood, but living human flesh. A quarantine service is 
dependent upon the intelligent service of the health department, upon the 
health department's ability to get prompt and complete reports of the human 
fires, the contagions that break out. If the fire is not reported there can 
be no response by the department entrusted with its control. None of the 
measures of quarantine, the details of which it is unnecessary to go into 
here, can .be thrown around an unknown source of infection to prevent it 
from involving a community and distant sections of the state. 

For the notification of the health department of the existence of con- 
tagious disease the public is dependent very largely upon the practicing 
physicians. I say very largely because there are many contagious diseases, 
and of a deadly nature, notable examples of which are measles and whoop- 
ing cough, that in many instances are too mild to call for a physician, and 
in such cases the public is dependent upon the intelligence and the willing- 



GENERAL SESSION 275 

ness of the citizen to undergo the possible inconvenience of quarantine as 
a result of reporting contagion in his own family. Proof is at hand to show 
that North Carolina physicians deserve to be commended for reports of con- 
tagious diseases. Only in typhoid is their record bad. To illustrate : In 
1919 there were 427 deaths in North Carolina from typhoid, and in the 
same year 2,956 cases were reported. Either the physicians are not report- 
ing all of their cases of typhoid or the North Carolina medical profession 
is losing about fifteen patients out of every hundred persons that have 
typhoid fever, whereas the average profession loses not more than ten per 
hundred. 

When a case of contagion is reported the responsibility is then upon the 
health department, the public, to make use of the report and to see that 
the disease is effectively quarantined. Health departments are not justified 
in inconveniencing either the profession or the public to report infectious 
diseases unless the health department maks full use of the report by im- 
mediately enforcing the State laws, rules and regulations applying to con- 
tagious diseases. 

4. Vaccination : Certain vaccinations, notably the vaccination for the 
prevention of smallpox and the vaccination for the prevention of typhoid 
fever, have been demonstrated to be almost 100 per cent effective. The 
furnishing free of cost of these established vaccines to all citizens and the 
devising and encouragment of the adoption of plans for the free vaccina- 
tion of the people is another of the obligations of the state in preventing 
unnecessary disease and deaths. 

5- Protection of Public Water Supplies: As populations become denser, 
as cities multiply, more and more does it become necessary and economically 
desirable that individuals pool their interests and as citizens establish com- 
mon or public water supplies. While it is possible in certain locations 
to secure a fairly adequate and suitable ground or well water supply for 
an urban settlement, this is the exception. For the majority of towns and 
cities the only available adequate and suitable water supply is the surface 
water of streams and rivers. Now a stream used as a public water supply 
lies beyond the official jurisdiction always of the city that uses it, and nearly 
always of the county in which the city is located, so that the only control 
for the protection of the purity of the stream is state control. For this 
reason most States, including our own State, have assumed and exercise 
a variable degree of oversight and regulation of the watersheds of their 
streams, creeks and rivers. 

6. Sanitary Control of Important Sources of Disea;,'eS During the last 
three years important investigations as to the practicability of eradicating 
malaria from thickly settled communities, villages and small towns, through 
the control of mosquito breeding by filling, drainage and oiling have been 
carried out. It has been demonstrated, notably in Arkansas, that with a 
per capita annual expenditure of from one dollar to a dollar and a half for 
the first year's work and thereafter an expenditure of from twenty-five to 
fifty cents per capita, the prevalence of malaria can be reduced from eighty 
to ninety-six per cent. The saving to the people of these communities 
in druggists' and doctors' bills and in time lost to productive labor amounts 
to five to ten dollars per capita; and this financial saving does not take into 



276 NORTH CAROLINA MEDICAL SOCIETY 

account the human side of the case — the anxiety, suffering and grief on 
account of disease. This important piece of work for controlling malaria 
in the more thickly settled communities is now being undertaken, to a 
limited extent, in many urban settlements scattered throughout the South. 

Another example of the sanitary control of important sources of disease 
is the act passed by the recent General Assembly of North Carolina, which 
prohibits the open, unsanitary privy in urban settlements. This act was 
restricted to urban communities for two reasons: (1) The town unsanitary 
privy is more dangerous than the rural unsanitary privy. The town privy 
has a fly-range — three hundred yards — on from fifteen to twenty homes, 
with a total population of from seventy-five to one hundred and twenty-five 
persons; whereas, the rural privy, as a rule, has a fly-range on only one 
home with a population of from five to seven. The act, therefore, applies 
to the more dangerous type of unsanitary privies, to those that are killing 
the larger number of people. (2) The open, unsanitary privy in the coun- 
try is under the immediate control of the person or persons injured or liable 
to be injured by it; whereas, the urban unsanitary privy is not, as a rule, 
under the control of those whose health and life it destroys. The State law' 
therefore, in restricting itself to urban privies, protects those individuals 
who are exposed to the dangerous closet over which they have no control. 

7. The Development of County Health Work : When the Federal Gov- 
ernment has done all within its power for a State the State may do much 
for itself ; when a State has done all within its power for its counties the 
counties may do much for themselves, just as a man can do more for himself 
than all assisting agencies together can do for him. One of the larger and 
more important objectives of State Medicine is to influence the local gov- 
ernments of a state, the counties, to assume a larger part in the protection 
of the health and lives of their citizens. This means, of course, the estab- 
lishment of full time county health machinery- In North Carolina there 
are at present twenty-eight counties with such full time machinery, and 
there are ten other counties that have already made financial provision for 
either a full time health ofiicer or nurse, or both, as soon as these officials 
can be found. Before 1920 has gone fifty per cent of the population of 
North Carolina will be living under the protection of some sort of full 
time local public health machinery. In this field of public health work 
North Carolina excels. 

Dependent upon the size of. the budget provided by the county, the fol- 
lowing units, or independent pieces, of county health work are being under- 
taken: (la thorough enforcement of the State quarantine laws, the en- 
forcement of which is always in direct proportion to the intelligence and 
courage of the county official; (2) an educational program directed to the 
general adoption of sanitary privies in rural homes, to the end that fecal- 
borne diseases — typhoid fever, dysentery, diarrheal diseases of infants, or 
summer complaint, and hookworm diseases — may be limited in their preva- 
lence; (3) the setting up of local dispensaries for giving free vaccination 
against typhoid fever and smallpox, and the encouragement by educational 
means, of the people to take advantage of the dispensaries; (4) providing 
the facilities for and encouraging the people, particularly adults, to submit 
themselves for periodic medical examinations in order that incipient disease 



GENERAL SESSION " 277 

may be detected and referred to the medical profession for treatment before 
it has become chronic and progresses beyond repair; (5) an educational 
program to interest the general public in the prevalence and the infectious 
character of tuberculosis, and to encourage persons with suspicions of the 
disease to apply at the office of the county health officer for a preliminary 
examination, and in case such person is found to be infected, referred to 
proper sources for early and effective treatment; (6) the use of nurses to 
get in touch with the mothers of the county, individually and collectively, 
and especially with the mothers of bottle-fed children and children suffer- 
ing from digestive disturbances, for the purpose of advising them as to the 
care of their babies, and in assisting in securing the necessary professional 
advice and treatment. 

MEDICAL RELIEF. 

1. Selecting Those Who Shall Attend the Sick: The States say to cer- 
tain persons "you may" and to certain other persons "you may not wait 
upon and prescribe for our sick." The practice of requiring persons pre- 
senting themselves to the public for the treatment of diseases to comply with 
certain conditions, and of excluding those who could not comply with the 
conditions, was the first step taken by the States in the field of State Medi- 
cine — it was the first recognition by the State of its great responsibility 
in seeing that its sick were properly treated. To the credit of North Caro- 
ilina it may be said that our State was the first, creating an official board 
of examiners in 1859, to see that those who attended the sick were qualified 
to do so. 

In passing upon the fitness of persons to treat the sick the practice of 
the majority of States has been to create commissions or boards of exam- 
iners composed of members of those groups that were successful in estab- 
lishing their claims with the legislature of being able to heal diseases; then 
to require all persons desiring a license to practice some form of healing 
to apply to that commission or board that represented the particular system 
of treatment which the applicant wished to use. 

In following this practice, State legislatures have assumed the responsi- 
bility of qualifying, legalizing, and establishing professions. This practice 
has resulted in multiple boards of examiners. We have a board of examin- 
ers for physicians, and another for dentists, and another for nurses, and 
another for optometrists, and another for osteopaths, and another for 
chiropractors, and another for pharmacists, and another for veterinarians, 
and another for embalmers, and another for plumbers, and perhaps others 
of the existence of which I am happily ignorant. 

States, in qualifying professions, in legalizing and establishing them ac- 
cording to the above described methods, commit two serious errors. The 
first error which the legislatures make in this practice is in permitting each 
group, those who are financially concerned, I will not say interested, to 
determine their own numbers and, therefore, the amount of competition 
within the group. Such a practice is inherently vicious. Moreover, as long 
as legislatures follow such a practice, havin'j established their precedent, 
having cut a deep rut in an unsound foundation, they get deeper and deeper 
in the mire in finding themselves unable to refuse tn a new group applving 
for a privilege that has been granted to all preceding applicants. The 



278 NORTH CAROLINA MEDICAL SOCIETY 

second error which legislatures make is in assuming that they are the proper 
bodies to investigate and determine the alleged claims of groups to legal 
professional standing. They are not. States need for this purpose com- 
missions with the peculiar training necessary to determine what are the basic 
and common requirements which all persons seeking to treat human dis- 
eases within the states should be able to meet. To illustrate my meaning: 
Such commissions would require a certain minimum of academic education 
for all persons applying for license to treat human diseases; they would 
require that all persons, in order to treat human diseases, show a knowledge 
of the fundamental biological sciences — chemistry, physics, biology, em- 
bryology, anatomy (gross and microscopic) and physiology- These com- 
missions would have the scientific training and viewpoint, and what is more 
important, they would have the time and the facilities needed to make a 
thorough investigation of the claims of any particular school teaching any 
system of healing or alleged healing. With such commissions all persons 
asking the permission of the States to treat their sick would be fed out of 
the same spoon. 

The personnel of these commissions on licensure would be composed 
of such men as the presidents of the universities, the superintendents of 
public instruction, the State commissioners of public welfare, perhaps the 
attorney generals, and three or four others selected because of their peculiar 
fitness to determine what is and what is not a profession, and to apply the 
intellectual tests necessary to determine a person's fitness to practice a pro- 
fession. Of course, such commissions would find themselves in need of and 
would use representatives of the various professions which they had char- 
tered to assist them in determining an applicant's understanding of subjects 
peculiar to the group. In this way, the commissions on licensure would 
have an advisory sub-committee composed of physicians, and another com- 
posed of dentists, another of nurses, et cetera, one for each profession which 
the commissions had chartered. 

North Carolina was first among the States in establishing the practice 
of selecting those who should treat her sick; she cannot now be first in 
establishing an impartial and central commission for determining the rights 
of groups to establish themselves as professions, but the opportunity yet 
waits upon our State and this Medical Society to make North Carolina 
one of the first to take this advanced and this inevitable step in the course 
of progress. 

2. Rendering Asjistance In Diagnosis: States, recognizing that accurate 
diagnosis is fundamental in effective treatment, have undertaken already 
to fi limited extent and will undertake more and more in the future as 
scientific discoveries make possible and as funds become available, ro assist 
ph\sicians in the diagnosis of disease. Certain laboratory tests are now 
available in most States free of cost to the physicians. Among such tests 
which physicians may avail themselves of are to be mentioned the blood 
examinations for the Widal, or typhoid fever reaction ; for the Wasser- 
Inann, or syphilis reaction, for the malaria parasite, and other blood ex- 
aminations ; examinations of the secretions and excretions for diagnostic 
criteria, such as swabs from the throat for diphtheria bacilli, sputa from 
the lungs for tubercule bacilli, pus for gonococci and other organisms; 



GENERAL SESSION 279 

feces for intestinal parasites; also nervous tissue of supposed rabid ani- 
mals for rabies, et cetera. 

3. Assisting Physicians In the Treatment of Disease: Most States have 
undertaken to furnish phj^sicians with certain costly curative agents which 
require a high degree of technical skill in making them reliable. I refer 
especially to the antitoxins, to the treatment for rabies, and to those 
selective chemical agents, such as arsphenamine and neo-arsphenamine. I 
anticipate that in a few years governments will be producing and furnishing 
free of cost, not only all of the now known complex specific remedies, but 
many others that future discoveries will unearth. 

4. Maintenance of Hospitals: There are certain diseases of a chronic 
nature which impose economic burdens upon the family and community 
so great that only the strength of the State is able to bear them; hence, 
the development of State insane hospitals, on which item alone our own 
State expends about $750,000 annually— one-fourth of the expenses of the 
State Government, if we exclude funds appropriated for the public sec- 
ondary schools. The development of tuberculosis sanatoria is another in- 
stance where the State has assumed to a limited extent and will assume 
to a still greater extent a burden which it alone can carry; however, in the 
case of tuberculosis the reason for State assistance is not only medical 
relief, the possible saving of the lives of the sick, but also the prevention 
of secondary cases, the saving of the well, by the elimination of the carrier. 

5. Medical Relief for Educational Purposes: For many years the State 
has realized that its permanency rests with its children and that childhood 
is its supremest interest; moreover, the State believes that its childhood 
(the State ten or twenty years from now), to bear efficiently the responsi- 
bilities of a great government, must be made intelligent and not be per- 
mitted to remain ignorant. For this reason two dollars out of every three 
dollars collected in North Carolina by the State and local governments are 
expended on education, or, in other words, the government. State and local, 
expends twice as much for education ^s it does for all other things com- 
bined. 

Within recent years the State has arrived at the conclusion that mental 
development is very closely related to physical vigor ; that to expect a mind 
built upon weak vitality to withstand the shifting winds of circumstances 
and the currents of adversity is to play the part of the fool who built his 
house on the sands. This newer idea in education as to its physical basis 
has been expressing itself almost incesasntly and extensively throughout the 
country in the establishment of free school lunches, in well-equipped gj^m- 
nasia, in playgrounds, and in the employment of ph^'sical directors, and 
in the detection and treatment of public school children for the common 
defects of childhood, for hookworm disease, bad teeth, defective vision, 
enlarged adenoids and tonsils, with impaired hearing, conditions which 
retard not only the diseased child, but the whole class in which he recites. 
The object of the State in improving the physical condition of school chil- 
dren with food, with well directed recreation and with the removal of their 
more common physical disadvantages is to insure itself against a tremendous 
waste of funds spent on public education. Medical relief restricted to 
public school children, not extended to the child out of school or in the 
private or parochial school, is an educational rather than a health measure. 



280 NORTH CAROLINA MEDICAL SOCIETY 

In this connection it may be interesting to know that there is now a bill 
pending before Congress, with splendid prospects of passing, which provides 
in a most extensive way for the teaching of hygiene in the public schools, 
for the development of proper physical exercises and for the completest 
system of medical inspection and treatment of school children. The bill 
provides an appropriation of $10,000,000 for this purpose, and this appro- 
priation is apportioned to the States on a population basis, the apportion- 
ment to each State becoming available when the State appropriates a like 
amount to that apportioned for the purpose of the bill. In this way, while 
the bill appropriates $10,000,000 of Federal funds, it provides for the ex- 
penditure of $20,000,000. It is interesting to note that the execution of 
this act is under the Bureau of Education of the Department of the Interior, 
not under the health service of the Federal Government. In other words, 
it is being considered by Congress primarily as an educational measure. 
Should this act become a law, as it promises. North Carolina would soon 
be expending, either under its Board of Health or its Department of Edu- 
cation or under the joint supervision of these two agencies, about $200,000 
a year in treating the common physical defects of its 800,000 school children. 

Last year, out of a total expenditure of something like $8,000,000 for 
public education, the State provided $80,000 for the detection and treat- 
ment of the common defects of its public school children. The full appro- 
priation did not become available until January 1st this year, so that during 
the last ten months only $29,000 in the medical inspection of schools has 
been expended. With this expenditure 1,174 children have been success- 
fully operated upon for enlarged adenoids and tonsils, and 16,104 children 
have had their teeth treated, 29,268 permanent fillings having been made. 
This work, if done without the State's assistance, would have cost $96.- 
568.90 more than it cost; I say done without State assistance, but let me 
remind you here that it has been waiting a mighty long time for State 
assistance, and the probability is that it would be waiting still had the 
State not come to the aid of these children. Like the poor that "you have 
always with you," there are thousands and tens of thousands of children 
whose growth and whose mental development is held back by physical 
defects so frequent in school children as to have earned the reference "com- 
mon defects," and the burden is on this profession to reach these children 
in every way possible and to treat everyone that they can persuade to 
accept treatment, and the burden is upon the State to see that those who 
cannot be reached by the individual physician and the profession collectively 
are reached with its longer and stronger arm. 

6 Compulsory Social I?7sura?ice, sometimes spoken of as sickness insur- 
ance or health insurance. 

Compulsory social insurance may be defined as a form of insurance made 
compulsory by law for wage earners whose economic status is below a cer- 
tain level. 

The object of social insurance is to distribute the burden of sickness over 
the total period of productive labor of the individual worker rather than tr 
rest suddenly and with crushing effect upon the individual or family. 

As an illustration of how compulsory social insurance operates, we will 
consider briefly the English compulsory social insurance act. In England 
about 15,000,000, or a third of the population, come under the compulsory 



GENERAL SESSION 281 

social insurance act. The act applies to all wage earners and their families 
where the total annual income of the wage earner does not exceed, I be- 
lieve, $840. Wage earners coming within the group pay 8 cents a week, 
the employer pays 8 cents a week, and the government 4 cents a week, 
thereby setting aside an insurance fund of 20 cents a week for each wage 
earner and his family to care for them and to protect them in case of sick- 
ness. I am not informed as to whether the war and the increased cost of 
living has affected the rates ; but if it has, I presume that the three parties 
— wage earner, employer and the government — are still paying in the same 
proportion, 40 per cent apiece for wage earner and employer and 20 per cent 
for the government. The equity of this distribution of the insurance fund 
rests upon the fact that in case of sickness the employer is responsible foj 
his emploj'ees and their surroundings, and is partly responsible for the sick- 
ness; the wage earner is also partly responsible for his own sickness, and 
the government is partly responsible for sanitary and hygienic conditions, 
and, therefore, for sickness; a further reason for the distribution of the 
insurance fund among the three parties is that all three parties are bene- 
fited in the prompt and effective treatment of sickness and, therefore, 
should share in the cost of the benefit. In a case of sickness of an insured 
wage earner or in case of sickness in his family, the sick person is treated 
free of cost, the government paying the bill out of the insurance fund; 
moreover, if during the wage earner's disability the family needs supplies, 
they are furnished by the government. The act protects very effectively 
against pauperism and charity practice. The fees to be charged by the 
physicians registered by the government to accept calls from the insured 
wage earner are determined by the government. In England the sick 
wage earner may choose his own physician from among those registered 
with the government ; and, by the way, 22,000 of 25,000 English physicians 
accept these calls ; that is to say, they are registered, or, as they say in 
England, are on the panels. 

In connection with the operation of this law or with any compulsory 
social insurance law, a rather extensive referee system has to be maintained. 
Where the physician is paid fees for treating sickness of the insured, it 
would be comparatively easy for the unscrupulous physician and insured 
to run up a number of visits on the government and for the insured to 
remain out of employment and receive the benefits of the insurance an 
unnecessarily long time. In countries where physicians are paid a salary 
on a capitation basis, a referee system is needed to see that the insured wage 
earners do not take advantage of their privileges in calling on physicians 
for inconsequential ailments, and to see that physicians, when called to a 
case of sickness really needing attention, respond promptly. 

As to the extent of social insurance, it may be said that some form of 
it is in operation in every country of Europe, with the exception of Turkey. 
In this country there is a considerable amount of optional, not compulsory, 
social insurance carried on by fraternal orders and by commercial enter- 
prises, as, for example, in this State by the Atlantic Coast Line Railroad. 
Nine State governments have appointed commissions to study the subject 
and to make recommendations to their general assemblies with respect to 
action. The State of New York last year passed a compulsory social in- 
surance bill in the Senate 30 to 20. The Governor supported the bill, 



282 NORTH CAROLINA MEDICAL SOCIETY 

but the lower house defeated it. The people of California, in 1918, held 
a referendum on this issue, but defeated it about two to one. Many of 
the State commissions appointed to study social insurance have recommended 
some form of compulsory sickness insurance ; no State has yet adopted it. 
Twenty-seven State Federations of Labor and twenty-six national trade 
unions have endorsed it. The American Federation of Labor has a com- 
mittee studying the subject. It is understood, however, that Mr. Gompers 
and most of the labor leaders, John Mitchell of the United Mine Workers 
of America excepted, are opposed to social insurance. Mr. Gompers and his 
friends take the position that the wage earner should be paid enough so that 
he wnll not be dependent upon the government in sickness. The National 
Women's Trade Union League, the National Consumers' League, the 
American Association for Labor Legislation, the Arnerican Hospital Asso- 
ciation, the National Conference of Jewish Charities, and the National 
Organization for Public Health Nursing have all endorsed the principle 
of social insurance. It is interesting to know that the British Medical 
Association, which almost called a strike in 1911 when the British social 
law went into effect, recommended in 1916 that the act be extended, and 
apparently the British Association, after five years' experience with com- 
pulsory social insurance, are favorable to the principle. Mr. Lloyd George 
has pointed out that the average physician's income has been increased under 
the provisions of the British act $750 a year. The American Medical 
Association, the State Health Officials and the American Public Health 
Association are maintaining an open mind on this question. A considerable 
amount of study is being given by these last named agencies to the subject. 
Some very able committees representing the last named agencies are 
making investigations and progress reports from time to time, but as yet 
none of the agencies mentioned have committed themselves for or against. 
The advantages of social insurance are : ( 1 ) it distributes the burden 
of sickness and makes it, relatively speaking, easy to bear; (2) it does away 
with pauperism to a large extent; (3) it does away with charity practice; 
and (4) makes thrift compulsory. The disadvantage of social insurance, 
especially in a democracy, is that it classifies people, economically speaking; 
however, this is done by many of the laws that regulate taxes. Only cer- 
tain persons pay income tax, and inheritance taxes, and the property tax is 
imposed according to ability to pay. To my mind the advantages of social 
insurance, or I will say some form of social insurance, outweigh its dis- 
advantages; but I believe that, notwithstanding the many advantages, the 
prospects for compulsory social insurance in North Carolina are rather 
remote compared with the prospects of its getting a foothold in other sec- 
tions of the country. Perhaps we shall have some form of social insurance 
in North Carolina within ten years from now; perhaps a little earlier, 
perhaps later. Now, the reasons for my saying that the movement will 
be delayed in reaching North Carolina are: First, when compulsory social 
insurance comes up in the South it will immediately become entangled with 
the race problem ; the explanation is obvious- Second, when the matter 
is proposed for serious consideration in North Carolina, we will have to 
deal with the fact that compulsory social insurance has never been applied 
to a class of the self-employed, to an agricultural population. It is a measure 
designed for the wage-earning group, and so far in practice it has been 



GENERAL SESSION 283 

limited almost entirely to the wage-earning group. As we all know, North 
Carolina is about 90 per cent agricultural. 

' This question of social insurance is the biggest problem that concerns 
the medical profession, individually and collectively. It is a question that 
every physician should approach with an open mind and should carefully 
study before reaching a conclusion. The trouble in England was that 
the medical profession were unconcerned and took no interest in social in- 
surance until the act was passed by the Government; then it was too late 
for them to inform themselves thoroughly and for them to have the in- 
fluence in shaping the legislation that they would have had and that they 
should have had if they had waked up a little earlier. 

I expect to see social insurance approach North Carolina in the form 
of a law whidh will make optional with the county the right to levy a tax 
for the care of sickness, to create a board to expend that tax in the construc- 
tion and maintenance of hospitals and in the employment of a medical staff 
properly apportioned as to specialists and paid by salaries rather than fees. 
It is an interesting fact that as long as doctors are paid fees for sickness 
it is to their business advantage, although in direct conflict with their pro- 
fessional ideals, to have as much sickness as possible ; whereas, the very 
minute the form of remuneration is changed from fees to salary and without 
changing the total remuneration per year a single mill, you completely 
reverse the business interest of the profession in sickness and make parallel 
the direction of both the ph3^sician's business and professional interests. A 
physician who hopes to collect $5,000 in fees in the present calendar year 
is dependent for the realization of his hope upon the occurrence of sickness. 
The same physician, paid a salary of $5,000 for taking care of the sick of a 
certain district or town or class, is not dependent upon sickness and is tre- 
mendously interested not only professionally, but as a business man, to see 
that sickness is prevented. It is to the interest of the profession that their 
interests, professional and business, should not be in conflict, as they are 
under present conditions, but parallel, and society can bring about this con- 
dition within the profession by changing not the amount of remuneration 
of physicians, but its form, in substituting salaries for fees. 
Dr. A. J. Crowell, Charlotte: 

I think the Medical Society of the State of North Carol'na is to be 
congratulated upon having at the head of its public health work a man 
with such ideals and vision as Dr. Rankin. His efforts to prevent the 
spread of disease are commendable. Dr. Rankin's ideals are one hundred 
per cent efficient and have made for him a national reputation. North 
Carolina stands at the head of the list in her efforts in prevention of the 
spread of preventable diseases largely because of his vision and efforts- 

We have in our midst this evening: another man who is interested in the 
uplift of North Carolina along a different line, to whom I think we could 
well afford to listen, for at least five minutes, and I move that Col. Leroy 
Kirkpatrick be heard from on a subject in which he and the physicians of 
North Carolina alike are vitally interested. 

Dr. Crowell 's motion was seconded by Dr. Albert Anderson and passed. 
Col. T. Leroy Kirkpatrick, Charlotte, N. C. : 

I only ask five minutes of your time, to ask that you endorse a resolution 



284 NORTH CAROLINA MEDICAL SOCIETY 

in the interest of a State System of Hard-Surfaced Highways. I do not 
make this request in my own behalf, but in the interest of the citizens of 
North Carolina, ^ 

Next to medicine and the uplift of the health and the education of the 
children of the Commonwealth, the construction of a State System of Hard- 
Surfaced Highways is the biggest question before our people. 

The movement for a modern system of State Highways has been endorsed 
by every commercial body in North Carolina, by the newspapers, and by 
a majority of the educational institutions of the State and by almost every 
organized unit in North Carolina, and we feel sure of your endorsement. 

I am not before you in behalf of my own selfish interest, but in the in- 
terest of the present generation and generations unborn, and to ask the 
most intelligent body in North Carolina to endorse this great movement. 

North Carolina can pull herself out of the mud, because she has the 
money to do it. Her total taxable resources approximate five billion 
dollars; her banking resources four hundred million; her checking deposits 
ninety-six million ; building and loans twenty-five million. Her citizens 
hold in Government securities two hundred million. And from her total 
resources from all crops last year approximated a billion and a half dollars. 
We are first in the manufacture of raw cotton ; rank second as a manufac- 
turing State in cotton goods ; we are fourth as an agricultural State and 
twenty-third as a stock raising State. 

The time has come when it is a disgrace to the good name of North 
Carolina to have her citizens driving through mud that is hub deep. We 
have a great western section of our State that is rich in natural resources 
in the way of minerals and timber, as well as agricultural advantages- We 
have a great east that offers as fine trucking facilities, because of the rich- 
ness of the lands, as Florida. We have a great Piedmont section that 
stands second as a manufacturing center. But one section of the State is 
unacquainted with the other because we are not linked together by accessible, 
rapid and cheap transportation system. 

If we expect to sell North Carolina commercially, invite emigrants to 
invest in our midst with their capital and become a part of us, we must put 
the State in a position to compete with Virginia, which has just voted 
sixty million dollars of bonds to build thirty-seven hundred and fifty males 
of road. Maine has issued twelve million dollars of bonds; Maryland, 
sixty million ; Illinois, sixtA^ million. Georgia is submitting a constitutional 
amendment providing for fiftv million dollars of bonds. Kansas proposes 
ten thousand and seven hundred miles of hard-surfaced roads ; Arkansas 
has a hundred-million-dollar program, covering more than seven thousand 
miles of road ; Missouri proposes a sixty million dollar bond issue ; Penn- 
svlvania has voted one hundred and twenty-five million dollars of bonds; 
Oklahoma, sixty million. 

Now, North Carolina, religiously, agriculturally and industrially, cannot 
enter into a friendly competition with these States without offering them, 
through a State system of modern highways, like benefits. 

Our North Carolina boys, through their patriotic efforts, gave a new 
interpretation to the constitution and added a new halo of glory to the flag. 
Many of them made the supreme sacrifice and broke the Hindenburg line. 



GENERAL SESSION 285 

But we, as yet, have not broken the line of sickness, the line of illiteracy or 
the mud line, and the time has come to do it. 

Dr. Cyrus Thompson, Jacksonville: 

Mr. President, I neve^ like to talk on limited time. It is like fighting. 
There is no particular objection to fighting except that you have to do so 
much of it in such a little while, or it is not worth while to do anything. 
I am interested in the matter of good roads, and I am going to introduce 
directly a resolution, by request. I consented to introduce the resolution 
because of the fact that I am interested in this subject. 

I was sitting yesterday at dinner at the Rotary Club next to a man by 
the name of Thomson. I said to him, "How do you spell your name?" 
He said, "T-h-o-m-s-o-n." "Son of Thomas-" I said, "That is not mine." 
He said, "It is the same name, isn't it?" "No," I said, "it is not the same. 
My name is T-h-o-m-p-s-o-n, which was spelled originally Thompstone 
or Thumpstone." Away back yonder, you see, my ancestors were interested 
in good roads, perhaps from criminal necessity. They helped to break the 
rocks to make hard roads, and so originated the "Thompson with a p." 
Etymology and imagination assure me of this fact. I am not saying that 
little about my original ancestors by way of detraction ; I don't suppose 
that yours were any better than mine. You see all our ancestors were 
bad — even the suffragette portion was bad; Adam testified to that. The 
only thing that any of us have to pride ourselves on is that we are better 
than our ancestors. We have made progress and are still making progress. 
Let us hope that the best is yet to come. 

Now, Colonel Kirkpatrick asked me to introduce this resolution, and I 
have explained to you why I consented to do it: 
"Be it Resolved: 

FIRST: That the State Medical Society of North 
Carolina, in meeting assembled, heartily endorse the con- 
struction of a State Sj^stem of Modern Highways. 

SECOND: We urge the members of the General 
Assembly of North Carolina, when they meet in extra 
session, to devise the necessary ways and means to build 
a State System of Modern Highways. And that said 
funds be equitably and impartially distributed to the 
several counties of the State. 

It is the sense of this meeting that a copy of this reso- 
lution be forwarded by its secretary to Honorable T. W. 
Bickett, Governor of Noth Carolina. 
I do not see that we could hurt anything much by endorsing this. We 
all want to make progress and have better roads. 

I just wish to say a word about Dr. Rankin's paper, which is an im- 
mensely progressive paper- He has in him a vision, a sort of idealism. He 
senses the spirit of the times. The idea of progress is rampant all through 
the world and we are coming on to new things. Whether we can get 
something higher and better than what we have or shall go off the log in 
one infernal crash, God Almighty knows. But we are getting away from 
individualism the world over and getting toward socialism. There is a 



286 NORTH CAROLINA MEDICAL SOCIETY 

whole lot here and I would love to talk longer about it, but I cannot. A 
simple suggestion in conclusion. When I was a young man, no campaign 
was made in North Carolina that was not ridgepoled upon States' rights. 
But you have not heard that doctrine in years until some fellow who did 
not want women to vote brought up the question. This is a union, an 
indissoluble union, of sovereign States, to be sure, but they are merged into 
one union, the greatest commonwealth on earth. 

I am going to stop ; but I wish I had time to run on a little longer. 
Dr. M. Eugene Street, Glendon: 

It is a great pleasure to me to see the State Medical Society, after 
eighteen vears, take up the subject of Good Roads. B3. reference to the 
Proceedings of the State Medical Society nt the Wrightsville meeting, 1902, 
you will see that a paper on the subject was read there, the first paper on 
this subject before this Society in all its history. The Society very enthu- 
siastically wanted the author of that paper to go to the Legislature. From 
that day to this I do not think there is any record of the Society's having 
gone on record for good roads, but I do hope that it will unanimously so 
go on record now. 
Dr. Crowell: 

Dr. Thompson read the resolution, but did not move its adoption. I 
take great pleasure in' moving that the resolution be adopted. 

This motion was seconded, and the resolution was adopted as read- After 
this the session adjourned. 

Thursday, April 22nd^ 11 A. M. 

President, Dr. C. V. Reynolds, in chair. 

The House of Delegates presented the report of the Nominating Com- 
mittee, as adopted by it, for the approval of the General Session. (See 
report of Nominating Committee to House of Delegates, pages 294 and 
295). 

In reporting the place of meeting for 1921 as Pinehurst, the House of 
Delegates reported that the local medical profession in Moore County 
would not be expected to furnish any entertainment. The time of meeting 
Avas left to the discretion of the President and Secretary, in order that 
satisfactory arrangements as to time could be made with the management 
at Pinehurst. 

On motion, the report from the House of Delegates was approved. 

The President, Dr. Reynolds, requested Drs. J. F. Highsmith and I. W. 
Faison to escort to the chair Dr. T. E. Anderson, President-elect. With a 
few felicitous remarks, the retiring President inducted Dr. T. E. Anderson 
into office. 

Dr. T. E. ANDERSON: 
To the Medical Society of the State of North Carolina: 

Gentlemen : — 

In accepting this distinguished honor which your kind indulgence has 
placed upon me, I could wish that I had the gift of tongues to adequately 
express my appreciation of it. These brave, true, noble men entrusted 
with the obligation to make these selections, perhaps, have been governed 



GENERAL SESSION 287 

more by their brotherly feelings towards me than by their best judgment. 
These were good men and, I think, fairly familiar with the Holy Scriptures, 
but I fear they did not give the solemn scriptures due consideration, which 
says: "There is a way which seemeth right unto a man, but the end thereof 
is death." In the early days of air flying the papers alluded to those ven- 
tures as "flirting with death." 

The Methodist Episcopal Church has always boasted that they have never 
made a mistake in the selection of their bishops. Up to this time that boast 
might have been made by the North Carolina Medical Society, but the 
future looks dark to me just now. However, the depth of my gratitude 
must remain unspoken. It is said "Out of the abundance of the heart the 
mouth speaketh." I wish that the heart had a language of its own, that 
it might indulge in unrestrained flowing speech in acknowledgement of 
this honor. 

Some years past it was my great pleasure and fortune to stand in the 
spacious Hall of the famed Ducal Palace at Old Venice and contemplate 
this splendid and well preserved relic of Medieval Architecture and splen- 
dor. Among the many things which hold the attention of the visitor is 
the row of pictures of the Doges once directing her destinies arranged 
around the upper walls, one frame only being vacant. This, it is explained, 
was on account of the treachery and villainy of one of her citizens holding 
this high place ; this vacant frame forever publishes his infamy. In the 
Palace of the Memories of the members of the North Carolina Medical 
Society, the frame allotted to me, enrolling me as one of your Presidents, 
will not be vacant if a lifetime of love and devotion to all her ideals and 
interests can place my image there- 

I will simply conclude by telling you that this is an honor which I never 
entertained in all my aspirations, because of a felt unfitness for it and that 
there were many more deserving of it than I. Gentlemen— I thank you 
most profoundly and ask your kind indulgence and help in discharging the 
duties involved. 

On motion of Dr. J. F. Highsmith, of Fayetteville, the appreciation and 
thanks of the Medical Society of the State of North Carolina were ex- 
tended to the Mecklenburg County Medical Society; to the Ladies' Enter- 
atinment Committee, who made the stay of the visiting ladies so delightful ; 
to the Committee on Arrangements, Dr. B. J. Witherspoon, the efficient 
chairman, being included, as was also Dr. John Q. Myers, chairman of 
the Hotel Committee ; and to the Masonic Order for the use of their mag- 
nificent temple as a meeting place. 

On motion of Dr. J. E. Brooks, of Blowing Rock, the thanks of the 
Medical Society were tendered our retiring President, Dr. C. V. Reynolds, 
for the efficiency, courtesy and kindness with which he had conducted the 
proceedings of the convention. 

At the first meeting of the new Board of Medical Examiners of North 
Carolina the following officers were elected and the following subjects 
assigned : 

Anatomv and Embryology: Dr. L. A. Crowell, President, Lincolnton, 

N. C. ■ 



288 NORTH CAROLINA MEDICAL SOCIETY 

Obstetrics, Gynecology and Pediatrics: Dr. K. P. B. Bonner, Secretary- 
Treasurer, Morehead City, N. C. 

Chemistry, Hygiene and Physiology: Dr. W. M. Jones, Greensboro, 
N. C. 

Bacteriology, Histology and Pathology: Dr. C. A. Shore, Raleigh 
N. C. 

Materia Medica, Therapeutics and Pharmacology: Dr. J. G. Murphy 
Wilmington, N. C. 

Practice of Medicine : Dr. W. P. Holt, Duke, N. C. 

Surgery: Dr. L. N. Glenn, Gastonia, N. C. 



Proceedings of the House of Delegates 

Tuesday, April 20th, 2:30 P. M. 

The House of Delegates was called to order by the President, Dr. C. \ 
Reynolds. The roll of counties was called, and representatives answered 
as follows: 

Alamance, C. M. Walters; Alexander, (see Iredell-Alexander) ; Alle 
ghany, not represented; Anson, not represented; Ashe, not represented; 
Avery, W. B. Burleson ; Beaufort, S. T. Nicholson ; Bertie, not represented ^ 
Bladen, E. S. Clark; Brunswick, not represented; Buncombe, H. H. Brigga 

D. E, Sevier and Thompson Frazer; Burke, I. M. Taylor; Cabarrus, not 
represented; Caldwell, A. B. Goodman; Camden, (see Pasquotank-Camden- 
Dare) ; Carteret, K. P. B. Bonner; Caswell, not represented; Catawba^ 
not represented; Chatham, not represented; Cherokee, N. B. Adams; 
Chowen-Perquimans, J. S. Mitchener; Clay, (see Macon-Clay) ; Cleveland, 

E. B. Lattimore ; Columbus, not represented ; Craven, not represented ; 
Cumberland, J. F. Highsmith; Currituck, not represented; Dare, (see 
Pasquotank-Camden-Dare); Davidson, C. A. Julian; Davie, not repre- 
sented ; Duplin, John W. Carroll ; Durham-Orange, B. W. Fassett and Foy 
Roberson ; Edgecombe, C. L. Outland ; Forsyth, D. L. Dalton ; Franklin, 
S. P. Burt; Gaston, James A. Anderson; Gates, not represented; Graham, 
not represented ; Granville, not represented ; Greene, John L. Carroll ; Guil- 
ford, John W. Long, J. T. Burrus and D. A. Stanton; Halifax, P. C. 
Carter; Harnett, W. P. Holt; Haywood, J. Howell Way; Henderson- 
Polk, not represented; Hertford, not represented; Hoke, L. B. McBrayer; 
Hyde, not represented; Iredell-Alexander, M, R. Adams; Jackson, not 
represented; Johnston, not represented; Jones, not represented; Lee, W. A. 
Monroe; Lenoir, W. F. Hargrove; Lincoln, W. F. Elliott; Macon-Clay, 
S. H. Lyle; Madison, W. A. Sams; Martin, B. L. Long; McDowell, J. F. 
Jonas ; Mecklenburg, B. J. Witherspoon ; J. E. S. Davidson, R. Z. Linney, 
and L. W. Hovis ; Mitchell-Watauga, C. E. Smath ; Montgomery, not 
represented; Moore, M. Eugene Street; Nash, not represented; New Han- 
over, J. G. Murphy ; Northampton, L. E. McDaniel ; Onslow, Cyrus 
Thompson; Orange, (see Durham-Orange); Pamlico, not represented; 
Pasquotank-Camden-Dare, R. L. Kendrick ; Pender, not represented ; Per- 
quimans, (see Chowan-Perquimans) ; Person, not represented; Pitt, Chas. 
O'H. Laughinghouse ; Polk, (see Henderson-Polk) ; Randolph. T. I. Fox; 
Richmond, not represented; Robeson, W. E. Evans; Rockingham, J. B. 
Ray; Rowan, J. L. Monk; Rutherford, D. R. Schenck ; Sampson, G. L. 
Sikes ; Scotland, not represented ; Stanly, not represented ; Stokes, R. G- 
Tuttle; Surry, J. B. Smith; Swain, A. M. Bennett; Transylvania, not rep- 
resented; Tyrell, (see Washington-Tyrell) ; Union, S. A. Stevens; Vance, 
not represented ; Wake, T. M. Jordan and J. B. Wright ; Warren, 
not represented; Washington-Tyrell, Joseph L. Spruill ; Watauga, (see' 
Mitchell-Watauga) ; Wayne, not represented; Wilkes, J. E. Duncan, 
C. S. Sink, alternate ; Wilson, K. C. Moore ; Yadkin, not represented ; 
Yancey, J. B. Gibbs- 

The Secretary read his report. On motion, the same was accepted and 
the financial part was referred to the Finance Committee. 



290 NORTH CAROLINA MEDICAL SOCIETY 

REPORT OF THE SECREARY-TREASURER TO THE 
MEDICAL SOCIETY OF THE SI ATE OF NORTH CAROLINA. 

Early following the close of the last session the Secretary notified all 
officers and committees of their appointment. He has also notified com- 
mittees that were to report to this session. 

MEMBERSHIP. 

On page 302, Transactions for 1919, we estimated in our report of one 
year ago that we would probably be able to get 1,200 paid-up members. 
The record shows that we had 1,213 plus 93 Honorary Fellows — 1,306 
members, the largest number by a few of any year in the history of the 
Society. We have today 1,115 paid-up members, which number plus the 
Honorary Fellows gives us 1,217 members. This is the largest paid-up 
membership by far that we have ever had at the convening of the Society. 
This is an indication, I take it, that a goodly number of doctors in North 
Carolina are taking more interest in the organized medical profession. We 
are hoping that we may add at least 200 more names to this roster before 
the Transactions go to press, and we certainly ought to have 500. May 
we express the hope that at least a few influential men in each county will 
interest themselves sufficiently to get the doctors in their county now out 
to come into their county society. The Secretary will be writing you about 
it when this meeting is over. 

IN REGARD TO FINANCES. 

You will find appended hereto the report of the Treasurer. You will 
note that all bills have been paid, except for printing program, which state- 
ment has not yet been received. You will note that the bank statement 
shows a balance of $1,565.92 as against $564-34 last year, an increase of 
one thousand dollars over last year. Part of this, however, is taken up in 
the larger percentage of members in good standing. 

As mentioned last year, we are gradually reducing our deficit. After a 
careful study of our assets and liabilities, we find that we can probably 
reduce our deficit by about $300 annually, provided we do not increase 
our expenses. You will no doubt be pleased to learn that our deficit now 
does not give us any particular trouble, for the reason that try hard as we 
can, we cannot get the printer to give us the Transactions until well along 
in the winter, contracts to the contrary notwithstanding. So that the dues 
for the succeeding year enable us to finish paying for the Transactions with- 
out a great deal of delay and without becoming liable for interest charge. 

CORRESPONDENCE 

The correspondence is necessarily large. We feel today that we ought 
to have done more. We feel that the officers and councilors could even 
do more than we have been doing if we kept in closer touch with the doctors 
of the State, members and non-members. We have sent out from the office 
986 personal letters and 9,354 multigraph or printed letters, some of these 
letters without expense to the Society for postgge. 

DELINQUENT COUNTY SOCIETIES. 

The following societies have not reported or paid dues for their members 
for 1920: Burke, Chowan-Perquimans, Craven, Gaston, Macon-Clay, 



PROCEEDINGS OF THE HOUSE OF DELEGATES 291 

Montgomery, Rockingham, Scotland, Swain, Transylvania, Yadkin. This 
represents 11 societies and 109 members as per last year's report. We take 
it that these 11 counties are not entitled to representation in the House of 
Delegates, nor are any physicians resident in these counties entitled to hold 
any office in the gift of this Society. (See Chapter 1, Section II, and 
Chapter 11, Sections I and II, By-Laws.) 

PROGRAM. 

No doubt the program will commend itself to you as one among the best 
presented to this Society. I desire to say that the chairmen of sections are 
entirely responsible for the same, and are due the thanks of the officers and 
members of our Society. 

All of which is respectfully submitted. 

(Signed) L. B. McBRAYER, 

Acting Secretary-Treasurer. 
April 16, 1920. 

TREASURER'S REPORT. 
April 12, 1919, to January 1, 1920. 

Balance April 12, 1919, as per statement in Transactions, p. 304 $ 564.34 

Dues 1,159.50 

Total Receipts $1,723.84 

ITEMIZED DISBURSEMENTS 

April 12, 1919, to January 1, 1920. 
Check No. 

17 Western Union T. Co. (telegrams) $ 2.65 

18 Dr. T. W. Shore (refund dues) 3-00 

19 Western Union T. Co. (telegrams) 7.85 

20 J. T. Jerome (rent moving picture Pinehurst) 9.50 

21 Void 

22 Miss Mary Robinson (reporting meeting) 49.98 

23 Commercial Printing Co. (program) 163.50 

24 Western Union T. Co. (telegrams) .81 

25 Western Union T. Co. (telegrams) 10.02 

26 Dr. J. L. Ransom (refund dues) 3.00 

27 Dr. J. T. J. Battle (excess dues returned) .50 

28 Mrs. T. W. Adickes (reporting meeting) 59.61 

29 Dr. R. C. Matheson (refund dues) 3.00 

30 Dr. B. B. Lloyd (refund dues) 3.00 

31 Mrs. M. L. Murrav (reporting meeting) 68.29 

32 Dr. W. L. Dunn ('refund dues) 3.00 

33 Mrs. T. W. Adickes (reporting meeting) 53.73 

34 Dr. C. W. Cocke (refund dues) 3.00 

35 Miss Mary Robinson (reporting meeting) , 84.40 

36 Edwards & Broughton (reprint President's address) 98.15 

37 Miss Mary Robinson (reporting meeting) 48.07 

38 Mr. T. B. Eldridge (proof reading) 22.50 

39 Edwards & Broughton (acct. Transactions) 1000.00 

TOTAL $1697.56 

Balance January 1, 1920 $ 26.28 



292 NORTH CAROLINA MEDICAL SOCIETY 

TREASURER'S REPORT. 
Jan. 1, 1920, to April 16, 1920. 

Balance from 1919 $ 26.28 

Interest on $1000.00 from April 24, 1919, to Jan. 1, 1920 26.67 

Dues : 3478.00 

Total Receipts $3530.95 

ITEMIZED DISBURSEMENTS 

Jan. 1, 1920, to April 16, 1920. 
Check No. 

40 Western Union T. Co. (telegrams) $ 1.41 

41 Dr. J. H. Harper (refund dues) 3.00 

42 Commercial Printing Co. (secretaries' reports) 23.50 

43 Edwards & Broughton (Transactions) 522.27 

44 Void 

45 Edwards & Broughton (Transactions) 601.01 

46 Void 

47 Postmaster (stamps) 127.41 

48 Dr. L. B. McBrayer (salary Sec.-Treas.) 600.00 

49 A. W. Snow (clerical help) 25.00 

50 Letitia Thorpe (clerical help) 10.00 

51 L. Mayhew (clerical help) 10.00 

52 Dr. Turner (refund dues) 3.00 

53 Commercial Printing Co. (announcements) 12.23 

54 Dr. Paul G. Parker (refund dues) 3.00 

55 Western Union T. Co. (telegrams) 20.20 

56 Dr. A. S. Jones (refund dues) 3.00 

Total $1965.03 

Balance April 16, 1920 (on deposit with Page Trust Co.) $1565.92 

Burke County not having made a report, Dr. I. M. Taylor, Honorary 
Fellow, being present, on motion was allowed to stand good for five mem- 
bers from his Society and was seated as a delegate. 

Dr. Charles O'H. Laughinghouse reported for the committee on Mid- 
wives. Report as follows: 



REPORT OF COMMITTEE ON REGULATION OF WORK OF 

MIDWIVES. 

Your Committee finds that the midwives are in attendance at 30,000 
of the 80.000 births that occur annually in North Carolina. 

Your Committee is of the opinion that under present conditions it is im- 
practicable, as well as impossible, for the State to prohibit attendance on 
obstetrical cases by midwives. Your Committee believes that because of 
extensive interest now shown by many States in the form of proposed 
/tgislation for maternity benefits and care, that in no distant time pregnancy 
and obstetrics will be accepted as a public responsibility and care 
at least to a limited extent, and that when this public recognition of the 



PROCEEDINGS OF THE HOUSE OF DELEGATES 293 

necessity of better professional service for pregnancy and obstetrics arrives, 
the problem of midwifery will be effectively solved- 

Under present conditions your Committee recommends: 

(l)That the North Carolina State Board of Health shall prepare, or 

have prepared, and published a simple primer on midwifery for the use of 

midwives. 

(2) That the State Board of Health prepare a standard county regula- 
tion for the control of midwives, for adoption by counties, with the effect 
of law, as provided for in section 9, chapter 62, Public Laws of 1911, as 
amended. 

(3 ) That the regulations above mentioned require that midwives be given 
a permit when they are able to stand a successful examination on the afore- 
mentioned primer, to be given by the whole-time county health officer or 
nurse. 

(4) That the aforesaid permit be a conditional permit, conditioned: (a) 
upon the midwife's compliance with the State laws relating to the practice 
of midwifery; (b) that the midwife shall refrain from making vaginal ex- 
aminations; (c) that the midwife decline to attend and that she refer to 
registered physicians, when the information is in her possession in time to 
do so, the following kind of cases: (1) cases of pregnancy or obstetrics that 
have suffered considerably with premonitory symptoms of eclampsia, as 
stated in the primer; (2) cases of pregnancy with a history of difficult 
labors; (3) cases of pregnancy or obstetrics with collapsed parts or ab- 
normal positions. 

On motion report was adopted. 

The Committee on Single Examining Board was continued. 

Dr. J. E. S. Davidson moved that the Secretary be instructed not to print 
the Transactions of the State Health Officers' Association in the Transac- 
tions of the Medical Societ}'. After remarks by Drs. Cyrus Thompson, 
I. M. Taylor and Charles O'H. Laughinghouse, Dr. Thompson moved 
to lay the motion on the table, which was seconded by Dr. J. Howell Way 
and carried unanimously. 

Dr. J. W. Long moved that Dr. J. B. Councill of Salisbury be placed 
^n the roster of Honorary Fellows; motion to lay on the table, carried. 
Dr. J. W. Long moved that a committee be appointed to look into and 
report on the status of Dr. J. B. Councill. Carried. In pursuance of Dr. 
Long's motion, the chair announced the following committee: Dr. J. W. 
Long, Dr. Cyrus Thompson. (Later— Dr. Councill has paid back dues 
and is now an Honorary Fellow.) 

The President requested the delegates from each of the ten districts to 
get together and select a member of the Nominating Committee from their 
district, and announced a recess of five minutes for such purpose. At the 
end of the five minutes the President called the House of Delegates to order 
and the members of the Nominating Committee were announced by the 
delegates from the different districts as follows: 



294 NORTH CAROLINA MEDICAL SOCIETY 

First District Joseph L. Spruill 

Second District Chas. O'H- Laughinghouse 

Third District J. G. Murphy 

Fourth District K. C. Moore 

Fifth District J. F. Highsmith 

Sixth District J. B. Wright 

Seventh District J. E. S. Davidson 

Eighth District J. T. Burrus 

Ninth District M. R. Adams 

Tenth District H. H. Briggs 

No further business occurring, on motion the House of Delegates ad- 
journed, subject to the call of the President. 

HOUSE OF DELEGATES. 
Thursday, April 22, 10:30 A. M. 

The President, Dr. C. V. Reynolds, presiding. 

The report of the Committee on Nominations was presented by Dr. 
Charles O'H. Laughinghouse : 

President: Dr. Thomas E. Anderson, Statesville. 

First Vice-President: Dr. C. S. Lawrence, Winston-Salem. 

Second Vice-President: Dr. W. H. Ward, Plymouth. 

Third Vice-President: Dr. John M. Manning, Durham. 

Committee on Scientific Work. 
Dr. E. J. Wood, Wilmington. 
Dr. Richard Dui¥y, New Bern. 
Dr. C. A. Shore, Raleigh. 

Committee on Publication. 
Dr. P. P. McCain, Sanatorium. 
Dr. C. A. Julian, Thomasville. 
Dr. W. L. Dunn, Asheville. 

Obituary Committee. 
Dr. E. J. Wood, Wilmington. 
Dr. B. S. Edwards, Asheville. 
Dr. N. D. Betting, Durham. 

Public Policy and Legislation. 
Dr. H. A. Royster, Raleigh. 
Dr. L. B. McBrayer, Sanatorium. 
Dr. Cyrus Thompson, Jacksonville. 

Finance Committee. 
Dr. J. W. Long, chairman, Greensboro. 
Dr. E. S. Bullock, Wilmington. 
Dr. E. B. Glenn, Asheville. 

Delegates to A, M. A. 
Dr. John Q. Myers, Charlotte. 
Dr. A. S. Boice, Rocky Mount. 



PROCEEDINGS OF THE HOUSE OF DELEGATES 295 

Alternates : 
Dr. C. L. Minor, Asheville. 
Dr. Isaac M. Taylor, Morganton. 

Delegates to Virginia Medical Society. 
Dr. Fred Hanes, Winston-Salem. 
Dr. R. L. Kendrick, Elizabeth City. 
Dr. B. C. Nalle, Charlotte. 

Delegates to the S. C. Association. 
Dr. D. A. Stanton, High Point. 
Dr. W. A. Monroe, Sanford. 
Dr. W. R. McCain, Waxhaw. 
The report was adopted. 

The following telegram from Mr. N. Buckner, Secretary of the Asheville 
Board of Trade, was read: 

Asheville, N. C, 4-21-20- 
Dr. C. V. Reynolds, 
State Medical Association, 
Charlotte, N. C. : 

Asheville Board of Trade heartily joins Asheville and Buncombe County 
doctors in invitation to State Medical Association to meet in Asheville next 
year, and will co-operate with you in every way to make meeting success. 

N. BUCKNER, Sect'y. 
Dr. Laughinghouse stated that Pinehurst had been recommended in the 
report of the committee on nominations as the next meeting place of the 
Society because that was the only town which had extended an invitation 
at the time the report was made up. 

The report of the committee on the President's address was presented 
by Dr. Laughinghouse, as follows: 

" Your committee to whom your president's address was referred begs to 
report that the address contains information on a subject that is now in 
process of evolution. The message is of such nature as to compel the con- 
clusion that nothing less than the highest type of altruism, refined and 
perfected by a most careful study, could have prompted it. 

"The class of legislation referred to in this address is of such a nature that 
it behooves the profession to keep constantly informed regarding it; there- 
fore, it is recommended that a committee be appointed consisting of the 
President of the Board of Health of the State of North Carolina, the Presi- 
dent of the Board of Medical Examiners for the State of North Carolina, 
and the President of North Carolina Hospital Association, vi^hose duty it 
will be to keep in touch with the vital questions contained in this address 
and report its findings to the Society at its next annual meeting. 

"It is further recommended that this committee be continued from year 
to year, making its report to the Society at its annual meetings, until such 
a time as the Society deems it wise to discontinue the committee. 

(Signed) "Chas. O'H. Laughinghouse. 
"John M. Manning, 
"B. L. Long." 
The report of the above committee was adopted unanimously. 



296 NORTH CAROLINA MEDICAL SOCIETY 

Dr. K. P. B. Bonner presented the report of the Board of Councilors, 
as follows: 

"As customary, the Board of Councilors beg leave to report upon the 
work of the Board as a whole as well as the situation of the medical organi- 
zation in each councilor district. 

"Aside from the routine work of settling disputes arising among physi- 
cians throughout the State, the most important function of the Board of 
Councilors is the conservation and promotion of the organization of medical 
men. The report of the Acting Secretary, Dr. McBrayer, on the first day 
of your meeting bears testimony to the present condition. of the Society. 
Never in the history of its organization has there been such a large mem- 
bership. It is true that spme counties have failed to report and remit dues 
for their membership, and this condition may be explained. Upon investiga- 
tion the Board has found that, practically without exception, these derelic- 
tions were occasioned by conditions existing locally in the county which 
were beyond the power of the local councilor to influence. Sooner or later 
the Board as a body is called upon to act in these cases, but it is impossible 
for the Board to handle these matters until brought officially to its attention. 

"The Board of Councilors respectfully calls the attention of the House 
of Delegates to the fact that the name of Dr. William Sharp, of New York, 
who was elected to honorary membership at the last meeting, was by some 
oversight omitted from your list of honorary members. 

"Respectfully submitted, 

(Signed) "K. P. B. Bonner, Secretar3\" 

The report was adopted. 

Dr. Laughinghouse : As one of the members of the Nominating Com- 
mittee I would like to have the place of meeting brought before the House 
of Delegates, for this reason, that we got an invitation from Asheville after 
we had already acted on the proposition, and if in the judgment of the 
House of delegates it is wiser to accept Asheville's invitation I would ii'ke 
to leave it open. 

Dr. Bonner moved that the report of the Nominating Committee be re- 
considered with reference to the next place of meeting. The motion was 
seconded, but not carried. 

The following telegram from the Southern Medical Association was read : 

Birmingham, Ala., April 21, 1920. 

North Carolina State Medical Association, in Convention Assembled, 
Charlotte, N. C. : 
Greetings. Our best wishes for a great meeting. 

Southern Medical Association, 

Seale Harris, Sec'y. Editor. 

Dr. M. L. Stevens of Asheville, Dr. J. F. Highsmith of Fayetteville, and 
Dr. J. M. Parrott of Kinston, were appointed by the President on the com- 
mittee requested by Dr. Hubert A. Royster, Secretary of the Board of Medi- 
cal Examiners, to receive and handle the funds of the Examining Board. 

The House of Delegates then adjourned. 



Memorial Exercises 

DR. W. P. MERCER. 
Read By Dr. E. G. Moore, Elm City. 

Dr. Mercer was born in Edgecombe County, North Carolina, March 
16, 1855, and died at his home near Elm City, N. C, May 28, 1919, after 
a severe illness of influenza. Thus passed from action another of the State's 
oldest physicians of wide repute and ability, and a genuine friend of man. 

Dr. Mercer was the son of John Routh Mercer, his mother being Miss 
Susan Margaret Vick. He married Miss Mary Speed Jones, of Warren 
County, North Carolina, who with five children survive him- 

Dr. Mercer graduated from Trinity College in the class of 1877- In 
the fall of 1877 he entered the medical class of the University of Virginia. 
He received his medical diploma from the University of the City of New 
York in 1879. The same year he located at his old home in Edgecombe 
County for the practice of his profession. He was a member of the Edge- 
combe County Medical Society; received his license from the Examining 
Board in 1879, and joined the State Medical Society in 1879. He repre- 
sented his county in the State Legislature two terms. He was a member 
and medical examiner of the Local Exemption Board for Edgecombe County. 

Information furnished by Mrs. W. P. Mercer. 

Mr. Howard F. Jones pays the following tribute taken from the "War- 
ren Record" : 

Feeble words cannot convey the love and esteem in which Dr. W. P. 
Mercer was held by those who knew him intimately; but I desire to give 
expression in the columns of this paper to the pleasure that years of inti- 
mate association with him have given me, and to my deep regret at his un- 
timely death. Having married my sister, of course I have known him and 
known of him for a number of years; but I did not know him intimately 
until I became an inmate of his home while I engaged with him in con- 
structing various telephone toll lines and systems in Eastern Carolina. I 
have never known a more unselfish man. I have never known a more de- 
voted husband or father, or better friend to man- If Dr. Mercer had 
never made an open profession of religion and associated himself with the 
church, his name, like that of Abou Ben Adhem's, "would lead all the rest, 
because he loved his fellow-men." 

If "Inasmuch as ye did it unto the least of these, my brethren, ye have 
done it unto Me" brings its reward on earth and in Heaven, Dr. Mercer 
is twice blest. If ministering unto the sick and going about doing good 
broadens and deepens character. Dr. Mercer's character was of unmeasured 
depth and breadth. 

Dr. Mercer filled any position he attempted. He was not a little man 
in any sense. He did not "rattle round." The place was often not big 
enough for the man, and whether it was making an annual address at the 
North Carolina Medical Society, or serving his county as State senator, 
or meeting his brethren of the profession in consultation, he towered above 
the rest. There was not a more proficient diagnostician in his profession, and 
as one who eulogized him at the simple funeral said, he was almost un- 



298 NORTH CAROLINA MEDICAL SOCIETY 

canny in medicine. And with it all he was unassuming. A graduate of 
Trinity College in the class with Senators Simmons and Overman and 
Representative Small ; a graduate in medicine of the Department of Medi- 
cine of the University of Virginia, a graduate of medicine of the University 
of Medicine of the City of New York, an interne for two years at Bellevue 
Hospital, New York, laid the foundation for a man of large brain and 
common sense to build upon towards the pinnacle of the profession. That 
he reached this pinnacle is not denied. 

That he laid down his life in the discharge of duty without thought of 
financial reward is admitted. As member of the War Board, his duties 
were arduous. During the severe winter of 1917-18 he drove day after 
day fifteen miles to discharge his duties as Examining Phj^sician, and then 
when the day's work was over would visit his patients far into the night. 
But this was not the cause of his collapse. The influenza epidemic came 
on, and his sense of duty kept him going when the flesh was so weary that 
he could scarcely go at all, and in this condition the disease fastened upon 
him and yet he would not stop — "for these people will die if someone 
does not look after them." Day after day he and his associate, Dr. Jones, 
would see more than a hundred cases per day, and speaking to me from 
his bed of sickness he said, "I became so weak that I would fall out of my 
car when I attempted to get out-" And a horny-handed neighbor said at 
his funeral, with sobs in his voice : "He came to see my little children when 
he